Exam 4

The nurse is teaching a client about dietary choices to prevent dumping syndrome after gastric bypass surgery. Which statement by the client indicates a need for further teaching? A. "I will need to avoid sweetened fruit juice beverages." B. "I can eat ice cream in moderation." C. "I cannot drink alcohol at all." D. "It is okay to have a serving of sugar-free pudding."

"I can eat ice cream in moderation." Milk products such as ice cream must be eliminated from the diet of the client with dumping syndrome. The client with dumping syndrome can no longer consume sweetened drinks. Alcohol must be eliminated from the diet. The client can eat sugar-free pudding, custard, and gelatin with caution.

The nurse is teaching a client with peptic ulcer disease about the prescribed drug regimen. Which statement made by the client indicates a need for further teaching before discharge? A. "Nizatidine (Axid) needs to be taken three times a day to be effective." B. "Taking ranitidine (Zantac) at bedtime should decrease acid production at night." C. "Sucralfate (Carafate) should be taken 1 hour before and 2 hours after meals." D. "Omeprazole (Prilosec) should be swallowed whole and not crushed."

"Nizatidine (Axid) needs to be taken three times a day to be effective." Nizatidine is most effective if administered once daily. A dose of ranitidine at bedtime should decrease acid production throughout the night. Sucralfate should be taken 1 hour before a

A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (Select all that apply.) a. Administer analgesics. b. Prevent wound infections. c. Provide fluid replacement. d. Decrease core temperature. e. Initiate physical therapy.

A, B, C Nursing priorities during the resuscitation phase include securing the airway, supporting circulation and organ perfusion by fluid replacement, keeping the client comfortable with analgesics, preventing infection through careful wound care, maintaining body temperature, and providing emotional support. Physical therapy is inappropriate during the resuscitation phase but may be initiated after the client has been stabilized.

A nurse cares for a client with burn injuries who is experiencing anxiety and pain. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.) a. Music as a distraction b. Tactile stimulation c. Massage to injury sites d. Cold compresses e. Increasing client control

A, B, E Nonpharmacologic comfort measures for clients with burn injuries include music therapy, tactile stimulation, massaging unburned areas, warm compresses, and increasing client control.

A client diagnosed with ulcerative colitis is to be discharged on loperamide (Imodium) for symptomatic management of diarrhea. What does the nurse include in the teaching about this medication? A. "Be aware of the symptoms of toxic megacolon that we discussed." B. "If diarrhea increases, you should let your health care provider know." C. "Pregnancy should be avoided." D. "You will need to decrease your dose of sulfasalazine (Azulfidine)."

A. Antidiarrheal drugs may precipitate colonic dilation and toxic megacolon. Toxic megacolon is characterized by an enlarged colon with fever, leukocytosis, and tachycardia. Loperamide will decrease diarrhea rather than increase it. Constipation is sometimes a problem. No contraindication for pregnancy is noted. Sulfasalazine therapy typically continues on a long-term basis.

The nurse is instructing a client with recently diagnosed diverticular disease about diet. What food does the nurse suggest the client include? A. A slice of 5-grain bread B. Chuck steak patty (6 ounces) C. Strawberries (1 cup) D. Tomato (1 medium)

A. Whole-grain breads are recommended to be included in the diet of clients with diverticular disease because cellulose and hemicellulose types of fiber are found in them. Dietary fat should be reduced in clients with diverticular disease. If the client wants to eat beef, it should be of a leaner cut. Foods containing seeds, such as strawberries, should be avoided. Tomatoes should be avoided unless the seeds are removed. The seeds may block diverticula in the client and present problems leading to diverticulitis.

1. A client who had a hysterectomy has a 200-mg dose of ciprofloxacin (Cipro) ordered to infuse in 30 minutes. At what rate should the nurse infuse the medication if the pharmacy provides 200 mg in a 100-mL bag of normal saline? (Record your answer using a whole number.) ___ mL/hr

ANS: 200 mL/hr 100 mL 2 = 200 mL/hr.

3. The nurse is taking the history of a 24-year-old client diagnosed with cervical cancer. What possible risk factors would the nurse assess? (Select all that apply.) a. Smoking b. Multiple sexual partners c. Poor diet d. Nulliparity e. Younger than 18 at first intercourse

ANS: A, B, C, E Smoking, multiple sexual partners, poor diet, and age less than 18 for first intercourse are all risk factors for cervical cancer. Nulliparity is a risk factor for endometrial cancer.

6. A postmenopausal client is experiencing low back and pelvic pain, fatigue, and bloody vaginal discharge. What laboratory tests would the nurse expect to see ordered for this client if endometrial cancer is suspected? (Select all that apply.) a. Cancer antigen-125 (CA-125) b. White blood cell (WBC) count c. Hemoglobin and hematocrit (H&H) d. International normalized ratio (INR) e. Prothrombin time (PT)

ANS: A, C Serum tumor markers such as CA-125 assess for metastasis, especially if elevated. H&H would evaluate the possibility of anemia, a common finding with postmenopausal bleeding with endometrial cancer. WBC count is not indicated since there are no signs of infection. The INR and PT are coagulation tests to measure the time it takes for a fibrin clot to form. They are used to evaluate the extrinsic pathway of coagulation in clients receiving oral warfarin.

1. A 28-year-old client is diagnosed with endometriosis and is experiencing severe symptoms. Which actions by the nurse are the most appropriate at this time? (Select all that apply.) a. Reduce the pain by low-level heat. b. Discuss the high risk of infertility with this diagnosis. c. Relieve anxiety by relaxation techniques and education. d. Discuss in detail the side effects of laparoscopic surgery. e. Suggest resources such as the Endometriosis Association.

ANS: A, C, E With endometriosis, pain is the predominant symptom, with anxiety occurring because of the diagnosis. Interventions should be directed to pain and anxiety relief, such as low-level heat, relaxation techniques, and education about the pathophysiology and possible treatment of endometriosis. The nurse could suggest resources to give more information about the diagnosis. Discussion of the possibility of infertility and side effects of laparoscopic surgery is premature and may increase the anxiety.

9. The nurse is doing preoperative teaching for a client who is scheduled for removal of cervical polyps in the office. Which statement by the client indicates a correct understanding of the procedure? a. I hope that I do not have cancer of the cervix. b. There should be little or no discomfort during the procedure. c. There may be a lot of bleeding after the polyp is removed. d. This may prevent me from having any more children.

ANS: B Polyp removal is a simple office procedure with the client feeling no pain. The other responses are incorrect. Cervical polyps are the most common benign growth of the cervix. Cautery is used to stop any bleeding, and there is no evidence that cervical polyps have a relationship to childbearing.

4. A client is scheduled to start external beam radiation therapy (EBRT) for her endometrial cancer. Which teaching by the nurse is accurate? (Select all that apply.) a. You will need to be hospitalized during this therapy. b. Your skin needs to be inspected daily for any breakdown. c. It is not wise to stay out in the sun for long periods of time. d. The perineal area may become damaged with the radiation. e. The technician applies new site markings before each treatment.

ANS: B, C, D EBRT is usually performed in ambulatory care and does not require hospitalization. The client needs to know to evaluate the skin, especially in the perineal area, for any breakdown, and avoid sunbathing. The technician does not apply new site markings, so the client needs to avoid washing off the markings that indicate the treatment site.

8. A client has a recurrent Bartholin cyst. What is the nurses priority action? a. Apply an ice pack to the area. b. Administer a prophylactic antibiotic. c. Obtain a fluid sample for laboratory analysis. d. Suggest moist heat such as a sitz bath.

ANS: C A major cause of an obstructed duct forming a cyst is infection. The laboratory specimen is a priority since a culture is needed in order to prescribe sensitive antibiotics. Comfort measures can then be used, such as ice packs and moist heat.

4. A 55-year-old post-menopausal woman is assessed by the nurse with a history of dyspareunia, backache, pelvis pressure, urinary tract infections, and a frequent urinary urgency. Which condition does the nurse suspect? a. Ovarian cyst b. Rectocele c. Cystocele d. Fibroid

ANS: C Dyspareunia, backache, pelvis pressure, urinary tract infections, and urinary urgency are all symptoms of a cystocelea protrusion of the bladder through the vaginal wall. Ovarian cysts are rare after menopause. A rectocele is associated with constipation, hemorrhoids, and fecal impaction. Fibroids are associated with heavy bleeding.

11. The client is emotionally upset about the recent diagnosis of stage IV endometrial cancer. Which action by the nurse is best? a. Let the client alone for a long period of reflection time. b. Ask friends and relatives to limit their visits. c. Tell the client that an emotional response is unacceptable. d. Create an atmosphere of acceptance and discussion.

ANS: D Discussion of a clients concerns about the presence of cancer and the potential for recurrence will provide emotional support and allay fears. Coping behaviors are encouraged with the support of friends and relatives. An emotional response should be accepted.

The nurse and the dietitian are planning sample diet menus for a client who is experiencing dumping syndrome. Which sample meal is best for this client? A. Chicken salad on whole wheat bread B. Liver and onions C. Chicken and rice D. Cobb salad with buttermilk ranch dressing

Chicken and rice Chicken and rice is the only selection suitable for the client who is experiencing dumping syndrome because it contains high protein without the addition of milk or wheat products. The client with dumping syndrome should not be allowed to have mayonnaise, onions, or buttermilk ranch dressing; the dressing is made from milk products. The client can have whole wheat bread only in very limited amounts.

A client admitted with severe diarrhea is experiencing skin breakdown from frequent stools. What is an important comfort measure for this client? A. Applying hydrocortisone cream B. Cleaning the area with soap and hot water C. Using sitz baths three times daily D. Wearing absorbent cotton underwear

C. Clients with skin breakdown may use sitz baths for comfort 2 or 3 times daily. Barrier creams, not hydrocortisone creams, may be used. The skin should be cleaned gently with soap and warm water. Absorbent cotton underwear helps keep the skin dry, but is not a comfort measure.

The nurse is instructing a client with breast cancer who will be undergoing chemotherapy about the side effects of doxorubicin (Adriamycin). Which side effect does the nurse instruct the client to report to the health care provider? A.) Diaphoresis B.) Dysphagia C.) Edema D.) Hearing loss

Edema Doxorubicin is an anthracycline, and clients must be instructed to be aware of and to report cardiotoxic effects, including edema, shortness of breath, chronic cough, and excessive fatigue. Diaphoresis (profuse sweating), dysphagia (difficulty swallowing), and hearing loss are not associated side effects of doxorubicin.

A client is receiving chemotherapy treatment for breast cancer and asks for additional support for managing the associated nausea and vomiting. Which complementary therapy does the nurse suggest? A.) Ginger B.) Journaling C.) Meditation D.) Yoga

Ginger It has long been believed that ginger helps alleviate nausea and vomiting. Current studies are being done on the effect of ginger on chemotherapy-induced nausea. Journaling is good for reducing anxiety, stress, and fear. Meditation helps reduce stress, improve mood, improve quality of sleep, and reduce fatigue. Yoga has been shown to improve physical functioning, reduce fatigue, improve sleep, and improve one's overall quality of life.

Which intervention is important for the nurse to include in the plan of care for a client who is to undergo paracentesis later today? A. Measure and record drainage. B. Monitor aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase. C. Obtain informed consent for the procedure. D. Have the client void before the procedure is performed.

Have the client void before the procedure is performed. Voiding before the procedure prevents bladder injury. The drainage color and amount will be recorded after the procedure. Liver enzymes are expected to be elevated; this is the purpose of the procedure. The health care provider performing the procedure should discuss the intervention and potential complications with the client and obtain informed consent.

When providing community education, the nurse emphasizes that which group should receive immunization for hepatitis B? A. Clients who work with shellfish B. Men who prefer sex with men C. Clients traveling to a third-world country D. Clients with elevations of aspartate aminotransferase and alanine aminotransferase

Men who prefer sex with men Men who prefer sex with men are at increased risk for hepatitis B, which is spread by the exchange of blood and body fluids during sexual activity. Consuming raw or undercooked shellfish may cause hepatitis A, not hepatitis B. Travel to third-world countries exposes the traveler to contaminated water and risk for hepatitis A; hepatitis B is not of concern, unless the client is exposed to blood and body fluids during travel. Clients who have liver disease should receive the vaccine, but men who have sex with men are at higher risk for contracting hepatitis B.

When providing discharge teaching to a client with cirrhosis, it is essential for the nurse to emphasize avoidance of which of these? A. Vitamin K-containing products B. Potassium-sparing diuretics C. Nonabsorbable antibiotics D. Nonsteroidal anti-inflammatory drugs (NSAIDs)

Nonsteroidal anti-inflammatory drugs (NSAIDs) Clients who have cirrhosis should not take NSAIDs because they may predispose to bleeding. The client with cirrhosis is prone to bleeding; vitamin K can decrease bleeding, so it is not necessary to restrict this in the diet. Potassium-sparing diuretics are used to reduce ascites. Nonabsorbable antibiotics are used to decrease ammonia levels.

The nurse is reviewing admitting requests for a client admitted to the intensive care unit with perforation of a duodenal ulcer. Which request does the nurse implement first? A. Apply antiembolism stockings. B. Place a nasogastric (NG) tube, and connect to suction. C. Insert an indwelling catheter, and check output hourly. D. Give famotidine (Pepcid) 20 mg IV every 12 hours.

Place a nasogastric (NG) tube, and connect to suction. To decrease spillage of duodenal contents into the peritoneum, NG suction should be rapidly initiated. This will minimize the risk for peritonitis. Antiembolism stockings will need to be applied, monitoring output is important, and famotidine (Pepcid) will need to be administered, but the nurse's first priority is to minimize the risk for peritonitis.

A large-breasted client reports discomfort, backaches, and fungal infections because of her excessive breast size. The nurse provides information to the client about which breast treatment option? A.) Augmentation B.) Compression C.) Reconstruction D.) Reduction mammoplasty

Reduction mammoplasty Breast reduction mammoplasty surgery removes excess breast tissue and repositions the nipple and remaining skin flaps to produce the best cosmetic effect. Breast augmentation surgery enhances the size, shape, or symmetry of breasts. Breast compression is not a treatment. Breast reconstruction surgery is typically performed for women after a mastectomy.

Following paracentesis, during which 2500 mL of fluid was removed, which assessment finding is most important to communicate to the heath care provider? A. The dressing has a 2-cm area of serous drainage. B. The client's platelet count is 135,000/mm3. C. The client's albumin level is 2.8 mg/dL. D. The client's heart rate is 122 beats/min.

The client's heart rate is 122 beats/min. Rapid removal of fluid may cause symptoms of shock; tachycardia, especially when associated with hypotension, should be reported to the provider. A small amount of serous fluid may leak; the dressing should be reinforced. Platelets will be checked before the procedure; these are slightly low, but this is not a cause for concern. An albumin level of 2.8 mg/dL is an expected finding for a client with cirrhosis; it is not life threatening. Awarded 1.0 points out of 1.0 possible points.

15. Which method is used to measure IOP? a. Corneal staining b. Tonometry c. Slit lamp examination d. Electroretinography

b

The nurse is teaching post-mastectomy exercises to a client. Which statement made by the client indicates that teaching has been effective? A.) "For the pulley exercise, I'll drape a 6-foot-long rope over a shower curtain rod or over the top of a door." B.) "In rope turning, I'll hold the rope with my arms flexed." C.) "In rope turning, I'll start by making large circles." D.) "With hand wall climbing, I'll walk my hands up the wall and back down until they are at waist level."

"For the pulley exercise, I'll drape a 6-foot-long rope over a shower curtain rod or over the top of a door." To perform the pulley exercise properly, the client should drape a 6-foot-long rope over a sturdy structure. In rope turning, the client holds the end of the rope and steps back from the door until the arm is almost straight out in front. The client starts with small circles and gradually increases to larger circles as the client becomes more flexible. With hand wall climbing, the client walks the hands up the wall and then back down until they are at shoulder level.

The nurse is teaching a client how to prevent recurrent chronic gastritis symptoms before discharge. Which statement by the client demonstrates a correct understanding of the nurse's instruction? A. "It is okay to continue to drink coffee in the morning when I get to work." B. "I will need to take vitamin B12 shots for the rest of my life." C. "I should avoid alcohol and tobacco." D. "I should eat small meals about six times a day."

"I should avoid alcohol and tobacco." The client with chronic gastritis should avoid alcohol and tobacco. The client should eliminate caffeine from the diet. The client will need to take vitamin B12 shots only if he or she has pernicious anemia. The client should not eat six small meals daily. This practice may actually stimulate gastric acid secretion.

A client has been discharged to home after being hospitalized with an acute episode of pancreatitis. The client, who is an alcoholic, is unwilling to participate in Alcoholics Anonymous (AA), and the client's spouse expresses frustration to the home health nurse regarding the client's refusal. What is the nurse's best response? A. "Your spouse will sign up for the meetings only when he is ready to deal with his problem." B. "Keep mentioning the AA meetings to your spouse on a regular basis." C. "I'll get you some information on the support group Al-Anon." D. "Tell me more about your frustration with your spouse's refusal to participate in AA."

"I'll get you some information on the support group Al-Anon." Putting the client's spouse in contact with an Al-Anon support group assists with the spouse's frustration. Telling the spouse that the client will sign up for AA meetings when the client is ready and telling the spouse to keep mentioning AA do not address the spouse's frustration with the client's refusal to participate in AA. Encouraging the spouse to say more about his or her frustration may allow the spouse to vent frustration, but it does not offer any options or solutions.

A client with peptic ulcer disease asks the nurse whether a maternal history of gastric cancer will cause the client to develop gastric cancer. What is the nurse's best response? A. "Yes, it is known that a family history of gastric cancer will cause someone to develop gastric cancer." B. "If you are concerned that you are at high risk, I recommend speaking to your provider about the possibility of genetic testing." C. "Have you spoken to your health care provider about your concerns?" D. "I wouldn't be too concerned about that as long as your diet limits pickled, salted, and processed food."

"If you are concerned that you are at high risk, I recommend speaking to your provider about the possibility of genetic testing." Genetic counseling will help the client determine whether he or she is at exceptionally high risk to develop gastric cancer. The client cannot know for certain whether family history places him or her at exceptionally high risk to develop gastric cancer unless specific testing is done. Asking the client what the provider has said is an evasive answer by the nurse and does not help answer the client's question. Although a diet high in pickled, salted, and processed foods does increase the risk for gastric cancer, a family history of specific types of cancer can also increase the risk.

Which statement by a client with cirrhosis indicates that further instruction is needed about the disease? A. "Cirrhosis is a chronic disease that has scarred my liver." B. "The scars on my liver create problems with blood circulation." C. "Because of the scars on my liver, blood clotting and blood pressure are affected." D. "My liver is scarred, but the cells can regenerate themselves and repair the damage."

"My liver is scarred, but the cells can regenerate themselves and repair the damage." Although cells and tissues will attempt to regenerate, this will result in permanent scarring and irreparable damage. Cirrhosis is a chronic condition that leaves scars on the liver. Permanent scars form in response to attempts by the cells to regenerate and create problems in blood circulation moving through the liver. Liver scarring will create problems with blood clotting, cholesterol levels, and blood pressure, as well as with the metabolism of drugs and toxins.

A client has been diagnosed with terminal gastric cancer and is interested in obtaining support from hospice, but expresses concern that pain management will not be adequate. What is the nurse's best response? A. "Pain control is a major component of the care provided by hospice and its staff members." B. "What has your provider told you about participating in hospice?" C. "I can speak to your provider about requesting adequate pain medication." D. "You don't want to become too dependent on pain medication and become an addict."

"Pain control is a major component of the care provided by hospice and its staff members." Telling the client that pain control is a major component of hospice care correctly describes the services provided by hospice and its staff members, and reassures the client about their expertise in pain management. Asking the client what the provider has said is an evasive response by the nurse and does not address the client's concerns. The nurse does not need to speak to the provider because pain control is an integral part of hospice services. It is inappropriate to tell a terminally ill client in need of pain control that he or she may become too dependent on pain medication.

The nurse is discussing treatment options with a client newly diagnosed with breast cancer. Which statement by the client indicates a need for further teaching? A.) "Hormonal therapy is only used to prevent the growth of cancer. It won't get rid of it." B.) "I might have chemotherapy before surgery." C.) "If I get radiation, I am not radioactive to others." D.) "Radiation will remove the cancer, so I might not need surgery."

"Radiation will remove the cancer, so I might not need surgery." Typically, radiation therapy follows surgery to kill residual tumor cells. Radiation therapy plays a critical role in the therapeutic regimen and is an effective treatment for almost all sites where breast cancer can metastasize. The purpose of radiation therapy is to reduce the risk for local recurrence of breast cancer. The purpose of hormonal therapy is to reduce the estrogen available to breast tumors to stop or prevent their growth. Chemotherapy drugs destroy breast cancer cells that may be present anywhere in the body; they are typically administered after surgery for breast cancer, although neoadjuvant chemotherapy may be given to reduce the size of a tumor before surgery. The client receiving radiation therapy is radioactive only if the radiation source is dwelling inside the breast tissue.

The nurse has placed a nasogastric (NG) tube in a client with upper gastrointestinal (GI) bleeding to administer gastric lavage. The client asks the nurse about the purpose of the NG tube for the procedure. What is the nurse's best response? A. "Saline goes down the tube to help clean out your stomach." B. "Medication goes down the tube to help clean out your stomach." C. "The provider requested the tube to be placed just in case it was needed." D. "We'll start feeding you through it once your stomach is cleaned out."

"Saline goes down the tube to help clean out your stomach." Gastric lavage involves the instillation of water or saline through an NG tube to clear out stomach contents and blood clots. It does not involve the instillation of medication. An NG tube is not typically placed in a client without a particular purpose in mind. Gastric lavage does not involve enteral feeding.

A client has developed acute pancreatitis after also developing gallstones. Which is the highest priority instruction for this client to avoid further attacks of pancreatitis? A. "You may need a surgical consult for removal of your gallbladder." B. "See your health care provider immediately when experiencing symptoms of a gallbladder attack." C. "If you have a gallbladder attack and pain does not resolve within a few days, call your health care provider." D. "You'll need to drastically modify your alcohol intake."

"See your health care provider immediately when experiencing symptoms of a gallbladder attack." In this case, the client's pancreatitis was likely triggered by the development of gallstones. A diagnostic statement must come from the provider. Also, the client may not require removal of the gallbladder. The client must see the provider promptly when experiencing gallbladder disease and should not wait. Because this client's acute pancreatitis is likely related to gallstones, alcohol consumption need not be restricted.

The nurse is assessing a client's alcohol intake to determine whether it is the underlying cause of the client's attacks of pancreatitis. Which question does the nurse ask to elicit this information? A. "Do you usually binge drink?" B. "Do you tend to drink more on holidays or weekends?" C. "Tell me more about your alcohol intake." D. "Estimate how many episodes of binge drinking you do in a week."

"Tell me more about your alcohol intake." Asking the client about his or her alcohol intake is the only way that will allow the client to provide information in the client's own words and to the extent that the client wishes to provide it. Asking the client if he or she binge drinks or tends to drink more on holidays or weekends may put the client on the defensive rather than provide the desired information. It has not yet been determined whether the client engages in binge drinking.

A client who has just been notified that the breast biopsy indicates a malignancy tells the nurse, "I just don't know how this could have happened to me." Which response by the nurse is best? A.) "Tell me what you mean when you say you don't know how this could have happened to you." B.) "Do you have a family history that might make you more likely to develop breast cancer?" C.) "Would you like me to help you find more information about how breast cancer develops?" D.) "Many risk factors for breast cancer have been identified, so it is difficult to determine what might have caused it."

"Tell me what you mean when you say you don't know how this could have happened to you." The client's statement that he or she does not know how this could have happened may indicate shock and denial or a request for more information. To provide appropriate care, further assessment is needed about the client's psychosocial status. The first action by the nurse in this situation is to obtain more data by asking open-ended questions. The nurse needs to further assess the client's emotional status before asking about family history of cancer or obtaining information for the client.

A client with peptic ulcer disease (PUD) asks the nurse whether licorice and slippery elm might be useful in managing the disease. What is the nurse's best response? A. "No, they probably won't be useful. You should use only prescription medications in your treatment plan." B. "These herbs could be helpful. However, you should talk with your provider before adding them to your treatment regimen." C. "Yes, these are known to be effective in managing this disease, but make sure you research the herbs thoroughly before taking them." D. "No, herbs are not useful for managing this disease. You can use any type of over-the-counter drugs though. They have been shown to be safe."

"These herbs could be helpful. However, you should talk with your provider before adding them to your treatment regimen." Although licorice and slippery elm may be helpful in managing PUD, the client should consult his or her health care provider before making a change in the treatment regimen. Alternative therapies may or may not be helpful in managing PUD. The client should not use over-the-counter medications without first discussing it with his or her provider.

An older female client is diagnosed with gastric cancer. Which statement made by the client's family demonstrates a correct understanding of the disorder? A. "This may be related to her recurring ulcer disease." B. "This is probably curable with surgery." C. "Gastric cancer has a strong genetic component." D. "Thank goodness she won't have to undergo surgery."

"This may be related to her recurring ulcer disease." Infection with Helicobacter pylori is the largest risk factor for gastric cancer because it carries the cytotoxin-associated antigen A (CagA) gene. Clients with chronic ulcers are probably infected with this organism. Surgery is not curative; most gastric cancers do not present with symptoms until late in the disease and have a high fatality rate. There is no strong genetic predisposition to gastric cancer. Surgery is part of the treatment.

A client diagnosed with acalculous cholecystitis asks the nurse how the gallbladder inflammation developed when there is no history of gallstones. What is the nurse's best response? A. "This may be an indication that you are developing sepsis." B. "The gallstones are present, but have become fibrotic and contracted." C. "This type of gallbladder inflammation is associated with hypovolemia." D. "This may be an indication of pancreatic disease."

"This type of gallbladder inflammation is associated with hypovolemia." This type of gallbladder inflammation is associated with hypovolemia. Although this type of gallbladder inflammation is associated with sepsis, it is not an indicator that sepsis is developing. Fibrotic and contracted gallstones are associated with chronic cholecystitis. The presence of acalculous cholecystitis is not an indicator that pancreatic disease has developed.

The nurse is caring for a client recently diagnosed with type 1 diabetes mellitus who has had an episode of acute pancreatitis. The client asks the nurse how he developed diabetes when the disease does not run in the family. What is the nurse's best response? A. "The diabetes could be related to your obesity." B. "What has your doctor told you about your disease?" C. "Do you consume alcohol on a frequent basis?" D. "Type 1 diabetes can occur when the pancreas is destroyed by disease."

"Type 1 diabetes can occur when the pancreas is destroyed by disease." Telling the client that type 1 diabetes can occur when the pancreas is destroyed by disease is the only response that accurately describes the relationship of the client's diabetes to pancreatic destruction. Type 2, not type 1, diabetes is usually related to obesity. Asking the client what the provider has said is an evasive response by the nurse and does not address the client's question. Many factors could produce acute pancreatitis other than alcohol consumption.

A client has a long-term history of Crohn's disease and has recently developed acute gastritis. The client asks the nurse whether Crohn's disease was a direct cause of the gastritis. What is the nurse's best response? A. "Yes, Crohn's disease is known to be a direct cause of the development of chronic gastritis." B. "We know that there can be an association between Crohn's disease and chronic gastritis, but Crohn's does not directly cause acute gastritis to develop." C. "What has your doctor told you about how your gastritis developed?" D. "Yes, a familial tendency to inherit Crohn's disease and gastritis has been reported. Have your other family members been tested for Crohn's disease?"

"We know that there can be an association between Crohn's disease and chronic gastritis, but Crohn's does not directly cause acute gastritis to develop." Crohn's disease may be an underlying disease process when chronic gastritis develops, but not when acute gastritis occurs. It is not known to be a direct cause of the disease. Although Crohn's disease tends to run in families, gastritis is a symptom of other disease processes and is not a disease process in and of itself. Asking the client what the doctor has said is an evasive response on the part of the nurse and does not help answer the client's question.

A client has just been diagnosed with pancreatic cancer. The client's upset spouse tells the nurse that they have recently moved to the area, have no close relatives, and are not yet affiliated with a church. What is the nurse's best response? A. "Maybe you should find a support group to join." B. "Would you like me to contact the hospital chaplain for you?" C. "Do you want me to try to find a therapist for you?" D. "Do you have any friends whom you want me to call?"

"Would you like me to contact the hospital chaplain for you?" It is appropriate for the nurse to suggest contacting the hospital chaplain as a counseling option for the client and family. Suggesting that the client find a support group does not assist the client and the family with the problem. It is inappropriate for the nurse to suggest that the client and the family need a therapist. The spouse has already told the nurse that they have recently moved to the area, so it is unlikely that they have already made close friends.

The nurse is instructing a client on how to perform breast self-examination (BSE). Which techniques does the nurse include in teaching the client about BSE? (Select all that apply.) A.) Instruct the client to keep her arm by her side while performing the examination. B.) Ensure that the setting in which BSE is demonstrated is private and comfortable. C.) Ask the client to remove her shirt. The bra may be left in place. D.) Ask the client to demonstrate her own method of BSE. E.) Use the fingertips, which are more sensitive than the finger pads, to palpate the breasts.

-Ensure that the setting in which BSE is demonstrated is private and comfortable. -Ask the client to demonstrate her own method of BSE. The setting should be private and comfortable to promote an environment conducive to learning and to prevent potential client embarrassment. Before teaching breast palpation, ask the client to demonstrate her own method, so that the nurse can assess the client's understanding of BSE. For better visualization, the arm should be placed over the head. The client should undress completely from the waist up. The finger pads, which are more sensitive than the fingertips, are used when palpating the breasts.

A nurse cares for a client with a fractured fibula. Which assessment should alert the nurse to take immediate action? a. Pain of 4 on a scale of 0 to 10 b. Numbness in the extremity c. Swollen extremity at the injury site d. Feeling cold while lying in bed

b

A nurse plans care for a client with burn injuries. Which interventions should the nurse implement to prevent infection in the client? (Select all that apply.) a. Ask all family members and visitors to perform hand hygiene before touching the client. b. Carefully monitor burn wounds when providing each dressing change. c. Clean equipment with alcohol between uses with each client on the unit. d. Allow family members to only bring the client plants from the hospitals gift shop. e. Use aseptic technique and wear gloves when performing wound care.

A, B, E To prevent infection in a client with burn injuries the nurse should ensure everyone performs hand hygiene, monitor wounds for signs of infection, and use aseptic technique, including wearing gloves when performing wound care. The client should have disposable equipment that is not shared with another client, and plants should not be allowed in the clients room.

A nurse cares for an older client with burn injuries. Which age-related changes are paired appropriately with their complications from the burn injuries? (Select all that apply.) a. Slower healing time Increased risk for loss of function from contracture formation b. Reduced inflammatory response Deep partial-thickness wound with minimal exposure c. Reduced thoracic compliance Increased risk for atelectasis d. High incidence of cardiac impairments Increased risk for acute kidney injury e. Thinner skin May not exhibit a fever when infection is present

A, C, D Slower healing time will place the older adult client at risk for loss of function from contracture formation due to the length of time needed for the client to heal. A pre-existing cardiac impairment increases risk for acute kidney injury from decreased renal blood flow, and reduced thoracic compliance places the client at risk for atelectasis. Reduced inflammatory response places the client at risk for infection without a normal response, including fever. Clients with thinned skin are at greater risk for deeper wounds from minimal exposure.

A nurse plans care for a client with burn injuries. Which interventions should the nurse include in this clients plan of care to ensure adequate nutrition? (Select all that apply.) a. Provide at least 5000 kcal/day. b. Start an oral diet on the first day. c. Administer a diet high in protein. d. Collaborate with a registered dietitian. e. Offer frequent high-calorie snacks.

A, C, D, E A client with a burn injury needs a high-calorie diet, including at least 5000 kcal/day and frequent high-calorie snacks. The nurse should collaborate with a registered dietitian to ensure the client receives a high-calorie and high-protein diet required for wound healing. Oral diet therapy should be delayed until GI motility resumes.

A male client with a long history of ulcerative colitis experienced massive bleeding and had emergency surgery for creation of an ileostomy. He is very concerned that sexual intercourse with his wife will be impossible because of his new ileostomy pouch. How does the nurse respond? A. "A change in position may be what is needed for you to have intercourse with your wife." B. "Have you considered going to see a marriage counselor with your wife?" C. "What has your wife said about your pouch system?" D. "You must get clearance from your health care provider before you attempt to have intercourse."

A. A simple change in positioning during intercourse may alleviate the client's apprehension and facilitate sexual relations with his wife. Suggesting marriage counseling may address the client's concerns, but it focuses on the wrong issue; the client has not stated that he has relationship problems. Asking the client what his wife has said about the pouch may address the client's concerns, but it similarly focuses on the wrong issue. Telling the client that he needs to get clearance from his health care provider is an evasive response that does not address the client's primary concern.

A client is scheduled for discharge after surgery for inflammatory bowel disease. The client's spouse will be assisting home health services with the client's care. What is most important for the home health nurse to assess in the client and the spouse with regard to the client's home care? A. Ability of the client and spouse to perform incision care and dressing changes B. Effective coping mechanisms for the client and spouse after the surgical experience C. Knowledge about the client's requested pain medications D. Understanding of the importance of keeping scheduled follow-up appointments

A. Assessing the client's and the spouse's ability to carry out incision care and dressing changes is essential for avoiding further development of the infectious process, as well as infection of the surgical incision itself. Assessing coping mechanisms and knowledge of the client's pain medication are important, but are not the priority. Understanding the importance of scheduled follow-up appointments is important, but is not the priority.

A client has undergone the Whipple procedure (radical pancreaticoduodenectomy) for pancreatic cancer. Which precautionary measures does the nurse implement to prevent potential complications? (Select all that apply.) A. Check blood glucose often. B. Check bowel sounds and stools. C. Ensure that drainage color is clear. D. Monitor mental status. E. Place the client in the supine position.

A. Check blood glucose often. B. Check bowel sounds and stools. D. Monitor mental status. Glucose should be checked often to monitor for diabetes mellitus. Bowels sounds and stools should be checked to monitor for bowel obstruction. A change in mental status or level of consciousness could be indicative of hemorrhage. Clear, colorless, bile-tinged drainage or frank blood with increased output may indicate disruption or leakage of a site of anastomosis. The client should be placed in semi-Fowler's position to reduce tension on the suture line and the anastomosis site and to optimize lung expansion.

The nurse is teaching a client who recently began taking sulfasalazine (Azulfidine) about the drug. What side effects does the nurse tell the client to report to the health care provider? (Select all that apply.) A. Anorexia B. Depression C. Drowsiness D. Frequent urination E. Headache F. Vomiting

A. E. F. Anorexia, headache, and nausea/vomiting are side effects of sulfasalazine that should be reported to the health care provider. Depression, drowsiness, and urinary problems are not side effects of sulfasalazine.

When caring for a client with portal hypertension, the nurse assesses for which potential complications? (Select all that apply.) A. Esophageal varices B. Hematuria C. Fever D. Ascites E. Hemorrhoids

A. Esophageal varices D. Ascites E. Hemorrhoids Portal hypertension results from increased resistance to or obstruction (blockage) of the flow of blood through the portal vein and its branches. The blood meets resistance to flow and seeks collateral (alternative) venous channels around the high-pressure area. Veins become dilated in the esophagus (esophageal varices), rectum (hemorrhoids), and abdomen (ascites due to excessive abdominal [peritoneal] fluid). Hematuria may indicate insufficient production of clotting factors in the liver and decreased absorption of vitamin K. Fever indicates an inflammatory process.

A client with an exacerbation of ulcerative colitis has been prescribed Vivonex PLUS. The client asks the nurse how this is helpful for improving symptoms. How does the nurse reply? A. "It is absorbed quickly and allows the affected part of the GI tract to rest and heal." B. "It provides key nutrients and extra calories to promote healing." C. "It is bland and reduces the secretion of gastric acids." D. "It does not contain caffeine or other GI tract stimulants."

A. For less severe exacerbations, an elemental or semi-elemental product such as Vivonex PLUS may be prescribed to induce remission. These products are absorbed in the jejunum and therefore permit the distal small intestine and colon to rest. Nutritional supplements such as Ensure or Sustacal are added to provide nutrients and more calories. GI stimulants such as caffeinated beverages and alcohol should be avoided, but this is not the reason for using Vivonex PLUS.

A client with a history of osteoarthritis has a 10-inch incision following a colon resection. The incision has become infected, and the wound requires extensive irrigation and packing. What aspect of the client's care does the nurse make certain to discuss with the health care provider before the client's discharge? A. Having a home health consultation for wound care B. Requesting an antianxiety medication C. Requesting pain medication for the client's osteoarthritis D. Placing the client in a skilled nursing facility for rehabilitation

A. Home health services are most appropriate for this client because wound care will be extensive and the client's mobility may be limited. No indication suggests that the client is experiencing anxiety regarding postoperative care. Pain medication may be needed for the client's osteoarthritis, but this is not the highest priority. A skilled nursing facility is not necessary if the client can remain in his or her home with sufficient support services.

When caring for a client with Laennec's cirrhosis, which of these does the nurse expect to find on assessment? (Select all that apply.) A. Prolonged partial thromboplastin time B. Icterus of skin C. Swollen abdomen D. Elevated magnesium E. Currant jelly stool F. Elevated amylase level

A. Prolonged partial thromboplastin time B. Icterus of skin C. Swollen abdomen The liver produces clotting factors; when it is damaged, prolonged coagulation times and bleeding may result. Icterus, or jaundice, results from cirrhosis. The client with cirrhosis may develop ascites, or fluid in the abdominal cavity. Elevated magnesium is not related to cirrhosis. The client with cirrhosis may develop hypocalcemia and/or hypokalemia. Currant jelly stool is consistent with intussusception, a type of bowel obstruction. Cirrhosis is consistent with elevations of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase; amylase is typically elevated in pancreatitis.

A client with ulcerative colitis (UC) has stage 1 of a restorative proctocolectomy with ileo-anal anastomosis (RPC-IPAA) procedure performed. The client asks the nurse, "How long do people with this procedure usually have a temporary ileostomy?" How does the nurse respond? A. "It is usually ready to be closed in about 1 to 2 months." B. "This is something that you will have to discuss with your health care provider." C. "The period of time is indefinite—I am sorry that I cannot say." D. "You will probably have it for 6 months or longer, until things heal.

A. The RPC-IPAA has become the most effective alternate method for UC clients who have surgery to remove diseased portions of intestines. Stage 1 creates a temporary ileostomy to be used while an internally created pouch is healing. Stage 2 closes the ileostomy, and the client begins to use the pouch for storage of stool. The time between the surgeries is generally 1 to 2 months. Telling the client that he or she will have to discuss it with the health care provider evades the question; the nurse can give generalities to the client based on past practice and available data. The time that the client has the ileostomy is not "indefinite." The intent of this procedure is to eliminate the need to have a permanent ileostomy. The pouch should heal in 1 to 2 months, not 6 months; this estimate is not based on the expected outcome.

A nurse is teaching a client with Crohn's disease about managing the disease with the drug adalimumab (Humira). Which instruction does the nurse emphasize to the client? A. "Avoid large crowds and anyone who is sick." B. "Do not take the medication if you are allergic to foods with fatty acids." C. "Expect difficulty with wound healing while you are taking this drug." D. "Monitor your blood pressure and report any significant decrease in it."

A. The client should avoid being around large crowds to prevent developing an infection. The client should not take the medication if he or she is allergic to certain proteins. Although immune suppression may occur to some degree, the client should not experience difficulty with wound healing while taking adalimumab. The client should not experience a decrease in blood pressure from taking this drug.

12. A client has scheduled brachytherapy sessions and states that she feels as though she is not safe around her family. What is the best response by the nurse? a. You are only reactive when the radioactive implant is in place. b. To be totally safe, it is a good idea to sleep in a separate room. c. It is best to stay a safe distance from friends or family between treatments. d. You should use a separate bathroom from the rest of the family.

ANS: A In brachytherapy, the surgeon inserts an applicator into the uterus. After placement is verified, the radioactive isotope is placed in the applicator for several minutes for a single treatment. There are no restrictions for the woman to stay away from her family or the public between treatments.

6. A nurse is caring for four postoperative clients who each had a total abdominal hysterectomy. Which client should the nurse assess first upon initial rounding? a. Client who has had two saturated perineal pads in the last 2 hours b. Client with a temperature of 99 F and blood pressure of 115/73 mm Hg c. Client who has pain of 4 on a scale of 0 to 10 d. Client with a urinary catheter output of 150 mL in the last 3 hours

ANS: A Normal vaginal bleeding should be less than one saturated perineal pad in 4 hours. Two saturated pads in such a short time could indicate hemorrhage, which is a priority. The other clients also have needs, but the client with excessive bleeding should be assessed first.

2. The nurse is educating a client on the prevention of toxic shock syndrome (TSS). Which statement by the client indicates a lack of understanding? a. I need to change my tampon every 8 hours during the day. b. At night, I should use a feminine pad rather than a tampon. c. If I dont use tampons, I should not get TSS. d. It is best if I wash my hands before inserting the tampon.

ANS: A Tampons need to be changed every 3 to 6 hours to avoid infection by such organisms as Staphylococcus aureus. All of the other responses are correct: use of feminine pads at night, not using tampons at all, and washing hands before tampon insertion are all strategies to prevent TSS. DIF: Applying/Application REF: 1485

2. The nurse is giving discharge instructions to a client who had a total abdominal hysterectomy. Which statements by the client indicate a need for further teaching? (Select all that apply.) a. I should not have any problems driving to see my mother, who lives 3 hours away. b. Now that I have time off from work, I can return to my exercise routine next week. c. My granddaughter weighs 23 pounds, so I need to refrain from picking her up. d. I will have to limit the times that I climb our stairs at home to morning and night. e. For 1 month, I will need to refrain from sexual intercourse.

ANS: A, B Driving and sitting for extended periods of time should be avoided until the surgeon gives permission. For 2 to 6 weeks, exercise participation should also be avoided. All of the other responses demonstrate adequate knowledge for discharge. The client should not lift anything heavier than 10 pounds, should limit stair climbing, and should refrain from sexual intercourse.

14. A 20-year-old client is interested in protection from the human papilloma virus (HPV) since she may become sexually active. Which response from the nurse is the most accurate? a. You are too old to receive an HPV vaccine. b. Either Gardasil or Cervarix can provide protection. c. You will need to have three injections over a span of 1 year. d. The most common side effect of the vaccine is itching at the injection site.

ANS: B Current HPV vaccines are Gardasil and Cervarix, which should be given before the first sexual contact to protect against the highest risk HPV types associated with cervical cancer. The client is not too old since it is recommended that young women up to 26 years should receive an HPV vaccine. The entire series consists of three injections over 6 months, not 1 year. Local pain and redness surrounding the injection site are very common, but this does not include itching.

10. A client has recently been diagnosed with stage III endometrial cancer and asks the nurse for an explanation. What response by the nurse is correct about the staging of the cancer? a. The cancer has spread to the mucosa of the bowel and bladder. b. It has reached the vagina or lymph nodes. c. The cancer now involves the cervix. d. It is contained in the endometrium of the cervix.

ANS: B Stage III of endometrial cancer reaches the vagina or lymph nodes. Stage I is confined to the endometrium. Stage II involves the cervix, and stage IV spreads to the bowel or bladder mucosa and/or beyond the pelvis.

3. A client is admitted to the emergency department with toxic shock syndrome. Which action by the nurse is the most important? a. Administer IV fluids to maintain fluid and electrolyte balance. b. Remove the tampon as the source of infection. c. Collect a blood specimen for culture and sensitivity. d. Transfuse the client to manage low blood count.

ANS: B The source of infection should be removed first. All of the other answers are possible interventions depending on the clients symptoms and vital signs, but removing the tampon is the priority.

5. The nurse is teaching a client who is undergoing brachytherapy about what to immediately report to her health care provider. Which signs and symptoms would be included in this teaching? (Select all that apply.) a. Constipation for 3 days b. Temperature of 99 F c. Abdominal pain d. Visible blood in the urine e. Heavy vaginal bleeding

ANS: C, D, E Health teaching for a client having brachytherapy should emphasize reporting abdominal pain, visible blood in the urine, and heavy vaginal bleeding. Severe diarrhea (not constipation), urethral burning, extreme fatigue, and a fever over 100 F should also be reported.

13. A client has just returned from a total abdominal hysterectomy and needs postoperative nursing care. What action can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Assess heart, lung, and bowel sounds. b. Check the hemoglobin and hematocrit levels. c. Evaluate the dressing for drainage. d. Empty the urine from the urinary catheter bag.

ANS: D The UAP is able to empty the urinary output from the catheter. The nurse would assess the heart, lung, and bowel sounds; check the hemoglobin and hematocrit levels; and evaluate the drainage on the dressing.

5. The nurse is caring for a postoperative client following an anterior colporrhaphy. What action can be delegated to the unlicensed assistive personnel (UAP)? a. Reviewing the hematocrit and hemoglobin results b. Teaching the client to avoid lifting her 4-year-old grandson c. Assessing the level of pain and any drainage d. Drawing a shallow hot bath for comfort measures

ANS: D The UAP is able to provide comfort through a bath. The registered nurse should review any laboratory results, complete any teaching, and assess pain and discharge.

1. Which action would the nurse teach to help the client prevent vulvovaginitis? a. Wipe back to front after urination. b. Cleanse the inner labial mucosa with soap and water. c. Use feminine hygiene sprays to avoid odor. d. Wear loose cotton underwear.

ANS: D To prevent vulvovaginitis, the client should wear cotton underwear. The client should wipe front to back after urination, not back to front. The client should cleanse the inner labial mucosa with water only, and avoid using feminine hygiene sprays.

7. A client has undergone a vaginal hysterectomy with a bilateral salpingo-oophorectomy. She is concerned about a loss of libido. What intervention by the nurse would be best? a. Suggest increasing vitamins and supplements daily. b. Discuss the value of a balanced diet and exercise. c. Reinforce that weight gain may be inevitable. d. Teach that estrogen cream inserted vaginally may help.

ANS: D Use of vaginal estrogen cream and gentle dilation can help with vaginal changes and loss of libido. Weight gain and masculinization are misperceptions after a vaginal hysterectomy. Vitamins, supplements, a balanced diet, and exercise are helpful for healthy living, but are not necessarily going to increase libido.

A client is experiencing an attack of acute pancreatitis. Which nursing intervention is the highest priority for this client? A. Measure intake and output every shift. B. Do not administer food or fluids by mouth. C. Administer opioid analgesic medication. D. Assist the client to assume a position of comfort.

Administer opioid analgesic medication. For the client with acute pancreatitis, pain relief is the highest priority. Although measuring intake and output, NPO status, and positioning for comfort are all important, they are not the highest priority.

The nurse finds a client vomiting coffee-ground emesis. On assessment, the client has blood pressure of 100/74 mm Hg, is acutely confused, and has a weak and thready pulse. Which intervention is the nurse's first priority? A. Administering a histamine2 (H2) antagonist B. Initiating enteral nutrition C. Administering intravenous (IV) fluids D. Administering antianxiety medication

Administering intravenous (IV) fluids Administering IV fluids is necessary to treat the hypovolemia caused by acute gastrointestinal (GI) bleeding. Administration of an H2 antagonist will not treat the basic problem, which is upper GI bleeding. Enteral nutrition will not be part of the treatment plan for acute GI bleeding. Administration of antianxiety medication will not treat the basic problem causing the client's change in mental status, which is hypovolemia.

When assessing a client for hepatic cancer, the nurse anticipates finding an elevation in which laboratory test result? A. Hemoglobin and hematocrit B. Leukocytes C. Alpha-fetoprotein D. Serum albumin

Alpha-fetoprotein Fetal hemoglobin (alpha-fetoprotein) is abnormal in adults; it is a tumor marker indicative of cancers. Although anemia may be present, elevated hemoglobin and hematocrit are not diagnostic of hepatic cancer. White blood cells (leukocytes) are not used to specifically diagnose cancers. Serum albumin levels may be low in liver cancer and in malnutrition.

A client with gastric cancer is scheduled to undergo surgery to remove the tumor once 5 pounds of body weight has been regained. The client is not drinking the vanilla-flavored enteral supplements that have been prescribed. Which is the highest priority nursing intervention for this client? A. Explain to the client the importance of drinking the enteral supplements prescribed. B. Ask the client's family to try to persuade the client to drink the supplements. C. Inform the client that a nasogastric tube may be necessary if he or she fails to comply. D. Ask the client if a change in flavor would make the supplement more palatable.

Ask the client if a change in flavor would make the supplement more palatable. Asking the client if a change in flavor would help shows that the nurse is attempting to determine why the client is not drinking the supplements. Many clients don't like certain supplement flavors. The nurse should not assume that the client does not understand the importance of drinking the supplements or that the client requires persuasion to drink the supplements. The problem may be entirely different. Telling the client that a nasogastric tube may be necessary could be construed as threatening the client.

The nurse asks a client with liver disease to raise the arms to shoulder level and dorsiflex the hands. A few moments later, the hand begins to flap upward and downward. How does the nurse correctly document this in the medical record? A. Positive Babinski's sign B. Hyperreflexia C. Kehr's sign D. Asterixis

Asterixis Liver flap or asterixis is related to increased serum ammonia levels—the dorsiflexed hands begin to flap upward and downward when outstretched for a few moments. Babinski's sign is positive when, as the sole of the foot is stroked, the great toe points up and the toes fan out. Hyperreflexia refers to deep tendon reflexes that are overactive. Kehr's sign is reflected by increased abdominal pain, exaggerated by deep breathing, and referred to the right shoulder.

A client is struggling with body image after breast cancer surgery. Which behavior indicates to the nurse that the client is maladaptive? A.) Avoiding eye contact with staff B.) Saying, "I feel like less of a woman" C.) Requesting a temporary prosthesis immediately D.) Saying, "This is the ugliest scar ever"

Avoiding eye contact with staff Avoiding eye contact may be an indication of decreased self-image. The client stating that she feels like less of a woman or that her scar is ugly illustrates an expected emotional state; by verbalizing her frustration, the client suggests a willingness to discuss and express feelings. Requesting a prosthesis can be a sign of healing and working through body image changes.

A client has developed gastroenteritis while traveling outside the country. What is the likely cause of the client's symptoms? A. Bacteria on the client's hands B. Ingestion of parasites in the water C. Insufficient vaccinations D. Overcooked food

B. A main cause of gastroenteritis when traveling outside the country is ingestion of water that is infested with parasites. Bacteria on the client's hands will not produce gastroenteritis unless food or water is contaminated with the bacteria. Insufficient vaccinations may cause other disease processes, but not gastroenteritis. Undercooked, not overcooked, food may produce gastroenteritis.

A client has vague symptoms that indicate an acute inflammatory bowel disorder. Which symptom is most indicative of Crohn's disease (CD)? A. Abdominal pain relieved by bending the knees B. Chronic diarrhea, abdominal pain, and fever C. Epigastric cramping D. Hypotension with vomiting

B. Chronic diarrhea, abdominal pain, and fever are symptoms more indicative of CD than of other acute inflammatory bowel disorders. Abdominal pain that is relieved by bending the knees is indicative of peritonitis or pancreatitis. Epigastric cramping is a symptom more indicative of appendicitis. Hypotension with vomiting is not characteristic of CD.

A client who developed viral gastroenteritis with vomiting and diarrhea is scheduled to be seen in the clinic the following day. What will the nurse teach the client to do in the meantime? A. "Avoid all solid foods to allow complete bowel rest." B. "Consume extra fluids to replace fluid losses." C. "Take an over-the-counter antidiarrheal medication." D. "Contact your provider for an antibiotic medication."

B. Clients should be taught to drink extra fluids to replace fluid lost through vomiting and diarrhea. It is not necessary to stop all solid food intake. Antidiarrheal medications are used if diarrhea is severe. Antibiotics are used if the infection is bacterial.

Which is a correct statement differentiating Crohn's disease (CD) from ulcerative colitis (UC)? A. Clients with CD experience about 20 loose, bloody stools daily. B. Clients with UC may experience hemorrhage. C. The peak incidence of UC is between 15 and 40 years of age. D. Very few complications are associated with CD.

B. Hemorrhage is commonly experienced by clients with UC. Five to six stools daily is common with CD. The peak incidences of UC are between 15 to 25 and 55 to 65 years of age. Fistulas commonly occur as a complication of CD.

A client admitted with severe gastroenteritis has been started on an IV, but the client continues having excessive diarrhea. Which medication does the nurse ask the health care provider about prescribing? A. Balsalazide (Colazal) B. Loperamide (Imodium) C. Mesalamine (Asacol) D. Milk of Magnesia (MOM)

B. If the health care provider determines that antiperistaltic agents are necessary, an initial dose of loperamide (Imodium) 4 mg can be administered orally, followed by 2 mg after each loose stool, up to 16 mg daily. Balsalazide is not the best choice for control of diarrhea in this scenario. Mesalamine is used for clients with ulcerative colitis for long-term therapy. MOM is a laxative.

A certified Wound, Ostomy, and Continence Nurse is teaching a client about caring for a new ileostomy. What information is most important to include? A. "After surgery, output from your ileostomy may be a loose, dark-green liquid with some blood present." B. "Call the health care provider if your stoma has a bluish or pale look." C. "Notify the health care provider if output from your stoma has a sweetish odor." D. "Remember that you must wear a pouch system at all times."

B. If the stoma has a bluish, pale, or dark look, its blood supply may be compromised and the health care provider must be notified immediately. It is true that output from the stoma after surgery may be a loose, greenish-colored liquid that may contain some blood, but this information is not the highest priority for instruction. It is normal for output from the stoma to have very little odor or a sweetish smell. Although it is true that the client will be required to wear a pouch system at all times, this is not the highest priority for instruction.

A client is admitted with severe viral gastroenteritis caused by norovirus. The client asks the nurse, "How did I get this disease?" Which answer by the nurse is correct? A. "You may have contracted it from an infected infant." B. "You may have consumed contaminated food or water." C. "You may have come into contact with an infected animal." D. "You may have had contact with the blood of an infected person."

B. Norovirus is the leading foodborne disease that causes gastroenteritis. It is transmitted via the fecal-oral route from person to person and from contaminated food and water. Vomiting causes the virus to become airborne. Campylobacter can be transmitted by contact with infected infants or animals. Escherichia coli may be spread via animals and contaminated food, water, or fomites. HIV may be spread via the blood, but not norovirus. Campylobacter and E. coli both cause bacterial gastroenteritis, while norovirus causes viral gastroenteritis.

A client with a recent surgically created ileostomy refuses to look at the stoma and asks the nurse to perform all required stoma care. What does the nurse do next? A. Asks the client whether family members could be trained in stoma care B. Has another client with a stoma who performs self-care talk with the client C. Requests that the health care provider request antidepressants and a psychiatric consult D. Suggests that the health care provider request a home health consultation so stoma care can be performed by a home health nurse

B. Talking with another client who successfully cares for his or her stoma may give the client the confidence to begin his or her self-care. If at all possible, the client should perform stoma care so that he or she can be as independent as possible. Although the client may need medication for depression, the priority is to encourage the client to look at, touch, and begin caring for the stoma. A home health nurse can be a support, but cannot provide all of the care that the client will need.

Which client does the charge nurse assign to an experienced LPN/LVN? A. A 28-year-old who requires teaching about how to catheterize a Kock ileostomy B. A 30-year-old who must receive neomycin sulfate (Mycifradin) before a colectomy C. A 34-year-old with ulcerative colitis (UC) who has a white blood cell count of 23,000/mm3 D. A 38-year-old with gastroenteritis who is receiving IV fluids at 250 mL/hr

B. The LPN/LVN should be familiar with the purpose, adverse effects, and client teaching required for neomycin. Teaching about how to catheterize a Kock ileostomy, assessing the client with UC with a high white blood cell count, and monitoring the client with gastroenteritis receiving IV fluids present complex problems that require assessment or intervention by an RN.

A nurse is teaching a client about dietary methods to help manage exacerbations ("flare-ups") of diverticulitis. What does the nurse advise the client? A. "Be sure to maintain an exclusively low-fiber diet to prevent pain on defecation." B. "Consume a low-fiber diet while your diverticulitis is active. When inflammation resolves, consume a high-fiber diet." C. "Maintain a high-fiber diet to prevent the development of hemorrhoids that frequently accompany this condition." D. "Make sure you consume a high-fiber diet while diverticulitis is active. When inflammation resolves, consume a low-fiber diet."

B. The most effective way to manage diverticulitis is with a low-fiber diet while inflammation is present, followed by a high-fiber diet once the inflammation has subsided. Neither an exclusively low-fiber diet or an exclusively high-fiber diet will effectively manage diverticulitis. A high-fiber diet while diverticulitis is active will only worsen the disease and its symptoms.

The RN receives a change-of-shift report about four clients. Which client does the nurse assess first? A. A 20-year-old with ulcerative colitis (UC) who had six liquid stools during the previous shift B. A 25-year-old who has just been admitted with possible appendicitis and has a temperature of 102° F C. A 56-year-old who had a colon resection earlier in the day and whose colostomy bag does not have any stool in it D. A 60-year-old admitted with acute gastroenteritis who is reporting severe cramping and nausea

B. This client with possible appendicitis may have developed a perforation and may be at risk for peritonitis. Rapid assessment and possible surgical intervention are needed. The client with UC who had six liquid stools, the client whose colostomy bag does not have any stool in it, and the client who was admitted with acute gastroenteritis all need assessment and intervention by an RN, but they are not at immediate risk for life-threatening complications. The client with possible appendicitis has a life-threatening emergency.

It is essential that the nurse monitor the client returning from hepatic artery embolization for hepatic cancer for which potential complication? A. Right shoulder pain B. Polyuria C. Bone marrow suppression D. Bleeding

Bleeding When monitoring a client post hepatic artery embolization, an arterial approach is taken; therefore, prompt detection of hemorrhage is the priority. Discomfort may be present, but the priority is to assess for hemorrhage. The nurse must assess for signs of shock, not polyuria. Embolization does not suppress the bone marrow; if chemotherapy or immune modulators are used, the nurse then assesses for bone marrow suppression.

The nurse is monitoring a client with gastric cancer for signs and symptoms of upper gastrointestinal bleeding. Which change in vital signs is most indicative of bleeding related to cancer? A. Respiratory rate from 24 to 20 breaths/min B. Apical pulse from 80 to 72 beats/min C. Temperature from 98.9° F to 97.9° F D. Blood pressure from 140/90 to 110/70 mm Hg

Blood pressure from 140/90 to 110/70 mm Hg A decrease in blood pressure is the most indicative sign of bleeding. A slight decrease in respiratory rate, apical pulse, and temperature is not the primary indication of bleeding.

A client has been newly diagnosed with ulcerative colitis (UC). What does the nurse teach the client about diet and lifestyle choices? A. "Drinking carbonated beverages will help with your abdominal distress." B. "It's OK to smoke cigarettes, but you should limit them to ½ pack per day." C. "Lactose-containing foods should be reduced or eliminated from your diet." D. "Raw vegetables and high-fiber foods may help to diminish your symptoms."

C. Lactose-containing foods are often poorly tolerated and should be reduced or eliminated from the diet of clients with UC. Carbonated beverages are GI stimulants that can cause discomfort and should be used rarely or completely eliminated from the diet. Cigarette smoking is a stimulant that can cause GI distress symptoms; nurses should never advise clients that any amount of cigarette smoking is "OK." Raw vegetables and high-fiber foods can cause GI symptoms in clients with UC.

A home health client has had severe diarrhea for the past 24 hours. Which nursing action does the RN delegate to the home health aide (unlicensed assistive personnel [UAP]) who assists the client with self-care? A. Instructing the client about the use of electrolyte-containing oral rehydration products B. Administering loperamide (Imodium) 4 mg from the client's medicine cabinet C. Checking and reporting the client's heart rate and blood pressure in lying, sitting, and standing positions D. Teaching the client how to clean the perineal area after each loose stool

C. Obtaining the client's blood pressure and heart rate is included in the education of home health aides and other UAP. Client teaching and medication administration are complex skills that should be performed by licensed nurses who have the education and scope of practice needed to safely implement these actions.

A client with ulcerative colitis is prescribed sulfasalazine (Azulfidine) and corticosteroid therapy. As the disease improves, what change does the nurse expect in the client's medication regimen? A. Corticosteroid therapy will be stopped. B. Sulfasalazine (Azulfidine) will be stopped. C. Corticosteroid therapy will be tapered. D. Sulfasalazine (Azulfidine) will be tapered.

C. Once clinical improvement has been established, corticosteroids are tapered over a 2- to 3-month period. Stopping corticosteroid therapy abruptly is unsafe—steroids must be gradually decreased in clients. Usually the amount that they have been taking dictates how quickly or slowly they can be stopped. Sulfasalazine therapy will be taken on a long-term basis. It may be increased or decreased, depending on the client's symptoms, but will likely never be stopped. These decisions are made over a long period of therapy.

When assessing a client with hepatitis B, the nurse anticipates which assessment findings? (Select all that apply.) A. Recent influenza infection B. Brown stool C. Tea-colored urine D. Right upper quadrant tenderness E. Itching

C. Tea-colored urine D. Right upper quadrant tenderness E. Itching The urine may be brown, tea-, or cola-colored in clients with hepatitis. Inflammation of the liver may cause right upper quadrant pain. Deposits of bilirubin on the skin, secondary to high bilirubin levels, and jaundice irritate the skin and cause itching. Hepatitis B virus, not the influenza virus, causes hepatitis B, which is spread by blood and body fluids. The stool in hepatitis may be tan or clay-colored.

An obese client is discharged 10 days after being hospitalized for peritonitis, which resulted in an exploratory laparotomy. Which assessment finding by the client's home health nurse requires immediate action? A. Pain when coughing B. States, "I am too tired to walk very much" C. States, "I feel like the incision is splitting open" D. Temperature of 100.8° F (38.2° C).

C. The client feeling like the incision is splitting open is at risk for poor wound healing and possible wound dehiscence; the nurse should immediately assess the wound and notify the health care provider. Reports of pain when coughing, being too tired to ambulate, and a temperature of 100.8° F (38.2° C) all require further assessment or intervention, but are not as great a concern as the possibility of wound dehiscence for this client.

A client returns to the unit after having an exploratory abdominal laparotomy. How does the nurse position this client after the client is situated in bed? A. High Fowler's B. Lateral Sims' (side-lying) C. Semi-Fowler's D. Supine

C. The client is maintained in semi-Fowler's position to facilitate the drainage of peritoneal contents into the lower region of the abdominal cavity after an abdominal laparotomy. This position also helps increase lung expansion. High-Fowler's position would be too high for the client postoperatively; it would place strain on the abdominal incision(s), and, if the client was still drowsy from anesthesia, this position would not enhance the client's ability to rest. Sims' position does not promote drainage to the lower abdomen. The supine position does not facilitate drainage to the abdomen or increased lung expansion; the client would be more likely to develop complications (wound drainage stasis and atelectasis) in this position.

Which client being cared for on the medical-surgical unit will be best to assign to a nurse who has floated from the intensive care unit (ICU)? A.) Recent radical mastectomy client requiring chemotherapy administration B.) Modified radical mastectomy client needing discharge teaching C.) Stage III breast cancer client requesting information about radiation and chemotherapy D.) Client with a Jackson-Pratt drain who just arrived from the postanesthesia care unit after a quadrantectomy

Client with a Jackson-Pratt drain who just arrived from the postanesthesia care unit after a quadrantectomy A nurse working in the ICU would be familiar with postoperative monitoring and care of clients with Jackson-Pratt drains. The recent radical mastectomy client requires chemotherapy, so it is more appropriate to assign her to nurses who are familiar with teaching, monitoring, and providing chemotherapy for clients with breast cancer. The modified radical mastectomy client who requires discharge teaching, and the stage III breast cancer client requiring information about radiation and chemotherapy are more appropriate to assign to nurses who are familiar with breast cancer.

The nursing team consists of an RN, an LPN/LVN, and a nursing assistant. Which client should be assigned to the RN? A. Client who is taking lactulose and has diarrhea B. Client with hepatitis C who requires a dressing change C. Client with end-stage cirrhosis who needs teaching about a low-sodium diet D. Obtunded client with alcoholic encephalopathy who needs a blood draw

Client with end-stage cirrhosis who needs teaching about a low-sodium diet The RN is responsible for client teaching; therefore, the client with end-stage cirrhosis should be assigned to the RN. Assisting a client with toileting and recording stool number and amount can be accomplished by nonprofessional staff. The LPN/LVN can provide dressing changes. Ancillary staff can perform venipuncture.

The RN has just received the change-of-shift report for the medical unit. Which client should the RN see first? A. Client with ascites who had a paracentesis 2 hours ago and is reporting a headache B. Client with portal-systemic encephalopathy (PSE) who has become increasingly difficult to arouse C. Client with hepatic cirrhosis and jaundice who has hemoglobin of 10.9 g/dL and thrombocytopenia D. Client with hepatitis A who has elevated alanine aminotransferase (ALT) and aspartate aminotransferase (AST)

Client with portal-systemic encephalopathy (PSE) who has become increasingly difficult to arouse A change in the level of consciousness (LOC) of the client with PSE is the greatest concern; actions to improve the client's LOC should be rapidly implemented. Although uncomfortable, a headache in the client with ascites is not likely related to liver disease and does not pose an immediate threat or complication. A hemoglobin of 10.9 g/dL and thrombocytopenia are expected findings in a client with cirrhosis and do not pose an immediate threat. Elevated ALT and AST levels are expected for the client with hepatitis A and do not indicate a risk for severe complications.

The nurse is caring for clients in the outpatient clinic. Which of these phone calls should the nurse return first? A. Client with hepatitis A reporting severe and ongoing itching B. Client with severe ascites who has a temperature of 101.4° F (38° C) C. Client with cirrhosis who has had a 3-pound weight gain over 2 days D. Client with esophageal varices and mild right upper quadrant pain

Client with severe ascites who has a temperature of 101.4° F (38° C) The client with ascites and an elevated temperature may have spontaneous bacterial peritonitis; the nurse should call this client first. Itching is anticipated with jaundice, this client may be called last. Weight gain with cirrhosis is not uncommon owing to low albumin levels. Cirrhosis may cause mild right upper quadrant pain; this client should be called after the client with severe ascites.

A client who was awaiting liver transplantation is excluded from the procedure after the presence of which condition is discovered? A. Colon cancer with metastasis to the liver B. Hypertension C. Hepatic encephalopathy D. Ascites and shortness of breath

Colon cancer with metastasis to the liver Transplantation is performed for hepatitis and primary (not secondary) liver cancers. Hypertension is a controllable factor and would not preclude the client from a liver transplant. Encephalopathy is a consequence of advanced liver disease, consistent with the condition of a client awaiting transplantation; it can be treated with lactulose and nonabsorbable antibiotics. Ascites and resulting shortness of breath are also consequences of advanced liver disease, consistent with the client awaiting transplantation; they can be managed with diuretics and paracentesis.

A client has been diagnosed with breast cancer. Which client-chosen treatment option requires the nurse to discuss with the client the necessity of considering additional therapy? A.) Chemotherapy B.) Complementary and alternative medicine (CAM) C.) Hormonal therapy D.) Neoadjuvant therapy

Complementary and alternative medicine (CAM) No proven benefit has been found with using CAM alone as a cure for breast cancer. The nurse must ensure that the client's choices can be safely integrated with conventional treatment for breast cancer. Chemotherapy is usually used for stage II or higher breast cancer and may or may not be used as a single treatment option. The purpose of hormonal therapy is to reduce the estrogen available to breast tumors to stop or prevent their growth; it may or may not be used with other treatment options. A large tumor is sometimes treated with chemotherapy, called neoadjuvant therapy, to shrink the tumor before it is surgically removed; an advantage of this therapy is that cancers can be removed by lumpectomy rather than mastectomy.

When providing dietary teaching to a client with hepatitis, what practice does the nurse recommend? A. Having a larger meal early in the morning B. Consuming increased carbohydrates and moderate protein C. Restricting fluids to 1500 mL/day D. Limiting alcoholic beverages to once weekly

Consuming increased carbohydrates and moderate protein To repair the liver, the client should have a high-carbohydrate and moderate-protein diet; fats may cause dyspepsia. The client with hepatitis feels full easily and should have four to six small meals daily. Fluids are restricted with ascites caused by cirrhosis; not all clients with hepatitis progress to cirrhosis. Complete abstention from alcohol is necessary until the liver enzymes return to normal.

An 80-year-old client with a 2-day history of myalgia, nausea, vomiting, and diarrhea is admitted to the medical-surgical unit with a diagnosis of gastroenteritis. Which health care provider request does the nurse implement first? A. Administer acetaminophen (Tylenol) 650 mg rectally. B. Draw blood for a complete blood count and serum electrolytes. C. Obtain a stool specimen for culture and sensitivity. D. Start an IV solution of 5% dextrose in 0.45 normal saline at 125 mL/hr.

D. Fluid therapy is the focus of treatment for clients with gastroenteritis. Older clients are at increased risk for the complications of dehydration such as hypovolemia and acute kidney failure. Acetaminophen 650 mg should be rapidly administered rectally, and blood draws and stool specimen collection should be implemented rapidly, but prevention and treatment of dehydration are the priorities for this client.

A client has an anal fissure. Which intervention most effectively promotes perineal comfort for the client? A. Administering a Fleet's enema when needed B. Applying heat to acute inflammation for pain relief C. Avoiding the use of bulk-forming agents D. Using hydrocortisone cream to relieve pain

D. Hydrocortisone cream may be effective in relieving the pain associated with anal fissures. Enemas should be avoided when an anal fissure is present. Cold packs should be applied to acute inflammation to diminish discomfort. Bulk-forming agents should be used to decrease pain associated with defecation.

A client who had surgery for inflammatory bowel disease is being discharged. The case manager will arrange for home health care follow-up. The client tells the nurse that family members will also be helping with care. What information is critically important for the nurse to provide to these collaborating members? A. A list of medical supply facilities where wound care supplies may be purchased B. Proper handwashing techniques to avoid cross-contamination of the client's wound C. The amount of pain medication that the client is allowed to take in each dose D. Written and oral instructions regarding symptoms to report to the health care provider

D. It is most important to provide the client and case manager with both written and oral instructions on reportable symptoms to avoid the development of complications. Although instruction on proper handwashing and the client's medication regimen are important, they are not the highest priority. It will be the home health nurse's responsibility to bring supplies to the client's home.

A client newly diagnosed with ulcerative colitis (UC) is started on sulfasalazine (Azulfidine). What does the nurse tell the client about why this therapy has been prescribed? A. "It is to stop the diarrhea and bloody stools." B. "This will minimize your GI discomfort." C. "With this medication, your cramping will be relieved." D. "Your intestinal inflammation will be reduced." Correct

D. Sulfasalazine (Azulfidine) is one of the primary treatments for UC. It is thought to inhibit prostaglandin synthesis and thereby reduce inflammation. Although it is hoped that reduction of inflammation will cause the diarrhea and bloody stools to stop, this is not the way that the drug works. Antidiarrheal drugs "stop" diarrhea. The drug's action as an anti-inflammatory will diminish the client's pain as the inflammation subsides, but this is not the purpose of the drug—it is not an analgesic.

An intensive care unit (ICU) RN is "floated" to the medical-surgical unit. Which client does the charge nurse assign to the float nurse? A. A 28-year-old with an exacerbation of Crohn's disease (CD) who has a draining enterocutaneous fistula B. A 32-year-old with ulcerative colitis (UC) who needs discharge teaching about the use of hydrocortisone enemas C. A 34-year-old who has questions about how to care for a newly created ileo-anal reservoir D. A 36-year-old with peritonitis who just returned from surgery with multiple drains in place

D. The ICU nurse is familiar with the care of a client with peritonitis, including monitoring for complications such as sepsis and kidney failure. The client with CD who has a draining enterocutaneous fistula, the client with UC who needs discharge teaching, and the client with questions about an ileo-anal reservoir are best assigned to a medical-surgical nurse who is more familiar with the care and teaching needed for clients with their respective disorders.

A client demonstrates the manifestations of diverticulitis with a suspected complication of peritonitis. What is the priority nursing intervention? A. Assessing the client for changes in vital signs B. Medicating the client for pain C. Monitoring for changes in the client's mentation D. Preparing the client for emergency surgery

D. The highest priority for this client is to prepare him or her for emergency surgery so that the source of the infection can be removed. It is expected that the client will experience changes in vital signs as a result of the infectious process and accompanying pain. Although monitoring the client's vital signs is important, the client has an immediate need to go to surgery. Medicating the client for pain and determining whether the client is experiencing changes in mentation are important, but are not the highest priority.

In caring for a client who has undergone paracentesis, which changes in the client's status should be promptly reported to the provider? A. Increased blood pressure, increased respiratory rate B. Decreased blood pressure, increased heart rate C. Increased respiratory rate, increased apical pulse, pallor D. Tachypnea, diaphoresis, increased blood pressure

Decreased blood pressure, increased heart rate Decreased blood pressure and increased heart rate are indicative of shock. Increased blood pressure, increased respiratory rate, increased apical pulse, pallor, tachypnea, and diaphoresis are all indicative of anxiety on the client's part.

The nurse suspects that a client may have acute pancreatitis as evidenced by which group of laboratory results? A. Deceased calcium, elevated amylase, decreased magnesium B. Elevated bilirubin, elevated alkaline phosphatase C. Elevated lipase, elevated white blood cell count, elevated glucose D. Decreased blood urea nitrogen (BUN), elevated calcium, elevated magnesium

Elevated lipase, elevated white blood cell count, elevated glucose Elevated lipase is more specific to a diagnosis of acute pancreatitis. Many pancreatic and nonpancreatic disorders can cause increased serum amylase levels. Bilirubin and alkaline phosphatase levels will be increased only if pancreatitis is accompanied by biliary dysfunction. Usually, calcium and magnesium will be increased and BUN increased, not decreased, in acute pancreatitis.

Which activity by the nurse will best relieve symptoms associated with ascites? A. Administering oxygen B. Elevating the head of the bed C. Monitoring serum albumin levels D. Administering intravenous fluids

Elevating the head of the bed The enlarged abdomen of ascites limits respiratory excursion; Fowler's position will increase excursion and reduce shortness of breath. The client may need oxygen, but first the nurse should raise the head of the bed to improve respiratory excursion and oxygenation. Monitoring will detect anticipated decreased serum albumin levels associated with cirrhosis and hepatic failure but does not relieve the symptoms of ascites. Administering IV fluids will contribute to fluid volume excess and fluid shifts into the peritoneal cavity, worsening ascites.

Which diagnostic results lead the nurse to suspect that a client may have gallbladder disease? A. Increased white blood cell (WBC) count, visualization of calcified gallstones, edema of the gallbladder wall B. Decreased WBC count, visualization of calcified gallstones, increased alkaline phosphatase C. Increased WBC count, visualization of noncalcified gallstones, edema of the gallbladder wall D. Decreased WBC count, visualization of noncalcified gallstones, increased alkaline phosphatase

Increased white blood cell (WBC) count, visualization of calcified gallstones, edema of the gallbladder wall An increased WBC count is evidence of inflammation. Only calcified gallstones will be visualized on abdominal x-ray. Ultrasonography of the right upper quadrant is the best diagnostic test for cholecystitis. Acute cholecystitis is seen as edema of the gallbladder wall and pericholecystic fluid. Alkaline phosphatase will be elevated if liver function is abnormal; this is not common in gallbladder disease.

The admission assessment for a client with acute gastric bleeding indicates blood pressure 82/40 mm Hg, pulse 124 beats/min, and respiratory rate 26 breaths/min. Which admission request does the nurse implement first? A. Type and crossmatch for 4 units of packed red blood cells. B. Infuse lactated Ringer's solution at 200 mL/hr. C. Give pantoprazole (Protonix) 40 mg IV now and then daily. D. Insert a nasogastric tube and connect to low intermittent suction.

Infuse lactated Ringer's solution at 200 mL/hr. The client's most immediate concern is the hypotension associated with volume loss. The most rapidly available volume expanders are crystalloids to treat hypovolemia. A type and crossmatch, administration of pantoprazole, and insertion of a nasogastric tube must all be done, but the nurse's immediate concern is correcting the client's hypovolemia.

A client is scheduled to undergo a liver transplantation. Which nursing intervention is most likely to prevent the complications of bile leakage and abscess formation? A. Preventing hypotension B. Keeping the T-tube in a dependent position C. Administering antibiotic vaccinations D. Administering immune-suppressant drugs

Keeping the T-tube in a dependent position Keeping the T-tube in a dependent position and secured to the client is likely to prevent bile leakage, abscess formation, and hepatic thrombosis. Preventing hypotension will help to prevent the complication of acute kidney injury. Administering antibiotic vaccinations will help to prevent infection. Administering immune-suppressant drugs will help to prevent graft rejection.

When caring for a client with hepatic encephalopathy, in which situation does the nurse question the use of neomycin (Mycifradin)? A. Kidney failure B. Refractory ascites C. Fetor hepaticus D. Paracentesis scheduled for today

Kidney failure The aminoglycoside drugs, which include neomycin, are nephrotoxic and ototoxic, and should not be taken by the client with hepatic encephalopathy. Cirrhosis and hepatic failure cause both ascites and encephalopathy; no contraindication for neomycin is known. Fetor hepaticus causes an ammonia smell to the breath when serum ammonia levels are elevated; neomycin is used to decrease serum ammonia levels. The client may be NPO for a few hours before paracentesis, but may take neomycin when the procedure is complete, or with less than 30 mL of water, depending on hospital policy.

A premenopausal client diagnosed with breast cancer will be receiving hormonal therapy. The nurse anticipates that the health care provider will request which medication for this client? A.) Anastrozole (Arimdex) B.) Fulvestrant (Faslodex) C.) Leuprolide (Lupron) D.) Trastuzumab (Herceptin)

Leuprolide (Lupron) Leuprolide is used in premenopausal women whose main estrogen source is the ovaries and who may benefit from luteinizing hormone-releasing hormone agonists that inhibit estrogen synthesis. Anastrozole is an aromatase inhibitor that is used in postmenopausal women whose main source of estrogen is not the ovaries, but rather body fat. Fulvestrant is a second-line hormonal therapy for postmenopausal women with advanced breast cancer. Trastuzumab is not a hormone and is used for targeted therapy for breast cancer.

A client who had been hospitalized with pancreatitis is being discharged with home health services. The client is severely weakened after this illness. Which nursing intervention is the highest priority in conserving the client's strength? A. Limiting the client's activities to one floor of the home B. Instructing the client to take an as-needed (PRN) sleeping medication at night C. Arranging for the client to have a nutritional consult to assess the client's diet D. Asking the health care provider for a request for PRN nasal oxygen

Limiting the client's activities to one floor of the home Limiting the client's activities to one floor of the home will prevent tiring the client with stair climbing. Taking a PRN sleeping medication may not necessarily increase the client's strength level or conserve strength; also, the client may not be experiencing difficulty sleeping. Arranging for a nutritional consult or placing the client on PRN nasal oxygen will not necessarily result in an increase in the client's strength level or conserve strength; no information suggests that the client has any history of breathing difficulties.

Which option for prevention and early detection of breast cancer is the option of choice for a client with a high genetic risk? A.) Breast self-examination (BSE) beginning at 20 years of age B.) Hormone replacement therapy (HRT) combining estrogen and progesterone C.) Magnetic resonance imaging (MRI) and mammography every year beginning at age 30 D.) Prophylactic mastectomy

Magnetic resonance imaging (MRI) and mammography every year beginning at age 30 The American Cancer Society recommends that high-risk women (>20% lifetime risk) have an MRI and mammogram every year beginning at age 30. BSE is an option for everyone, not just those at high genetic risk for breast cancer. Use of HRT containing both estrogen and progestin increases risk; risk diminishes after 5 years of discontinuation. With a prophylactic mastectomy, there is a small risk that breast cancer will develop in residual breast glandular tissue because no mastectomy reliably removes all mammary tissue.

Which statement about breast reconstruction surgery is correct? A.) Many women want breast reconstruction using their own tissue immediately after mastectomy. B.) Placement of saline- or gel-filled prostheses is not recommended because of the nature of the surgery. C.) Reconstruction of the nipple-areola complex is the first stage in the reconstruction of the breast. D.) The surgeon should offer the option of breast reconstruction surgery once healing has occurred after a mastectomy.

Many women want breast reconstruction using their own tissue immediately after mastectomy. Many women want autogenous reconstruction after mastectomy. Saline- or gel-filled prostheses are recommended as breast expanders in breast augmentation surgery, not for reconstructive surgery. Reconstruction of the nipple-areola complex is the last stage in breast reconstruction surgery. Breast reconstruction surgery should be discussed before mastectomy takes place.

What teaching does the home health nurse give the family of a client with hepatitis C to prevent the spread of the infection? A. The client must not consume alcohol. B. Avoid sharing the bathroom with the client. C. Members of the household must not share toothbrushes. D. Drink only bottled water and avoid ice.

Members of the household must not share toothbrushes. Toothbrushes, razors, towels, and items that may spread blood and body fluids should not be shared. The client should not consume alcohol, but abstention will not prevent spread of the virus. The client may share a bathroom if he or she is continent. To prevent hepatitis A when traveling to foreign countries, bottled water should be consumed and ice made from tap water should be avoided.

The nurse expects that which client will be discharged to the home environment first? A. Older obese adult who has had a laparoscopic cholecystectomy B. Middle-aged thin adult who has had a laparoscopic cholecystectomy C. Middle-aged thin adult with a heart murmur who has had a traditional cholecystectomy D. Older obese adult with chronic obstructive pulmonary disease (COPD) who has had a traditional cholecystectomy

Middle-aged thin adult who has had a laparoscopic cholecystectomy The combination of client age, a thin frame, and the type of procedure performed will determine that the middle-aged thin client who had a laparoscopic cholecystectomy will be discharged first. Although the older obese client who had a laparoscopic cholecystectomy will have a faster discharge time than one with a traditional cholecystectomy, the client's obesity and age probably will require a longer stay. A traditional cholecystectomy will always require a longer recovery time. The older obese client with a history of COPD will likely have a more lengthy recovery because of associated breathing problems.

Which client has the highest risk for breast cancer? A.) Older adult woman with high breast density B.) Nullipara older adult woman C.) Obese older adult male with gynecomastia D.) Middle-aged woman with high breast density

Older adult woman with high breast density People at high increased risk for breast cancer include women age 65 years and older with high breast density. Nullipara women are at low increased risk for breast cancer. Men are not at high increased risk for breast cancer, but obesity can cause gynecomastia. Being middle-aged does not indicate a high increased risk for breast cancer.

The nurse reviews a medication history for a client newly diagnosed with peptic ulcer disease (PUD) who has a history of using ibuprofen (Advil) frequently for chronic knee pain. The nurse anticipates that the health care provider will request which medication for this client? A. Bismuth subsalicylate (Pepto-Bismol) B. Magnesium hydroxide (Maalox) C. Metronidazole (Flagyl) D. Misoprostol (Cytotec)

Misoprostol (Cytotec) Misoprostol is a prostaglandin analogue that protects against nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers. Bismuth subsalicylate is an antidiarrheal drug that contains salicylates, which can cause bleeding and should be avoided in clients who have PUD. Magnesium hydroxide is an antacid that may be used to neutralize stomach secretions, but is not used specifically to help prevent NSAID-induced ulcers. Metronidazole is an antimicrobial agent used to treat Helicobacter pylori infection.

Which action can the same-day surgery charge nurse delegate to an experienced unlicensed assistive personnel (UAP) who is helping with the care of a client who is having a breast biopsy? A.) Assess anxiety level about the surgery. B.) Monitor vital signs after surgery. C.) Obtain data about breast cancer risk factors. D.) Teach about postoperative routine care.

Monitor vital signs after surgery. Vital sign assessment is included in UAP education and usually is part of the job description for UAP working in a hospital setting. Nursing assessment, obtaining data, and client teaching are not within the scope of practice for UAP and should be done by licensed nursing staff.

Which assessment finding indicates to the nurse that a client is at high risk for a malignant breast lesion? A.) A 1-cm freely mobile rubbery mass discovered by the client B.) Ill-defined painful rubbery lump in the outer breast quadrant C.) Backache and breast fungal infection D.) Nipple discharge and dimpling

Nipple discharge and dimpling Nipple discharge and dimpling are high-risk assessment findings for a malignant breast lesion. On clinical examination, fibroadenomas are oval, freely mobile, rubbery masses usually discovered by the woman herself; their size varies from smaller than 1 cm in diameter to as large as 15 cm in diameter. Although the immediate fear is breast cancer, the risk of its occurring within a fibroadenoma is very small. Breast pain and tender lumps or areas of thickening in the breasts are typical symptoms of a fibrocystic breast condition; the lumps are rubbery, ill-defined, and commonly found in the upper outer quadrant of the breast. Many large-breasted women develop fungal infection under the breasts, especially in hot weather, because it is difficult to keep this area dry and exposed to air. Backaches from the added weight are also common.

The nurse suspects that which client is at highest risk for developing gallstones? A. Obese male with a history of chronic obstructive pulmonary disease B. Obese female on hormone replacement therapy C. Thin male with a history of coronary artery bypass grafting D. Thin female who has recently given birth

Obese female on hormone replacement therapy Both obesity and altered hormone levels increase a woman's risk for developing gallstones. Men are at lower risk than women for developing gallstones. Although pregnancy increases the risk for a woman to develop gallstones, this woman's thin frame lessens that risk.

A client with a history of esophageal varices has just been admitted to the emergency department after vomiting a large quantity of blood. Which action does the nurse take first? A. Obtain the charts from the previous admission. B. Listen for bowel sounds in all quadrants. C. Obtain pulse and blood pressure. D. Ask about abdominal pain.

Obtain pulse and blood pressure. The nurse should assess vital signs to detect hypovolemic shock caused by hemorrhage. Obtaining charts, assessing bowel sounds, and pain assessment can be delayed until the client has stabilized. Assessment for adequate perfusion is the highest priority at this time.

A client with acute cholecystitis is admitted to the medical-surgical unit. Which nursing activity associated with the client's care will be best for the nurse to delegate to unlicensed assistive personnel (UAP)? A. Assessing dietary risk factors for cholecystitis B. Checking for bowel sounds and distention C. Determining precipitating factors for abdominal pain D. Obtaining the admission weight, height, and vital signs

Obtaining the admission weight, height, and vital signs Obtaining height, weight, and vital signs is included in the education for UAP and usually is included in the job description for these staff members. Assessment, checking bowel sounds, and determining precipitating factors for abdominal pain require broader education and are within the scope of practice of licensed nursing staff.

The nurse is caring for an older adult male client who reports stomach pain and heartburn. Which symptom is most significant in determining whether the client's ulceration is gastric or duodenal in origin? A. Pain occurs 1½ to 3 hours after a meal, usually at night. B. Pain is worsened by the ingestion of food. C. The client has a malnourished appearance. D. The client is a man older than 50 years.

Pain occurs 1½ to 3 hours after a meal, usually at night. A key symptom of duodenal ulcers is that pain usually awakens the client between 1:00 a.m. and 2:00 a.m., occurring 1½ to 3 hours after a meal. Pain that is worsened with ingestion of food and a malnourished appearance are key features of gastric ulcers. A male over 50 years is a finding that could apply to either type of ulcer.

The RN is caring for a client with end-stage liver disease that has resulted in ascites. Which action does the RN delegate to unlicensed assistive personnel (UAP)? A. Assessing skin integrity and abdominal distention B. Drawing blood from a central venous line for electrolyte studies C. Evaluating laboratory study results for the presence of hypokalemia D. Placing the client in a semi-Fowler's position

Placing the client in a semi-Fowler's position Positioning the client in a semi-Fowler's position is included within UAP education and scope of practice, although the RN will need to supervise the UAP in providing care and will evaluate the effect of the semi-Fowler's position on client comfort and breathing. Assessment of skin integrity and abdominal distention, obtaining blood from a central line, and evaluation of laboratory results should be done by the RN.

Which problem for a client with cirrhosis takes priority? A. Insufficient knowledge related to the prognosis of the disease process B. Discomfort related to the progression of the disease process C. Potential for injury related to hemorrhage D. Inadequate nutrition related to an inability to tolerate usual dietary intake

Potential for injury related to hemorrhage Potential for injury related to hemorrhage is the priority client problem because this complication could be life-threatening. Insufficient knowledge, discomfort, and inadequate nutrition are not priorities because these issues are not immediately life-threatening.

Which set of assessment findings indicates to the nurse that a client may have acute pancreatitis? A. Absence of jaundice, pain of gradual onset B. Absence of jaundice, pain in right abdominal quadrant C. Presence of jaundice, pain worsening when sitting up D. Presence of jaundice, pain worsening when lying supine

Presence of jaundice, pain worsening when lying supine Pain that worsens when lying supine and the presence of jaundice are the only assessment findings indicative of acute pancreatitis. Pain associated with acute pancreatitis usually has an abrupt onset, is located in the mid-epigastric or upper left quadrant, and lessens with sitting up; also, jaundice is present.

The nurse administers lactulose (Evalose) to a client with cirrhosis for which purpose? A. Provides enzymes necessary to digest dairy products B. Reduces portal pressure C. Promotes gastrointestinal (GI) excretion of ammonia D. Decreases GI bleeding

Promotes gastrointestinal (GI) excretion of ammonia Lactulose reduces serum ammonia levels by excreting ammonia through the GI tract. Lactase is the enzyme that digests dairy products. The mechanism of action of lactulose is not to reduce portal pressure. Lactulose does not affect bleeding.

A client has been placed on enzyme replacement for treatment of chronic pancreatitis. In teaching the client about this therapy, the nurse advises the client not to mix enzyme preparations with foods containing which element? A. Carbohydrates B. High fat C. High fiber D. Protein

Protein Enzyme preparations should not be mixed with foods containing protein because the enzymes will dissolve the food into a watery substance. No evidence suggests that enzyme preparations should not be mixed with carbohydrates, food with high fat content, and food with high fiber content.

A client is scheduled to be discharged after a gastrectomy. The client's spouse expresses concern that the client will be unable to change the surgical dressing adequately. What is the nurse's highest priority intervention? A. Providing both oral and written instructions on changing the dressing and on symptoms of infection that must be reported to the provider B. Asking the provider for a referral for home health services to assist with dressing changes C. Asking the spouse whether other family members could be taught how to change the dressing D. Trying to determine specific concerns that the spouse has regarding dressing changes

Providing both oral and written instructions on changing the dressing and on symptoms of infection that must be reported to the provider Providing the client and spouse with both oral and written instructions on symptoms to report to the provider, as well as on how to perform the dressing change, will reinforce important points and boost the spouse's confidence. Obtaining a referral and recruiting other family members prevent the client and spouse from taking responsibility for the client's care. The spouse's concerns have already been clearly expressed.

A client who recently had a mastectomy requests a volunteer to visit her home to help with recovery. Which community resource does the nurse recommend? A.) National Breast Cancer Coalition B.) Reach to Recovery C.) Susan G. Komen for the Cure D.) Young Survival Coalition

Reach to Recovery The American Cancer Society's program Reach to Recovery provides volunteers who visit clients in the hospital or at home. They bring personal messages of hope; informational materials on breast cancer recovery; and a soft, temporary breast form. The National Breast Cancer Coalition is an organization dedicated to ending breast cancer through action and advocacy. Susan G. Komen for the Cure is an organization that supports breast cancer research. The Young Survival Coalition is an organization dedicated to educating the medical, research, breast cancer, and legislative communities about breast cancer, as well as serving as a point of contact for young women living with breast cancer. None of these other community resources provide volunteers to visit the home.

Which nursing action is best for the charge nurse to delegate to an experienced LPN/LVN? A. Retape the nasogastric tube for a client who has had a subtotal gastrectomy and vagotomy. B. Reinforce the teaching about avoiding alcohol and caffeine for a client with chronic gastritis. C. Document instructions for a client with chronic gastritis about how to use "triple therapy." D. Assess the gag reflex for a client who has arrived from the postanesthesia care unit after a laparoscopic gastrectomy.

Reinforce the teaching about avoiding alcohol and caffeine for a client with chronic gastritis. Reinforcement of teaching done by the RN is within the scope of practice for an LPN/LVN. Retaping the nasogastric tube for a client who has had a subtotal gastrectomy and vagotomy is a complex task that should be done by the RN. Assessment and documenting instructions about how to use triple therapy are nursing functions that should be done by the RN.

A client who has just been discharged from the hospital after a modified radical mastectomy is referred to a home health agency. Which nursing action is most appropriate to delegate to an experienced home health aide? A.) Assessing the safety of the home environment B.) Developing a plan to decrease lymphedema risk C.) Monitoring pain level and analgesic effectiveness D.) Reinforcing the guidelines for hand and arm care

Reinforcing the guidelines for hand and arm care Reinforcement of previously taught information about hand and arm care should be done by all caregivers. Assessment, developing a care plan, and monitoring pain level and analgesic effectiveness are not within the scope of practice of a home health aide and should be done by licensed nursing staff.

A health care worker believes that he may have been exposed to hepatitis A. Which intervention is the highest priority to prevent him from developing the disease? A. Requesting vaccination for hepatitis A B. Using a needleless system in daily work C. Getting the three-part hepatitis B vaccine D. Requesting an injection of immunoglobulin

Requesting an injection of immunoglobulin The administration of immunoglobulin, antibodies to hepatitis A, may prevent development of the disease. The vaccine for hepatitis A will take several weeks to stimulate the development of antibodies; passive immunity in the form of immunoglobulin is needed. Implementing a needleless system and getting the three-part vaccine may prevent the development of hepatitis B, not hepatitis A.

How does the home care nurse best modify the client's home environment to manage side effects of lactulose (Evalose)? A. Provides small frequent meals for the client B. Suggests taking daily potassium supplements C. Elevates the head of the bed in high-Fowler's position D. Requests a bedside commode for the client

Requests a bedside commode for the client Lactulose therapy increases the frequency of stools, so a bedside commode should be made available to the client, especially if he or she has difficulty reaching the toilet. Small frequent meals and elevating the head of the bed will not have any effect on the side effects of lactulose. Although lactulose produces excessive stools and could potentially result in loss of potassium, it is inappropriate for the nurse to suggest that the client take potassium supplements.

A client has been discharged home after surgery for gastric cancer, and a case manager will follow up with the client. To ensure a smooth transition from the hospital to the home setting, which information provided by the hospital nurse to the case manager is given the highest priority? A. Schedule of the client's follow-up examinations and x-ray assessments B. Information on family members' progress in learning how to perform dressing changes C. Copy of the diet plan prepared for the client by the hospital dietitian D. Detailed account of what occurred during the client's surgical procedure

Schedule of the client's follow-up examinations and x-ray assessments Because recurrence of gastric cancer is common, it will be a priority for the client to have follow-up examinations and x-rays, so that a recurrence can be detected quickly. It may take family members a long time to become proficient at tasks such as dressing changes. Although the case manager should be aware of the diet, family members will likely be preparing the client's daily diet, and they should be provided with this information. It is not necessary for the case manager to have details of the client's surgical procedure unless a significant event has occurred during the procedure.

The nurse is attempting to position a client having an acute attack of pancreatitis in the most comfortable position possible. In which position does the nurse place this client? A. Supine, with a pillow supporting the abdomen B. Up in a chair between frequent periods of ambulation C. High-Fowler's position, with pillows used as needed D. Side-lying position, with knees drawn up to the chest

Side-lying position, with knees drawn up to the chest The side-lying position with the knees drawn up has been found to relieve abdominal discomfort related to acute pancreatitis. No evidence suggests that supine position, sitting up in a chair, or high-Fowler's position have any effect on abdominal discomfort related to acute pancreatitis.

A client is experiencing bleeding related to peptic ulcer disease (PUD). Which nursing intervention is the highest priority? A. Starting a large-bore IV B. Administering IV pain medication C. Preparing equipment for intubation D. Monitoring the client's anxiety level

Starting a large-bore IV A large-bore IV should be placed as requested, so that blood products can be administered. IV pain medication is not a recommended treatment for gastrointestinal bleeding. Intubation is not a recommended treatment for bleeding related to PUD. The mental status of the client should be monitored, but it is not necessary to monitor the anxiety level of the client.

A client who has undergone breast surgery is struggling with issues concerning her sexuality. What is the best way for the nurse to address the client's concerns? A.) Allow the client to bring up the topic first. B.) Remind the client to avoid sexual intercourse for 2 months after the surgery. C.) Suggest that the client wear a bra or camisole during intercourse. D.) Teach the client that birth control is a priority.

Suggest that the client wear a bra or camisole during intercourse. Clients may prefer to lay a pillow over the surgical site or wear a bra or camisole to prevent contact with the surgical site during intercourse. The client may be embarrassed to discuss the topic of sexuality, so the nurse must be sensitive to possible concerns and approach the subject first. Sexual intercourse can be resumed after surgery whenever the client is comfortable. Sexually active clients receiving chemotherapy or radiotherapy must use birth control because of the therapy's teratogenic effects, but this is not necessary for clients who have had surgery only.

Which statement about the early detection of breast masses is correct? A.) Clinical breast examinations should be done yearly starting at age 20. B.) Detection of breast cancer before or after axillary node invasion yields the same survival rate. C.) Mammography as a baseline screening is recommended by the American Cancer Society at 30 years of age. D.) The goal of screening for breast cancer is early detection.

The goal of screening for breast cancer is early detection. The purpose of screening is early detection of cancer before it spreads. It is recommended that the clinical breast examination be part of a periodic health assessment at least every 3 years for women in their 20s and 30s, and every year for asymptomatic women who are at least 40 years of age. Detection of breast cancer before axillary node invasion increases the chance of survival. The American Cancer Society recommends screening with mammography annually beginning at age 40.

Which client assessment information is correlated with a diagnosis of chronic gastritis? A. Anorexia, nausea, and vomiting B. Frequent use of corticosteroids C. Hematemesis and anorexia D. Treatment with radiation therapy

Treatment with radiation therapy Treatment with radiation therapy is known to be associated with the development of chronic gastritis. Anorexia, nausea, and vomiting are all symptoms of acute gastritis. Corticosteroid use and hematemesis are also more likely to be signs of acute gastritis.

The nurse is teaching a client with gallbladder disease about diet modification. Which meal does the nurse suggest to the client? A. Steak and French fries B. Fried chicken and mashed potatoes C. Turkey sandwich on wheat bread D. Sausage and scrambled eggs

Turkey sandwich on wheat bread Turkey is an appropriate low-fat selection for this client. Steak, French fries, fried chicken, and sausage are too fatty, and eggs are too high in cholesterol for a client with gallbladder disease.

The nurse is preparing to instruct a client with chronic pancreatitis who is to begin taking pancrelipase (Cotazym). Which instruction does the nurse include when teaching the client about this medication? A. Administer pancrelipase before taking an antacid. B. Chew tablets before swallowing. C. Take pancrelipase before meals. D. Wipe your lips after taking pancrelipase.

Wipe your lips after taking pancrelipase. Pancrelipase is a pancreatic enzyme used for enzyme replacement for clients with chronic pancreatitis. To avoid skin irritation and breakdown from residual enzymes, the lips should be wiped. Pancrelipase should be administered after antacids or histamine2 blockers are taken. It should not be chewed to minimize oral irritation and allow the drug to be released more slowly. It should be taken with meals and snacks and followed with a glass of water.

After receiving change-of-shift report on these clients, which client does the nurse plan to assess first? A. Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min B. Adult client admitted with cholecystitis who is experiencing severe right upper quadrant abdominal pain C. Middle-aged client who has an elevated temperature after undergoing endoscopic retrograde cholangiopancreatography D. Older adult client who is receiving total parenteral nutrition after a Whipple procedure and has a glucose level of 235 mg/dL

Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min Acute respiratory distress syndrome is a possible complication of acute pancreatitis. The dyspneic client is at greatest risk for rapid deterioration and requires immediate assessment and intervention. The client with cholecystitis and the client with an elevated temperature will require further assessment and intervention, but these are not medical emergencies requiring the nurse's immediate attention. The older adult client's glucose level will require intervention but, again, is not a medical emergency.

The nurse working during the day shift on the medical unit has just received report. Which client does the nurse plan to assess first? A. Young adult with epigastric pain, hiccups, and abdominal distention after having a total gastrectomy B. Adult who had a subtotal gastrectomy and is experiencing dizziness and diaphoresis after each meal C. Middle-aged client with gastric cancer who needs to receive omeprazole (Prilosec) before breakfast D. Older adult with advanced gastric cancer who is scheduled to receive combination chemotherapy

Young adult with epigastric pain, hiccups, and abdominal distention after having a total gastrectomy The client with epigastric pain is experiencing symptoms of acute gastric dilation, which can disrupt the suture line. The surgeon should be notified immediately because the nasogastric tube may need irrigation or re-positioning. The client who had a subtotal gastrectomy is not in a life-threatening situation and does not require immediate assessment. The client with gastric cancer and the older adult with advanced gastric cancer are in stable condition and do not require immediate assessment.

12. What is an early sign/symptom of macular degeneration? a. Mild blurring b. Decreased tear production c. Loss of central vision d. Difficulty with activities of daily living

a

13. A 46-year-old patient calls the clinic and reports sudden "floating dark spots" in her vision. What should the nurse say to the patient? a. Advise the patient to immediately call her ophtalmologist. b. Advise the patient that this is normal for her age. c. Ask the patient if the spots were accompanied by pain. d. Tell the patient to mention this during her annual eye appointment.

a

21. What is the pathophysiology that underlies the development of glaucoma? a. Pressure on retinal vessels decreases blood flow so photoreceptors and nerve fibers become hypoxic. b. Decreased muscle tone reduces ability to keep the gaze focused on a single object. c. Cornea flattens and the surface becomes irregular with worsening of astigmatism and blurred vision. d. The lens hardens, shrinks, and loses elasticity and cataracts begin to form.

a

25. Which intervention would be best to use for a patient with presbyopia? a. Encouragement to get a prescription for reading glasses b. Administration of the prescribed eye medications c. Reminder to wear sunglasses to protective against UV light d. Follow-up appointments to detect acute glaucoma

a

25. Which patient is most likely to have the lowest threshold for hearing tones and speech? a. 25-year-old patient with no previous hearing problems b. 76-year-old patient with significant hearing loss c. 43-year-old patient with no known health problems

a

29. Tympanometry is helpful in distinguishing which disorder? a. Middle ear infections b. External ear infections c. Hearing loss for low-pitched tones d. Indurated lesions on the pinna

a

An emergency department nurse triages a client with diabetes mellitus who has fractured her arm. Which action should the nurse take first? a. Remove the medical alert bracelet from the fractured arm. b. Immobilize the arm by splinting the fractured site. c. Place the client in a supine position with a warm blanket. d. Cover any open areas with a sterile dressing.

a (A clients medical alert bracelet should be removed from the fractured arm before the affected extremity swells. Immobilization, positioning, and dressing should occur after the bracelet is removed.)

A home health nurse assesses a client with diabetes who has a new cast on the arm. The nurse notes the clients fingers are pale, cool, and slightly swollen. Which action should the nurse take first? a. Raise the arm above the level of the heart. b. Encourage range of motion. c. Apply heat to the affected hand. d. Bivalve the cast to decrease pressure.

a (Arm casts can impair circulation when the arm is in the dependent position. The nurse should immediately elevate the arm above the level of the heart, ensuring that the hand is above the elbow, and should re-assess the extremity in 15 minutes. If the fingers are warmer and less swollen, the cast is not too tight and adjustments do not need to be made, but a sling should be worn when the client is upright. Encouraging range of motion would not assist the client as much as elevating the arm. Heat would cause increased edema and should not be used. If the cast is confirmed to be too tight, it could be bivalved.)

A nurse reviews prescriptions for an 82-year-old client with a fractured left hip. Which prescription should alert the nurse to contact the provider and express concerns for client safety? a. Meperidine (Demerol) 50 mg IV every 4 hours b. Patient-controlled analgesia (PCA) with morphine sulfate c. Percocet 2 tablets orally every 6 hours PRN for pain d. Ibuprofen elixir every 8 hours for first 2 days

a (Meperidine (Demerol) should not be used for older adults because it has toxic metabolites that can cause seizures. The nurse should question this prescription. The other prescriptions are appropriate for this clients pain management.)

A nurse cares for a client placed in skeletal traction. The client asks, What is the primary purpose of this type of traction? How should the nurse respond? a. Skeletal traction will assist in realigning your fractured bone. b. This treatment will prevent future complications and back pain. c. Traction decreases muscle spasms that occur with a fracture. d. This type of traction minimizes damage as a result of fracture treatment.

a (Skeletal traction pins or screws are surgically inserted into the bone to aid in bone alignment. As a last resort, traction can be used to relieve pain, decrease muscle spasm, and prevent or correct deformity and tissue damage. These are not primary purposes of skeletal traction.)

A nurse assesses an older adult client who was admitted 2 days ago with a fractured hip. The nurse notes that the client is confused and restless. The clients vital signs are heart rate 98 beats/min, respiratory rate 32 breaths/min, blood pressure 132/78 mm Hg, and SpO2 88%. Which action should the nurse take first? a. Administer oxygen via nasal cannula. b. Re-position to a high-Fowlers position. c. Increase the intravenous flow rate. d. Assess response to pain medications.

a (The client is at high risk for a fat embolism and has some of the clinical manifestations of altered mental status and dyspnea. Although this is a life-threatening emergency, the nurse should take the time to administer oxygen first and then notify the health care provider. Oxygen administration can reduce the risk for cerebral damage from hypoxia.)

An emergency department nurse cares for a client who sustained a crush injury to the right lower leg. The client reports numbness and tingling in the affected leg. Which action should the nurse take first? a. Assess the pedal pulses. b. Apply oxygen by nasal cannula. c. Increase the IV flow rate. d. Loosen the traction.

a (These symptoms represent early warning signs of acute compartment syndrome. In acute compartment syndrome, sensory deficits such as paresthesias precede changes in vascular or motor signs. If the nurse finds a decrease in pedal pulses, the health care provider should be notified as soon as possible.)

After teaching a client who is recovering from a vertebroplasty, the nurse assesses the clients understanding. Which statement by the client indicates a need for additional teaching? a. I can drive myself home after the procedure. b. I will monitor the puncture site for signs of infection. c. I can start walking tomorrow and increase my activity slowly. d. I will remove the dressing the day after discharge.

a (avoid driving or operating machinery for the first 24 hours. The client should monitor the puncture site for signs of infection. Usual activities can resume slowly, including walking and slowly increasing activity over the next few days. The client should keep the dressing dry and remove it the next day.)

A nurse notes crepitation when performing range-of-motion exercises on a client with a fractured left humerus. Which action should the nurse take next? a. Immobilize the left arm. b. Assess the clients distal pulse. c. Monitor for signs of infection. d. Administer prescribed steroids.

a (key word is crepitation - rubbing of bones. . . need to stop it by immobilizing)

A nurse cares for a client with a fracture injury. Twenty minutes after an opioid pain medication is administered, the client reports pain in the site of the fracture. Which actions should the nurse take? (Select all that apply.) a. Administer additional opioids as prescribed. b. Elevate the extremity on pillows. c. Apply ice to the fracture site. d. Place a heating pad at the site of the injury. e. Keep the extremity in a dependent position.

a, b, c (The client with a new fracture likely has edema; elevating the extremity and applying ice probably will help in decreasing pain. Administration of an additional opioid within the dosage guidelines may be ordered. Heat will increase edema and may increase pain. Dependent positioning will also increase edema. **this was on the test)

A nurse plans care for a client who is recovering from open reduction and internal fixation (ORIF) surgery for a right hip fracture. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Elevate heels off the bed with a pillow. b. Ambulate the client on the first postoperative day. c. Push the clients patient-controlled analgesia button. d. Re-position the client every 2 hours. e. Use pillows to encourage subluxation of the hip.

a, b, d (Postoperative care for a client who has ORIF of the hip includes elevating the clients heels off the bed and re-positioning every 2 hours to prevent pressure and skin breakdown. It also includes ambulating the client on the first postoperative day, and using pillows or an abduction pillow to prevent subluxation of the hip)

A nurse teaches a client with a fractured tibia about external fixation. Which advantages of external fixation for the immobilization of fractures should the nurse share with the client? (Select all that apply.) a. It leads to minimal blood loss. b. It allows for early ambulation. c. It decreases the risk of infection. d. It increases blood supply to tissues. e. It promotes healing.

a, b, e (External fixation is a system in which pins or wires are inserted through the skin and bone and then connected to a ridged external frame. With external fixation, blood loss is less than with internal fixation, but the risk for infection is much higher. The device allows early ambulation and exercise, maintains alignment, stabilizes the fracture site, and promotes healing. The device does not increase blood supply to the tissues. The nurse should assess for distal circulation, movement, and sensation, which can be disturbed by fracture injuries and treatments.)

A nurse teaches a client who is at risk for carpal tunnel syndrome. Which health promotion activities should the nurse include in this clients teaching? (Select all that apply.) a. Frequently assess the ergonomics of the equipment being used. b. Take breaks to stretch fingers and wrists during working hours. c. Do not participate in activities that require repetitive actions. d. Take ibuprofen (Motrin) to decrease pain and swelling in wrists. e. Adjust chair height to allow for good posture.

a, b, e (Health promotion activities to prevent carpal tunnel syndrome include assessing the ergonomics of the equipment being used, taking breaks to stretch fingers and wrists during working hours, and adjusting chair height to allow for good posture. The client should be allowed to participate in activities that require repetitive actions as long as precautions are taken to promote health. Pain medications are not part of health promotion activities.)

A nurse assesses a client with a cast for potential compartment syndrome. Which clinical manifestations are correctly paired with the physiologic changes of compartment syndrome? (Select all that apply.) a. Edema Increased capillary permeability b. Pallor Increased blood flow to the area c. Unequal pulses Increased production of lactic acid d. Cyanosis Anaerobic metabolism e. Tingling A release of histamine

a, c, d (Clinical manifestations of compartment syndrome are caused by several physiologic changes. Edema is caused by increased capillary permeability, release of histamine, decreased tissue perfusion, and vasodilation. Unequal pulses are caused by an increased production of lactic acid. Cyanosis is caused by anaerobic metabolism. Pallor is caused by decreased oxygen to tissues, and tingling is caused by increased tissue pressure.)

15. Which signs and symptoms should a patient who has had cataract surgery report to the health care provider? (Select all that apply.) a. Sharp, sudden pain in the eye b. Decreased vision c. Mild eye itching d. Green or yellow thick discharge e. Flashes of light

a,b,d,e

59. How should the nurse respond to a patient who has auditory sensory perception problems? (Select all that apply.) a. Reduce the background sound when speaking to the person. b. Speak slowly, distinctly, and with a deeper tone. c. Initiate fall precautions. d. Determine if the patient uses sign language. e. Face the patient while speaking.

a,b,d,e

30. What might the nurse notice if the patient is experiencing reduced sensory perception? (Select all that apply.) a. Patient squints or tilts the head when viewing objects or print at a distance. b. Patient closes one eye to read or see at a distance. c. Patient startles easily when a sudden move is made at the face. d. Pupils are equal and react to light. e. Patient does not make eye contact and turns head toward sounds rather than sights.

a,b,e

14. Which are correct procedures for instilling ophthalmic drops in a patient's eyes? (Select all that apply.) a. Check the name, strength, and expiration date of the solution. b. Have the patient tilt the head backward and look down. c. Release drops into the conjunctival pocket. d. Avoid contaminating the tip of the bottle. e. After instilling the drop, instruct to squeeze eyelids tightly.

a,c,d

23. Which conditions or diseases can adversely affect a patient's eyes and vision? (Select all that apply.) a. Pregnancy b. Inflammatory bowel disease c. Diabetes d. Hypertension e. Osteoarthritis

a,c,d

18. Which assessment findings of the eye are normal? (Select all that apply.) a. Presbyopia in a 45-year-old woman b. Ptosis of the eyelids c. Yellow sclera with small pigmented dots in a dark-skinned person d. Pupil constriction in response to accomaodation e. Pupil constriction within 2 seconds in response to light f. Nystagmus in the far lateral gaze

a,c,d,f

A nurse cares for a client with burn injuries. Which intervention should the nurse implement to appropriately reduce the clients pain? a. Administer the prescribed intravenous morphine sulfate. b. Apply ice to skin around the burn wound for 20 minutes. c. Administer prescribed intramuscular ketorolac (Toradol). d. Decrease tactile stimulation near the burn injuries.

a. Administer the prescribed intravenous morphine sulfate. Drug therapy for pain management requires opioid and nonopioid analgesics. The IV route is used because of problems with absorption from the muscle and the stomach. For the client to avoid shivering, the room must be kept warm, and ice should not be used. Ice would decrease blood flow to the area. Tactile stimulation can be used for pain management.

A 34-year-old client comes to the clinic with concerns about an enlarged left testicle and heaviness in his lower abdomen. Which diagnostic test would the nurse expect to be ordered to confirm testicular cancer? a. Alpha-fetoprotein (AFP) b. Prostate-specific antigen (PSA) c. Prostate acid phosphatase (PAP) d. C-reactive protein (CRP)

a. Alpha-fetoprotein (AFP)

An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough. Which action should the nurse take first? a. Apply oxygen and continuous pulse oximetry. b. Provide small quantities of ice chips and sips of water. c. Request a prescription for an antitussive medication. d. Ask the respiratory therapist to provide humidified air.

a. Apply oxygen and continuous pulse oximetry. Brassy cough and wheezing are some of the signs seen with inhalation injury. The first action by the nurse is to give the client oxygen. Clients with possible inhalation injury also need continuous pulse oximetry. Ice chips and humidified room air will not help the problem, and antitussives are not warranted.

The nurse is conducting a history on a male client to determine the severity of symptoms associated with prostate enlargement. Which finding is cause for prompt action by the nurse? a. Cloudy urine b. Urinary hesitancy c. Post-void dribbling d. Weak urinary stream

a. Cloudy urine

A nurse administers topical gentamicin sulfate (Garamycin) to a clients burn injury. Which laboratory value should the nurse monitor while the client is prescribed this therapy? a. Creatinine b. Red blood cells c. Sodium d. Magnesium

a. Creatinine Gentamicin is nephrotoxic, and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitored. Topical gentamicin will not affect the red blood cell count or the sodium or magnesium levels.

A client is interested in learning about the risk factors for prostate cancer. Which factors does the nurse include in the teaching? (Select all that apply.) a. Family history of prostate cancer b. Smoking c. Obesity d. Advanced age e. Eating too much red meat f. Race

a. Family history of prostate cancer d. Advanced age e. Eating too much red meat f. Race

The nurse assesses a client who has a severe burn injury. Which statement indicates the client understands the psychosocial impact of a severe burn injury? a. It is normal to feel some depression. b. I will go back to work immediately. c. I will not feel anger about my situation. d. Once I get home, things will be normal.

a. It is normal to feel some depression. During the recovery period, and for some time after discharge from the hospital, clients with severe burn injuries are likely to have psychological problems that require intervention. Depression is one of these problems. Grief, loss, anxiety, anger, fear, and guilt are all normal feelings that can occur. Clients need to know that problems of physical care and psychological stresses may be overwhelming.

A nurse delegates hydrotherapy to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this activity? a. Keep the water temperature constant when showering the client. b. Assess the wound beds during the hydrotherapy treatment. c. Apply a topical enzyme agent after bathing the client. d. Use sterile saline to irrigate and clean the clients wounds.

a. Keep the water temperature constant when showering the client. Hydrotherapy is performed by showering the client on a special shower table. The UAP should keep the water temperature constant. This process allows the nurse to assess the wound beds, but a UAP cannot complete this act. Topical enzyme agents are not part of hydrotherapy. The irrigation does not need to be done with sterile saline.

A client is diagnosed with metastatic prostate cancer. The client asks the nurse the purpose of his treatment with the luteinizing hormonereleasing hormone (LH-RH) agonist leuprolide (Lupron) and the bisphosphonate pamidronate (Aredia). Which statement by the nurse is most appropriate? a. The treatment reduces testosterone and prevents bone fractures. b. The medications prevent erectile dysfunction and increase libido. c. There is less gynecomastia and osteoporosis with this drug regimen. d. These medications both inhibit tumor progression by blocking androgens.

a. The treatment reduces testosterone and prevents bone fractures.

The nurse is teaching a client with benign prostatic hyperplasia (BPH). What statement indicates a lack of understanding by the client? a. There should be no problem with a glass of wine with dinner each night. b. I am so glad that I weaned myself off of coffee about a year ago. c. I need to inform my allergist that I cannot take my normal decongestant. d. My normal routine of drinking a quart of water during exercise needs to change.

a. There should be no problem with a glass of wine with dinner each night.

14. A patient has had cataract surgery and is ready to go home. In the discharge education, what does the nurse tell the patient about activities? a. Driving in the daylight is okay, but do not drive at night. b. Meal preparation and doing dishes are acceptable activities. c. Vacumming and mopping are okay, but do not bend over to scrub. d. Exercises, such as jogging or swimming, can be done at a slow pace.

b

16. In caring for a patient who was recently diagnosed with dry age-related macular degeneration, which teaching point would the nurse emphasize? a. Importance of adhering to the exact schedule for eyedrops b. Dietary modifications to slow progression of vision loss c. Avoiding activities that cause rapid or jerking head movements d. Good handwashing and keeping the tip of the eyedropper clean

b

20. The patient has an IOP greater than 21 mm Hg. The patient's use of which over-the-counter product should be brought to the immediate attention of the ophthalmologist? a. Aspirin b. Antihistamine c. Vitamin supplement d. Artificial tear eyedrops

b

21. The home health nurse is visiting the patient for the first time. The nurse notices that the patient frequently tilts his head and gives odd answers to simple questions. The nurse has a stethoscope, a digital watch, a pen, and a blood pressure cuff in her supply bag. Which method would the nurse use to test hearing during this visit? a. Hold the watch about 5 inches from the each ear and ask the patient what he hears. b. Stand 2 feet away and whisper a sentence into the unblocked ear and ask patient to repeat the sentence. c. Apply the blood pressure cuff and ask if patient can hear the separation of the Velcro fastener. d. Have the patient don the stethoscope and ask the patient to listen to and count his own heartbeat.

b

23. The patient is wearing corrective lenses. The nurse uses a Snellen chart and the patient's visual acuity is 20/200. What is the clinical significance of this finding? a. Patient needs to be advised to get a new prescription for corrective lenses. b. Patient is considered legally blind with a visual acuity of 20/200 with corrective lenses. c. Patient should be assessed with other methods, such as counting fingers, or hand movements. d. Patient should be referred to an eye surgeon for possible vision enhancement surgery.

b

24. Which activity is most likely to be very difficult for the patient if the visual function of accommodation is not working correctly? Reading a newspaper b. Playing tennis c. Watching a sunset d. Walking in a dark hallway

b

26. The nurse is teaching a patient about self-medication with eyedrops for glaucoma. Which intervention does the nurse suggest to prevent systemic absorption of the medication? a. Wait 15 minutes between instilling different eyedrops. b. Place pressure on the corner of the eye near the nose. c. Place all eye medications in one eye, then the other. d. Blink rapidly after instilling drops and keep head upright.

b

27. A neighbor calls the nurse for advice, because he thinks he may have got some metal shavings in his eye while working on a home improvement project. What advice should the nurse give? a. Rinse the eye with water and then don protective eyewear b. Immediately notify his health care provider or ophthalmologist c. Mention the incident during the annual eye examination d. Resting the eye is sufficient unless there is pain or loss of vision

b

32. The nurse is assessing a patient who is unable to see the 20/400 characters on the Snellen chart. Which assessment will the nurse try first? a. Ask the patient to detect stationary, left-right, or up-down hand movements. b. Ask the patient to count the number of fingers held up in front of the eyes. c. Ask the patient to report "on" or "off" when detecting light in a darkened room.

b

47. The patient tells the nurse that he has unpredictable episodes of vertigo. What instructions are the most important to give to the unlicensed assistive personnel (UAP) who is assisting the patient with activities of daily living (ADLs)? a. "Face the patient directly whenever speaking to him." b. "There is a high risk for falls, so use a gait belt during ambulation." c. "Noise from the television or hallway should be minimized." d. "Patient is likely to have severe pain, so immediately report pain."

b

55. Which action could prevent ear trauma? a. Holding the nose when sneezing to reduce pressure b. Not using small objects to clean the external ear canal c. Occluding one nostril when blowing the nose d. NOt washing the external ear and canal

b

9. Which technique would the nurse use to perform otoscopic assessment? a. The patient's head should be tilted slightly toward the nurse. b. The nurse holds the otoscope upside down, like a large pen. c. The pinna is pulled down and back. d. The internal canal is visualized while the speculum is slowly inserted.

b

A nurse plans care for a client who is recovering from a below-the-knee amputation of the left leg. Which intervention should the nurse include in this clients plan of care? a. Place pillows between the clients knees. b. Encourage range-of-motion exercises. c. Administer prophylactic antibiotics. d. Implement strict bedrest in a supine position.

b

A nurse cares for a client who had a long-leg cast applied last week. The client states, I cannot seem to catch my breath and I feel a bit light-headed. Which action should the nurse take next? a. Auscultate the clients lung fields anteriorly and posteriorly. b. Administer oxygen to keep saturations greater than 92%. c. Check the clients blood glucose level. d. Ask the client to take deep breaths.

b (The clients symptoms are consistent with the development of pulmonary embolism caused by leg immobility in the long cast. The nurse should check the clients pulse oximetry reading and provide oxygen to keep saturations greater than 92%. Auscultating lung fields, checking blood glucose level, or deep breathing will not assist this client.)

A nurse assesses a client with a fracture who is being treated with skeletal traction. Which assessment should alert the nurse to urgently contact the health provider? a. Blood pressure increases to 130/86 mm Hg b. Traction weights are resting on the floor c. Oozing of clear fluid is noted at the pin site d. Capillary refill is less than 3 seconds

b (The immediate action of the nurse should be to reapply the weights to give traction to the fracture. The health care provider must be notified that the weights were lying on the floor, and the client should be realigned in bed.)

A nurse cares for an older adult client with multiple fractures. Which action should the nurse take to manage this clients pain? a. Meperidine (Demerol) injections every 4 hours around the clock b. Patient-controlled analgesia (PCA) pump with morphine c. Ibuprofen (Motrin) 600 mg orally every 4 hours PRN for pain d. Morphine 4 mg intravenous push every 2 hours PRN for pain

b (The older adult client should never be treated with meperidine because toxic metabolites can cause seizures. The client should be managed with a PCA pump to control pain best. Motrin most likely would not provide complete pain relief with multiple fractures. IV morphine PRN would not control pain as well as a pump that the client can control)

An emergency nurse assesses a client who is admitted with a pelvic fracture. Which assessments should the nurse monitor to prevent a complication of this injury? (Select all that apply.) a. Temperature b. Urinary output c. Blood pressure d. Pupil reaction e. Skin color

b, c, e (With a pelvic fracture, internal organ damage may result in bleeding and hypovolemic shock. The nurse monitors the clients heart rate, blood pressure, urine output, skin color, and level of consciousness frequently to determine whether shock is manifesting. It is important to monitor the urine for blood to assess whether the urinary system has been damaged with the pelvic fracture. Changes in temperature and pupil reactions are not directly associated with hypovolemic shock.)

22. Which medications can adversely affect the eyes and vision? (Select all that apply.) a. Heparin b. Decongestants c. Oral contraceptives d. Acetaminophen e. Corticosteroids

b,c,e

3. A patient who works on the tarmac at a busy airport is being seen for a routine exam. What protection measures for hearing does the nurse suggest to the patient? (Select all that apply.) a. Wear cotton ball ear inserts. b. Wear foam ear inserts. c. Wear a hat with ear covers. d. Wear an over-the-ear headset. e. Limit exposure time on tarmac.

b,d

12. Before performing a physical exam, what assessments related to the patient's hearing can be done while observing the patient? (Select all that apply.) a. Note how the patient is dressed. b. Observe body posture and position. c. Observe if the patient is anxious or fearful. d. See if the patient asks for questions to be repeated. e. Note whether the patient tilts the head toward the examiner.

b,d,e

A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The clients urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question? a. Increase intravenous fluids by 100 mL/hr. b. Administer furosemide (Lasix) 40 mg IV push. c. Continue to monitor urine output hourly. d. Draw blood for serum electrolytes STAT.

b. Administer furosemide (Lasix) 40 mg IV push. The plan of care for a client with a burn includes fluid and electrolyte resuscitation. Furosemide would be inappropriate to administer. Postburn fluid needs are calculated initially by using a standardized formula such as the Parkland formula. However, needs vary among clients, and the final fluid volume needed is adjusted to maintain hourly urine output at 0.5 mL/kg/hr. Based on this clients inadequate urine output, fluids need to be increased, urine output needs to be monitored hourly, and electrolytes should be evaluated to ensure appropriate fluids are being infused.

The nurse is administering sulfamethoxazole-trimethoprim (Bactrim) to a client diagnosed with bacterial prostatitis. Which finding causes the nurse to question this medication for this client? a. Urinary tract infection b. Allergy to sulfa medications c. Hematuria d. Elevated serum white blood cells

b. Allergy to sulfa medications

The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination? a. Use a disposable blood pressure cuff to avoid sharing with other clients. b. Change gloves between wound care on different parts of the clients body. c. Use the closed method of burn wound management for all wound care. d. Advocate for proper and consistent handwashing by all members of the staff.

b. Change gloves between wound care on different parts of the clients body. Autocontamination is the transfer of microorganisms from one area to another area of the same clients body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, only changing gloves between performing wound care on different parts of the clients body can prevent autocontamination.

A nurse cares for a client with burn injuries from a house fire. The client is not consistently oriented and reports a headache. Which action should the nurse take? a. Increase the clients oxygen and obtain blood gases. b. Draw blood for a carboxyhemoglobin level. c. Increase the clients intravenous fluid rate. d. Perform a thorough Mini-Mental State Examination.

b. Draw blood for a carboxyhemoglobin level. These manifestations are consistent with moderated carbon monoxide poisoning. This client is at risk for carbon monoxide poisoning because he or she was in a fire in an enclosed space. The other options will not provide information related to carbon monoxide poisoning.

A 70-year-old client returned from a transurethral resection of the prostate 8 hours ago with a continuous bladder irrigation. The nurse reviews his laboratory results as follows: Sodium 128 mEq/L Hemoglobin 14 g/dL Hematocrit 42% Red blood 4.5 cell count What action by the nurse is the most appropriate? a. Consider starting a blood transfusion. b. Slow down the bladder irrigation if the urine is pink. c. Report the findings to the surgeon immediately. d. Take the vital signs every 15 minutes.

b. Slow down the bladder irrigation if the urine is pink.

A client has returned from a transurethral resection of the prostate with a continuous bladder irrigation. Which action by the nurse is a priority if bright red urinary drainage and clots are noted 5 hours after the surgery? a. Review the hemoglobin and hematocrit as ordered. b. Take vital signs and notify the surgeon immediately. c. Release the traction on the three-way catheter. d. Remind the client not to pull on the catheter.

b. Take vital signs and notify the surgeon immediately.

A nurse assesses a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding should alert the nurse to a potential complication? a. Partial pressure of arterial oxygen (PaO2) of 80 mm Hg b. Urine output of 20 mL/hr c. Productive cough with white pulmonary secretions d. Core temperature of 100.6 F (38 C)

b. Urine output of 20 mL/hr A significant loss of fluid occurs with burn injuries, and fluids must be replaced to maintain hemodynamics. If fluid replacement is not adequate, the client may become hypotensive and have decreased perfusion of organs, including the brain and kidneys. A low urine output is an indication of poor kidney perfusion. The other manifestations are not complications of burn injuries.

12. The nurse reads in the patient's chart that the patient's visual acuity is 20/40. What is the correct interpretation of this documentation? a. Patient has 50% of the ideal 20/20 visual acuity. b. Patient stood 40 feet from the chart rather than 20 feet from the chart. c. Patient sees at 20 feet from the chart what a healthy eye sees at 40 feet. d. Patient stood 20 feet from the chart and sees 40% of the letters.

c

15. How would the nurse use body position and the surrounding environment when conducting an interview with a patient who may have a hearing problem? a. Conduct the interview in a quiet, darkened room without distractions. b. Sit beside the patient and speak directly into the patient's ear. c. Sit directly in front of the patient in a room with adequate lighting. d. Stand over the patient and use hand motions for emphasis

c

18. Which child is most likely to develop hearing loss in adulthood? a. 1-year-old with ear infections related to "night bottles" b. 2-year-old who stumbles and bumps his head on a table c. 5-year-old who is diagnosed with Down syndrome d. 10-year-old with a grandparent who has hearing problem.

c

19. The nurse hears in shift report that a patient suffers from hyperacusis. Which intervention is the nurse most likely to use in the care of this patient? a. Supply a writing tablet and pen. b. Speak loudly and carefully enunciate. c. Ensure that environmental noise is controlled. d. Instruct the patient to sit up slowly.

c

20. The nurse is assisting an inexperienced health care provider who is trying to perform an otoscopic examination on an older patient who is being treated for delirium caused by infection. What should the nurse do? a. Quietly talk to the patient to distract him as the provider inserts the speculum. b. Gently hold the patient's head to prevent movement during the examination. c. Suggest that the otoscopic examination be deferred until the delirium resolves. d. Suggest using a Rinne turning fork test instead of the otoscopic examination.

c

21. A 10-year-old patient was hit in the left eye with a baseball. There is discoloration around the eye. Which treatment does the nurse expect to give for this patient? a. Eye patch to rest the eye b. Warm, moist compresses c. Small ice application to area d. Bedrest in semi-Fowler's position

c

22. The nurse reads in the patient's chart that the Weber tuning fork test showed that the patient had lateralization to the right. Based on this information, what would the nurse do while the caring for the patient? a. Instruct the patient to turn his head to the right if he is having trouble hearing. b. Ask the patient in which ear the sound is louder, because the test in inconclusive. c. Position self to the patient's right, so that voice travels directly to the right ear. d. Lateralization indicates normal hearing, so the nurse would perform routine care.

c

26. For a person who is just beginning to notice some hearing loss, which sounds would be the most difficult to clearly hear? a. A woman singing in the soprano range b. Toddler who is angry and screaming c. Cell phone ringing with low-frequency tones d. Gunfire shots on a television show

c

26. Which patient is advised to have yearly eye examinations because of the increased risk for cataracts? a. 5-year-old who was treated for an episode of conjunctivitis b. 10-year-old who was struck in the face by a basketball c. 55-year-old with no history of eye problems or vision changes d. 25-year-old who is pregnant with her first child

c

30. Which method would the nurse use to perform a corneal assessment? a. Inspect the corneas to determine if they equal distance from the nose. b. Quickly and unexpectedly bring a hand towards the patient's cornea. c. Use a penlight and direct the light on the cornea from the side. d. Ask the patient to open and close eyelids and observe the cornea.

c

31. The nurse reads PERRLA in the patient's chart as noted by the nurse who worked the previous shift. What does the nurse do in order to determine if the patient still displays PERRLA or if the patient's status has changed? a. Assesses for presence, relief, or reduction of pain b. Checks pulse, respiratory rate, and lung auscultation c. Assesses the size, shape, and reacitivity of pupils d. Checks for signs of presbyopia or retinal detachment

c

54. What should the nurse teach a patient who is learning to use a hearing aid? a. Soak the hearing aid in a solution of mild soap and water. b. Plug the hearing aid into an electrical source when not in use. c. Avoid exposing the hearing aid to extreme temperatures. d. Adjust volume to the highest setting to maximize hearing.

c

58. What might the nurse notice if the patient has auditory sensory perception problems? a. Patient frequently looks away when being spoken to. b. Patient startles very easily at unexpected sounds. c. Patient frequently asks speaker to repeat statements. d. Patient often seeks out others for assistance.

c

7. An adult patient is having problems with hearing. which of the patient's medications is ototoxic? a. Vitamin B12 b. Digoxin (Lanoxin) c. Furosemide (Lasix) d. Levothyroxine (Synthroid)

c

A nurse cares for a client recovering from an above-the-knee amputation of the right leg. The client reports pain in the right foot. Which prescribed medication should the nurse administer first? a. Intravenous morphine b. Oral acetaminophen c. Intravenous calcitonin d. Oral ibuprofen

c (The client is experiencing phantom limb pain, which usually manifests as intense burning, crushing, or cramping. IV infusions of calcitonin during the week after amputation can reduce phantom limb pain. Opioid analgesics such as morphine are not as effective for phantom limb pain as they are for residual limb pain. Oral acetaminophen and ibuprofen are not used in treating phantom limb pain)

A nurse delegates care of a client in traction to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene care for this client? a. Remove the traction when re-positioning the client. b. Inspect the clients skin when performing a bed bath. c. Provide pin care by using alcohol wipes to clean the sites. d. Ensure that the weights remain freely hanging at all times.

d

A nurse coordinates care for a client with a wet plaster cast. Which statement should the nurse include when delegating care for this client to an unlicensed assistive personnel (UAP)? a. Assess distal pulses for potential compartment syndrome. b. Turn the client every 3 to 4 hours to promote cast drying. c. Use a cloth-covered pillow to elevate the clients leg. d. Handle the cast with your fingertips to prevent indentations.

c (When delegating care to a UAP for a client with a wet plaster cast, the UAP should be directed to ensure that the extremity is elevated on a cloth pillow instead of a plastic pillow to promote drying. The client should be turned every 1 to 2 hours to allow air to circulate and dry all parts of the cast. Providers should handle the cast with the palms of the hands to prevent indentations.)

A nurse uses the rule of nines to assess a client with burn injuries to the entire back region and left arm. How should the nurse document the percentage of the clients body that sustained burns? a. 9% b. 18% c. 27% d. 36%

c. 27% According to the rule of nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to the back (18%) and one arm (9%), totaling 27% of the body.

A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first? a. Assess the level of consciousness and pupillary reactions. b. Ascertain the time food or liquid was last consumed. c. Auscultate breath sounds over the trachea and bronchi. d. Measure abdominal girth and auscultate bowel sounds.

c. Auscultate breath sounds over the trachea and bronchi. Inhalation injuries are present in 7% of clients admitted to burn centers. Drooling and difficulty swallowing can mean that the client is about to lose his or her airway because of this injury. Absence of breath sounds over the trachea and bronchi indicates impending airway obstruction and demands immediate intubation. Knowing the level of consciousness is important in assessing oxygenation to the brain. Ascertaining the time of last food intake is important in case intubation is necessary (the nurse will be more alert for signs of aspiration). However, assessing for air exchange is the most important intervention at this time. Measuring abdominal girth is not relevant in this situation.

A 25-year-old client has recently been diagnosed with testicular cancer and is scheduled for radiation therapy. Which intervention by the nurse is best? a. Ask the client about his support system of friends and relatives. b. Encourage the client to verbalize his fears about sexual performance. c. Explore with the client the possibility of sperm collection. d. Provide privacy to allow time for reflection about the treatment.

c. Explore with the client the possibility of sperm collection.

A nurse assesses a client who has a burn injury. Which statement indicates the client has a positive perspective of his or her appearance? a. I will allow my spouse to change my dressings. b. I want to have surgical reconstruction. c. I will bathe and dress before breakfast. d. I have secured the pressure dressings as ordered.

c. I will bathe and dress before breakfast. Indicators that the client with a burn injury has a positive perception of his or her appearance include a willingness to touch the affected body part. Self-care activities such as morning care foster feelings of selfworth, which are closely linked to body image. Allowing others to change the dressing and discussing future reconstruction would not indicate a positive perception of appearance. Wearing the dressing will assist in decreasing complications but will not enhance self-perception.

A nurse teaches a client being treated for a full-thickness burn. Which statement should the nurse include in this clients discharge teaching? a. You should change the batteries in your smoke detector once a year. b. Join a program that assists burn clients to reintegration into the community. c. I will demonstrate how to change your wound dressing for you and your family. d. Let me tell you about the many options available to you for reconstructive surgery.

c. I will demonstrate how to change your wound dressing for you and your family. Teaching clients and family members to perform care tasks such as dressing changes is critical for the progressive goal toward independence for the client. All of the other options are important in the rehabilitation stage. However, dressing changes have priority.

A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn injury. The client asks, Why am I taking this medication? How should the nurse respond? a. Tagamet stimulates intestinal movement so you can eat more. b. It improves fluid retention, which helps prevent hypovolemic shock. c. It helps prevent stomach ulcers, which are common after burns. d. Tagamet protects the kidney from damage caused by dehydration.

c. It helps prevent stomach ulcers, which are common after burns. Ulcerative gastrointestinal disease (Curlings ulcer) may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and a decreased mucosal barrier. This process occurs because of the sympathetic nervous system stress response. Cimetidine is a histamine2 blocker and inhibits the production and release of hydrochloric acid. Cimetidine does not affect intestinal movement and does not prevent

A 55-year-old African-American client is having a visit with his health care provider. What test should the nurse discuss with the client as an option to screen for prostate cancer, even though screening is not routinely recommended? a. Complete blood count b. Culture and sensitivity c. Prostate-specific antigen d. Cystoscopy

c. Prostate-specific antigen

A nurse obtains the health history of a client with a fractured femur. Which factor identified in the clients history should the nurse recognize as an aspect that may impede healing of the fracture? a. Sedentary lifestyle b. A 30 pack-year smoking history c. Prescribed oral contraceptives d. Pagets disease

d

A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately? a. Arterial pH: 7.32 b. Hematocrit: 52% c. Serum potassium: 6.5 mEq/L d. Serum sodium: 131 mEq/L

c. Serum potassium: 6.5 mEq/L The serum potassium level is changed to the degree that serious life-threatening responses could result. With such a rapid rise in potassium level, the client is at high risk for experiencing severe cardiac dysrhythmias and death. All the other findings are abnormal but do not show the same degree of severity; they would be expected in the emergent phase after a burn injury.

The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern? a. I get my chimney swept every other year. b. My hot water heater is set at 120 degrees. c. Sometimes I wake up at night and smoke. d. I use a space heater when it gets below zero.

c. Sometimes I wake up at night and smoke. House fires are a common occurrence and often lead to serious injury or death. The nurse should be most concerned about a person who wakes up at night and smokes. The nurse needs to question this person about whether he or she gets out of bed to do so, or if this person stays in bed, which could lead to falling back asleep with a lighted cigarette. Although it is recommended to have chimneys swept every year, skipping a year does not pose as much danger as smoking in bed, particularly if the person does not burn wood frequently. Water heaters should be set below 140 F. Space heaters should be used with caution, and the nurse may want to ensure that the person does not allow it to get near clothing or bedding.

A nurse cares for a client who has facial burns. The client asks, Will I ever look the same? How should the nurse respond? a. With reconstructive surgery, you can look the same. b. We can remove the scars with the use of a pressure dressing. c. You will not look exactly the same but cosmetic surgery will help. d. You shouldnt start worrying about your appearance right now.

c. You will not look exactly the same but cosmetic surgery will help. Many clients have unrealistic expectations of reconstructive surgery and envision an appearance identical or equal in quality to the preburn state. The nurse should provide accurate information that includes something to hope for. Pressure dressings prevent further scarring; they cannot remove scars. The client and the family should be taught the expected cosmetic outcomes.

10. What is an early sign/symptom of a cataract? a. Double vision b. Photophobia c. Decreased depth perception d. Decreased color perception

d

11. The nurse is suing an ophthalmoscope to examine the lens of a patient with a cataract. Which finding does the nurse expect to see? a. Dilated pupil b. Decrased lens density c. Enlarged retina d. Opaque lens

d

13. The nurse gently taps over the patient's mastoid process and the patient reports tenderness. This finding may indicate which condition? a. Excessive cerument b. Hyperacusis c. Ruptured eardrum d. Inflammatory process

d

16. What is a correct part of the procedure for using an ophthalmoscope? a. The nurse comes toward the patient's eye from 6 inches away. b. The test should be done in a brightly lit room to enhance visibility. c. When examining confused patients, an assistant can steady the patient. d. The nurse stands on the same side as the eye being examined.

d

17. Which person has the highest risk for developing hearing problems because of occupation? a. Nurse who works night shift in an emergency department b. Coach who coaches a high school swim team c. Bus driver who picks up elementary school children d. Bartender who works in a night club with live music

d

19. Why might the health care provider order CT to examine the eye? a. To validate the function of extraocular muscles b. To verify IOP c. To determine the degree of peripheral vision d. To detect an ocular tumor in the orbital space

d

20. A patient with myopia tells the nurse that he forgot to bring his glasses to the hospital and that his wife will bring them later when she comes to see him. Which activity is the patient most likely to have difficulty with while he is waiting for his glasses? a. Eating his lunch b. Looking at a brochure c. Using his cell phone d. Watching television

d

22. Which traumatic injury of the eye is the most likely to cause loss of vision in the injured eye? a. Foreign body b. Contusion c. Laceration d. Penetration injury

d

25. What is the priority for a patient with impaired vision? a. Self-care b. Communication c. Mobility d. Safety

d

28. A patient is having problems with speech discrimination. What is the nurse most likely to observe? a. Patient speaks very loudly during a conversation. b. Patient can hear high tones, but not low tones. c. Patient cannot accurately repeat two syllable words. d. Patient repeats back "gay" when the nurse says "gray."

d

28. Which food would be particularly good for eye health? a. Whole-grain cereal b. Low-fat milk c. Raw almonds d. Fresh tomatoes

d

6. A sensorineural hearing loss results from impairment of which structure? Fused bony ossicles b. First cranial nerve c. Seventh cranial nerve d. Eighth cranial nerve

d

A nurse cares for a client in skeletal traction. The nurse notes that the skin around the clients pin sites is swollen, red, and crusty with dried drainage. Which action should the nurse take next? a. Request a prescription to decrease the traction weight. b. Apply an antibiotic ointment and a clean dressing. c. Cleanse the area, scrubbing off the crusty areas. d. Obtain a prescription to culture the drainage.

d

A phone triage nurse speaks with a client who has an arm cast. The client states, My arm feels really tight and puffy. How should the nurse respond? a. Elevate your arm on two pillows and get ice to apply to the cast. b. Continue to take ibuprofen (Motrin) until the swelling subsides. c. This is normal. A new cast will often feel a little tight for the first few days. d. Please come to the clinic today to have your arm checked by the provider.

d

After teaching a client with a fractured humerus, the nurse assesses the clients understanding. Which dietary choice demonstrates that the client correctly understands the nutrition needed to assist in healing the fracture? a. Baked fish with orange juice and a vitamin D supplement b. Bacon, lettuce, and tomato sandwich with a vitamin B supplement c. Vegetable lasagna with a green salad and a vitamin A supplement d. Roast beef with low-fat milk and a vitamin C supplement

d

A trauma nurse cares for several clients with fractures. Which client should the nurse identify as at highest risk for developing deep vein thrombosis? a. An 18-year-old male athlete with a fractured clavicle b. A 36-year old female with type 2 diabetes and fractured ribs c. A 55-year-old woman prescribed aspirin for rheumatoid arthritis d. A 74-year-old man who smokes and has a fractured pelvis

d (Deep vein thrombosis (DVT) as a complication with bone fractures occurs more often when fractures are sustained in the lower extremities and the client has additional risk factors for thrombus formation. Other risk factors include obesity, smoking, oral contraceptives, previous thrombus events, advanced age, venous stasis, and heart disease. The other clients do not have risk factors for DVT.)

A nurse is caring for a client who is recovering from an above-the-knee amputation. The client reports pain in the limb that was removed. How should the nurse respond? a. The pain you are feeling does not actually exist. b. This type of pain is common and will eventually go away. c. Would you like to learn how to use imagery to minimize your pain? d. How would you describe the pain that you are feeling?

d (The nurse should ask the client to rate the pain on a scale of 0 to 10 and describe how the pain feels. Although phantom limb pain is common, the nurse should not minimize the pain that the client is experiencing by stating that it does not exist or will eventually go away. Antiepileptic drugs and antispasmodics are used to treat neurologic pain and muscle spasms after amputation. Although imagery may assist the client, the nurse must assess the clients pain before determining the best action.)

A nurse assesses a client with a pelvic fracture. Which assessment finding should the nurse identify as a complication of this injury? a. Hypertension b. Constipation c. Infection d. Hematuria

d (The pelvis is very vascular and close to major organs. Injury to the pelvis can cause integral damage that may manifest as blood in the urine (hematuria) or stool. The nurse should also assess for signs of hemorrhage and hypovolemic shock, which include hypotension and tachycardia.)

A nurse plans care for a client who is prescribed skeletal traction. Which intervention should the nurse include in this plan of care to decrease the clients risk for infection? a. Wash the traction lines and sockets once a day. b. Release traction tension for 30 minutes twice a day. c. Do not place the traction weights on the floor. d. Schedule for pin care to be provided every shift.

d (key word is decrease risk for infection)

A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours later the wheezing is no longer heard. Which action should the nurse take? a. Document the findings and reassess in 1 hour. b. Loosen any constrictive dressings on the chest. c. Raise the head of the bed to a semi-Fowlers position. d. Gather appropriate equipment and prepare for an emergency airway.

d. Gather appropriate equipment and prepare for an emergency airway. Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose effective movement of air. When this occurs, wheezing is no longer heard, and neither are breath sounds. These clients can lose their airways very quickly, so prompt action is needed. The client requires establishment of an emergency airway. Swelling usually precludes intubation. The other options do not address this emergency situation.

A nurse and an unlicensed assistive personnel (UAP) are caring for a client with an open radical prostatectomy. Which comfort measure could the nurse delegate to the UAP? a. Administering an antispasmodic for bladder spasms b. Managing pain through patient-controlled analgesia c. Applying ice to a swollen scrotum and penis d. Helping the client transfer from the bed to the chair

d. Helping the client transfer from the bed to the chair

A client is diagnosed with benign prostatic hyperplasia and seems sad and irritable. After assessing the clients behavior, which statement by the nurse would be the most appropriate? a. The urine incontinence should not prevent you from socializing. b. You seem depressed and should seek more pleasant things to do. c. It is common for men at your age to have changes in mood. d. Nocturia could cause interruption of your sleep and cause changes in mood.

d. Nocturia could cause interruption of your sleep and cause changes in mood.

A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action should the nurse take next? a. Administer furosemide (Lasix). b. Perform chest physiotherapy. c. Document and reassess in an hour. d. Place the client in an upright position.

d. Place the client in an upright position. Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young healthy person. Placing the client in an upright position can relieve lung congestion immediately before other measures can be carried out. Although Lasix may be used to treat pulmonary edema in clients who are fluid overloaded, a client with a burn injury will lose a significant amount of fluid through the broken skin; therefore, Lasix would not be appropriate. Chest physiotherapy will not get rid of fluid.

The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client? a. Administer the prescribed tetanus toxoid vaccine. b. Assess the clients wounds for signs of infection. c. Encourage the client to breathe deeply every hour. d. Wash your hands on entering the clients room.

d. Wash your hands on entering the clients room. Infection can occur when microorganisms from another person or from the environment are transferred to the client. Although all of the interventions listed can help reduce the risk for infection, handwashing is the most effective technique for preventing infection transmission.

A nurse cares for a client who has burn injuries. The clients wife asks, When will his high risk for infection decrease? How should the nurse respond? a. When the antibiotic therapy is complete. b. As soon as his albumin levels return to normal. c. Once we complete the fluid resuscitation process. d. When all of his burn wounds have closed.

d. When all of his burn wounds have closed. Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much time has passed since the burn injury, the client remains at high risk for infection as long as any area of skin is open. Although the other options are important goals in the clients recovery process, they are not as important as skin closure to decrease the clients risk for infection.