Final Exam
A client is scheduled for a colonoscopy. What does the nurse tell the client to do before the procedure is performed? A. "Begin a clear liquid diet 12 to 24 hours before the test." B. "Do not eat or drink anything for 12 hours before the test." C. "Give yourself tap water enemas until the fluid returns are clear." D. "You will have to drink a contrast liquid 2 hours before the test."
"Begin a clear liquid diet 12 to 24 hours before the test." The client is instructed to be on a liquid diet for 12 to 24 hours to cleanse the bowel before a colonoscopy. The client must be NPO (except for water) 4 to 6 hours before a colonoscopy. The client is instructed to drink a liquid preparation for cleaning the bowel (such as sodium phosphate) the evening before the colonoscopy, and may repeat that procedure on the morning of the test. In some cases, the client may require laxatives, suppositories, or one or more small-volume (i.e., Fleet) cleansing enemas. The client is not given an oral contrast liquid to swallow for a colonoscopy.
The nurse wishes to reduce the incidence of hospital-acquired acute kidney injury. Which question by the nurse to the interdisciplinary health care team will result in reducing client exposure? "Should we filter air circulation?" "Can we use less radiographic contrast dye?" "Should we add low-dose dobutamine?" "Should we decrease IV rates?"
"Can we use less radiographic contrast dye?" Contrast dye is severely nephrotoxic, and other options can be used in its place. Air circulation and low-dose dopamine are not associated with nephrotoxicity. Pre-renal status results from decreased blood flow to the kidney, such as fluid loss or dehydration; IV fluids can correct this.
Which statement made by a client allows the nurse to recognize whether the client receiving brachytherapy for ovarian cancer understands the treatment plan? A.) "I may lose my hair during this treatment." B.) "I must be positioned in the same way during each treatment." C.) "I will have a radioactive device in my body for a short time." D.) "I will be placed in a semiprivate room for company."
"I will have a radioactive device in my body for a short time." Brachytherapy refers to short-term insertion of a radiation source. Side effects of radiation therapy are site-specific; this client is unlikely to experience hair loss from treating ovarian cancer with radiation. The client undergoing teletherapy (external beam radiation), not brachytherapy, must be positioned precisely in the same position each time. The client who is receiving brachytherapy must be in a private room.
The nurse is educating a group of older adults about screening for colorectal cancer. Which statement by a group member indicates the need for further clarification about these guidelines? A. "A barium enema every 5 years is a screening option." B. "I will need to have a routine colonoscopy every 5 years." C. "My routine flexible sigmoidoscopy every 5 years is OK." D. "The 'virtual' colonoscopy every 5 years is acceptable."
"I will need to have a routine colonoscopy every 5 years." The 2010 guidelines indicate that routine screening with colonoscopy is performed every 10 years, not every 5 years. Other options are performed at 5-year intervals. A barium enema every 5 years is a screening option. A flexible sigmoidoscopy and a "virtual" colonoscopy every 5 years are also acceptable for screening.
A client is scheduled to undergo kidney transplant surgery. Which teaching point does the nurse include in the preoperative teaching session? "Your diseased kidneys will be removed at the same time the transplant is performed." "The new kidney will be placed directly below one of your old kidneys." "It is essential for you to wash your hands and avoid people who are ill. "You will receive dialysis the day before surgery and for about a week after."
"It is essential for you to wash your hands and avoid people who are ill. Anti-rejection medications increase the risks for infection, sepsis, and death. Strict aseptic technique and handwashing are essential. Unless severely infected, the client's kidneys are left in place and the graft is placed in the iliac fossa. Dialysis is performed the day before surgery; after the surgery, the new kidney should begin to make urine.
Discharge teaching has been provided for a client recovering from kidney transplantation. Which information indicates that the client understands the instructions? "I can stop my medications when my kidney function returns to normal." "If my urine output is decreased, I should increase my fluids." "The anti-rejection medications will be taken for life." "I will drink 8 ounces of water with my medications."
"The anti-rejection medications will be taken for life." Immune-suppressant therapy must be taken for life to prevent organ rejection. Adherence to immunosuppressive drugs is crucial to survival for clients with transplanted kidneys. Lack of adherence can lead to complications such as rejection, graft loss, return to dialysis, and death. Oliguria is a symptom of transplant rejection; the transplant team should be contacted immediately if this occurs. It is not necessary to take anti-rejection medication with 8 ounces of water.
The outpatient clinic nurse is caring for a recovering client who had a colonoscopy. The client asks for a drink. How does the nurse respond to this request? A. "After I hear bowel sounds, you can have a drink." B. "Twenty minutes after the procedure was completed, you may have some liquids." C. "When you are able to pass flatus (gas), you can have a drink." D. "You can have fluids when you get home and are settled."
"When you are able to pass flatus (gas), you can have a drink." Fluids are permitted after the client's peristalsis has returned, which is validated by the client's passing flatus, not by auscultation of bowel sounds. There is no set time period after the procedure that is considered safe for the client to have something to drink. The client will not be discharged home without the nurse determining that peristalsis has returned. The client must report that he or she is passing flatus to go home; therefore, the client should be given a drink before being sent home.
(Chp. 31; elsevier resources)
(Chp. 31; elsevier resources)
The nurse has received in report that a client receiving chemotherapy has severe neutropenia. Which interventions does the nurse plan to implement? (Select all that apply.) A.) Assess for fever. B.) Observe for bleeding. C.) Administer pegfilgrastim (Neulasta). D.) Do not permit fresh flowers or plants in the room. E.) Do not allow the client's 16-year-old son to visit. F.) Teach the client to omit raw fruits and vegetables from the diet.
-Assess for fever -Administer pegfilgramtim (Neulasta) -Do not permit fresh flowers or plants in the room -Teach the client to omit raw fruits and vegetables from the diet Any temperature elevation in a client with neutropenia is considered a sign of infection and should be reported immediately to the health care provider. Administration of biological response modifiers, such as filgrastim (Neupogen) and pegfilgrastim (Neulasta), is indicated in neutropenia to prevent infection and sepsis. Flowers and plants may harbor organisms such as fungi or viruses and are to be avoided for the immune-suppressed client. All fruits and vegetables should be cooked well; raw fruits and vegetables may harbor organisms. Thrombocytopenia, or low platelet levels, causes bleeding, not low neutrophils (a type of white blood cell). The client is at risk for infection, not the visitors, if they are well; however, very small children, who may get frequent colds and viral infections, may pose a risk.
When caring for a client who has had a colostomy created during treatment for colon cancer, which nursing actions help support the client in accepting changes in appearance or function? (Select all that apply.) A.) Explain to the client that the colostomy is only temporary. B.) Encourage the client to participate in changing the ostomy. C.) Obtain a psychiatric consultation. D.) Offer to have a person who is coping with a colostomy visit. E.) Encourage the client and family members to express their feelings and concerns.
-Encourage the client to participate in changing the ostomy. -Offer to have a person who is coping with a colostomy visit. -Encourage the client and family members to express their feelings and concerns. Encouraging the client to participate in changing the ostomy is an appropriate way for the client to become familiar with the ostomy and its care. A visit from a person who is successfully coping with an ostomy can demonstrate to the client that many aspects of life can be the same after surgery. Offering to listen to feelings and concerns is part of a therapeutic relationship and therapeutic communication. Ostomies may be temporary for bowel rest, such as after a perforation, but are typically permanent for cancer treatment. Obtaining a psychiatric consultation may need to be done for clients with persistent depression, but would not be done immediately.
A client with septic shock is to receive dopamine at 18 mcg/kg/min. The client's weight is 154 pounds. How many mcg/min does the nurse administer? Record your answer as a whole number with no punctuation. ___mcg/min
1,260 mcg/min Rationale: First convert pounds to kilograms: 154 lb ÷ 2.2 = 70 kg. Then, 70 kg × 18 mcg/kg/min = 1260 mcg/min
What metabolic changes occur as a result of tissue ischemia during the compensatory stage of hypovolemic shock? Select all that apply. 1 Acidosis 2 Alkalosis 3 Hypokalemia 4 Hyperkalemia 5 Vasodilatation
1. Acidosis 4. Hyperkalemia Rationale: In the compensatory (nonprogressive) stage of shock, tissue hypoxia leads to acidosis because of changes in anaerobic metabolism. Hyperkalemia occurs as well from the changes in metabolism. The client is acidotic, not alkalotic. Hypovolemic shock is associated with vasoconstriction, not vasodilation.
Where are the baroreceptors that are responsible for detection of pressure changes within the arterial system located? 1 Aortic arch 2 Radial sinus 3 Brachial arch 4 Femoral sinus
1. Aortic arch Rationale: The baroreceptors responsible for detecting pressure changes in the arterial system are located in aortic arch and carotid sinus. There are no baroreceptors located in radial sinus, brachial arch, and femoral sinus.
A client is exhibiting signs and symptoms of early shock. What is important for the nurse to do to support the psychosocial integrity of the client? Select all that apply. 1 Ask family members to stay with the client. 2 Call the health care provider. 3 Increase IV and oxygen rates. 4 Remain with the client. 5 Reassure the client that everything is being done for him or her.
1. Ask family members to stay with the client. 4. Remain with the client. 5. Reassure the client that everything is being done for him or her. Rationale: Having a familiar person nearby may provide comfort to the client. The nurse should remain with the client who is demonstrating physiologic deterioration. Offering genuine reassurance supports the client who is anxious. The health care provider should be notified, and increasing IV and oxygen may be needed, but these actions do not support the client's psychosocial integrity.
After norepinephrine (Levophed) is administered to a client with hypovolemic shock, which assessment factor is used to verify the effectiveness of the treatment? 1 Blood pressure 2 Urinary output 3 Level of consciousness 4 Blood glucose
1. Blood pressure Rationale: Norepinephrine (Levophed) is a vasoconstrictor drug used in hypovolemic shock to increase perfusion and oxygenation. These drugs constrict the blood vessels and increase venous return. Urine production will not increase until blood pressure rises and perfuses the kidneys. Norepinephrine does not have any effect on a client's level of consciousness or blood glucose levels.
The nurse is administering continuous intravenous infusion of norepinephrine (Levophed) to a client in shock. Which finding causes the nurse to decrease the rate of infusion? 1 Blood pressure 170/96 mm Hg 2 Respiratory rate 22 breaths/min 3 Urine output of 70 mL/hr 4 Heart rate 98 beats/min
1. Blood pressure 170/96 mm Hg Rationale: Signs of excess vasoconstricting drugs include headache, hypertension, and decreased renal perfusion manifested by oliguria. While vasoconstricting medications and the shock state may cause tachycardia (heart rate greater than 100 beats/min), this client's heart rate is within normal range. Vasoconstricting drugs do not affect the respiratory rate; shock itself causes an increased respiratory rate in an effort to deliver more oxygen to the tissues.
A client is admitted to the hospital with two of the systemic inflammatory response system (SIRS) variables: temperature of 95° F (35° C) and high white blood cell count. Which intervention from the sepsis resuscitation bundle does the nurse initiate? 1 Broad-spectrum antibiotics 2 Blood transfusion 3 Cooling baths 4 Nothing by mouth (NPO) status
1. Broad-spectrum antibiotics Rationale: Broad-spectrum antibiotics must be initiated within 1 hour of establishing diagnosis. A blood transfusion is indicated for low red blood cell (RBC) count or low hemoglobin and hematocrit; transfusion is not part of the sepsis resuscitation bundle. Cooling baths are not indicated because the client is hypothermic, nor is this part of the sepsis resuscitation bundle. NPO status is not indicated for this client, nor is it part of the sepsis resuscitation bundle.
How is a client with systemic inflammatory response syndrome (SIRS) differentiated from a client with sepsis? 1 Client with sepsis has hypotension. 2 Client with sepsis has a negative fluid balance. 3 Client with SIRS has hyperglycemia. 4 Client with SIRS has an elevated creatinine level.
1. Client with sepsis has hypotension. Rationale: The client with sepsis has two or more SIRS criteria and one of the following: hypotension, oliguria, positive fluid balance, decreased capillary refill, hyperglycemia, change in mental status, or increasing creatinine. The SIRS criteria include temperature of >100.4° F or < 96.8° F, pulse >90 beats/min, respiratory rate >20 breaths/min or a Paco2 <32 mm Hg, or white blood cell count of >12,000/mm3 or <4000/mm3.
The nursing assistant is concerned about a postoperative client with blood pressure (BP) of 90/60 mm Hg, heart rate of 80 beats/min, and respirations of 22/min. What does the supervising nurse do? 1 Compare these vital signs with the last several readings. 2 Request the surgeon see the client. 3 Increase the rate of intravenous fluids. 4 Reassess vital signs using different equipment.
1. Compare these vital signs with the last several readings. Rationale: Vital sign trends must be taken into consideration; a BP of 90/60 may be normal for this client. Calling the surgeon is not necessary at this point, and increasing IV fluids is not indicated. The same equipment should be used when vital signs are taken postoperatively.
Which assessment findings are consistent with the nonprogressive (compensatory) phase of shock? Select all that apply. 1 Cool skin 2 Bradycardia 3 Elevated liver function tests 4 Restlessness 5 Tachypnea 6 Anxiety
1. Cool skin 4. Restlessness 5. Tachypnea 6. Anxiety Rationale: Thirst, anxiety, restlessness, tachycardia, and increased respiratory rate (tachypnea) along with oliguria and narrowing pulse pressure appear in the nonprogressive (compensatory) stage of shock. Organ damage manifested by increased liver enzymes or kidney function occur in the progressive or intermediate phase of shock. Tachycardia, rather than bradycardia, occurs in shock states secondary to catecholamines released as compensatory mechanisms.
What are the actions of renin in the maintenance of blood pressure? Select all that apply. 1 Decrease urine output 2 Decrease sodium reabsorption 3 Constrict peripheral blood vessels 4 Stimulate cardiac pump activity 5 Increase blood potassium levels
1. Decrease urine output 3. Constrict peripheral blood vessels Rationale: Renin is produced in the body as a response to low blood pressure. This enzyme helps in maintaining blood pressure by decreasing urine output and constricting peripheral blood vessels. Renin also increases sodium reabsorption in the kidney which causes further retention of water. Renin does not directly affect cardiac function or potassium levels.
Which sign of hypovolemic shock does the nurse instruct the client who had an outpatient surgical procedure to report immediately? 1 Dizziness 2 Lack of appetite 3 Mild pain at the site of the procedure 4 1-cm clear yellow drainage from incision
1. Dizziness Rationale: Dizziness or lightheadedness may indicate hypotension and possible shock. Thirst, rather than anorexia, is a symptom of hypovolemic shock. Mild pain may occur after a surgical procedure, but increases in pain should be reported because this may indicate further bleeding with tissue compression. Obvious bleeding, rather than serous drainage, should be reported to the provider.
The client with which problem is at highest risk for hypovolemic shock? 1 Esophageal varices 2 Kidney failure 3 Arthritis and daily acetaminophen use 4 Kidney stone
1. Esophageal varices Rationale: Esophageal varices are caused by portal hypertension; the portal vessels are under high pressure and are prone to rupture, causing massive upper gastrointestinal (GI) bleeding and hypovolemic shock. As the kidneys fail, fluid is typically retained, causing fluid volume excess, not hypovolemia. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen and ibuprofen, not acetaminophen, predispose the client to GI bleeding and hypovolemia. Although a kidney stone may cause hematuria, there is not generally massive blood loss and hypovolemia.
A client has developed hypovolemic shock related to profound ascites and fluid shift. Which laboratory value does the nurse expect to see? 1 Hematocrit 54% 2 Paco2 45 mm Hg 3 Potassium 4.4 mEq/L 4 Lactic acid 2.2 mmol/L
1. Hematocrit 54% Rationale: Shock caused by dehydration or fluid shifts results in increased hemoglobin and hematocrit levels due to hemoconcentration. The Paco2, potassium, and lactic acid values given are within normal limits; they would be increased in the client who is in a shock state.
Which are risk factors for hypovolemic shock? Select all that apply. 1 Hemophilia 2 Malnutrition 3 Diuretic therapy 4 Spinal cord injury 5 Myocardial infarction
1. Hemophilia 2. Malnutrition 3. Diuretic therapy Rationale: Specific risk factors for hypovolemic shock include hemophilia, malnutrition, and diuretic therapy. Hypovolemia can be caused by impaired clotting in clients with hemophilia and malnourishment. Excessive diuresis due to diuretic therapy can also cause reduction in blood volume. Clients with spinal cord injury have distributive shock in which the total blood volume is not reduced but fluid shifts from the central vascular space. In clients with myocardial infarction, cardiac function is impaired which causes cardiogenic shock.
The client with which lab result is at risk for hemorrhagic shock? 1 International Normalized Ratio (INR) 7.9 2 Partial thromboplastin time (PTT) 12.5 seconds 3 Platelets 170,000/mm3 4 Hemoglobin 8.2 g/dL
1. International Normalized Ratio (INR) 7.9 Rationale: Prolonged INR indicates that blood takes longer than normal to clot; this client is at risk for bleeding. PTT of 12.5 and a platelet value of 170,000/mm3 are both normal and pose no risk for bleeding. Although a hemoglobin of 8.2 g/dL is low, the client could have severe iron deficiency or could have received medication affecting the bone marrow.
Which are cardiovascular manifestations of hypovolemic shock? Select all that apply. 1 Narrow pulse pressure 2 Postural hypotension 3 Decreased pulse rate 4 Decreased cardiac output 5 Bounding peripheral pulses
1. Narrow pulse pressure 2. Postural hypotension 4. Decreased cardiac output Rationale: In hypovolemic shock, total body fluid is reduced; therefore, the difference between systolic and diastolic pressure (pulse pressure) is decreased. Blood pressure in the body drops also causing postural hypotension. The decrease in blood volume causes a simultaneous decrease in cardiac output. There is a compensatory increase in pulse rate to restore cardiac output in shock. Peripheral pulses become weak in hypovolemic shock.
A client in hypovolemic shock presents with a normal hematocrit and hemoglobin. What type of fluid should the nurse anticipate the healthcare provider will prescribe to restore oncotic pressure? 1 Plasma 2 Whole blood 3 Ringer's lactate 4 Packed red cells
1. Plasma Rationale: The ideal intervention for restoring osmotic pressure in a client with normal hematocrit and hemoglobin is plasma. Plasma protein fractions and synthetic plasma expanders are used to increase fluid volume. Whole blood is suitable for replacing large blood losses in clients with a decrease in hemoglobin and hematocrit levels. Ringer's lactate does not restore oncotic pressure; it is a crystalloid that restores fluid volume and is used in instances where the client needs volume expansion and correction of acidosis. Packed red cells are chosen for moderate blood losses when the client needs red blood cells without added fluid volume.
A 70-year-old client is admitted after a spider bite to the finger 12 hours ago. Which of these assessment data suggest the client has sepsis? Select all that apply. RR 28/min, temp 101.5, HR 116, BP 92/60, lungs CTA, BG 142, WBC 14,500, Hgb 15g/dL, Na 140, K 4.1, AxO, anxious 1 Respiratory rate 2 Blood pressure 3 Breath sounds 4 Serum glucose 5 Anxiety 6 Serum potassium
1. Respiratory rate 2. Blood pressure 4. Serum glucose Rationale: Clients with sepsis present with a cluster of symptom manifestations in response to a systemic infection. Symptoms consistent with inflammation (tachycardia, tachypnea, temperature, white blood cell change) and additional clinical manifestations (hypotension, decreased urine output, positive fluid balance, decreased capillary refill, hyperglycemia, mental status change, increased serum creatinine) are seen in clients with sepsis.
A client recovering from an open reduction of the femur suddenly feels lightheaded, with increased anxiety and agitation. Which key vital sign differentiates a pulmonary embolism from early sepsis? 1 Temperature 2 Pulse 3 Respiration 4 Blood pressure
1. Temperature Rationale: A sign of early sepsis is low-grade fever. Both early sepsis and thrombus may cause tachycardia, tachypnea, and hypotension.
Which vital sign change in a client with hypovolemic shock indicates to the nurse that the fluid resuscitation therapy is effective? 1 Urine output increase from 5 to 35 mL/hr 2 Heart rate increase from 62 to 76 beats/min 3 Respiratory rate increase from 22 to 26 breaths/min 4 Core body temperature decrease from 98.8° F (37.1° C) to 98.2° F (36.8° C)
1. Urine output increase from 5 to 35 mL/hr Rationale: During shock, the kidneys and baroreceptors sense an ongoing decrease in mean arterial pressure and trigger the release of renin, antidiuretic hormone (ADH), aldosterone, epinephrine, and norepinephrine to start kidney compensation, which is very sensitive to changes in fluid volume. Renin, secreted by the kidney, causes decreased urine output. ADH increases water reabsorption in the kidney, further reducing urine output. These actions compensate for shock by attempting to prevent further fluid loss. This response is so sensitive that urine output is a very good indicator of fluid resuscitation adequacy. If the therapy is not effective, urine output does not increase. An increase in respiratory rate, increase in heart rate, and a decrease in core body temperature are not expected findings of successful fluid resuscitation.
A client wants to lose 1.5 pounds a week. After reviewing a diet history, the nurse determines the client typically eats 2450 calories a day. What should the client's calorie goal be to achieve this weight loss? (Record your answer using a whole number.) __ calories/day
1700 calories/day
A client experiencing shock asks the nurse, "What is going to happen to me?" Which response is best for the nurse to convey? 1 "You seem quite anxious. What do you think will happen?" 2 "We are doing everything appropriate for your condition, and I am monitoring you closely." 3 "The shock condition is taking the blood away from your brain. That is why you are anxious." 4 "Your blood pressure is quite low, which happens when you lose a lot of blood."
2. "We are doing everything appropriate for your condition, and I am monitoring you closely." Rationale: The client in shock should be reassured that appropriate treatment is being carried out. Reflecting the client's anxiety back to him or her at this time is not therapeutic, as the client has asked for information. Providing the physiologic rationale for the client's anxiety is not appropriate at this time, nor does it speak to the client's concerns. There is no indication that the client is losing blood, but in a shock state the blood pressure is low; however, this response does not answer the client's concern as to what will happen.
Which client does the nurse consider to be at highest risk for the development of sepsis? 1 75-year-old man with hypertension and early Alzheimer's disease 2 45-year-old woman 2 days postoperative from bowel surgery for treatment of cancer 3 80-year-old community-dwelling man with no other health problems undergoing cataract surgery 4 54-year-old woman with type 2 diabetes mellitus and severe degenerative joint disease of the right knee
2. 45-year-old woman 2 days postoperative from bowel surgery for treatment of cancer Rationale: The 45-year-old woman has several risk factors. First she has cancer which compromises immune function. Bowel surgery is the more significant risk factor for this client, as not only does major surgery further reduce the immune response, but the bowel cannot be "sterilized" for surgery. Therefore the usual bacteria of the bowel have the chance to escape the site and enter the bloodstream when the bowel is disrupted. The 75-year-old client with hypertension and Alzheimer's disease and the 80-year-old undergoing cataract surgery only have age as a risk factor for sepsis. The 54-year-old with type 2 diabetes and degenerative joint disease is at risk for sepsis due to the diabetes, but this client has no other risk factors.
A client with septic shock has been started on dopamine (Intropin) at 12 mcg/kg/min. Which response indicates a positive outcome? 1 Hourly urine output 10-12 mL/hr 2 Blood pressure 90/60 and mean arterial pressure (MAP) 70 3 Blood glucose 245 4 Serum creatinine 3.6 mg/d
2. Blood pressure 90/60 and mean arterial pressure (MAP) 70 Rationale: Dopamine improves blood flow by increasing peripheral resistance, which increases blood pressure—a positive response. Urine output less than 30 mL/hr or 0.5 mL/kg/hr and elevations in serum creatinine indicate poor tissue perfusion to the kidney and is a negative consequence of shock, not a positive response. Although a blood glucose of 245 is an abnormal finding, dopamine increases blood pressure and myocardial contractility, not glucose levels.
Which problem in the clients below best demonstrates the highest risk for hypovolemic shock? 1 Client receiving a blood transfusion 2 Client with severe ascites 3 Client with myocardial infarction 4 Client with syndrome of inappropriate antidiuretic hormone (SIADH) secretion
2. Client with severe ascites Rationale: Fluid shifts from vascular to intraabdominal may cause decreased circulating blood volume and poor tissue perfusion. Volume depletion is only one reason why a person may require a blood transfusion; anemia is another. The client receiving a blood transfusion does not have as high a risk as the client with severe ascites. Myocardial infarction results in tissue necrosis in the heart muscle; no blood or fluid losses occur. Owing to excess ADH secretion, the client with SIADH will retain fluid and therefore is not at risk for hypovolemic shock.
A client admitted with a bleeding duodenal ulcer is NPO and has a nasogastric tube in place connected to low continuous suction. What assessment finding does the nurse report to the provider as a possible indicator of nonprogressive stage of shock? 1 Serum potassium level of 4.7 mEq/L 2 Decrease in mean arterial pressure (MAP) from 76 mm Hg to 62 mm Hg 3 Urine output of 30 mL/hour 4 Increased confusion
2. Decrease in mean arterial pressure (MAP) from 76 mm Hg to 62 mm Hg Rationale: When shock progresses from the initial stage to the nonprogressive stage, symptoms are subtle but present. Once the client enters the progressive and refractory stage of shock, manifestations are more obvious and may not be responsive to therapy. Recognizing early manifestations of shock are important to client outcomes. The nonprogressive stage of shock is present when the MAP decreases by 10-15 mm Hg from baseline, urine output decreases, and heart rate and respiratory rate increase. Confusion and moderate hyperkalemia is observed in the progressive stage of shock. The client's urine output is still within normal limits as may be seen in the initial stage of shock, but urine output will continue to decrease as the shock stages progress.
The nurse plans to administer an antibiotic to a client newly admitted with septic shock. What action does the nurse take first? 1 Administer the antibiotic immediately. 2 Ensure that blood cultures were drawn. 3 Obtain signature for informed consent. 4 Take the client's vital signs.
2. Ensure that blood cultures were drawn. Rationale: Cultures must be taken to identify the organism for more targeted antibiotic treatment before antibiotics are administered. Antibiotics are not administered until after all cultures are taken. A signed consent is not needed for medication administration. Monitoring the client's vital signs is important, but the antibiotic must be administered within 1-3 hours; timing is essential.
Which finding contributes to an acidotic state in a client with septic shock? 1 Hemoglobin of 12 g/dL 2 Lactate level of 9.2 mmol/L 3 Platelet count of 150,000 cells/mm3 4 Peripheral oxygen saturation of 95%
2. Lactate level of 9.2 mmol/L Rationale: Elevated lactate levels occur with anaerobic metabolism consistent with metabolic acidosis. Hemoglobin of 12 g/dL is within normal range and does not reflect disseminated intravascular coagulation (DIC), which may be found in clients with septic shock. Platelets are low, but may reflect DIC if they drop further, rather than metabolic acidosis. A pulse oximetry reading of 95% is a normal value and does not support hypoxemia or tissue hypoxia.
Which clinical symptoms in a postoperative client indicate early sepsis with an excellent recovery rate if treated? 1 Localized erythema and edema 2 Low-grade fever and mild hypotension 3 Low oxygen saturation rate and decreased cognition 4 Reduced urinary output and an increased respiratory rate
2. Low-grade fever and mild hypotension Rationale: Low-grade fever and mild hypotension indicate very early sepsis, but with treatment, the probability of recovery is high. Localized erythema and edema indicate local infection. A low oxygen saturation rate and decreased cognition indicate active (not early) sepsis. Reduced urinary output and an increased respiratory rate indicate severe sepsis.
A client who underwent a radical colon resection for metastatic cancer has developed septic shock and remains neurologically unresponsive, unable to breathe without mechanical ventilator support, requires dialysis for renal function, is not tolerating tube feedings, and is beginning to show signs of hepatic failure. What condition does the nurse suspect the client has developed based on these clinical manifestations? 1 Late stage of septic shock 2 Multiple organ dysfunction syndrome (MODS) 3 Intercerebral hemorrhage 4 Adverse reaction to sedating agents
2. Multiple organ dysfunction syndrome (MODS) Rationale: Shock that progresses to the refractory stage causes irreversible cell death and tissue damage, releasing toxic metabolites that cause organs to fail. Once the sequence of multiple organs begins to fail because of the buildup of metabolites and toxins, the client's condition is termed multiple organ dysfunction syndrome. MODS involves the presence of altered organ functions in two or more organ systems. In this client, four organs have "failed' with a fifth (the liver) imminent.
Which term best describes the symptoms that occur in the nonprogressive (compensatory) phase of shock? 1 Hypoxemia 2 Oliguria 3 Decreased tissue perfusion 4 Blood loss related to hemorrhage
2. Oliguria Rationale: Compensatory mechanisms in the nonprogressive stage of shock result from increased sympathetic nervous stimulation and release of antidiuretic hormone (ADH); vasoconstriction and water retention to maintain fluid volume occur with oliguria as a result. Problems such as reduction in mean arterial pressure and tissue perfusion, hypoxemia, and acid-base imbalances occur in the compensatory phase, but compensatory mechanisms keep the pulse oximetry reading within 2-5% of baseline. Blood loss may occur in hemorrhagic or hypovolemic shock; this question addresses the overall shock state.
The client in shock has the following vital signs: T 99.8° F, P 132, R 32, and BP 80/58. Calculate the pulse pressure and record as a whole number.
22 Rationale: Pulse pressure is the difference between the systolic and diastolic pressures. 80 (systolic) - 58 (diastolic) = 22 (pulse pressure)
A client is receiving continuous tube feeding at 70 mL/hr. When the bag is empty, how much formula does the nurse add? (Record your answer using a whole number.) _____ mL
280 mL
The nurse is instructing a client about infection prevention strategies to reduce the risk of sepsis. Which client response suggests further self-management teaching is needed prior to discharge? 1 "I will avoid crowds and large gatherings until I am better." 2 "I'll make sure the dishwasher is set on hot to wash and dry my dishes." 3 "I won't need help anymore to care for my cats and change the litter box." 4 "I guess I won't work in the garden for a few more months."
3. "I won't need help anymore to care for my cats and change the litter box." Rationale: Protecting clients from infection and sepsis at home through education is an important nursing function. Clients need to understand the importance of good handwashing, balanced diet, rest and exercise, as well as staying away from large crowds and other sources of infection like dirt and animal litter boxes.
Which medications are often used to provide adrenal support for the client with severe sepsis? Select all that apply. 1 Penicillin 2 Levofloxacin (Levoquin) 3 Hydrocortisone (Solu-cortef) 4 Fludrocortisone (Florinef) 5 Vancomycin (Vancocin)
3. Hydrocortisone (Solu-cortef) 4. Fludrocortisone (Florinef) Rationale: During severe sepsis, the body's immune response can become self-destructive if not controlled. Drugs that provide adrenal support during severe sepsis are IV hydrocortisone and oral fludrocortisone. IV penicillin, levofloxacin, and vancomycin are antibiotics that help to kill the bacteria causing the sepsis.
A client in hypovolemic shock has been placed on an infusion of the vasopressor agent norepinephrine (Levophed). Which parameter indicates a desired client response to the therapy? 1 Heart rate change from 112 to 123 beats/min 2 Decreased peripheral pulses 3 Mean arterial pressure change from 66 to 78 mm Hg 4 Urine output remains at 30 mL/hour
3. Mean arterial pressure change from 66 to 78 mm Hg Rationale: If fluid therapy is not effective in increasing blood pressure, vasoconstricting drugs may be added to increase tissue perfusion. When vasoactive agents are administered, the nurse monitors for effectiveness by evaluating improvements in cardiac output and mean arterial pressure. An increase, not decrease, in urine output is a desired response. An increased heart rate is expected due to sympathetic nervous system stimulation of norepinephrine. Decreased peripheral pulses may occur due to vasoconstrictor effects, but it is not a desired response.
A client is scheduled for thoracotomy later today. Which entry noted on the medication reconciliation record poses a risk for perioperative hemorrhagic shock and causes the nurse to contact the provider immediately? 1 Captopril (Catapres) 2 Furosemide (Lasix) 3 Naproxen (Naprosyn) 4 Omeprazole (Prilosec)
3. Naproxen (Naprosyn) Rationale: Naproxen is a nonsteroidal antiinflammatory agent that poses a risk for bleeding. Captopril (for hypertension), furosemide (for heart failure), or omeprazole (prevents gastroesophageal reflux disease and gastrointestinal bleeding from stomach ulcers) do not pose risks for bleeding. Anticoagulants, aspirin, and NSAIDs should be questioned.
Which problem places a client at highest risk for sepsis? 1 Pernicious anemia 2 Pericarditis 3 Post-kidney transplant 4 Client owns an iguana
3. Post-kidney transplant Rationale: The post-kidney transplant client will need to take lifelong immune suppressant therapy and is at risk for infection from internal and external organisms. Pernicious anemia is related to lack of vitamin B12, not to bone marrow failure (aplastic anemia), which would place the client at risk for infection. Inflammation of the pericardial sac is an inflammatory condition that does not pose a risk for septic shock. Although owning pets, especially cats and reptiles, poses a risk for infection, the immune-suppressed kidney-transplant client has a very high risk for infection, sepsis, and death.
Which assessment data suggest that antibiotic therapy may be effective in the treatment of a client with sepsis? 1 Serum creatinine increases from 1.2 to 1.8 mg/dL 2 White blood cell count decreases from 15,000 to 13,500/mm3 3 Procalcitonin level decreases from 2.3 to 1.3 µg/L 4 Serum glucose increases from 112 to 146 mg/dL
3. Procalcitonin level decreases from 2.3 to 1.3 µg/L Rationale: No single laboratory test confirms the presence of sepsis. The return of abnormal labs to normal and stabilization of the client's presentation are used to evaluate treatment effectiveness. Procalcitonin is a promising new biomarker used in the evaluation of sepsis treatment. As levels of blood procalcitonin decrease, blood bacterial levels are also decreasing and may suggest that antibiotics are effectively treating the bacterial infection. An increase in serum creatinine clearance does not indicate the effectiveness of treatment for sepsis. A decrease in serum glucose would be expected, not an increase. The slight decrease in white blood cells may not signify the effectiveness of antibiotic therapy.
What typical sign/symptom indicates the early stage of septic shock? 1 Pallor and cool skin 2 Blood pressure 84/50 mm Hg 3 Tachypnea and tachycardia 4 Respiratory acidosis
3. Tachypnea and tachycardia Rationale: Signs of systemic inflammatory response syndrome, which precede sepsis, include rapid respiratory rate, leukocytosis, and tachycardia. In the early stage of septic shock, the client is usually warm and febrile. Hypotension does not develop until later in septic shock due to compensatory mechanisms. Respiratory alkalosis occurs early in shock because of an increased respiratory rate.
A client is receiving antineoplastic chemotherapy. Which measure does the nurse teach that will help prevent infection and sepsis? 1 Drink only bottled water. 2 Use disposable dishes. 3 Wash the dishes in the dishwasher. 4 Avoid being in the same room as the family pet.
3. Wash the dishes in the dishwasher. Rationale: Dishes should be washed in hot, soapy water or in a dishwasher to thoroughly cleanse them; there is no need to use disposable tableware. Water that has been standing longer than 15 minutes should be discarded; however, bottled water is not necessary. The client may be in the same room as, as well as touch, the family pet (with the exception of changing a litterbox—this should not be done); however, the client should wash the hands thoroughly with an antimicrobial soap after touching pets.
Which problem places a client at highest risk for septic shock? 1 Kidney failure 2 Cirrhosis 3 Lung cancer 4 40% burn injury
4. 40% burn injury Rationale: The skin forms the first barrier to prevent entry of organisms into the body; this client is at very high risk for sepsis and death. Although the client with kidney failure has an increased risk for infection, his skin is intact, unlike the client with burn injury. Although the liver acts as a filter for pathogens, the client with cirrhosis has intact skin, unlike the burned client. The client with lung cancer may be at risk for increased secretions and infection, but risk is not as high as for a client with open skin.
A client admitted with pneumonia and possible sepsis has a blood pressure of 90/46 mm Hg, heart rate of 128 beats/min, respiratory rate of 28/min, temperature of 38.5° C, no urine output for 4 hours, and central venous pressure of 2 mm Hg. The client arouses to name but is not oriented. Which order does the nurse implement first? 1 Obtain blood cultures. 2 Insert an indwelling urinary catheter. 3 Apply a cooling blanket. 4 Administer 500 mL intravenous colloid bolus over 30 minutes.
4. Administer 500 mL intravenous colloid bolus over 30 minutes. Rationale: A resuscitation bundle is used for the treatment of sepsis. While several interventions are part of a bundle, the nurse prioritizes the interventions based on the assessment of the client. Establishing perfusion is a priority with this client, thus starting the IV fluid bolus should be the first priority in care. Obtaining blood cultures, especially prior to administering antibiotics, is also important along with placing an indwelling urinary catheter to monitor the client's response to fluid therapy. A cooling blanket is not part of the bundle and may not be an appropriate intervention.
When caring for an obtunded client admitted with shock of unknown origin, which action does the nurse take first? 1 Obtain IV access and hang prescribed fluid infusions. 2 Apply the automatic blood pressure cuff. 3 Assess level of consciousness and pupil reaction to light. 4 Check the airway and respiratory status.
4. Check the airway and respiratory status. Rationale: When caring for any client, determining airway and respiratory status is the priority. The airway takes priority over obtaining IV access, applying the blood pressure cuff, and assessing for changes in the client's mental status.
A client is admitted to the hospital with elevated serum amylase and lipase levels and a decreased calcium level. Which gastrointestinal health problem is indicated by these laboratory findings? A. Acute pancreatitis B. Cirrhosis C. Crohn's disease D. Diarrhea
Acute pancreatitis These laboratory values are commonly found in clients with acute pancreatitis. They are not indicative of cirrhosis of the liver or Crohn's disease. These laboratory values are not found in a client with diarrhea.
The nurse is caring for a client who is receiving rituximab (Rituxan) for treatment of lymphoma. During the infusion, it is essential for the nurse to observe for which side effect? A.) Alopecia B.) Allergy C.) Fever D.) Chills
Allergy Allergy is the most common side effect of monoclonal antibody therapy (rituximab). Monoclonal antibody therapy does not cause alopecia. Although fever and chills are side effects of monoclonal antibody therapy, they would not take priority over an allergic response that could potentially involve the airway.
When caring for the client with hyperuricemia associated with tumor lysis syndrome (TLS), for which medication does the nurse anticipate an order? A.) Recombinant erythropoietin (Procrit) B.) Allopurinol (Zyloprim) C.) Potassium chloride D.) Radioactive iodine-131 (131I)
Allopurinol (Zyloprim) TLS results in hyperuricemia (elevation of uric acid in the blood), hyperkalemia, and other electrolyte imbalances; allopurinol decreases uric acid production and is indicated in TLS. Recombinant erythropoietin is used to increase red blood cell production and is not a treatment for hyperuricemia. Administering additional potassium is dangerous. Radioactive iodine-131 is indicated in the treatment of thyroid cancer, not TLS.
A client who is undergoing chemotherapy for breast cancer reports problems with concentration and memory. Which nursing intervention is indicated at this time? A.) Explain that this occurs in some clients and is usually permanent. B.) Inform the client that a small glass of wine may help her relax. C.) Protect the client from infection. D.) Allow the client an opportunity to express her feelings.
Allow the client an opportunity to express her feelings. Although no specific intervention for this side effect is known, therapeutic communication and listening may be helpful to the client. Evidence regarding problems with concentration and memory loss with chemotherapy is not complete, but the current thinking is that this process is usually temporary. The client should be advised to avoid the use of alcohol and recreational drugs at this time because they also impair memory. Chemotherapeutic agents are implicated in central nervous system function in this scenario, not infection.
Which finding in the first 24 hours after kidney transplantation requires immediate intervention? Abrupt decrease in urine output Blood-tinged urine Incisional pain Increase in urine output
An abrupt decrease in urine output may indicate complications such as rejection, acute kidney injury, thrombosis, or obstruction. Blood-tinged urine, incisional pain, and an increase in urine output are expected findings after kidney transplantation
Your patient is the 68-year-old man from the previous Clinical Judgment Challenge who had shortness of breath (SOB) for the past 2 to 3 days. His clinical condition deteriorated further, requiring intubation. The health care provider orders a CT scan of the chest. 3. A large fluid collection on the left side is found during the CT scan, and a thoracentesis is planned. What are your responsibilities in preparing for and assisting with this procedure?
An explanation of the procedure to the patient, verify that a consent has been obtained, determine allergies if a local anesthetic is to be used, and properly position the patient (although this may be modified from a nonintubated patient's position).
Which clinical manifestation indicates the need for increased fluids in a client with kidney failure? Increased blood urea nitrogen (BUN) Increased creatinine level Pale-colored urine Decreased sodium level
An increase in BUN can be an indication of dehydration, and an increase in fluids is needed. Increased creatinine indicates kidney impairment. Urine that is pale in color is diluted; an increase in fluids is not necessary. Sodium is increased, not decreased, with dehydration.
A 65-year old client is seeing his primary care provider for an annual examination. Which assessment finding alerts the nurse to an increased risk for bladder cancer? A. Smoking B. Urine with a high specific gravity C. Recurrent urinary tract infections D. History of cancer in another organ or tissue
Answer: A Rationale: Many compounds in tobacco enter the bloodstream and affect other organs, such as the bladder. Concentrated urine is associated with kidney stones and UTIs. The urinary bladder is not a common site for metastases.
An 84-year-old male client is being admitted after surgery to remove a section of his bowel (colectomy) following a diagnosis of colon cancer. His urine output from an indwelling urinary catheter after 3 hours in the postanesthesia care unit plus the amount in the bag on admission to the medical-surgical unit totals 100 mL. The urine is cloudy and dark yellow. He also has a history of hypertension. After evaluating the patency of the collection device, what is the most appropriate action for the nurse to perform? A. Notify the health care provider of the low urine output. B. Increase the rate of intravenous fluids until urine output is 0.5 mL/kg/hr. C. Continue to assess the client and re-evaluate urine output in 4 hours. D. Ask about his typical voiding patterns and about any previous episodes of urinary problems.
Answer: A Rationale: The lowest acceptable urine output to avoid acute kidney injury (AKI) is 0.5 mL/kg/hr, which, in this 70-kg man, is about 35 mL/hr or a total of at least 105 mL. Surgery places clients at risk for both hypo- and hypervolemia. Waiting an additional 4 hours to obtain 6-hour trend data delays the prompt assessment and intervention necessary to avoid AKI. It is not appropriate to increase fluid rate, and it is unlikely the client is ready to take oral fluid this soon after surgery on the gastrointestinal tract. Voiding is not an issue with a urinary collection device.
When providing care to a client who has undergone a nephrostomy for hydronephrosis, which observation alerts the nurse to a possible complication? A. Urine output of 15 mL/hr B. Tenderness at the surgical site C. Blood urea nitrogen (BUN) of 23 mg/dL D. Pink-tinged urine draining from the nephrostomy
Answer: A Rationale: Urine output after a nephrostomy should be at least 25 to 40 mL/hr. Tenderness is expected at a new incisional site; the slight elevation of BUN alone is not alarming or indicative of a complication specific to nephrostomy. Pink-tinged urine indicating hematuria is common after instrumentation, but frank blood or increased bleeding over time is not expected.
For which problem does the nurse assess the client who cannot breathe through the nose because of a severe septal deviation? A. Dry respiratory tract membranes B. Frequent episodes of tonsillitis C. Development of nasal polyps D. Difficulty swallowing
Answer: A *Rationale:* When inspired air passes through the nose, it is filtered, warmed, and humidified. When a person is unable to breathe through the nose because of an anatomical obstruction, he or she is at risk for excessive drying of the respiratory mucous membranes. This anatomical problem does not influence the development of tonsillitis or difficulty swallowing. Nasal polyps can contribute to nasal obstruction but is not caused by a septal deviation.
The client arrives to the primary care clinic with a problem of new abdominal pain and blood in her urine. She is afebrile. Which information is most important for the nurse to obtain from this client's history? A. Kidney cancer in the client's family B. Injury or trauma to the abdomen or pelvis C. Treatment for a urinary tract infection in the past 12 months D. Recent exposure to heavy metals, drugs, or other nephrotoxins
Answer: B Rationale: Bladder trauma or injury should be considered in the patient with abdominal pain. Lack of fever reduces suspicion for infection; pain is not usually associated with kidney cancer or acute and chronic kidney injury from nephrotoxins
A 60-year-old African-American client is newly diagnosed with mild chronic kidney disease (stage 2 CKD). She has a history of diabetes, and her current A1C is 8.0%. She asks the nurse whether any of the following factors could have caused this problem. Which factor should the nurse indicate may have influenced the development of CKD? A. She heavily salted her food as a child and teenager but added no extra salt to her food as an adult. B. Her chronic hyperglycemia caused blood vessel changes in the kidney that can damage kidney tissue. C. Her paternal grandparents had type 2 diabetes and hypertension. D. She drinks 2 cups of coffee water daily.
Answer: B Rationale: Diabetic nephropathy is the most common cause of end-stage renal disease (ESRD) needing dialysis. Managing hyperglycemia delays the onset and progression of CKD. This level of caffeine intake would not lead to either kidney damage or hypertension. The fact that she has reduced her salt intake during adulthood would only help prevent hypertensive kidney disease. The family history of type 2 diabetes and hypertension is a potential risk factor, but her own diabetes and lack of glycemic control manifested by the elevated A1C have a more direct and great adverse effect on kidney function.
Which statement made by the client newly diagnosed with polycystic kidney disease (PKD) indicates to the nurse that additional teaching for self-management is needed? A. "I will need to increase my daily water intake." B. "I will restrict my sodium to less than 2 mg daily." C. "Now I will need to take a blood pressure drug daily." D. "If I become sexually active or plan to have a family, I will seek genetic counseling."
Answer: B Rationale: Patients with PKD waste sodium rather than retaining it. They need an increased sodium and water intake. Aggressive control of hypertension is needed to preserve kidney function. Genetic counseling is advised before having children because PKD is inherited.
When assessing a client with diabetic nephropathy, which question about self-management should the nurse ask to determine whether the client is currently following best practices to slow progression of this condition? A. "Have you increased your protein intake to promote healing of the damaged nephrons?" B. "Do you avoid contact sports to reduce the risk for causing trauma to your kidneys?" C. "How do you manage your diet to keep your blood glucose levels in the target range?" D. "Have you increased your fluid intake based on urine output?"
Answer: C Rationale: All strategies to avoid prolonged or frequent hyperglycemia can slow progression of diabetic complications, and the open-ended question is nonjudgmental. Protein intake is likely to be advised to be decreased in response to kidney damage regardless of cause. Avoiding renal trauma is a good idea but not linked to best practices in diabetic nephropathy care. Although increasing fluid intake based on urine output may be a good idea during periods of strenuous activity or other dehydrating conditions, it is not linked to best practices for this condition.
The client passes a urinary stone that laboratory analysis indicates is composed of calcium oxalate. Based on this analysis, which instruction does the nurse specifically include for dietary prevention of the problem? A. "Increase your intake of meat, fish, and cranberry juice." B. "Avoid citrus fruits and citrus juices such as oranges." C. "Avoid dark green leafy vegetables such as spinach." D. "Decrease your intake of dairy products, especially milk."
Answer: C Rationale: Calcium oxalate stones form more easily in the presence of oxalate. Sources of oxalate include spinach, black tea, and rhubarb. Avoiding these sources of oxalate may reduce the number of stones formed. Citrus intake is not restricted in this type of stone and is often suggested to be increased. Dietary intake of calcium does not appear to affect calcium-based stone formation, although the client should avoid calcium mineral supplements. Moderation of meat reduces stone formation in general.
The nurse is completing documentation for a client with acute kidney injury who is being discharged today. The nurse notices that the client has a serum potassium level of 5.8 mEq/L. Which is the priority nursing action? A. Asking the client to drink an extra 500 mL of water to dilute the electrolyte concentration and then re-checking the serum potassium level B. Encouraging the client to eat potassium-binding foods and to contact his or her primary care provider within 24 hours. C. Checking the remaining values on the electrolyte panel and informing the provider of all results before the client is discharged. D. Applying a cardiac monitor and evaluating the client's muscle strength and muscle irritability.
Answer: C Rationale: Repeating the laboratory test is a reasonable option, but the provider must make this decision after being informed about the context, including the results of the entire electrolyte panel, which will also have information about renal function (creatinine and blood urea nitrogen). Although the potassium level is slightly elevated, it is not a value commonly associated with cardiac dysrhythmias or skeletal muscle changes. Although additional fluid intake may dilute some electrolytes, potassium is not generally altered by plasma volume. There are no foods that specifically bind potassium and, depending on the rapidity of the rise in serum potassium, waiting a day may result in harm to the patient.
For which hospitalized client does the nurse recommend the ongoing use of a urinary catheter? A. 36-year-old woman who is blind receiving diuretics B. 46-year-old man who has paraplegia and is admitted for asthma management C. 56-year-old woman who is admitted with a vaginal-rectal fistula and diabetes D. 66-year-old man who has severe osteoarthritis and high risk for falling
Answer: C Rationale: This client has a wound that can be irritated by urine and whose urinary tract could become infected by the draining fistula (her diabetes increases her overall risk for infection). All of these other clients could be managed with frequent toileting. The men could also be managed with external urine collection devices.
Which assessments are most important for the nurse to perform when monitoring a client who returns to the medical-surgical unit after a dye-enhanced CT scan? A. Body temperature and urine odor B. Kidney tenderness and flank pain C. Urine volume and color D. Specific gravity and pH
Answer: C Rationale: To prevent dye-induced nephrotoxicity, the nurse should evaluate the urine and ensure a large, dilute output for several hours after the test. Generally, the amount of contrast does not cause dehydration; the concern is that the high osmolar content of some dyes has a direct nephrotoxic affect. Kidney tenderness and flank pain may indicate bleeding, a complication from a kidney biopsy. Body temperature and urine odor may indicate a UTI after manipulation of the urinary tract system and manipulation (e.g., placement of a urinary catheter or instilling of fluid into the bladder) does not occur with a CT scan.
What is the effect of age-related decreased skeletal muscle strength on the effectiveness of gas exchange? A. Reduced gas exchange as a result of decreased alveolar surface B. Reduced gas exchange as a result of longer relaxation of bronchiolar smooth muscles. C. Reduced gas exchange as a result of decreased changes in pressures of the chest cavity. D. Reduced gas exchange as a result of failure of pulmonary circulation to fully perfuse lung tissue
Answer: C *Rationale:* Breathing occurs through changes in the size of and pressure within the chest cavity. Contraction and relaxation of chest muscles (and the diaphragm) cause changes in the size and pressure of the chest cavity. When skeletal muscle strength is decreased in these muscles, pressure changes are decreased, and less air moves in and out of the lungs. This reduced airflow limits gas exchange at the alveolar-capillary membrane. The alveolar surface itself is not decreased by weaker skeletal muscles, nor does this cause any relaxation of bronchiolar smooth muscle. Weaker skeletal muscles do not directly affect pulmonary circulation.
When auscultating the client's breath sounds, the nurse hears soft rustling sounds at the lung edges. What is the nurse's best action? A. Listen again with the bell of the stethoscope rather than the diaphragm. B. Ask the client to cough and spit out any collected mucus. C. Document the finding as the only action. D. Notify the health care provider.
Answer: C *Rationale:* The sounds described are vesicular sounds, which are normally heard at the peripheral lung fields where air flows through smaller bronchioles and alveoli. Thus, this is a normal finding that does not require any action other than documentation.
The client's urinalysis shows all of the following abnormal results. Which result does the nurse report to the health care provider immediately? A. pH 7.8 B. Protein 31 mg C. Sodium 15 mEq/L D. Leukoesterase and nitrate positive
Answer: D Rationale: Although the alkaline pH is abnormal, it may be the results of diet or other benign factors; the slight increase in protein is concerning but not urgent and may be explained by diet, strenuous activity, or other benign causes, similar to the slightly elevated sodium, which could be from salty food ingestion. However, the most common cause of positive leukoesterase result is a UTI, and this test is further confirmed with a positive nitrate result.
A client in the community health clinic is prescribed trimethoprim/sulfamethoxazole for cystitis. She reports that she developed hives to "something called Septra." What is the nurse's best action? A. Reassure the client that Septra is not trimethoprim/sulfamethoxazole. B. Highlight this important information in the client's medical record. C. Place an allergy alert band on the client's wrist. D. Notify the prescriber immediately.
Answer: D Rationale: Septra is a brand name for TMP-SMX, a sulfa-based antibiotic with multiple brand names. It is inappropriate to band a wrist in a community health clinic. This information may need to be added to the client's medical record, but simply highlighting the information will not prevent an avoidable adverse drug event. The provider needs the allergy information in order to substitute another effective antibiotic.
The patient is a 68-year-old man who has had shortness of breath (SOB) for the past 2 to 3 days. His past medical history includes a 40-packyear smoking history, COPD, and heart failure. He reports that he became concerned when he woke from sleep because he could not breathe. Your physical assessment reveals crackles in the lower lobes bilaterally. His oxygen saturation (SpO2) is 84% without supplemental oxygen. 1. What are some areas of focus to assess as part of this patient's current history?
Ask the patient to describe the onset of manifestations and any actions that exacerbate or alleviate them. Ask about the paroxysmal nocturnal dyspnea (PND), if the patient experiences orthopnea, and if so, how many pillows does he require in order to sleep. Ask about his endurance, how far he can walk, and if his SOB has affected his ability to complete his activities of daily living. Your history should also include all current over-the-counter and prescription medications as well as herbal supplements. Does the patient use oxygen at home? Is the patient working? If so, what type of work? Is there exposure to toxins? Does he have a cough? You should inquire about his smoking history; if he is currently smoking, does he have a plan to stop smoking? Smoking cessation counseling should be offered, and if agreeable to the patient, drugs for smoking cessation should be considered. Ask about other smokers in the home.
A client is being treated for kidney failure. Which statement by the nurse encourages the client to express his or her feelings and concerns about the risk for death and the disruption of lifestyle? "All of this is new. What can't you do?" "Are you afraid of dying?" "How are you doing this morning?" "What concerns do you have about your kidney disease?"
Asking the client about any concerns is open-ended and specific to the client's concerns. Asking the client to explain what he or she can't do implies inadequacy on the client's part. Asking the client if he or she is afraid of dying is too direct and would likely cause the client to be anxious. Asking the client how he or she is doing is too general and does not encourage the client to share thoughts on a specific topic.
The nurse is assessing a client who had abdominal surgery yesterday. What method provides the most accurate data about resumption of peristalsis in the client? A. Asking the client whether he or she has passed flatus (gas) B. Auscultating bowel sounds in all abdominal quadrants C. Counting the number of bowel sounds in each abdominal quadrant D. Observing the abdomen for symmetry and distention
Asking the client whether he or she has passed flatus (gas) The best and most reliable method for assessing the return of peristalsis following abdominal surgery is the client's report of passing flatus within the past 8 hours or stool within the past 12 hours. Although auscultation and counting the number of sounds was once a method of assessing for bowel activity, it is no longer considered the most effective method. Observing the abdomen is one method of examining a client's abdomen, but it is not a reliable way to assess for resumption of activity after surgery.
When caring for a client with a left forearm arteriovenous fistula created for hemodialysis, which actions must the nurse take? (Select all that apply.) Check brachial pulses daily. Auscultate for a bruit every 8 hours. Teach the client to palpate for a thrill over the site. Elevate the arm above heart level. Ensure that no blood pressures are taken in that arm.
Auscultate for a bruit every 8 hours. Correct Teach the client to palpate for a thrill over the site. Correct Ensure that no blood pressures are taken in that arm. Correct A bruit or swishing sound, and a thrill or buzzing sensation upon palpation should be present in this client, indicating patency of the fistula. No blood pressure, venipuncture, or compression, such as lying on the fistula, should occur. Distal pulses and capillary refill should be checked, and for a forearm fistula, the radial pulse is checked—the brachial pulse is proximal. Elevating the arm increases venous return, possibly collapsing the fistula.
A client with chronic kidney disease reports chest pain. The nurse notes tachycardia and low-grade fever. Which additional assessment is warranted? Auscultate for pericardial friction rub. Assess for crackles. Monitor for decreased peripheral pulses. Determine if the client is able to ambulate.
Auscultate for pericardial friction rub. The client with uremia is prone to pericarditis; symptoms include inspiratory chest pain, low-grade fever, and ST-segment elevation. Crackles and tachycardia are symptomatic of fluid overload; fever is not present. Although the nurse will monitor pulses, and ambulation is important to prevent weakness and deep vein thrombosis, these are not pertinent to the constellation of symptoms of pericarditis that the client presents with.
Which instruction by the nurse will help a client with chronic kidney disease prevent renal osteodystrophy? Consuming a low-calcium diet Avoiding peas, nuts, and legumes Drinking cola beverages only once daily Increasing dairy products enriched with vitamin D
Avoiding peas, nuts, and legumes Kidney failure causes hyperphosphatemia; this client must restrict phosphorus-containing foods such as beans, peas, nuts (peanut butter), and legumes. Calcium should not be restricted; hyperphosphatemia results in a decrease in serum calcium and demineralization of the bone. Cola beverages and dairy products are high in phosphorus, contributing to hypocalcemia and bone breakdown.
The client has been admitted for a pulmonary embolism and is receiving heparin infusion. What safety priority does the nurse include in the plan of care? A. Teach the client to avoid using dental floss. B. Monitor the platelet count daily. C. Ensure adequate staffing for the unit. D. Notify radiology of an impending scan.
B
The nurse is assessing a client who is receiving mechanical ventilation with positive end-expiratory pressure (PEEP). Which findings would cause the nurse to suspect a left-sided tension pneumothorax? A. Chest caves in on inspiration and "puffs out" on expiration. B. Trachea is deviated to the right side and cyanosis is present. C. The left lung field is dull to percussion with crackles present on auscultation. D. Client has bloody sputum and wheezes.
B
The nurse is caring for a client with impending respiratory failure who refuses intubation and mechanical ventilation. Which method provides an alternative to mechanical ventilation? A. Oropharyngeal airway B. Bi-level positive airway pressure (BiPAP) C. Non-rebreathing mask with 100% oxygen D. Positive end-expiratory pressure (PEEP)
B
The nurse is caring for a group of clients. The client with which condition is in greatest need of immediate intubation? A. Difficulty swallowing oral secretions B. Hypoventilation and decreased breath sounds C. O2 saturation of 90% D. Thick, purulent secretions and crackles
B
The ventilated client in the intensive care unit begins to pick at the bedcovers. Which action should the nurse take next? A. Increase the sedation, B. Assess for adequate oxygenation, C. Explain to the client that he has a tube in his throat to help him breathe, D. Request that the family leave to decrease the client's agitation,
B
When caring for a client with pulmonary embolism, which blood gas result does the nurse anticipate early in the course of the disease? A. pH 7.24, PCO2 55, HCO 26, PO2 56 B. pH 7.46, PCO2 30, HCO 26, PO2 68 C. pH 7.35, PCO2 45, HCO 24, PO2 80 D. pH 7.47, PCO2 35, HCO 30, PO2 75
B
Which client needs immediate attention by the RN? A. 40-year-old who is receiving continuous positive airway pressure (CPAP) and has intermittent wheezing B. 54-year-old who is mechanically ventilated and has tracheal deviation C. 57-year-old who was recently extubated and is reporting a sore throat D. 60-year-old who is receiving O2 by facemask and whose respiratory rate is 24
B
The client receiving continuous oxygen therapy by nasal cannula for an acute respiratory problem is becoming increasingly confused. What is your best first action? A. Notify the physician immediately. B. Increase the oxygen flow rate. C. Document the observation. D. Reposition the client from a high-Fowler's to a low-Fowler's position.
B Cerebral hypoxia is a cause of confusion and a sensitive indicator that the client needs more oxygen. Untreated or inadequately treated hypoxemia is life threatening. Although you would want to notify the physician of the change in the client's condition, the best action is first to increase the oxygen flow rate and then notify the physician.
The client is 24 hours postoperative after a tracheostomy has been performed. You find the client cyanotic, with the tracheostomy tube lying on his chest. What is your best first action? A. Assess the client's breath sounds bilaterally. B. Use a manual resuscitation bag to ventilate the client. C. Call the resuscitation team, including an anesthesiologist. D. Attempt to reinsert the tube, taking care to use the obturator.
B Reinsertion of the tracheostomy tube into the immature stoma at this time must be performed by a surgeon or anesthesiologist experienced with airway management. Using a manual resuscitation bag should provide enough airflow to prevent cerebral hypoxia until the emergency team arrives.
The client is prescribed to have 50% oxygen administered continuously in a noninvasive manner. Which type of delivery system should you select to meet these criteria? A. Nasal cannula B. Venturi mask C. Partial rebreather mask D. Transtracheal oxygen
B The Venturi mask is a high-flow oxygen delivery system that delivers the most accurate oxygen concentrations in a noninvasive manner.
Which nursing intervention in the preparation for or implementation of tracheal suctioning prevents tissue damage? A. Monitoring oxygen saturation while suctioning B. Applying suction only as the catheter is removed C. Hyperoxygenating the client before starting the procedure D. Selecting the largest catheter that fits into the tracheal lumen
B The actual suction can pull tissue into the openings of the suction catheter and damage this delicate mucous membrane. Applying suction only during removal of the catheter (and using a twirling motion) increases the chances that secretions are actually present when suction is applied and reduces the time that the tissues are exposed to suction.
Which low-flow oxygen delivery system provides the highest oxygen level to the client? A. Partial rebreather mask B. Nonrebreather mask C. Simple face mask D. Nasal cannula
B The nonrebreather mask has a one-way valve between the mask and the reservoir and two flaps over the exhalation ports. The valve allows the client to draw all needed oxygen from the reservoir bag, and the flaps prevent room air from entering through the exhalation ports. During exhalation, air leaves through these exhalation ports while the one-way valve prevents exhaled air from re-entering the reservoir bag. A nonrebreather mask provides the highest oxygen level of the low-flow systems and can deliver an FIO2 greater than 90%, depending on the client's breathing pattern
Which assessment finding indicates to you that the ties are properly secured after you have changed the tracheostomy ties? A. The tracheal tube moves slightly with each respiratory cycle. B. You can fit two fingers between the ties and the neck. C. The ties are fitted snugly against the client's neck. D. The ties hang loosely around the client's neck.
B Ties need to be secure enough to inhibit tube movement and loose enough not to impinge on neck structures
Which statement by a client with chronic obstructive pulmonary disease (COPD) indicates the need for additional follow-up instruction? A) "I don't need to use my oxygen all the time." B) "I don't need to get a flu shot." C) "I need to eat more protein." D) "It is normal to feel more tired than I used to." (Chp. 30; elseview resources)
B) "I don't need to get a flu shot." (Chp. 30; elseview resources)
A client is scheduled for a total laryngectomy. Which statement by the client indicates the need for further teaching about the procedure? A) "I hope I can learn esophageal speech." B) "I will have to take special care not to aspirate while eating." C) "I won't be able to breathe through my nose anymore." D) "It is hard to believe that I will never hear my own voice again." (Chp. 29; elsevier resources)
B) "I will have to take special care not to aspirate while eating." (Chp. 29; elsevier resources)
A client has been diagnosed with asthma. Which statement below indicates that the client correctly understands how to use an inhaler with a spacer? A) "I don't have to wait between the two puffs if I use a spacer." B) "If the spacer makes a whistling sound, I am breathing in too rapidly." C) "I should rinse my mouth and then swallow the water to get all of the medicine." D) "I should shake the inhaler only if I want to see whether it is empty." (Chp. 30; elseview resources)
B) "If the spacer makes a whistling sound, I am breathing in too rapidly." (Chp. 30; elseview resources)
The nurse is overseeing a nursing student who is administering medications to a group of clients with pulmonary disorders. Which statement by the student nurse indicates a correct understanding about thrombolytic therapy? A) "You will receive a dose of enoxaparin (Lovenox) intramuscularly for 3 days." B) "Therapy with warfarin (Coumadin) is effective when your INR is between 2 and 3." C) "Once the health care provider orders warfarin (Coumadin), we will discontinue the intravenous heparin." D) "If bleeding develops, we will give you platelets to reverse the anticoagulant." (Chp. 32, elsevier resources)
B) "Therapy with warfarin (Coumadin) is effective when your INR is between 2 and 3." (Chp. 32, elsevier resources)
The client says, "I hate this stupid COPD." What is the best response by the nurse? A) "Then you need to stop smoking." B) "What is bothering you?" C) "Why do you feel this way?" D) "You will get used to it." (Chp. 30; elseview resources)
B) "What is bothering you?" (Chp. 30; elseview resources)
A client is being discharged home with active tuberculosis. Which information does the nurse include in the discharge teaching plan? A) "You are not contagious unless you stop taking your medication." B) "You will not be contagious to the people you have been living with." C) "You will have to take these medications for at least 1 year." D) "Your sputum may turn a rust color as your condition gets better." (Chp. 31; elsevier resources)
B) "You will not be contagious to the people you have been living with." (Chp. 31; elsevier resources)
Which client needs immediate attention by the nurse? A) A 40-year-old who is receiving continuous positive airway pressure and has intermittent wheezing B) A 54-year-old who is mechanically ventilated and has tracheal deviation C) A 57-year-old who was recently extubated and is reporting a sore throat D) A 60-year-old who is receiving O2 by facemask and whose respiratory rate is 24 breaths/min (Chp. 32, elsevier resources)
B) A 54-year-old who is mechanically ventilated and has tracheal deviation (Chp. 32, elsevier resources)
A ventilated client in the intensive care unit (ICU) begins to pick at the bedcovers. Which action should the nurse take next? A) Increase the sedation. B) Assess for adequate oxygenation. C) Explain to the client that he has a tube in his throat to help him breathe. D) Request that the family leave to decrease the client's agitation. (Chp. 32, elsevier resources)
B) Assess for adequate oxygenation. (Chp. 32, elsevier resources)
The nurse coming on shift prepares to perform an initial assessment of a sedated, ventilated client. Which are priorities for the nurse to carry out? Select all that apply. A) Ask visitors to leave. B) Assess the client's color and respirations. C) Confirm alarms and ventilator settings. D) Ensure that the tube cuff is inflated and is in the proper position. E) Listen for bilateral breath sounds. F) Provide routine tracheotomy and endotracheotomy and mouth care. (Chp. 32, elsevier resources)
B) Assess the client's color and respirations. C) Confirm alarms and ventilator settings. D) Ensure that the tube cuff is inflated and is in the proper position. E) Listen for bilateral breath sounds. (Chp. 32, elsevier resources)
The nurse is caring for a client with impending respiratory failure who refuses intubation and mechanical ventilation. Which method provides an alternative to mechanical ventilation? A) Oropharyngeal airway B) Bi-level positive airway pressure (BiPAP) C) Non-rebreather mask with 100% oxygen D) Positive end-expiratory pressure (PEEP) (Chp. 32, elsevier resources)
B) Bi-level positive airway pressure (BiPAP) (Chp. 32, elsevier resources)
The change-of-shift report has just been completed on the medical-surgical unit. Which client will the oncoming nurse plan to assess first? A) Client with chronic obstructive pulmonary disease (COPD) who is ready for discharge, but is not able to pay for prescribed home medications. B) Client with cystic fibrosis (CF) who has an elevated temperature and a respiratory rate of 38 breaths/min. C) Hospice client with terminal pulmonary fibrosis and an oxygen saturation level of 89%. D) Client with lung cancer who needs an IV antibiotic administered before going to surgery. (Chp. 30; elseview resources)
B) Client with cystic fibrosis (CF) who has an elevated temperature and a respiratory rate of 38 breaths/min. (Chp. 30; elseview resources)
Which of these clients should the charge nurse assign to the LPN/LVN working on the medical-surgical unit? A) Client with group A beta-hemolytic streptococcal pharyngitis who has stridor B) Client with pulmonary tuberculosis who is receiving multiple medications C) Client with sinusitis who has just arrived after having endoscopic sinus surgery D) Client with tonsillitis who has a thick-sounding voice and difficulty swallowing (Chp. 31; elsevier resources)
B) Client with pulmonary tuberculosis who is receiving multiple medications (Chp. 31; elsevier resources)
Which components belong to the ventilator bundle approach to prevent ventilator-associated pneumonia (VAP)? Select all that apply. A) Administering antibiotic prophylaxis B) Continuous removal of subglottic secretions C) Elevating the head of the bed at least 30 degrees whenever possible D) Handwashing before and after contact with the client E) Placing a nasogastric tube F) Placing the client in a negative-airflow room (Chp. 32, elsevier resources)
B) Continuous removal of subglottic secretions C) Elevating the head of the bed at least 30 degrees whenever possible D) Handwashing before and after contact with the client (Chp. 32, elsevier resources)
A client with pneumonia caused by aspiration after alcohol intoxication has just been admitted. The client is febrile and agitated. Which health care provider order should the nurse implement first? A) Administer levofloxacin (Levaquin) 500 mg IV. B) Draw aerobic and anaerobic blood cultures. C) Give lorazepam (Ativan) as needed for agitation. D) Refer to social worker for alcohol counseling. (Chp. 31; elsevier resources)
B) Draw aerobic and anaerobic blood cultures. (Chp. 31; elsevier resources)
Which method is the best way to prevent outbreaks of pandemic influenza? A) Avoiding public gatherings at all times B) Early recognition and quarantine C) Vaccinating everyone with pneumonia vaccine D) Widespread distribution of antiviral drugs (Chp. 31; elsevier resources)
B) Early recognition and quarantine (Chp. 31; elsevier resources)
What does the nurse do first when setting up a safe environment for the new client on oxygen? A) Ensures that staff members wear protective clothing B) Ensures that no combustion hazards are present in the room C) Sets the oxygen delivery to maintain no fewer than 16 breaths/min D) Uses a pulse oximetry unit (Chp. 30; elseview resources)
B) Ensures that no combustion hazards are present in the room (Chp. 30; elseview resources)
The standard laryngectomy plan of care for a client admitted with laryngeal cancer includes these interventions. Which intervention will be most important for the nurse to accomplish before the surgery? A) Educate the client about ways to avoid aspiration when swallowing after the surgery. B) Establish a means for communicating during the immediate postoperative period, such as a Magic Slate or an alphabet board. C) Discuss appropriate clothing to wear that will help cover the laryngectomy stoma and decrease social isolation after surgery. D) Teach the client and significant others about how to suction and do wound care of the stoma. (Chp. 29; elsevier resources)
B) Establish a means for communicating during the immediate postoperative period, such as a Magic Slate or an alphabet board. (Chp. 29; elsevier resources)
Which symptom of pneumonia may present differently in the older adult than in the younger adult? A) Crackles on auscultation B) Fever C) Headache D) Wheezing (Chp. 31; elsevier resources)
B) Fever (Chp. 31; elsevier resources)
The charge nurse at an assisted-living facility receives report from an emergency department (ED) nurse about one of the resident clients. The client was sent to the ED with a fever, chills, muscle aches, and headache. The ED nurse reports the client's rapid influenza report came back from the laboratory positive for influenza A. What action by the nurse at the assisted-living facility is most appropriate? A) Prepare to administer antibiotics. B) Have the resident eat meals in his room. C) Provide oseltamivir (Tamiflu) to the staff. D) Arrange a follow-up chest x-ray in 2 weeks. (Chp. 31; p. 587)
B) Have the resident eat meals in his room. (Chp. 31; p. 587)
The client with which condition is in greatest need of immediate intubation? A) Difficulty swallowing oral secretions B) Hypoventilation and decreased breath sounds C) O2 saturation of 90% D) Thick, purulent secretions and crackles (Chp. 32, elsevier resources)
B) Hypoventilation and decreased breath sounds (Chp. 32, elsevier resources)
A client who has fallen off a roof arrives in the emergency department with possible head, neck, and chest trauma. All of these health care provider requests are received. Which action will the nurse take first? A) Give oxygen to keep O2 saturation greater than 93%. B) Immobilize the neck with a cervical collar. C) Infuse normal saline by large-bore IV catheter. D) Obtain computed tomography (CT) scan of head, neck, and chest. (Chp. 29; elsevier resources)
B) Immobilize the neck with a cervical collar. (Chp. 29; elsevier resources)
The nurse is teaching a client who has been newly diagnosed with cancer. For which side effect specific to radiation does the nurse teach prevention techniques? A) Hair loss B) Increased risk for sunburn C) Loss of appetite D) Pain at site of treatment (Chp. 30; elseview resources)
B) Increased risk for sunburn (Chp. 30; elseview resources)
An older client presents to the emergency department with a 2-day history of cough, pain on inspiration, shortness of breath, and dyspnea. The client never had a pneumococcal vaccine. The client's chest x-ray shows density in both bases. The client has wheezing upon auscultation of both lungs. Would a bronchodilator be beneficial for this client? A) It would not be beneficial for this client. B) It would help decrease the bronchospasm. C) It would clear up the density in the bases of the client's lungs. D) It would decrease the client's pain on inspiration. (Chp. 31; elsevier resources)
B) It would help decrease the bronchospasm. (Chp. 31; elsevier resources)
A client has been admitted for a pulmonary embolism and is receiving heparin infusion. What safety priority does the nurse include in the plan of care? A) Teach the client to avoid using dental floss. B) Monitor the platelet count daily. C) Ensure adequate staffing for the unit. D) Notify radiology of an impending scan. (Chp. 32, elsevier resources)
B) Monitor the platelet count daily. (Chp. 32, elsevier resources)
Which parameter indicates to the nurse that the short-acting beta-adrenergic agonist the client took 5 minutes ago for an acute asthma attack is effective? A) SpO2 decrease from 85% to 78% B) Peak expiratory flow rate increase from 50% to 70% C) The obvious use of accessory muscles during inhalation and exhalation D) Active bubbling in the humidifier chamber of the oxygen delivery system (Chp. 30; p. 557)
B) Peak expiratory flow rate increase from 50% to 70% (Chp. 30; p. 557)
The nurse is planning care for the non-English-speaking client who is on complete voice rest. What alternative method of communication does the nurse implement? A) Alphabet board B) Picture board C) Translator at the bedside D) Word board (Chp. 29; elsevier resources)
B) Picture board (Chp. 29; elsevier resources)
The nurse is assessing a client who is receiving mechanical ventilation with positive end-expiratory pressure. Which findings would cause the nurse to suspect a left-sided tension pneumothorax? A) The chest caves in on inspiration and "puffs out" on expiration. B) The trachea is deviated to the right side and cyanosis is present. C) The left lung field is dull to percussion with crackles present on auscultation. D) The client has bloody sputum and wheezes. (Chp. 32, elsevier resources)
B) The trachea is deviated to the right side and cyanosis is present. (Chp. 32, elsevier resources)
When caring for a client with pulmonary embolism (PE), which arterial blood gas results does the nurse anticipate early in the course of the disease? A) pH 7.24, PaCO2 55 mm Hg, HCO3- 26 mEq/L, PaO2 56 mm Hg B) pH 7.46, PaCO2 30 mm Hg, HCO3- 26 mEq/L, PaO2 68 mm Hg C) pH 7.35, PaCO2 45 mm Hg, HCO3- 24 mEq/L, PaO2 80 mm Hg D) pH 7.47, PaCO2 35 mm Hg, HCO3- 30 mEq/L, PaO2 75 mm Hg (Chp. 32, elsevier resources)
B) pH 7.46, PaCO2 30 mm Hg, HCO3- 26 mEq/L, PaO2 68 mm Hg (Chp. 32, elsevier resources)
Which priority problems may be considered for the client with heart failure? Select all that apply. a. Decreased fluid volume related to compromised regulatory mechanism b. Impaired Physical Mobility related to limited cardiovascular endurance c. Impaired Gas Exchange related to ventilation-perfusion imbalance d. Potential for pulmonary edema e. Risk for Ineffective renal Perfusion related to hypervolemia
B, C, D, E: Owing to intra-alveolar edema and poor cardiac output, the client is fatigued, has limited endurance, and may develop hypoxemia. Owing to limited cardiac reserve, the client is at risk for pulmonary edema. The client with heart failure has poor cardiac output, reduced blood flow to the kidney, and accumulation of pulmonary and peripheral fluid.
The nurse caring for the client with heart failure is concerned that digoxin toxicity has developed. For which signs and symptoms of digoxin toxicity does the nurse notify the provider? Select all that apply. a. Hypokalemia b. Sinus bradycardia c. Fatigue d. Serum digoxin level of 1.5 e. Anorexia
B, C, E: Digoxin toxicity may be manifested by bradycardia, fatigue, and/or anorexia. A - Incorrect: Hypokalemia causes increased sensitivity to the drug and toxicity, but it is not a symptom of toxicity. D - Incorrect: This represents a therapeutic value that is between 0.8 and 2.0.
The nurse in the urology clinic is providing teaching for a female client with cystitis. Which of these should be included in the teaching plan? Select all that apply. A. Cleanse the perineum from back to front after using the bathroom. B. Try to take in 64 ounces of fluid each day. C. Be sure to complete the full course of antibiotics. D. If your urine remains cloudy, call the clinic. E. Expect some flank discomfort until the antibiotic has worked.
B,C,D: Between 64 and 100 ounces (2 to 3 liters) of fluid should be taken daily to dilute bacteria and prevent infection. Not completing the course of antibiotics could suppress the bacteria, but would not destroy all bacteria, causing the infection to resurface. For persistent symptoms of infection, the client should contact the provider. The perineal area should be cleansed from front to back or "clean to dirty" to prevent infection. Cystitis produces suprapubic symptoms; flank pain occurs with infection or inflammation of the kidney.
When assessing the client with pyelonephritis, which finding does the nurse anticipate will be present? Select all that apply. A. Suprapubic pain B. Vomiting C. Chills D. Dysuria E. Oliguria
B,C,D: Burning (dysuria), urgency, and frequency, Chills along with fever, Nausea and vomiting are symptoms of pyelonephritis. Suprapubic pain is indicative of cystitis, not kidney infection (pyelonephritis). Oliguria is related to kidney impairment from severe or long-standing pyelonephritis.
Pt is diagnosed with stress incontinence and is started on propantheline (Pro-Banthine). What interventions does the nurse suggest to alleviate the side effects of this anticholinergic drug? Select all that apply. A. Administer the drug at bedtime. B. Encourage increased fluids. C. Increase fiber. D. Limit the intake of dairy products. E. Offer hard candy for "dry" mouth.
B,C,E. Anticholinergics cause dry mouth and constipation. Increasing fluids and fiber will help.
Which interventions are helpful in preventing bladder cancer? Select all that apply. A. Drinking 2½ liters of fluid a day B. Showering after working with or around chemicals C. Stopping the use of tobacco D. Using pelvic floor muscle exercises E. Wearing a lead apron when working with chemicals F. Wearing gloves and a mask when working around chemicals and fumes
B,C,F: Certain chemicals are known to be carcinogenic in evaluating the risk for bladder cancer. Bathing after exposure and Protective gear is advisable.Tobacco use is one of the highest if not the highest risk factor in the development of bladder cancer.
The health care provider prescribes the drug, estrogen (Premarin). Which risks does the nurse tell the client to expect? Select all that apply. A. Dry mouth B. Endometrial cancer C. Increased intraocular pressure D. Thrombophlebitis E. Vaginitis
B,D: Estrogen use can increase the risk for endometrial cancer and the risk for thrombophlebitis. Women who smoke-especially-should not use this drug.
The client is taking fludrocortisone (Florinef) for adrenal hypofunction. The nurse instructs the client to report which symptom while taking this drug? A. Anxiety B. Headache C. Nausea D. Weight loss
B. A side effect of fludrocortisone is hypertension. New onset of headache should be reported, and the client's blood pressure should be monitored. Anxiety is not a side effect of fludrocortisone and is not associated with adrenal hypofunction. Nausea is associated with adrenal hypofunction; it is not a side effect of fludrocortisone. Sodium-related fluid retention and weight gain, not loss, are possible with fludrocortisone therapy.
A client recently admitted with hyperparathyroidism has a very high urine output. Of these actions, what does the nurse do next? A. Calls the health care provider B. Monitors intake and output C. Performs an immediate cardiac assessment D. Slows the rate of IV fluids
B. Diuretic and hydration therapies are used most often for reducing serum calcium levels in clients with hyperparathyroidism. Usually, a diuretic that increases kidney excretion of calcium is used together with IV saline in large volumes to promote renal calcium excretion. The health care provider does not need to be notified in this situation, given the information available in the question. Cardiac assessment is part of the nurse's routine evaluation of the client. Slowing the rate of IV fluids is contraindicated because the client will become dehydrated due to the use of diuretics to increase kidney excretion of calcium.
A client had a parathyroidectomy 18 hours ago. Which finding requires immediate attention? A. Edema at the surgical site B. Hoarseness C. Pain on moving the head D. Sore throat
B. Hoarseness or stridor is an indication of respiratory distress and requires immediate attention. Edema at the surgical site of any surgery is an expected finding. Pain when the client moves the head or attempts to lift the head off the bed is an expected finding after a parathyroidectomy. Any time a client has been intubated for surgery, a sore throat is a common occurrence in the postoperative period. This is especially true for clients who have had surgery involving the neck.
A client being treated for hyperthyroidism calls the home health nurse and mentions that his heart rate is slower than usual. What is the nurse's best response? A. Advise the client to go to a calming environment. B. Ask whether the client has increased cold sensitivity or weight gain. C. Instruct the client to see his health care provider immediately. D. Tell the client to check his pulse again and call back later.
B. Increased sensitivity to cold and weight gain are symptoms of hypothyroidism, indicating an overcorrection by the medication. The client must be assessed further because he may require a lower dose of medication. A calming environment will not have any effect on the client's heart rate. The client will want to notify the health care provider about the change in heart rate. If other symptoms such as chest pain, shortness of breath, or confusion accompany the slower heart rate, then the client should see the health care provider immediately. If the client was concerned enough to call because his heart rate was slower than usual, the nurse needs to stay on the phone with the client while he re-checks his pulse. This time could also be spent providing education about normal ranges for that client.
A client has been diagnosed with hypothyroidism. What medication is usually prescribed to treat this disorder? A. Atenolol (Tenormin) B. Levothyroxine sodium (Synthroid) C. Methimazole (Tapazole) D. Propylthiouracil
B. Levothyroxine is a synthetic form of thyroxine (T4) that is used to treat hypothyroidism. Atenolol is a beta blocker that is used to treat cardiovascular disease. Methimazole and propylthiouracil are used to treat hyperthyroidism.
A client presents to the emergency department with acute adrenal insufficiency and the following vital signs: P 118 beats/min, R 18 breaths/min, BP 84/44 mm Hg, pulse oximetry 98%, and T 98.8° F oral. Which nursing intervention is the highest priority for this client? A. Administering furosemide (Lasix) B. Providing isotonic fluids C. Replacing potassium losses D. Restricting sodium
B. Providing isotonic fluid is the priority intervention because this client's vital signs indicate volume loss that may be caused by nausea and vomiting and may accompany acute adrenal insufficiency. Isotonic fluids will be needed to administer IV medications such as hydrocortisone. Furosemide is a loop diuretic, which this client does not need. Potassium is normally increased in acute adrenal insufficiency, but potassium may have been lost if the client has had diarrhea; laboratory work will have to be obtained. Any restrictions, including sodium, should not be started without obtaining laboratory values to establish the client's baseline.
A client has undergone a transsphenoidal hypophysectomy. Which intervention does the nurse implement to avoid increasing intracranial pressure (ICP) in the client? A. Encourages the client to cough and deep-breathe B. Instructs the client not to strain during a bowel movement C. Instructs the client to blow the nose for postnasal drip D. Places the client in the Trendelenburg position
B. Straining during a bowel movement increases ICP and must be avoided. Laxatives may be given and fluid intake encouraged to help with this. Although deep breathing is encouraged, the client must avoid coughing early after surgery because this increases pressure in the incision area and may lead to a cerebrospinal fluid (CSF) leak. If the client has postnasal drip, he or she must inform the nurse and not blow the nose; postnasal drip may indicate leakage of CSF. The head of the bed must be elevated after surgery.
Family members of a client diagnosed with hyperthyroidism are alarmed at the client's frequent mood swings. What is the nurse's response? A. "How does that make you feel?" B. "The mood swings should diminish with treatment." C. "The medications will make the mood swings disappear completely." D. "Your family member is sick. You must be patient."
B. Telling the family that the client's mood swings should diminish over time with treatment will provide information to the family, as well as reassurance. Asking how the family feels is important; however, the response should focus on the client. Any medications or treatment may not completely remove the mood swings associated with hyperthyroidism. The family is aware that the client is sick; telling them to be patient introduces guilt and does not address the family's concerns.
A client admitted with hyperthyroidism is fidgeting with the bedcovers and talking extremely fast. What does the nurse do next? A. Calls the provider B. Encourages the client to rest C. Immediately assesses cardiac status D. Tells the client to slow down
B. The client with hyperthyroidism often has wide mood swings, irritability, decreased attention span, and manic behavior. The nurse should accept the client's behavior and provide a calm, quiet, and comfortable environment. Because the client's behavior is expected, there is no need to call the provider. Monitoring the client's cardiac status is part of the nurse's routine assessment. Telling the client to slow down is unsupportive and unrealistic.
A 49-year-old woman comes to the emergency department with reports of black tarry stools that started 2 weeks ago. In taking a gastrointestinal (GI) history, which questions does the nurse ask that pertain to Gordon's Functional Health Patterns? (Select all that apply.) A. "Are you having any difficulty having sex? How frequently do you have sex?" B. "Do you have any difficulty chewing or swallowing?" C. "Do you have pain, diarrhea, gas, or any other problems? Do any specific foods cause these symptoms for you?" D. "What is your usual bowel elimination pattern? Frequency? Character?" E. "When was your last colonoscopy?"
B. "Do you have any difficulty chewing or swallowing?" C. "Do you have pain, diarrhea, gas, or any other problems? Do any specific foods cause these symptoms for you?" D. "What is your usual bowel elimination pattern? Frequency? Character?" E. "When was your last colonoscopy?" Chewing or swallowing difficulties affect the client's ability to get food into her GI system. Pain, diarrhea, gas, and foods that cause these symptoms constitute very important data for collection in the GI history. The client needs to be questioned about usual bowel elimination patterns—frequency and character are two descriptors. Colonoscopy history is also elicited from the client. Sexual difficulties and frequency are not generally affected by GI problems; this would not be a routine question in a GI problem inquiry.
Which clinical manifestation in the client with pyelonephritis indicates that treatment has been effective? A. Decreased urine output B. Decreased urine white blood cells C. Increased red blood cell count D. Increased urine specific gravity
B. A decreased presence of white blood cells indicates the eradication of infection.
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 nurse receives the change-of-shift report on four clients. Which client does the nurse decide to assess first? A. 26-year-old admitted 2 days ago with urosepsis with an oral temperature of 99.4° F (37.4° C) B. 28-year-old with urolithiasis who has been receiving morphine sulfate and has not voided for 8 hours C. 32-year-old admitted with hematuria and possible bladder cancer who is scheduled for cystoscopy D. 40-year-old with noninfectious urethritis who is reporting "burning" and has estrogen cream prescribed
B. Anuria may indicate urinary obstruction at the bladder neck or urethra and is an emergency because obstruction can cause acute kidney failure. The client may be oversedated and may not be aware of any discomfort caused by bladder distention.
A nurse is teaching a client with a neurogenic bladder to use intermittent self-catheterization for bladder emptying. Which client statement indicates a *need for further clarification*? A. "A small-lumen catheter will help prevent injury to my urethra." B. "I will use a new, sterile catheter each time I do the procedure." C. "My family members can be taught to help me if I need it." D. "Proper handwashing before I start the procedure is very important."
B. Catheters are cleaned and re-used. Proper handwashing and cleaning of the catheter have shown no increase in bacterial complications. Catheters are replaced when they show signs of deteriorating.
Which factor is an indicator for a diagnosis of hydronephrosis? A. History of nocturia B. History of urinary stones C. Recent weight loss D. Urinary incontinence
B. Causes of hydronephrosis or hydroureter include tumors, stones, trauma, structural defects, and fibrosis.
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.
What should the nurse teach the client who is undergoing a study using contrast media? A. "You will need to have anesthesia or sedation." B. "A feeling of heat or warmth occurs when the contrast is injected." C. "Expect your urine to have a pink or red tinge after the procedure." D. "You will not be able to eat or drink for 4 to 6 hours after the procedure."
B. Contrast medium causes a sensation of flushing, heat, or warmth as it circulates through the bloodstream.
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.
The charge nurse is making client assignments for the day shift. Which client would be best to assign to an LPN/LVN? A. A client who has just returned from having a kidney artery angioplasty B. A client with polycystic kidney disease who is having a kidney ultrasound C. A client who is going for a cystoscopy and cystourethroscopy D. A client with glomerulonephritis who is having a kidney biopsy
B. Kidney ultrasounds are noninvasive procedures without complications; the LPN/LVN can provide this care.
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.
Which factors place a client at risk for gastrointestinal (GI) problems? (Select all that apply.) A. Eating a high-fiber diet B. Smoking a half-pack of cigarettes per day C. Socioeconomic status D. Some herbal preparations E. Use of nonsteroidal anti-inflammatory drugs (NSAIDs)
B. Smoking a half-pack of cigarettes per day C. Socioeconomic status D. Some herbal preparations E. Use of nonsteroidal anti-inflammatory drugs (NSAIDs) Smoking or any tobacco use places a client in a higher-risk category for GI problems. Socioeconomic status can also influence the risk for GI problems; clients may not be able to afford to seek care or treatment and may put off seeking help. Some herbal preparations contribute to GI problems, such as Ayurvedic herbs, which can affect appetite, absorption, and elimination. NSAIDs can predispose clients to peptic ulcer disease or GI bleeding. High-fiber diets are generally believed to be healthy for most clients.
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.
The RN is caring for a client who has just had a kidney biopsy. Which of these actions should the nurse perform first? A. Obtain BUN and creatinine. B. Position the client supine. C. Administer pain medications. D. Check urine for hematuria.
B. The client is positioned supine for several hours after a kidney biopsy to decrease the risk for hemorrhage.
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.
A male client being treated for bladder cancer has a live virus compound instilled into his bladder as a treatment. What instructions does the nurse provide for postprocedure home care? A. "After 12 hours, your toilet should be cleaned with a 10% solution of bleach.". B. "Do not share your toilet with family members for the next 24 hours." C. "Please be sure to stand when you are urinating." D. "Your underwear worn during the procedure and for the first 12 hours afterward should be bagged and discarded."
B. The toilet should not be shared for 24 hours following the procedure because others using the toilet could be infected with the live virus that was instilled into the client. If the toilet must be shared, then specific cleaning precautions need to be taken each time the client uses the toilet. The best scenario is for the client not to share the toilet.
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.
While assessing a client with overactive bladder, the nurse discovers the client also has the following health problems. Which health problem could be made worse by the drug tolterodine (Detrol)? A. Asthma B. Glaucoma C. Hypotension D. Diabetes mellitus
B. Tolterodine is an anticholinergic drug that can raise intraocular pressure and make some types of glaucoma worse. It is absolutely contraindicated for clients with uncontrolled narrow- or closed-angle glaucoma. It can be used with caution for clients who are being treated for open-angle glaucoma if the disease is well controlled.
A 67-year-old client who had an abdominal x-ray as part of pre-admission testing for a gastrointestinal problem has just been told that he has a horseshoe-shaped kidney. He is very upset, telling the nurse that he has never had any health problems until the past month and now feels that he is "falling apart." What is the nurse's best response? A. Remind him that it was lucky that he was being x-rayed anyway and that the problem was found at an early stage. B. Reassure him that it is unlikely that the kidney shape is important since he has not had other kidney problems. C. Ask him whether anyone else in his family has ever been diagnosed with a horseshoe-shaped kidney. D. Reassure him that his health care provider will request a consultation with a kidney specialist.
B. Variations in the number and shape of the kidneys are relatively common. Most variations are not harmful and do not require further assessment. The fact that this client is 67 years old and has had few health problems is a good indication that this is just an incidental finding on x-ray and has no meaning for his kidney health.
Which percussion technique does the nurse use to assess the client with reports of flank pain? A. Places fingers outstretched over the flank area and percusses with fingertips B. Places one hand with palm down flat over the flank area and uses the other fisted hand to thump the hand on the flank C. Places one hand with the palm up over the flank area and cups the other hand to percuss the hand on the flank D. Quickly taps the flank area with cupped hands
B. While the client assumes a sitting, side-lying, or supine position, form one of the hands into a clenched fist. Place the other hand flat over the costovertebral (CVA) angle of the client. Then, quickly deliver a firm thump to the hand over the CVA area.
The client begins therapy with lisinopril (Prinivil, Zestril). What should the nurse consider at the start of therapy with this medication? a. The client's ability to understand medication teaching b. The risk for hypotension c. The potential for bradycardia d. Liver function tests (LFTs)
B: Angiotensin-converting enzyme (ACE) inhibitors are associated with first-dose hypotension and orthostatic hypotension, which are more likely in those older than 75 years. Although desirable, understanding of medication teaching is not essential. ACE inhibitors are vasodilators; they do not affect heart rate. Renal function, not liver function, may be altered by ACE inhibitors.
The home health nurse visits a client with heart failure who has gained 5 pounds in the past 3 days. The client states, "I feel so tired and short of breath." Which action should the nurse take first? a. Assess the client for peripheral edema. b. Listen to the client's posterior breath sounds. c. Notify the physician about the client's weight gain. d. Remind the client about dietary sodium restrictions.
B: Because the client is at risk for pulmonary edema and hypoxemia, the first action should be to assess breath sounds. Assessment of edema may be delayed while the nurse focuses on breathing and breath sounds. After a full assessment, the nurse should notify the physician. Defer this action until physiologic stability is attained; then ask the client about behaviors that may have caused the weight gain, such as increased sodium intake or changes in medications.
The nurse recognizes that which medication when given in heart failure may improve morbidity and mortality? a. Dobutamine (Dobutrex) b. Carvedilol (Coreg) c. Digoxin (Lanoxin) d. Bumetamide (Bumex)
B: Beta-adrenergic blockers reverse consequences of sympathetic stimulation and catecholamine release that worsen heart failure; they improve morbidity, mortality, and quality of life. Dobutamine and digoxin are inotropic agents used in acute heart failure; they do not improve mortality. Bumetamide is a high-ceiling diuretic that promotes fluid excretion; it does not improve morbidity and mortality.
A client with heart failure has furosemide (Lasix). Which finding would concern the nurse with this new prescription? a. Serum sodium level of 135 mEq/L b. Serum potassium level of 2.8 mEq/L c. Serum creatinine of 1.0 mg/dL d. Serum magnesium level of 1.9 mEq/L
B: Clients taking loop diuretics should be monitored for potassium deficiency from diuretic therapy.
How does the nurse in the cardiac clinic recognize that the client with heart failure has demonstrated a positive outcome related to the addition of metoprolol (Lopressor) to the medication regimen? a. Ejection fraction is 25%. b. Client states that she is able to sleep on one pillow. c. Client was hospitalized five times last year with pulmonary edema. d. Client reports that she experiences palpitations.
B: Improvement in activity tolerance, less orthopnea, and improved symptoms represent a positive response to beta blockers. An ejection fraction of 25% is well below the normal ejection fraction of 50% to 70% and indicates poor cardiac output. Repeated hospitalization for acute exacerbation of left-sided heart failure does not demonstrate a positive outcome. Although metoprolol decreases the heart rate, palpitations are defined as the feeling of the heart beating fast in the chest; this is not a positive outcome.
The client who has been admitted for the third time this year for cardiac failure says, "This isn't worth it anymore. I just want it all to end." What is the nurse's best response? a. Calls the family to lift the client's spirits b. Considers further assessment for depression c. Sedates the client to decrease myocardial oxygen demand d. Tells the client that things will get better
B: This client is at risk for depression because of the diagnosis of heart failure, and further assessment should be done. Calling the family to help distract the client does not address the core issue. Sedation is inappropriate in this situation because it ignores the client's feelings. Telling the client that things will get better may give the client false hope and ignores his feelings.
Which of these clients is best to assign to an LPN/LVN working on the telemetry unit? a. A client with heart failure who is receiving dobutamine (Dobutrex) b. A client with restrictive cardiomyopathy who uses oxygen for exertional dyspnea c. A client with pericarditis who has a paradoxical pulse and distended jugular veins d. A client with rheumatic fever who has a new systolic murmur
B: This client, who needs oxygen only with exertion, is the most stable; administration of oxygen to a stable client is within the scope of LPN/LVN practice. Option A: This client is receiving an intravenous inotropic agent, which requires monitoring by the professional nurse. Option C: This client is displaying signs of cardiac tamponade and requires immediate life-saving intervention. Option D: A new-onset murmur requires assessment and notification of the provider, which is within the scope of practice of the professional nurse.
Which clinical manifestation alerts you to the presence of hypoventilation when you are monitoring a client with chronic lung disease and hypercarbia who is receiving oxygen therapy? A. Coarse crackles and wheezes on auscultation B. Slow, shallow respirations C. Pulse oximetry of 90% D. Clubbing of the fingers
BAs the client's PaO2 rises, the client's color and pulse oximetry improve and cannot be used to determine hypoventilation. As the client's PaO2 rises, respirations decrease in depth and rate, indicating hypoventilation.
The nurse coming on shift prepares to perform an initial assessment of the sedated ventilated client. Which are priorities for the nurse to carry out? Select all that apply. A. Ask visitors to leave. B. Assess the client's color and respirations. C. Confirm alarms and ventilator settings. D. Ensure that the tube cuff is inflated and is in the proper position. E. Listen for bilateral chest sounds. F. Provide routine tracheotomy and endotracheotomy and mouth care.
BCDE
What is the physiologic consequences of CO2 narcosis? A. Excessive sleepiness in the client with hypercarbia B. Failure of rising blood levels of CO2 to trigger more rapid and deeper respirations C. A change in the ventilation-perfusion ratio, in which ventilation exceeds perfusion D. Increase in the percentage of oxygen delivered to the client does not result in an increased PaO2
BIn the healthy person, a rising PaCO2 level is the drive to breathe and stimulates an increased rate and depth of respiration. When the PaCO2 rises gradually, the central chemoreceptors lose their sensitivity and are no longer the drive to breathe, a condition called CO2 narcosis. Thus, the only trigger to stimulate breathing in clients with CO2 narcosis is hypoxemia, a declining PaO2 level
The nurse is teaching a client who is receiving an antiestrogen drug about the side effects she may encounter. Which side effects does the nurse include in the discussion? (Select all that apply.) A.) Heavy menses B.) Smooth facial skin C.) Hyperkalemia D.) Breast tenderness Correct E.) Weight loss F.) Deep vein thrombosis Correct
Breast tenderness Deep vein thrombosis Breast tenderness and shrinking breast tissue may occur with antiestrogen therapy. Venous thromboembolism may also occur. Irregular menses or no menstrual period is the typical side effect of antiestrogen therapy. Acne may also develop. Hypercalcemia, not hyperkalemia, is typical. Fluid retention with weight gain may also occur.
When caring for the client receiving cancer chemotherapy, which signs or symptoms related to thrombocytopenia should the nurse report to the health care provider? (Select all that apply.) A.) Bruises B.) Fever C.) Petechiae D.) Epistaxis E.) Pallor
Bruises Petechiae Epistaxis Bruising, petechiae, and epistaxis (nosebleeds) are symptoms of a low platelet count. Fever is a sign of infection secondary to neutropenia. Pallor is a sign of anemia.
The nurse is caring for a client who is receiving mechanical ventilation and hears the high-pressure alarm. Which action should the nurse take first? A. Check the ventilator alarm settings. B. Assess the set tidal volume. C. Listen to the client's breath sounds. D. Call the respiratory therapist
C
The nurse is caring for a group of clients. Which person does the nurse identify as having the highest risk for pulmonary embolism (PE)? A. A client with diabetes and cellulitis of the leg B. A client receiving IV fluids through a peripheral line C. A client returning from an open reduction and internal fixation of the tibia D. A client with hypokalemia receiving potassium supplements
C
The nurse is caring for a group of critically ill clients. Which client has the greatest risk for developing acute respiratory distress syndrome (ARDS)? A. A client with diabetic ketoacidosis (DKA) B. A client with atrial fibrillation C. A client with aspiration pneumonia D. A client with acute renal failure
C
The nurse is developing the plan of care for the client with pulmonary embolism (PE). Which client problem does the nurse establish as the priority? A. Inadequate nutrition related to food-drug interactions and anticoagulant therapy B. Potential for infection related to leukocytosis C. Hypoxemia related to ventilation-perfusion mismatch Insufficient knowledge related to the cause of pulmonary
C
The nurse is teaching the family of a client who is receiving mechanical ventilation. Which statement reflects appropriate information that the nurse should communicate? A. Sedation is needed so your loved one does not rip the breathing tube out. B. Suctioning is important to remove organisms from the lower airway. C. Paralysis and sedatives help decrease the demand for oxygen. D. We are encouraging oral and intravenous fluids to keep your loved one hydrated.
C
Which action should you take to prevent hypoxia during nasotracheal suctioning? A. Measuring pulse oximetry throughout the procedure B. Inserting the suction catheter through the vocal cords when the client exhales C. Administering 100% oxygen by manual resuscitation bag before initiating suctioning D. Removing the suction tube from the nasopharynx as soon as the client begins to cough
C Hyperoxygenating the client before the procedure helps prevent hypoxia
Which blood gas value indicates that the client is experiencing hypercarbia? A. pH = 7.33 B. Bicarbonate = 20 mEq/L C. PaCO2 = 60 mm Hg D. PaO2 = 80 mm Hg
C The low pH, the elevated carbon dioxide level, and the low oxygen concentration all indicate that the client is experiencing poor gas exchange and has acidosis. The low pH and the low oxygen concentration could occur without hypercarbia. Only the elevated carbon dioxide concentration confirms hypercarbia.
You notice that the reservoir bag on the partial rebreather mask of the client receiving oxygen therapy is only about two-thirds inflated during inhalation. What is your best action? A. Notify the physician. B. Increase the oxygen flow rate. C. Document the finding. D. Assess the client's arterial blood gas values.
C The reservoir bag on partial rebreather masks should be two-thirds inflated. Full inflation does not increase the efficiency of the oxygen delivery
Which technique should you teach the caregiver and client with a tracheostomy to reduce the risk for aspiration during feeding/eating? A. Encourage the client to swallow as fast as possible to limit the time the client is at risk for aspiration. B. Tell the client and family to keep the phone nearby during feedings to shorten the time it takes to dial 911. C. Teach the client/caregiver to thicken liquids and avoid foods that generate thin liquids during chewing. D. Instruct the client/caregiver to inflate the cuff maximally during and for 1 hour after the feeding.
C Thin liquids are hard to control and can slip past the epiglottis and into the trachea. Thicker liquids remain as a bolus that the client can control during breathing so that he or she does not attempt to swallow during an inhalation.
After receiving education on the correct use of emergency drug therapy for asthma, which statement by the client indicates a correct understanding of the nurse's instructions? A) "Asthma drugs help everybody breathe better." B) "I must carry my emergency inhaler only when activity is anticipated." C) "I must have my emergency inhaler with me at all times." D) "Preventive drugs can stop an attack." (Chp. 30; elseview resources)
C) "I must have my emergency inhaler with me at all times." (Chp. 30; elseview resources)
Which precaution is most important for the nurse to teach a client who is a secretary and just had nasal tubes removed after a posterior nasal bleed? A) "Avoid NSAIDs for at least 1 week." B) "Wait 4 weeks before returning to work." C) "If bleeding recurs, call 911 immediately." D) "Do not blow your nose for at least a month." (Chp. 29; p. 533)
C) "If bleeding recurs, call 911 immediately." (Chp. 29; p. 533)
The nurse is teaching the family of a client who is receiving mechanical ventilation. Which statement reflects appropriate information that the nurse should communicate? A) "Sedation is needed so your loved one does not rip the breathing tube out." B) "Suctioning is important to remove organisms from the lower airway." C) "Paralysis and sedatives help decrease the demand for oxygen." D) "We are encouraging oral and IV fluids to keep your loved one hydrated." (Chp. 32, elsevier resources)
C) "Paralysis and sedatives help decrease the demand for oxygen." (Chp. 32, elsevier resources)
The nurse is caring for a group of clients. Which person does the nurse identify as having the highest risk for pulmonary embolism (PE)? A) A client with diabetes and cellulitis of the leg B) A client receiving IV fluids through a peripheral line C) A client returning from an open reduction and internal fixation of the tibia D) A client with hypokalemia receiving potassium supplements (Chp. 32, elsevier resources)
C) A client returning from an open reduction and internal fixation of the tibia (Chp. 32, elsevier resources)
What is the greatest risk factor for lung cancer? A) Alcohol consumption B) Asbestos exposure C) Cigarette smoking D) Smoking marijuana (Chp. 30; elseview resources)
C) Cigarette smoking (Chp. 30; elseview resources)
A local hunter is admitted to the intensive care unit with a diagnosis of inhalation anthrax. Which medications does the RN anticipate the health care provider will order? A) Amoxicillin (Amoxil, Triamox) 500 mg orally every 8 hours B) Ceftriaxone (Rocephin) 2 g IV every 8 hours C) Ciprofloxacin (Cipro) 400 mg IV every 12 hours D) Pyrazinamide (Zinamide) 1000 to 2000 mg orally every day (Chp. 31; elsevier resources)
C) Ciprofloxacin (Cipro) 400 mg IV every 12 hours (Chp. 31; elsevier resources)
Which critically ill client has the greatest risk for developing acute respiratory distress syndrome (ARDS)? A) Client with diabetic ketoacidosis (DKA) B) Client with atrial fibrillation C) Client with aspiration pneumonia D) Client with acute kidney failure (Chp. 32, elsevier resources)
C) Client with aspiration pneumonia (Chp. 32, elsevier resources)
The medical-surgical unit has one negative-airflow room. Which of these four clients who have just arrived on the unit should the charge nurse admit to this room? A) Client with bacterial pneumonia and a cough productive of green sputum B) Client with neutropenia and pneumonia caused by Candida albicans C) Client with possible pulmonary tuberculosis who currently has hemoptysis D) Client with right empyema who has a chest tube and a fever of 103.2° F (Chp. 31; elsevier resources)
C) Client with possible pulmonary tuberculosis who currently has hemoptysis (Chp. 31; elsevier resources)
The nurse is preparing a client for discharge who has undergone percutaneous needle aspiration of a peritonsillar abscess. Which is most important to teach the client about follow-up care? A) Completing the antibiotic medication regimen B) Taking pain medications every 4 to 6 hours C) Contacting the provider if the throat feels more swollen D) Using warm saline gargles and irrigations (Chp. 31; elsevier resources)
C) Contacting the provider if the throat feels more swollen (Chp. 31; elsevier resources)
The chest tube of a client 16 hours postoperative from a lobectomy is accidentally pulled out by a portable x-ray machine. What is the nurse's best first action? A) Clamp the tubing with padded clamps as close as possible to the insertion site. B) Reposition the client on the nonoperative side and support the tube(s) with pillows. C) Cover the insertion site with a sterile occlusive dressing and tape down on three sides. D) Don sterile gloves and attempt to reinsert the chest tube at the original insertion site. (Chp. 30; p. 579)
C) Cover the insertion site with a sterile occlusive dressing and tape down on three sides. (Chp. 30; p. 579)
The client is a woman with severe angioedema and tongue swelling from exposure to seafood. She has stridor, and her oxygen saturation is 70%. For which type of respiratory support does the nurse prepare? A) Nasal BiPAP B) Tracheotomy C) Cricothyroidotomy D) Endotracheal intubation (Chp. 29; p. 537)
C) Cricothyroidotomy (Chp. 29; p. 537)
The nurse is assessing a client who underwent nasoseptoplasty 24 hours ago. Which finding requires immediate intervention by the nurse? A) Ecchymosis B) Edema C) Excessive swallowing D) Sore throat (Chp. 29; elsevier resources)
C) Excessive swallowing (Chp. 29; elsevier resources)
The nurse is developing a plan of care for a client with pulmonary embolism (PE). Which client problem does the nurse establish as the priority? A) Inadequate nutrition related to food-drug interactions and anticoagulant therapy B) Potential for infection related to leukocytosis C) Hypoxemia related to ventilation-perfusion mismatch D) Insufficient knowledge related to the cause of PE (Chp. 32, elsevier resources)
C) Hypoxemia related to ventilation-perfusion mismatch (Chp. 32, elsevier resources)
A client is 1 day postoperative from a total laryngectomy for cancer. He has indicated to the nurse that he is experiencing pain. Pain management for him is best achieved with which medication? A) IV ketorolac (Toradol) B) IV midazolam (Versed) C) IV morphine sulfate (Morphine) D) Oral acetaminophen (Tylenol) (Chp. 29; elsevier resources)
C) IV morphine sulfate (Morphine) (Chp. 29; elsevier resources)
The nurse is caring for a client who is receiving mechanical ventilation and hears the high-pressure alarm. Which action should the nurse take first? A) Check the ventilator alarm settings. B) Assess the set tidal volume. C) Listen to the client's breath sounds. D) Call the respiratory therapist. (Chp. 32, elsevier resources)
C) Listen to the client's breath sounds. (Chp. 32, elsevier resources)
A client has asthma that gets worse during the summer. She tells the nurse that she takes a medication every day so she does not get short of breath when she walks to work. About which medicine does the nurse need to educate the client? A) Albuterol (Proventil) inhaler B) Guaifenesin (Organidin) C) Montelukast (Singulair) D) Omalizumab (Xolair) (Chp. 30; elseview resources)
C) Montelukast (Singulair) (Chp. 30; elseview resources)
A client who has recently traveled to Vietnam comes to the emergency department with fatigue, lethargy, night sweats, and a low-grade fever. What is the nurse's first action? A) Contact the health care provider for tuberculosis (TB) medications. B) Perform a TB skin test. C) Place a respiratory mask on the client. D) Test all family members for TB. (Chp. 31; elsevier resources)
C) Place a respiratory mask on the client. (Chp. 31; elsevier resources)
A client is admitted to the emergency department (ED) with a possible diagnosis of avian influenza ("bird flu"). Which of these actions included in the hospital protocol for avian influenza will the nurse take first? A) Ensure that ED staff members receive oseltamivir (Tamiflu). B) Obtain specimens for the H5 polymerase chain reaction test. C) Place the client in a negative air pressure room. D) Start an IV line and administer rehydration therapy. (Chp. 31; elsevier resources)
C) Place the client in a negative air pressure room. (Chp. 31; elsevier resources)
What is the purpose of wearing fluoride gel trays during radiation therapy of the mouth? A) Keep the mouth moist during treatments B) Keep the teeth from turning yellow after treatment C) Prevent radiation scatter when the beam hits metal in the mouth D) Protect the taste buds on the tongue (Chp. 29; elsevier resources)
C) Prevent radiation scatter when the beam hits metal in the mouth (Chp. 29; elsevier resources)
The nurse has been teaching improved airflow techniques to the client, who has continued to have restrictive breathing problems. Which is the best indicator of success? A) Peak flowmeter readings that are yellow after the third reading B) Productive cough C) SpO2 level of 92% after ambulating 50 feet D) Stable arterial blood gases (ABGs) (Chp. 30; elseview resources)
C) SpO2 level of 92% after ambulating 50 feet (Chp. 30; elseview resources)
Which action does the postanesthesia care unit (PACU) nurse perform first when caring for a client who has just arrived after a total thyroidectomy? A. Assess the wound dressing for bleeding. B. Give morphine sulfate 4 to 8 mg IV for pain. C. Monitor oxygen saturation using pulse oximetry. Correct D. Support the head and neck with sandbags.
C. Airway assessment and management is always the first priority with every client. This is especially important for a client who has had surgery that involves potential bleeding and edema near the trachea. Assessing the wound dressing for bleeding is a high priority, although this is not the first priority. Pain control and supporting the head and neck with sandbags are important priorities, but can be addressed after airway assessment.
A client diagnosed with hyperpituitarism resulting from a prolactin-secreting tumor has been prescribed bromocriptine mesylate (Parlodel). As a dopamine agonist, what effect does this drug have by stimulating dopamine receptors in the brain? A. Decreases the risk for cerebrovascular disease B. Increases the risk for depression C. Inhibits the release of some pituitary hormones D. Stimulates the release of some pituitary hormones
C. Bromocriptine mesylate inhibits the release of both prolactin and growth hormone. It does not decrease the risk for cerebrovascular disease leading to stroke. Increased risk for depression is not associated with the use of bromocriptine mesylate; however, hallucinations have been reported as a side effect. Bromocriptine mesylate does not stimulate the release of any hormones.
Which client does the nurse identify as being at highest risk for acute adrenal insufficiency resulting from corticosteroid use? A. Client with hematemesis, upper epigastric pain for the past 3 days not relieved with food, and melena B. Client with right upper quadrant pain unrelieved for the past 2 days, dark-brown urine, and clay-colored stools C. Client with shortness of breath and chest tightness, nasal flaring, audible wheezing, and oxygen saturation of 85% for the second time this week D. Client with three emergency department visits in the past month for edema, shortness of breath, weight gain, and jugular venous distention
C. Corticosteroids may be used to treat signs and symptoms of asthma, such as shortness of breath and chest tightness, nasal flaring, audible wheezing, and oxygen saturation of 85%. This places the client at risk for adrenal insufficiency. Corticosteroids are not used to treat signs and symptoms of GI bleeding or peptic ulcer disease (hematemesis, upper epigastric pain for the past 3 days not relieved with food, and melena), gallbladder disease (right upper quadrant pain unrelieved for the past 2 days, dark brown urine, and clay-colored stools), or congestive heart failure (edema, shortness of breath, weight gain, and jugular venous distention).
These data are obtained by the RN who is assessing a client who had a transsphenoidal hypophysectomy yesterday. What information has the most immediate implications for the client's care? A. Dry lips and oral mucosa on examination B. Nasal drainage that tests negative for glucose C. Client report of a headache and stiff neck D. Urine specific gravity of 1.016
C. Headache and stiff neck (nuchal rigidity) are symptoms of meningitis that have immediate implications for the client's care. Dry lips and mouth are not unusual after surgery. Frequent oral rinses and the use of dental floss should be encouraged because the client cannot brush the teeth. Any nasal drainage should test negative for glucose; nasal drainage that tests positive for glucose indicates the presence of a cerebrospinal fluid leak. A urine specific gravity of 1.016 is within normal limits.
Which laboratory result indicates that fluid restrictions have been effective in treating syndrome of inappropriate antidiuretic hormone (SIADH)? A. Decreased hematocrit B. Decreased serum osmolality C. Increased serum sodium D. Increased urine specific gravity
C. Increased serum sodium due to fluid restriction indicates effective therapy. Hemoconcentration is a result of hypovolemic hyponatremia caused by SIADH and diabetes insipidus. Plasma osmolality is decreased as a result of SIADH. Urine specific gravity is decreased with diabetes insipidus and is increased with SIADH.
A client with hypothyroidism is being discharged. Which environmental change may the client experience in the home? A. Frequent home care B. Handrails in the bath C. Increased thermostat setting D. Strict infection-control measures
C. Manifestations of hypothyroidism include cold intolerance. Increased thermostat settings or additional clothing may be necessary. A client with a diagnosis of hypothyroidism can be safely managed at home with adequate discharge teaching regarding medications and instructions on when to notify the health care provider or home health nurse. In general, hypothyroidism does not cause mobility issues. Activity intolerance and fatigue may be an issue, however. A client with hypothyroidism is not immune-compromised or contagious, so no environmental changes need to be made to the home.
An older client with an elevated serum calcium level is receiving IV furosemide (Lasix) and an infusion of normal saline at 150 mL/hr. Which nursing action can the RN delegate to unlicensed assistive personnel (UAP)? A. Ask the client about any numbness or tingling. B. Check for bone deformities in the client's back. C. Measure the client's intake and output hourly. D. Monitor the client for shortness of breath.
C. Measuring intake and output is a commonly delegated nursing action that is within the UAP scope of practice. Numbness and tingling is part of the client assessment that needs to be completed by a licensed nurse. Bony deformities can be due to pathologic fractures; physical assessment is a complex task that cannot be delegated. An older client receiving an IV at 150 mL/hr is at risk for congestive heart failure; careful monitoring for shortness of breath is the responsibility of the RN.
An RN and LPN/LVN are caring for a group of clients on the medical-surgical unit. Which client will be the best to assign to the LPN/LVN? A. Client with Graves' disease who needs discharge teaching after a total thyroidectomy B. Client with hyperparathyroidism who is just being admitted for a parathyroidectomy C. Client with infiltrative ophthalmopathy who needs administration of high-dose prednisone (Deltasone) D. Newly diagnosed client with hypothyroidism who needs education about the use of thyroid supplements
C. Medication administration for the client with infiltrative ophthalmopathy is within the scope of practice of the LPN/LVN. Discharge teaching is a complex task that cannot be delegated to the LPN/LVN. A client being admitted for a parathyroidectomy needs preoperative teaching, which must be provided by the RN. A client who has a new diagnosis will have questions about the disease and prescribed medications; teaching is a complex task that is appropriate for the RN.
Which type of thyroid cancer often occurs as part of multiple endocrine neoplasia (MEN) type II? A. Anaplastic B. Follicular C. Medullary D. Papillary
C. Medullary carcinoma commonly occurs as part of MEN type II, which is a familial endocrine disorder. Anaplastic carcinoma is an aggressive tumor that invades surrounding tissue. Follicular carcinoma occurs more frequently in older clients and may metastasize to bone and lung. Papillary carcinoma is the most common type of thyroid cancer. It is slow growing and, if the tumor is confined to the thyroid gland, the outlook for a cure is good with surgical management.
The nurse is providing discharge instructions to a client on spironolactone (Aldactone) therapy. Which comment by the client indicates a need for further teaching? A. "I must call the provider if I am more tired than usual." B. "I need to increase my salt intake." C. "I should eat a banana every day." D. "This drug will not control my heart rate."
C. Spironolactone increases potassium levels, so potassium supplements and foods rich in potassium, such as bananas, should be avoided to prevent hyperkalemia. While taking spironolactone, symptoms of hyponatremia such as drowsiness and lethargy must be reported; the client may need increased dietary sodium. Spironolactone will not have an effect on the client's heart rate.
A client with Cushing's disease begins to laugh loudly and inappropriately, causing the family in the room to be uncomfortable. What is the nurse's best response? A. "Don't mind this. The disease is causing this." B. "I need to check the client's cortisol level." C. "The disease can sometimes affect emotional responses." D. "Medication is available to help with this."
C. The client may have neurotic or psychotic behavior as a result of high blood cortisol levels. Being honest with the family helps them to understand what is happening. Telling the family not to mind the laughter and that the disease is causing it is vague and minimizes the family's concern. This is the perfect opportunity for the nurse to educate the family about the disease. Cushing's disease is the hypersecretion of cortisol, which is abnormally elevated in this disease and, because the diagnosis has already been made, blood levels do not need to be redrawn. Telling the family that medication is available to help with inappropriate laughing does not assist them in understanding the cause of or the reason for the client's behavior.
A client has hyperparathyroidism. Which incident witnessed by the nurse requires the nurse's intervention? A. The client eating a morning meal of cereal and fruit B. The physical therapist walking with the client in the hallway C. Unlicensed assistive personnel pulling the client up in bed by the shoulders D. Visitors talking with the client about going home
C. The client with hyperparathyroidism is at risk for pathologic fracture. All members of the health care team must move the client carefully. A lift sheet should be used to re-position the client. The client with hyperparathyroidism is not restricted from eating and should maintain a balanced diet. The client can benefit from moderate exercise and physical therapy, and is not restricted from having visitors.
The nurse is teaching a client about thyroid replacement therapy. Which statement by the client indicates a need for further teaching? A. "I should have more energy with this medication." B. "I should take it every morning." C. "If I continue to lose weight, I may need an increased dose." D. "If I gain weight and feel tired, I may need an increased dose."
C. Weight loss indicates a need for a decreased dose, not an increased dose. One of the symptoms of hypothyroidism is lack of energy; thyroid replacement therapy should help the client have more energy. The correct time to take thyroid replacement therapy is in the morning. If the client is gaining weight and continues to feel tired, that is an indication that the dose may need to be increased.
Which instruction does the nurse give the client who needs a clean catch urine specimen? A. Save all urine for 24 hours. B. I will collect the first specimen of the morning. C. Do not touch the inside of the container. D. You will receive an isotope injection, then I will collect your urine.
C. A clean catch specimen is used to obtain urine for culture and sensitivity of organisms present; contamination by the client's hands will alter the specimen and results.
Which statement made by a client who has acute pyelonephritis indicates to the nurse correct understanding of the antibiotic therapy? A. "If my temperature is normal for 3 days in a row, the infection is gone and I can stop taking the drug." B. "If my temperature goes above 100° for 2 days, I should take double the dose of the drug." C. "Even if I feel completely well, I should take the drug exactly as prescribed until it is gone." D. "I should notify my prescriber to change the medication if I develop diarrhea while taking this drug."
C. Antibiotic therapy is most effective when taken for the entire course and not just when symptoms are present. Most antibiotic therapy results in some degree of diarrhea. Although additional drugs may be needed to control this side effect, it is usually unnecessary to stop the drug.
When reviewing the medical record for a client with polycystic kidney disease who is scheduled for computed tomography (CT) angiography with contrast, it is essential for the nurse to perform which intervention? A. Obtain a thyroid-stimulating hormone (TSH) level. B. Report the blood urea nitrogen (BUN) and creatinine. C. Hold the metformin 24 hours before and on the day of the procedure. D. Notify provider regarding blood glucose and hemoglobin A1c values.
C. Before studies with contrast media are performed, the nurse must withhold metformin, which may cause lactic acidosis.
A 53-year-old postmenopausal woman is diagnosed with stress incontinence. What does the nurse tell the client about how certain drugs may be able to help with her? A. "They can relieve your anxiety associated with incontinence." B. "They help your bladder to empty." C. "They may be used to improve urethral resistance." D. "They decrease your bladder's tone."
C. Bladder pressure is greater than urethral resistance; drugs may be used to improve urethral resistance.
The client prescribed cephalexin (Keflex) for cystitis reports that she has had a severe allergic reaction to penicillin in the past. What is the nurse's best action? A. Reassure the client that Keflex is not penicillin. B. Place an allergy alert band on the client's wrist. C. Notify the prescriber before administering the first Keflex dose. D. Highlight this important information in the client's medical record.
C. Cephalexin is a cephalosporin and has a chemical structure very similar to the structure of penicillin. Often a person who is allergic to penicillin is also allergic to cephalosporins. Even if the prescriber wishes to proceed with cephalosporin therapy, he or she may first prescribe premedication to reduce the risk for an allergic response
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.
A nurse is instructing an older adult female client about interventions to decrease the risk for cystitis. Which client comment indicates that the teaching was effective? A. "I must avoid drinking carbonated beverages." B. "I need to douche vaginally once a week." C. "I should drink 2½ liters of fluid every day." D. "I will not drink fluids after 8 PM each evening."
C. Drinking 2½ liters of fluid a day flushes out the urinary system and helps reduce the risk for cystitis.
Which of the following would alarm the nurse immediately after return of the client from the operating room for cystoscopy performed under conscious sedation? A. Pink-tinged urine B. Urinary frequency C. Temperature of 100.8 D. Client lethargic
C. Fever, chills, or an elevated white blood cell (WBC) count suggests infection after an invasive procedure; notify the provider.
When a diabetic client returns to the medical unit after IV urography, all of these interventions are prescribed. Which action will the nurse take first? A. Give lisper (Humalog) insulin, 12 units subcutaneously. B. Request a breakfast tray for the client. C. Infuse 0.45% normal saline at 125 mL/hr. D. Administer captopril (Capote).
C. Fluids are needed because the dye has an osmotic effect, causing dehydration and potential kidney failure.
A 32-year-old female with a urinary tract infection reports urinary frequency, urgency, and some discomfort upon urination. Her vital signs are stable except for a temperature of 100° F. Which drug does the nurse expect the health care provider to prescribe? A. Nitrofurantoin after intercourse B. Premarin C. Trimethoprim/sulfamethoxazole D. Trimethoprim with intercourse
C. Guidelines indicate that a 3-day course of trimethoprim/sulfamethoxazole or fosfomycin is effective in treating uncomplicated, community-acquired UTI in women.
A cognitively impaired client has urge incontinence. Which method for achieving continence does a nurse include in the client's care plan? A. Bladder training B. Credé method C. Habit training D. Kegel exercises
C. Habit training (scheduled toileting) will be most effective in reducing incontinence for a cognitively impaired client because the caregiver is responsible for helping the client to a toilet on a scheduled basis.
Which nursing activity illustrates proper aseptic technique during catheter care? A. Applying Betadine ointment to the perineal area after catheterization B. Irrigating the catheter daily C. Positioning the collection bag below the height of the bladder D. Sending a urine specimen to the laboratory for testing
C. Keep urine collection bags below the level of the bladder at all times. Elevating the collection bag above the bladder causes reflux of pathogens from the bag into the urinary tract.
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.
When caring for the client with uremia, the nurse assesses for which of these symptoms? A. Tenderness at the costovertebral angle (CVA) B. Cyanosis of the skin C. Nausea and vomiting D. Insomnia
C. Manifestations of uremia include anorexia, nausea, vomiting, weakness, and fatigue.
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.
Which type of incontinence benefits from pelvic floor muscle (Kegel) exercise? A. Functional B. Overflow C. Stress D. Urge
C. Pelvic floor (Kegel) exercise therapy for women with stress incontinence strengthens the muscles of the pelvic floor, thereby helping decrease the occurrence of incontinence
The client is in the emergency department (ED) for an inability to void and for bladder distention. What is most important for the nurse to provide to the client? A. Increased oral fluids B. IV fluids C. Privacy D. Health history forms
C. Provide privacy, assistance, and voiding stimulants, such as warm water over the perineum, as needed, for the client with urinary problems.
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.
The certified wound, ostomy, continence nurse (CWOCN) or enterostomal therapist (ET) teaches a client who has had a cystectomy about which care principles for the client's post-discharge activities? A. Nutritional and dietary care B. Respiratory care C. Stoma and pouch care D. Wiping from front to back (asepsis)
C. The enterostomal therapist demonstrates external pouch application, local skin care, pouch care, methods of adhesion, and drainage mechanisms.
A client's urinalysis shows all of the following results. Which result does the nurse report to the health care provider? A. pH 5.8 B. Osmolarity 450 C. Nitrites present D. Sodium 5 mEq/L
C. The osmolarity, pH, and sodium concentration are within normal ranges. Nitrites are not usually present in urine. Many types of bacteria, when present in the urine, convert nitrates (normally found in urine) into nitrites. A positive finding indicates a urinary tract infection.
When performing bladder scanning to detect residual urine in a female client, the nurse must first assess which of these? A. Abdominal girth B. Presence of urinary infection C. History of hysterectomy D. Hematuria
C. The scanner must be in the scan mode for male clients to ensure the scanner subtracts the volume of the uterus from the measurement.
A newly admitted client who is diabetic and has pyelonephritis and prescriptions for intravenous antibiotics, blood glucose monitoring every 2 hours, and insulin administration should be cared for by which staff member? A. An RN whose other assignments include a client receiving chemotherapy for renal cell carcinoma B. An RN who is caring for a client who just returned after having renal artery balloon angioplasty C. An RN who has just completed preoperative teaching for a client who is scheduled for nephrectomy D. An RN who is currently admitting a client with acute hypertension and possible renal artery stenosis
C. This RN is caring for the most stable client and will have time to do the frequent monitoring and interventions that are needed for the newly admitted client.
The nurse is teaching the client how to provide a "clean catch" urine specimen. Which statement by the client indicates that teaching was effective? A. "I must clean with the wipes and then urinate directly into the cup." B. "I will have to drink 2 liters of fluid before providing the sample." C. "I'll start to urinate in the toilet, stop, and then urinate into the cup." D. "It is best to provide the sample while I am bathing."
C. To provide a clean catch urine sample, the client should initiate voiding, then stop, then resume voiding into the container. A midstream collection further removes secretions and bacteria because urine flushes the distal portion of the internal urethra.
A nurse is educating a female about hygiene measures to reduce her risk for urinary tract infection. What does the nurse instruct the client to do? A. "Douche-but only once a month." B. "Use only white toilet paper." C. "Wipe from your front to your back." D. "Wipe with the softest toilet paper available."
C. Wiping front to back keeps organisms in the stool from coming close to the urethra, which increases the risk for infection.
The nurse receives report on a client with hydronephrosis. Which laboratory study should the nurse monitor? A. Hemoglobin and hematocrit (H&H) B. White blood cell (WBC) count C. Blood urea nitrogen and creatinine D. Lipid levels
C. With back pressure on the kidney, glomerular filtration is reduced or absent resulting in permanent kidney damage; BUN and creatinine are kidney function tests.
In monitoring the diagnostic test of a client admitted with heart failure (HF), which finding is consistent with this diagnosis? a. Serum potassium level of 3.2 mEq/L b. Ejection fraction of 60% c. B-type natriuretic peptide (BNP) of 760 ng/dL d. Chest x-ray report showing right middle lobe consolidation
C: BNP is produced and released by the ventricles when the client has fluid overload as a result of HF; a normal value is less than 100 pg/mL. Hypokalemia may occur in response to diuretic therapy for heart failure but may also occur with other conditions; it is not specific to heart failure. Consolidation on chest x-ray may indicate pneumonia.
Which of these nursing actions should the nurse delegate to a nursing assistant working on the medical unit? a. Determine the usual alcohol intake for a client with cardiomyopathy. b. Monitor the pain level for a client with acute pericarditis. c. Obtain daily weights for several clients with class IV heart failure. d. Check for peripheral edema in a client with endocarditis.
C: Daily weight assessment is included in the role of the nursing assistant, who will report the weights to the RN. The role of the professional nurse is to perform assessments; do not delegate this activity.
Which intervention will best assist the client with acute pulmonary edema in reducing anxiety and dyspnea? a. Monitor pulse oximetry and cardiac rate and rhythm. b. Reassure the client that his distress can be relieved with proper intervention. c. Place the client in high Fowler's position with the legs down. d. Ask a family member to remain with the client.
C: High Fowler's position and placing the legs in a dependent position will decrease venous return to the heart, thus decreasing pulmonary venous congestion. Monitoring of vital signs will detect abnormalities but will not prevent them. Option B may help to alleviate anxiety, but dyspnea and anxiety result from hypoxemia secondary to intra-alveolar edema, which must be relieved. Option D may help to alleviate anxiety, but dyspnea and anxiety result from hypoxemia secondary to intra-alveolar edema, which must be relieved.
The client, a college athlete who has collapsed during soccer practice, has been diagnosed with hypertrophic cardiomyopathy. The client says, "This can't be. I am in great shape. I eat right and exercise." What is the nurse's best response? a. "How does this make you feel?" b. "This can be caused by taking performance-enhancing drugs." c. "This may be caused by a genetic trait." d. "Just imagine how bad it would be if you weren't in good shape."
C: Hypertrophic cardiomyopathy is often transmitted as a single-gene autosomal dominant trait.
Which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy? a. Client ambulates around the nursing unit with a walker. b. The nurse monitors the client's pulse and blood pressure frequently. c. The nurse obtains a bedside commode before administering furosemide. d. The nurse returns the client to bed when he becomes tachycardic.
C: Limiting the need for ambulation on the first day of admission to sitting in a chair or performing basic leg exercises promotes physical rest and reduced oxygen demand. On the day of admission, the client is experiencing dyspnea, fatigue, and weakness; this activity will increase oxygen demand. Monitoring of vital signs will alert the nurse to increased energy expenditures but will not prevent them. Waiting until tachycardia occurs permits increased oxygen demand; the nurse should prevent this situation.
When caring for a client who has undergone a partial left ventriculectomy, which of these new-onset clinical manifestations indicates the need for immediate action by the nurse? a. Chest pain with movement b. Fatigue after ambulation c. Muffled heart sounds d. Bi-basilar fine crackles
C: Muffled heart sounds may be a clinical manifestation of bleeding into the pericardial space; the nurse should assess the client for possible decreased cardiac output and should notify the surgeon. Surgery will result in pain with mobility; pain should be treated but not until physiologic stability is ensured. This procedure was performed for heart failure; this client has had surgery as well and will need some time to recover his energy. Although the nurse should strive to prevent atelectasis or dependent crackles, this common after chest surgery. This client should be gotten out of bed and shown how to use an incentive spirometer.
The nurse is assessing the client with a cardiac infection. Which symptoms support the diagnosis of infective endocarditis instead of pericarditis or rheumatic carditis? a. Friction rub auscultated at the left lower sternal border b. Pain aggravated by breathing, coughing, and swallowing c. Splinter hemorrhages d. Thickening of the endocardium
C: Splinter hemorrhages are indicative of infective endocarditis. Friction rub in the left lower sternal border is a sign of chronic constrictive pericarditis. Pain aggravated by breathing, coughing, and swallowing is indicative of signs and symptoms of chronic constrictive pericarditis. Thickening of the endocardium is indicative of rheumatic carditis.
The nurse in the emergency department is caring for a client with acute heart failure who is experiencing severe dyspnea, pink, frothy sputum, and crackles throughout the lung fields. Which prescription should the nurse carry out first? a. Enalapril b. Heparin c. Furosemide d. I & O
C: The client is displaying typical signs of acute pulmonary edema, secondary to fluid-filled alveoli and pulmonary congestion; a diuretic will promote fluid loss. Although enalapril will promote vasodilation and decrease cardiac workload, the client is demonstrating signs of acute pulmonary edema secondary to intra-alveolar fluid. Heparin will prevent deep vein thrombosis (DVT) secondary to immobility but will not reduce fluid excess. Although all clients with congestive heart failure (CHF) should have I & O maintained, this is not a priority; removing fluid volume and treating dyspnea are matters of priority.
When following up in the clinic with a client with heart failure, how does the nurse recognize that the client has been compliant with fluid restrictions? a. Auscultation of crackles b. Pedal edema c. Weight loss of 6 pounds since the last visit d. Reports sucking on ice chips all day for dry mouth
C: Weight loss in this client indicates effective fluid restriction and diuretic drug therapy. Lung crackles indicate intra-alveolar edema and fluid excess. Pedal edema indicates fluid excess. This indicates noncompliance with fluid restrictions; alternative methods of treating dry mouth should be explored.
Your patient is the 68-year-old man from the previous Clinical Judgment Challenge who had shortness of breath (SOB) for the past 2 to 3 days. His clinical condition deteriorated further, requiring intubation. The health care provider orders a CT scan of the chest. 2. Why is it important to monitor your patient using capnography?
Capnography is a noninvasive measurement of carbon dioxide levels. This information provides information about CO2 production, alveolar function, and respiratory patterns. It reflects changes in breathing effectiveness before hypoxia occurs.
Which finding alarms the nurse when caring for a client receiving chemotherapy who has a platelet count of 17,000/mm3? A.) Increasing shortness of breath B.) Diminished bilateral breath sounds C.) Change in mental status D.) Weight gain of 4 pounds in 1 day
Change in mental status A change in mental status could result from spontaneous bleeding; in this case, a cerebral hemorrhage may have developed. Increasing shortness of breath is typically related to anemia, not to thrombocytopenia. Diminished breath sounds may be related to many factors, including poor respiratory excursion, infection, and atelectasis, which is not related to thrombocytopenia. A large weight gain in a short period may be related to kidney or heart failure; bleeding is the major complication of thrombocytopenia.
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 RN working on an oncology unit has just received report on these clients. Which client should be assessed first? A.) Client with chemotherapy-induced neutropenia who has just been admitted with an elevated temperature B.) Client with lymphoma who will need administration of an antiemetic before receiving chemotherapy C.) Client with metastatic breast cancer who is scheduled for external beam radiation in 1 hour D.) Client with xerostomia associated with laryngeal cancer who needs oral care before breakfast
Client with chemotherapy-induced neutropenia who has just been admitted with an elevated temperature Neutropenia poses high risk for life-threatening sepsis and septic shock, which develop and progress rapidly in immune-suppressed people; the nurse should see the client with chemotherapy-induced neutropenia first. The client with lymphoma and the client with metastatic breast cancer are not in distress and can be assessed later. The client with dry mouth (xerostomia) can be assessed later, or the nurse can delegate mouth care to unlicensed assistive personnel.
The RN has just received change-of-shift report. Which of the assigned clients should be assessed first? Client with chronic kidney failure who was just admitted with shortness of breath Client with kidney insufficiency who is scheduled to have an arteriovenous fistula inserted Client with azotemia whose blood urea nitrogen and creatinine are increasing Client receiving peritoneal dialysis who needs help changing the dialysate bag
Client with chronic kidney failure who was just admitted with shortness of breath The dyspnea of the client with chronic kidney failure may indicate pulmonary edema and should be assessed immediately. The client with kidney insufficiency is stable and assessment can be performed later. The client with azotemia requires assessment and possible interventions, but is not at immediate risk for life-threatening problems. The client receiving peritoneal dialysis can be seen last because it is a slow process and the client has no urgent needs.
A client with a recently created vascular access for hemodialysis is being discharged. In planning discharge instructions, which information does the nurse include? Avoiding venipuncture and blood pressure measurements in the affected arm Modifications to allow for complete rest of the affected arm How to assess for a bruit in the affected arm How to practice proper nutrition
Compression of vascular access causes decreased blood flow and may cause occlusion; if this occurs, dialysis will not be possible. The arm should be exercised to encourage venous dilation, not rested. The client can palpate for a thrill; a stethoscope is not needed to auscultate the bruit at home. The nurse should take every opportunity to discuss nutrition, even as it relates to wound healing, but loss of the graft or fistula by compression or occlusion must take priority because lifesaving dialysis cannot be performed.
To prevent pre-renal acute kidney injury, which person is encouraged to increase fluid consumption? Construction worker Office secretary Schoolteacher Taxicab driver
Construction worker Physical labor and working outdoors, especially in warm weather, cause diaphoresis and place the construction worker at risk for dehydration and pre-renal azotemia. The office secretary and schoolteacher work indoors and, even without air conditioning, will not lose as much fluid to diaphoresis as someone performing physical labor. The taxicab driver, even without air conditioning, will not experience diaphoresis and fluid loss like the construction worker.
Which instruction is most appropriate for the nurse to convey to the client with chemotherapy-induced neuropathy? A.) Bathe in cold water. B.) Wear cotton gloves when cooking. C.) Consume a diet high in fiber. D.) Make sure shoes are snug.
Consume a diet high in fiber. A high-fiber diet will assist with constipation due to neuropathy. The client should bathe in warm water, not hotter than 96° F. Cotton gloves may prevent harm from scratching; protective gloves should be worn for washing dishes and gardening. Wearing cotton gloves while cooking can increase the risk for burns. Shoes should allow sufficient length and width to prevent blisters. Shoes that are snug can increase the risk for blisters in a client with peripheral neuropathy.
The patient is a 68-year-old man who has had shortness of breath (SOB) for the past 2 to 3 days. His past medical history includes a 40-packyear smoking history, COPD, and heart failure. He reports that he became concerned when he woke from sleep because he could not breathe. Your physical assessment reveals crackles in the lower lobes bilaterally. His oxygen saturation (SpO2) is 84% without supplemental oxygen. 2. Who should you contact and why?
Contact this patient's primary health care provider and inform him or her of the patient's oxygen saturation. Contact respiratory therapy for additional support with an appropriate oxygen delivery method and to provide additional treatments as needed.
A client with acute kidney injury is receiving a fluid challenge of 500 mL of normal saline over 1 hour. With a drop factor of 20 drops/mL, how many drops per minute does the nurse infuse? _________
Correct Responses 167 drops/min 20 gtt × 500 mL = 10,000/60 min = 167 drops/min
Which signs and symptoms indicate rejection of a transplanted kidney? (Select all that apply.) Blood urea nitrogen (BUN) 21 mg/dL, creatinine 0.9 mg/dL Crackles in the lung fields Temperature of 98.8° F (37.1° C) Blood pressure of 164/98 mm Hg 3+ edema of the lower extremities
Crackles in the lung fields Correct Blood pressure of 164/98 mm Hg Correct 3+ edema of the lower extremities Correct Signs and symptoms of fluid retention (e.g., crackles in the lung fields and 3+ edema of the lower extremities) indicate transplant rejection. Increased blood pressure is also a symptom of transplant rejection. Increasing BUN and creatinine are symptoms of rejection; a BUN of 21 mg/dL and a creatinine of 0.9 mg/dL reflect normal values. Fever, not normothermia, is symptomatic of transplant rejection.
The nurse is caring for a client who was discharged 3 weeks ago after a diagnosis of pulmonary embolism (PE). He is currently admitted with gastrointestinal bleeding and an international normalized ratio (INR) of 6.9. For which of the following should the nurse assess this client? A. Consumption of green leafy vegetables B. Prolonged exhalation C. Client has massaged his calves. D. Use of aspirin or salicylates
D
Which nursing intervention would you use to prevent injury in the client receiving oxygen therapy by continuous nasal cannula? A. Providing mouth care every 8 hours B. Lubricating the lips with water-soluble jelly C. Draining the condensation in the tubing every 2 hours D. Changing the position of the elastic band every 4 hours
D Clients receiving oxygen by nasal cannula are prone to skin breakdown on the ears, back of the neck, and face.
Why should you post a "no smoking" sign on the door of a room where a client is receiving oxygen therapy? A. Cigarette smoke would further compromise or irritate the respiratory status of a client receiving oxygen therapy. B. Clients with respiratory problems are too dyspneic to move quickly in an emergency situation such as a fire. C. Oxygen is a combustible gas and may explode in the presence of an open flame. D. Combustion is enhanced by the presence of oxygen.
D Oxygen does not burn, but it supports combustion
What is your teaching priority for the client who will be using oxygen therapy at home via an H cylinder? A. Keeping the tubing free of condensation B. Explaining that the client should avoid crowds C. Ensuring that adequate humidification is available D. Reinforcing that the cylinder must be secured in a stand or a rack
D The contents of the large (H) cylinders of oxygen are under considerable pressure. If the cylinder is unsecured and is knocked over, rapid decompression can cause this heavy equipment to move around the room and cause harm to anyone in the room
Which nursing action ensures that there is no disruption of oxygen therapy for the client receiving low-flow oxygen by simple face mask? A. Keeping a small cylinder of oxygen in the client's closet or bedside stand for emergency use in case the central oxygen delivery system fails B. Sealing the edges of the mask to the client's skin with a water-soluble lubricant C. Ensuring that the flaps are closed over the exhalation ports D. Changing to a nasal cannula during meals
D The face mask covers the client's mouth and must be removed during meals. Use of a nasal cannula when the client eats prevents hypoventilation or hypoxemia from the face mask being off during mealtime.
While suctioning the client who had a tracheostomy placed 4 days ago, you note particles of food in the tracheal secretions. What is your best first action? A. Increase the inflation pressure in the tracheostomy cuff. B. Document the finding. C. Make the client NPO. D. Notify the physician.
D This manifestation most commonly accompanies tracheomalacia, a condition caused by excessive cuff pressure against the tracheal lining, leading to tracheal dilation and erosion of the cartilage.
A client with chronic obstructive pulmonary disease (COPD) prescribed a long-acting inhaled beta2 agonist reports hating the inhaler and asks why the drug can't be taken as a pill. What is the nurse's best response? A) "Drugs taken by inhaler work more slowly and remain in the system longer." B) "Drugs taken by inhaler have no side effects and are less expensive." C) "Drugs taken by mouth are more expensive because they must be sterile." D) "Drugs taken by mouth have systemic side effects and are harder to control." (Chp. 30; p. 564)
D) "Drugs taken by mouth have systemic side effects and are harder to control." (Chp. 30; p. 564)
Which statement by a client with a laryngectomy indicates a need for further discharge teaching? A) "I must avoid swimming." B) "I can clean the stoma with soap and water." C) "I can project mucus when I laugh or cough." D) "I can't put anything over my stoma to cover it." (Chp. 29; elsevier resources)
D) "I can't put anything over my stoma to cover it." (Chp. 29; elsevier resources)
A client's mother asks what is the most important thing she will need to know to care for her son, who is having an inner maxillary fixation completed as an outpatient. What does the nurse tell her? A) "Give him Phenergan (promethazine) by rectum around the clock so he does not vomit." B) "He can only drink milk and eat ice cream until the wires come off." C) "He must brush his teeth every 2 hours." D) "Make sure he always has wire cutters with him." (Chp. 29; elsevier resources)
D) "Make sure he always has wire cutters with him." (Chp. 29; elsevier resources)
The 62-year-old client whose brother was just diagnosed with head and neck cancer asks the nurse what he could do to reduce his risk for also developing this cancer. What is the nurse's best response? A) "Because head and neck cancer has a strong hereditary component, participating in screening twice yearly is critical for you." B) "Always wear sunscreen with a 50% or greater protection factor whenever you are outdoors." C) "Avoid shouting and singing to prevent stress to your vocal cords and larynx." D) "Stop smoking, and drink alcohol only in moderation." (Chp. 29; p. 539)
D) "Stop smoking, and drink alcohol only in moderation." (Chp. 29; p. 539)
The nurse has taught a client about influenza infection control. Which client statement indicates the need for further teaching? A) "Handwashing is the best way to prevent transmission." B) "I should avoid kissing and shaking hands." C) "It is best to cough and sneeze into my upper sleeve." D) "The intranasal vaccine can be given to everybody in the family." (Chp. 31; elsevier resources)
D) "The intranasal vaccine can be given to everybody in the family." (Chp. 31; elsevier resources)
A client was intubated 30 minutes ago for acute respiratory distress syndrome and possible sepsis. The following orders have been given for the client. In what sequence would the nurse perform these orders for this client? 1. Infuse levofloxacin (Levaquin) 500 mg IV. 2. Obtain baseline aerobic and anaerobic sputum cultures. 3. Teach the client and family methods of communicating. 4. Analyze postintubation arterial blood gases (ABGs). A) 2, 1, 3, 4 B) 4, 3, 1, 2 C) 3, 4, 2, 1 D) 4, 2, 1, 3 (Chp. 32, elsevier resources)
D) 4, 2, 1, 3 (Chp. 32, elsevier resources)
Which precaution is most important for the nurse to teach a client who has cystic fibrosis? A) Report a weight change of 2 pounds to your health care provider immediately. B) Use supplemental oxygen whenever your oxygen saturation is less than 95%. C) Eat six small meals each day instead of only three larger ones. D) Avoid crowds and people who are ill. (Chp. 30; p. 569)
D) Avoid crowds and people who are ill. (Chp. 30; p. 569)
The nurse is preparing to administer oxygen to a client with chronic obstructive pulmonary disease (COPD) who is hypoxemic and hypercarbic. How will the nurse administer the oxygen for this client? A) By nasal cannula at a rate of no more than 1 to 3 L/min B) By nasal cannula at a rate of no more than 2 to 4 L/min C) By Venturi mask at a rate of at least 60% D) By maintaining oxygen saturations greater than 88% (Chp. 30; elseview resources)
D) By maintaining oxygen saturations greater than 88% (Chp. 30; elseview resources)
The nurse answers a client's call light and realizes that the client has an upper airway obstruction. What is the nurse's first action? A) Attempt to remove the obstruction. B) Call the Rapid Response Team to intubate immediately. C) Call the Rapid Response Team to perform an emergency cricothyroidotomy. D) Determine the cause of the obstruction. (Chp. 29; elsevier resources)
D) Determine the cause of the obstruction. (Chp. 29; elsevier resources)
A client has been diagnosed with oral and laryngeal cancer. He completed a course of radiation, and it is 2 days since he underwent a total laryngectomy. The client had been very anxious about his surgery. Which medications does the nurse expect to find on his home medication list? A) Amitriptyline (Elavil) B) Diazepam (Valium) C) Ketorolac (Toradol) D) Lorazepam (Ativan) (Chp. 29; elsevier resources)
D) Lorazepam (Ativan) (Chp. 29; elsevier resources)
A client has been diagnosed with chronic bronchitis and started on a mucolytic. What is the rationale for ordering a mucolytic for this client? A) Mucolytics decrease secretion production. B) Mucolytics increase gas exchange in the lower airways. C) Mucolytics provide bronchodilation in clients with chronic obstructive pulmonary disease. D) Mucolytics thin secretions, making them easier to expectorate. (Chp. 30; elseview resources)
D) Mucolytics thin secretions, making them easier to expectorate. (Chp. 30; elseview resources)
The nurse is preparing to admit an adult client with pertussis. Which symptom does the nurse anticipate finding in this client? A) "Whooping" after a cough B) Hemoptysis C) Mild cold-like symptoms D) Post-cough emesis (Chp. 31; elsevier resources)
D) Post-cough emesis (Chp. 31; elsevier resources)
Community health nurses are tasked with providing education on prevention of respiratory infection for diseases such as the flu. Which target audience is given the highest priority? A) Homeless people B) Hospital staff C) Politicians D) Prison staff and inmates (Chp. 31; elsevier resources)
D) Prison staff and inmates (Chp. 31; elsevier resources)
The nurse notices a visitor walking into the room of a client on airborne isolation with no protective gear. What does the nurse do? A) Ensures that the client is wearing a mask B) Tells the visitor that the client cannot receive visitors at this time C) Provides a particulate air respirator to the visitor D) Provides a mask to the visitor (Chp. 31; elsevier resources)
D) Provides a mask to the visitor (Chp. 31; elsevier resources)
A newly diagnosed client with asthma says that his peak flowmeter is reading 82% of his personal best. What does the nurse do? A) Nothing. This is in the green zone. B) Provide the rescue drug and reassess. C) Provide the rescue drug and seek emergency help. D) Repeat the peak flow test. (Chp. 30; elseview resources)
D) Repeat the peak flow test. (Chp. 30; elseview resources)
The client is a marathon runner who has asthma. Which category of medication is used as a rescue inhaler? A) Corticosteroids B) Long-acting beta agonists C) Nonsteroidal anti-inflammatory drugs (NSAIDs) D) Short-acting beta agonists (Chp. 30; elseview resources)
D) Short-acting beta agonists (Chp. 30; elseview resources)
Which clinical manifestation in the client with facial trauma is the nurse's first priority? A) Bleeding B) Decreased visual acuity C) Pain D) Stridor (Chp. 29; elsevier resources)
D) Stridor (Chp. 29; elsevier resources)
Which clinical manifestation requires immediate action by the nurse for a client with laryngeal trauma? A) Aphonia B) Hemoptysis C) Hoarseness D) Tachypnea (Chp. 29; elsevier resources)
D) Tachypnea (Chp. 29; elsevier resources)
An environmental assessment of a factory finds inhalation exposure with a high level of particulate matter. What does the factory nurse do to generate the quickest compliance? A) Encourages proper building ventilation B) Refers workers to a tobacco cessation program C) Suggests that workers find another job D) Teaches workers how to use a mask (Chp. 30; elseview resources)
D) Teaches workers how to use a mask (Chp. 30; elseview resources)
A client is admitted with asthma. How is this disease differentiated from other chronic lung disorders? A) It affects only young people. B) The client has dyspnea. C) The client is coughing. D) The client is symptom-free between exacerbations. (Chp. 30; elseview resources)
D) The client is symptom-free between exacerbations. (Chp. 30; elseview resources)
A client comes to the emergency department with a sore throat. Examination reveals redness and swelling of the pharyngeal mucous membranes. Which diagnostic test does the nurse expect will be requested first? A) Chest x-ray B) Complete blood count (CBC) C) Tuberculosis (TB) skin test D) Throat culture (Chp. 31; elsevier resources)
D) Throat culture (Chp. 31; elsevier resources)
A student nurse is working with a client in the ICU who is intubated and being mechanically ventilated. What action by the student causes the registered nurse to intervene? A) Repositioning the client every 2 hours B) Providing oral care with chlorhexidine rinse C) Checking tube placement at the client's incisor D) Turning off ventilator alarms while working in the room (Chp. 32; p. 619)
D) Turning off ventilator alarms while working in the room (Chp. 32; p. 619)
A new client arrives in the medical-surgical unit with a flap after a total laryngectomy. The flap appears dusky in color. What is the nurse's first action? A) Apply a hot pack over the flap site. B) Massage the flap site vigorously. C) Place a tight dressing over the flap. D) Use a Doppler device to assess flow to the area. (Chp. 29; elsevier resources)
D) Use a Doppler device to assess flow to the area. (Chp. 29; elsevier resources)
The nurse is caring for a client who was discharged 3 weeks ago after a diagnosis of pulmonary embolism (PE). He is currently admitted with gastrointestinal (GI) bleeding and an international normalized ratio (INR) of 6.9. For which factors should the nurse assess this client? A) Consumption of green leafy vegetables B) Prolonged exhalation C) Client has massaged his calves D) Use of aspirin or salicylates (Chp. 32, elsevier resources)
D) Use of aspirin or salicylates (Chp. 32, elsevier resources)
The nurse manager at a long-term-care facility is planning care for a client who is receiving radiation therapy for laryngeal cancer. Which of these tasks will be best to delegate to a nursing assistant? A) Administering throat-numbing lozenges B) Assessing the mouth for inflammation and infection C) Teaching about skin care while receiving radiation D) Washing the skin with soap and water (Chp. 29; elsevier resources)
D) Washing the skin with soap and water (Chp. 29; elsevier resources)
The nurse is caring for a client with severe acute respiratory syndrome. What is the most important precaution the nurse should take when preparing to suction this client? A) Keeping the head of the bed elevated 30 to 45 degrees B) Performing oral care after suctioning the oropharynx C) Washing hands and donning gloves prior to the procedure D) Wearing a disposable particulate mask respirator and protective eyewear (Chp. 31; elsevier resources)
D) Wearing a disposable particulate mask respirator and protective eyewear (Chp. 31; elsevier resources)
The RN has just received change-of-shift report on the medical-surgical unit. Which client will need to be assessed first? A. Client with Hashimoto's thyroiditis and a large goiter B. Client with hypothyroidism and an apical pulse of 51 beats/min C. Client with parathyroid adenoma and flank pain due to a kidney stone D. Client who had a parathyroidectomy yesterday and has muscle twitching
D. A client who is 1 day postoperative for parathyroidectomy and has muscle twitching is showing signs of hypocalcemia and is at risk for seizures. Rapid assessment and intervention are needed. Clients with Hashimoto's thyroiditis are usually stable; this client does not need to be assessed first. Although an apical pulse of 51 is considered bradycardia, a low heart rate is a symptom of hypothyroidism. A client with a kidney stone will be uncomfortable and should be asked about pain medication as soon as possible, but this client does not need to be assessed first.
The nurse is caring for a client with hypercortisolism. The nurse begins to feel the onset of a cold but still has 4 hours left in the shift. What does the nurse do? A. Asks another nurse to care for the client B. Monitors the client for cold-like symptoms C. Refuses to care for the client D. Wears a facemask when caring for the client
D. A client with hypercortisolism will be immune-suppressed. Anyone with a suspected upper respiratory infection who must enter the client's room must wear a mask to prevent the spread of infection. Although asking another nurse to care for the client might be an option in some facilities, it is not generally realistic or practical. The nurse, not the client, feels the onset of the cold, so monitoring the client for cold-like symptoms is part of good client care for a client with hypercortisolism. Refusing to care for the client after starting care would be considered abandonment.
The charge nurse is making client assignments for the medical-surgical unit. Which client will be best to assign to an RN who has floated from the pediatric unit? A. Client in Addisonian crisis who is receiving IV hydrocortisone B. Client admitted with syndrome of inappropriate antidiuretic hormone (SIADH) secondary to lung cancer C. Client being discharged after a unilateral adrenalectomy to remove an adrenal tumor D. Client with Cushing's syndrome who has elevated blood glucose and requires frequent administration of insulin
D. An RN who works with pediatric clients would be familiar with glucose monitoring and insulin administration. A client in Addisonian crisis would best be monitored by an RN from the medical-surgical floor. Although the float RN could complete the admission history, the client with SIADH secondary to lung cancer might require teaching and orientation to the unit that a nurse more familiar with that area would be better able to provide. Discharge teaching specific to adrenalectomy should be provided by the RN who is regularly assigned to the medical-surgical floor and is more familiar with taking care of postoperative adult clients with endocrine disorders.
A client is referred to a home health agency after a transsphenoidal hypophysectomy. Which action does the RN case manager delegate to the home health aide who will see the client daily? A. Document symptoms of incisional infection or meningitis. B. Give over-the-counter laxatives if the client is constipated. C. Set up medications as prescribed for the day. D. Test any nasal drainage for the presence of glucose.
D. Cerebrospinal fluid (CSF) will test positive using a glucose "dipstick." Nasal drainage that is positive for glucose after a transsphenoidal hypophysectomy would indicate a CSF leak that would require immediate notification of the health care provider. Home health aides can be taught the correct technique to perform this procedure. Assessing for symptoms of infection and documenting them in the record, medication administration, and setting up medication are not within the scope of practice of the home health aide.
A client with thyroid cancer has just received 131I ablative therapy. Which statement by the client indicates a need for further teaching? A. "I cannot share my toothpaste with anyone." B. "I must flush the toilet three times after I use it." C. "I need to wash my clothes separately from everyone else's clothes." D. "I'm ready to hold my newborn grandson now."
D. Clients undergoing 131I therapy should avoid close contact with pregnant women, infants, and young children for 1 week after treatment. Clients should remain at least 1 meter (39 inches, or roughly 3 feet) away, and limit exposure to less than 1 hour per day. Some radioactivity will remain in the client's salivary glands for up to 1 week after treatment. Care should be taken to avoid exposing others to the saliva. Flushing the toilet three times after use will ensure that all urine has been diluted and removed. Clothing needs to be washed separately and the washing machine then needs to be run empty for a full cycle before it is used to wash the clothing of others.
How does the drug desmopressin (DDAVP) decrease urine output in a client with diabetes insipidus (DI)? A. Blocks reabsorption of sodium B. Increases blood pressure C. Increases cardiac output D. Works as an antidiuretic hormone (ADH) in the kidneys
D. Desmopressin is a synthetic form of ADH that binds to kidney receptors and enhances reabsorption of water, thus reducing urine output. Desmopressin does not have any effect on sodium reabsorption. It may cause a slight increase or a transient decrease in blood pressure, but this does not affect urine output. Desmopressin does not increase cardiac output.
A client with a possible adrenal gland tumor is admitted for testing and treatment. Which nursing action is most appropriate for the charge nurse to delegate to the nursing assistant? A. Assess skin turgor and mucous membranes for hydration status. B. Discuss the dietary restrictions needed for 24-hour urine testing. C. Plan ways to control the environment that will avoid stimulating the client. D. Remind the client to avoid drinking coffee and changing position suddenly.
D. Drinking caffeinated beverages and changing position suddenly are not safe for a client with a potential adrenal gland tumor because of the effects of catecholamines. Reminding the client about previous instructions is an appropriate role for a nursing assistant who may observe the client doing potentially risky activities. Client assessment, client teaching, and environment planning are higher-level skills that require the experience and responsibility of the RN, and are not within the scope of practice of the nursing assistant.
A client with Cushing's disease says that she has lost 1 pound. What does the nurse do next? A. Auscultates the lungs for crackles B. Checks urine for specific gravity C. Forces fluids D. Weighs the client
D. Fluid retention with weight gain is more of a problem than weight loss in clients with Cushing's disease. Weighing the client with Cushing's disease is part of the nurse's assessment. Crackles in the lungs indicate possible fluid retention, which would cause weight gain, not weight loss. Urine specific gravity will help assess hydration status, but this would not be the next step in the client's assessment. Forcing fluids is not appropriate because usually excess water and sodium reabsorption cause fluid retention in the client with Cushing's disease.
What effect can starting a dose of levothyroxine sodium (Synthroid) too high or increasing a dose too rapidly have on a client? A. Bradycardia and decreased level of consciousness B. Decreased respiratory rate C. Hypotension and shock D. Hypertension and heart failure
D. Hypertension and heart failure are possible if the levothyroxine sodium dose is started too high or raised too rapidly, because levothyroxine would essentially put the client into a hyperthyroid state. The client would be tachycardic, not bradycardic. The client may have an increased respiratory rate. Shock may develop, but only as a late effect and as the result of "pump failure."
The nurse reviews the vital signs of a client diagnosed with Graves' disease and sees that the client's temperature is up to 99.6° F. After notifying the health care provider, what does the nurse do next? A. Administers acetaminophen B. Alerts the Rapid Response Team C. Asks any visitors to leave D. Assesses the client's cardiac status completely
D. If the client's temperature has increased by even 1°, the nurse's first action is to notify the provider. Continuous cardiac monitoring should be the next step. Administering a nonsalicylate antipyretic such as acetaminophen is appropriate, but is not a priority action for this client. Alerting the Rapid Response Team is not needed at this time. Asking visitors to leave would not be the next action, and if visitors are providing comfort to the client, this would be contraindicated.
A client is taking methimazole (Tapazole) for hyperthyroidism and would like to know how soon this medication will begin working. What is the nurse's best response? A. "You should see effects of this medication immediately." B. "You should see effects of this medication within 1 week." C. "You should see full effects from this medication within 1 to 2 days." D. "You should see some effects of this medication within 2 weeks."
D. Methimazole is an iodine preparation that decreases blood flow through the thyroid gland. This action reduces the production and release of thyroid hormone. The client should see some effects within 2 weeks; however, it may take several more weeks before metabolism returns to normal. Although onset of action is 30 to 40 minutes after an oral dose, the client will not see effects immediately. Effects will take longer than 1 week to become apparent when methimazole is used. Methimazole needs to be taken every 8 hours for an extended period of time. Levels of triiodothyronine (T3) and thyroxine (T4) will be monitored and dosages adjusted as levels fall.
The nurse has the following assignment. Which client should be encouraged to consume 2 to 3 liters of fluid each day? A. Client with chronic kidney disease B. Client with heart failure C. Client with complete bowel obstruction D. Client with hyperparathyroidism
D. A major feature of hyperparathyroidism is hypercalcemia, which predisposes to kidney stones; this client should remain hydrated.
Which laboratory test result for a client who is about to have a nephrostomy for hydronephrosis does the nurse report immediately to the physician? A. Serum sodium 137 mEq/L B. Serum potassium 4.8 mEq/L C. Blood urea nitrogen (BUN) 23 mg/dL D. International normalized ratio (INR) 4.6
D. Although the sodium and BUN levels are slightly higher than normal, they are within the ranges expected with hydronephrosis. The INR, however, is seriously elevated and indicates a dangerously long clotting time with a greatly increased risk for bleeding. It must be corrected before surgery.
A client is admitted for extracorporeal shock wave lithotripsy (ESWL). What information obtained on admission is most critical for a nurse to report to the health care provider before the ESWL procedure begins? A. "Blood in my urine has become less noticeable; maybe I don't need this procedure." B. "I have been taking cephalexin (Keflex) for an infection." C. "I previously had several ESWL procedures performed." D. "I take over-the-counter naproxen (Aleve) twice a day for joint pain."
D. Because a high risk for bleeding during ESWL has been noted, clients should not take NSAIDs before this procedure. The ESWL will have to be rescheduled for this client.
When planning an assessment of the urethra, what does the nurse do first? A. Examines the meatus B. Notes any unusual discharge C. Records the presence of abnormalities D. Dons gloves
D. Before examination begins, body fluid precautions (gloves) must be donned first.
Which of these staff members should be assigned to a client who has benign prostatic hyperplasia and hydronephrosis and needs an indwelling catheter inserted? A. An RN float nurse who has 10 years of experience with pediatric clients B. An LPN/LVN who has worked in the hospital's kidney dialysis unit until recently C. An RN without recent experience who has just completed an RN refresher course D. An LPN/LVN with 5 years of experience in an outpatient urology surgery center
D. Catheterization of a client with an enlarged prostate, a skill within the scope of practice of the LPN/LVN, would be performed frequently in a urology center.
What does the nurse teach the client to prevent the risk for urinary tract infection (UTI)? A. Limit fluid intake. B. Increase caffeine consumption. C. Limit sugar intake. D. Drink about 3 liters of fluid daily.
D. Drinking about 3 liters of fluid daily, if another medical problem does not require fluid restriction, helps prevent dehydration and UTIs.
A nurse is caring for clients on a renal/kidney medical-surgical unit. Which drug, requested by a health care provider, for a client with a urinary tract infection (UTI) does the nurse question? A. Bactrim B. Cipro C. Noroxin D. Tegretol
D. Drug alerts state that confusion is frequent (sound alike and look alike) between the drugs Tequin and Tegretol. The former is used for UTI, and the latter is prescribed as an oral anticonvulsant.
The client had IV urography 8 hours ago. Which nursing intervention is the priority for this client? A. Maintaining bedrest B. Medicating for pain C. Monitoring for hematuria D. Promoting fluid intake
D. Ensure adequate hydration by urging the client to take oral fluid or by giving IV fluids. Hydration reduces the risk for kidney damage.
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 nurse is teaching a client who is scheduled for a neobladder and a Kock pouch. Which client statement indicates correct understanding of these procedures? A."If I restrict my oral intake of fluids, the adjustment will be easier." B. "I must go to the restroom more often because my urine will be excreted through my anus." C. "I need to wear loose-fitting pants so the urine can flow into my ostomy bag." D. "I will have to drain my pouch with a catheter."
D. For the client with a neobladder and a Kock pouch, urine is collected in a pouch and is drained with the use of a catheter.
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.
Which client does the nurse manager on a medical unit assign to an experienced LPN/LVN? A. 42-year-old with painless hematuria who needs an admission assessment B. 46-year-old scheduled for cystectomy who needs help in selecting a stoma site C. 48-year-old receiving intravesical chemotherapy for bladder cancer D. 55-year-old with incontinence who has intermittent catheterization prescribed
D. Insertion of catheters is within the education and legal scope of practice for LPNs/LVNs.
For which client living at home is intermittent self-catheterization an inappropriate method for incontinence management? A. 36-year-old woman who is blind B. 46-year-old man who has paraplegia C. 56-year-old woman who has diabetes D. 66-year-old man who has severe osteoarthritis
D. Intermittent self-catheterization requires significant manual dexterity to reach the area and perform the catheterization without contaminating the catheter. A person with severe osteoarthritis is not likely to be able to perform this technique safely. The technique does not require vision or the use of the lower extremities. A person with diabetes would be at increased risk for infection and would need to understand how to avoid contamination.
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 health care provider requests phenazopyridine (Pyridium) for a client with cystitis. What does the nurse tell the client about the drug? A. "It will act as an antibacterial drug." B. "This drug will treat your infection, not the symptoms of it." C. "You need to take the drug on an empty stomach." D. "Your urine will turn red or orange while on the drug."
D. Phenazopyridine (Pyridium) will turn the client's urine red or orange. Care should be taken because it will stain undergarments. Clients should be warned about this effect of the drug because it will be alarming to them if they are not informed.
A client who is 6 months pregnant comes to the Prenatal Clinic with a suspected urinary tract infection (UTI). What action does the nurse take with this client? A. Discharges the client to her home for strict bedrest for the duration of the pregnancy B. Instructs the client to drink a minimum of 3 liters of fluids, especially water, every day to "flush out" bacteria C. Recommends that the client refrain from having sexual intercourse until after she has delivered her baby D. Refers the client to the Clinic Nurse Practitioner (CNP) for immediate follow-up
D. Pregnant women with UTI require prompt and aggressive treatment because simple cystitis can lead to acute pyelonephritis. This in turn can cause preterm labor-with adverse effects for the fetus.
Which nursing intervention or practice is most effective in helping to prevent urinary tract infection (UTI) in hospitalized clients? A. Encouraging them to drink fluids B. Irrigating all catheters daily with sterile saline C. Recommending catheters should be placed in all clients D. Re-evaluating periodically the need for indwelling catheters
D. Studies have shown that re-evaluating the need for indwelling catheters in clients is the most effective way to prevent UTI in the hospital setting.
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."
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.
The client is scheduled for a cystoscopy later this morning. The consent form is not signed, and the client has not had any preoperative medication. The nurse notes that the provider visited the client the day before. What action does the nurse take? A. Asks the client to sign the informed consent B. Cancels the procedure C. Asks the client's spouse to sign the form D. Notifies the department and the provider
D. The client may be asked to sign the consent form in the department; notifying both the provider and the department ensures communication across the continuum of care, with less likelihood of omission of information.
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.
A nurse is talking to adult clients about urinary and sexual hygiene. Which words does the nurse use when referring to the client's reproductive body parts? A. Children's terms that are easily understood B. Slang words and terms that are heard "socially" C. Technical and medical terminology D. Words that the client uses
D. The nurse should use the terms with which the client is most familiar, so there is no chance for the client to misunderstand information. Using the client's language ensures the comfort level for the client.
The client with diabetes who also has persistent proteinuria asks what he could do to prevent eventual kidney failure. What is the nurse's best response? A. "Wear pads and other protective gear around your lower back when engaging in contact sports." B. "Drink at least 3 L of water daily and avoid carbonated beverages." C. "Limit your intake of proteins to less than 100 g daily." D. "Keep your blood glucose levels in the target range."
D. The presence of persistent proteinuria indicates kidney damage has already occurred and is likely to eventually progress to kidney failure. Although kidney failure cannot be prevented, the decline in kidney function can be slowed with tight glycemic control. The severity of diabetic kidney disease is related to the degree of hyperglycemia the client generally experiences. With poor control of hyperglycemia, the complicating problems of atherosclerosis, hypertension, and neuropathy (which promote loss of bladder tone, urinary stasis, and urinary tract infection) are more severe and more likely to cause additional kidney damage sooner.
Which technique does the nurse use to obtain a sterile urine specimen from the client with a Foley catheter? A. Disconnects the Foley catheter from the drainage tube and collects urine directly from the Foley B. Removes the existing catheter and obtains a sample during the process of inserting a new Foley C. Uses a sterile syringe to withdraw urine from the urine collection bag D. Clamps the tubing, attaches a syringe to the specimen, and withdraws at least 5 mL of urine
D. This is the correct technique for obtaining a sterile urine specimen from the client with a Foley catheter.
An older adult woman confides to a nurse, "I am so embarrassed about buying adult diapers for myself." How does the nurse respond? A. "Don't worry about it. You need them." B. "Shop at night-when stores are less crowded." C. "Tell everyone that they are for your husband." D. "That is tough. What do you think might help?"
D. This response acknowledges the client's concerns and attempts to help the client think of methods to solve her problem.
The client with pyelonephritis has been prescribed urinary antiseptic medication. What purpose does this medication serve? A. Decreases bacterial count B. Destroys white blood cells C. Enhances the action of antibiotics D. Provides comfort
D. Urinary antiseptic drugs such as nitrofurantoin (Macrodantin) are prescribed to provide comfort for clients with pyelonephritis.
A client is referred to a home health agency after being hospitalized with overflow incontinence and a urinary tract infection (UTI). Which nursing action can the home health RN delegate to a home health aide? A. Assisting the client in developing a schedule for when to take prescribed antibiotics B. Inserting a straight catheter as necessary if the client is unable to empty the bladder C. Teaching the client how to use the Credé maneuver to empty the bladder more fully D. Using a bladder scanner (with training) to check residual bladder volume after the client voids
D. Use of a bladder scanner is noninvasive and can be accomplished by a home health aide (UAP) who has been trained and evaluated in this skill.
A nurse is teaching a client about pelvic muscle exercises. What information does the nurse include? A. "For the best effect, perform all your exercises while you are seated on the toilet." B. "Limit your exercises to 5 minutes twice a day, or you will injure yourself." C. "Results should be visible to you within 72 hours." D. "You know that you are exercising correct muscles if you can stop urine flow in midstream."
D. When the client can start and stop the urine stream, the pelvic muscles are being used.
Although the client with cardiac failure is asymptomatic, the nurse suspects noncompliance with prescribed home therapy. Which laboratory test confirms the nurse's suspicions? a. B-type natriuretic peptide (BNP) 90 pg/mL b. Serum electrolytes c. Hemoglobin and hematocrit d. Digoxin level of 0.2 ng/dL
D: A therapeutic digoxin level is 0.8 to 2.0 ng/dL. A level of 0.2 ng/dL indicates that the client has not been taking his digoxin as prescribed. A BNP test is a cardiac failure diagnostic tool but is not the best indicator of decreased compliance. Electrolytes are not an early indicator of decreased cardiac compliance. Hemoglobin and hematocrit are not early indicators of decreased cardiac compliance.
The nurse prepares to administer digoxin to a client with heart failure and notes the following information: Temperature: 99.8 Pulse: 48 and irregular Respirations: 20 Potassium level: 3.2 mEq/L What action does the nurse take? a. Give digoxin; reassess the heart rate in 30 minutes. b. Give the digoxin; document assessment findings in the medical record. c. Hold the digoxin, and obtain a prescription for an additional dose of furosemide. d. Hold the digoxin, and obtain a prescription for a potassium supplement.
D: Digoxin causes bradycardia; hypokalemia potentiates digitalis. The nurse seeks to correct this situation through collaboration with the provider. Digoxin causes bradycardia, so should be held. Digoxin is given to treat heart failure and atrial fibrillation, an irregular heart rate. Regardless of mental status, the drug should be held. Hypokalemia potentiates digitalis toxicity. Lasix decreases circulating blood volume and depletes potassium; no indication suggests that the client has fluid excess at this time.
The nurse is caring for the client with congestive heart failure (CHF) in the coronary care unit (CCU). The client is now exhibiting signs of air hunger and anxiety. Which nursing intervention does the nurse perform first for this client? a. Determines the client's physical limitations b. Encourages alternate rest and activity periods c. Monitors and documents heart rate, rhythm, and pulses d. Positions the client to alleviate dyspnea
D: Positioning the client to alleviate dyspnea will help ease air hunger and anxiety. Determining the client's physical limitations and encouraging alternate rest and activity periods are not priorities in this situation. Monitoring of heart rate, rhythm, and pulses is important but is not the priority for this client.
A client admitted for heart failure has a priority problem of Excess Fluid Volume related to compromised regulatory mechanisms. Which of these assessment data obtained the day after admission is the best indicator that the treatment has been effective? a. The client has a diuresis of 400 mL in 24 hours. b. The client's blood pressure is 122/84 mm Hg. c. The client has an apical pulse of 82 beats/min. d. The client's weight decreases by 2.5 kg.
D: The best indicator of fluid volume loss is daily weight; because each kilogram represents approximately 1 L, this client has lost approximately 2500 mL of fluid. Option A: This volume of urine represents oliguria, not the needed response of diuresis. Option B: Although this is a normal finding, alone it is not significant for relief of fluid volume excess. Option C: Although this is a normal finding, alone it is not significant to determine whether fluid excess is relieved.
The patient is a 68-year-old man who has had shortness of breath (SOB) for the past 2 to 3 days. His past medical history includes a 40-packyear smoking history, COPD, and heart failure. He reports that he became concerned when he woke from sleep because he could not breathe. Your physical assessment reveals crackles in the lower lobes bilaterally. His oxygen saturation (SpO2) is 84% without supplemental oxygen. 3. What are some factors that may affect gas exchange for this patient?
Decreased alveolar surface area (age related) is likely. Crackles may represent interstitial edema, which will further reduce gas exchange. The patient's decreased endurance will decrease gas exchange. Both his long-standing COPD and his existing heart failure negatively affect his gas exchange.
What is a common gastrointestinal problem that older adults experience more frequently as they age? A. Decreased hydrochloric acid B. Excess lipase production C. Increased liver enzymes D. Increased peristalsis
Decreased hydrochloric acid Atrophy of the gastric mucosa causes a decreased ratio of gastrin-secreting cells to somatostatin-secreting cells. This results in a decrease in hydrochloric acid, causing decreased absorption of iron and vitamin B12. In the pancreas, calcification of pancreatic vessels occurs, with a decrease in lipase production. The decrease in lipase results in decreased fat absorption and digestion. Steatorrhea and diarrhea can subsequently occur. The number and size of hepatic cells are decreased, which results in decreased enzyme activity; decreased liver enzyme activity depresses drug metabolism, and therefore may cause accumulation of drugs to toxic levels. In the large intestine, peristalsis is decreased and nerve impulses are dulled, which can result in postponement of bowel movements in older adults.
Your patient is the 68-year-old man from the previous Clinical Judgment Challenge who had shortness of breath (SOB) for the past 2 to 3 days. His clinical condition deteriorated further, requiring intubation. The health care provider orders a CT scan of the chest. 1. What are your responsibilities when preparing the patient for the CT scan?
Determine patient sensitivity to intravenous contrast; allergies to iodine or shellfish; and renal function, including baseline creatinine level.
A client with end-stage kidney disease has been put on fluid restrictions. Which assessment finding indicates that the client has not adhered to this restriction? Blood pressure of 118/78 mm Hg Weight loss of 3 pounds during hospitalization Dyspnea and anxiety at rest Central venous pressure (CVP) of 6 mm Hg
Dyspnea is a sign of fluid overload and possible pulmonary edema; the nurse should assist the client in correlating symptoms of fluid overload with nonadherence to fluid restriction. Nonadherence to fluid restriction results in fluid volume excess and higher blood pressures; 118/78 mm Hg is a normal blood pressure. Excess fluid intake and fluid retention are manifested by an elevated CVP (>8 mm Hg) and weight gain, not weight loss.
When assisting with dietary protein needs for a client on peritoneal dialysis, the nurse recommends that the client select which food? Eggs Ham Eggplant Macaroni
EGGs Suggested protein-containing foods for a client on peritoneal dialysis are milk, meat, and eggs. Although a protein, ham is high in sodium, which should be avoided. Vegetables and pasta contain mostly carbohydrates. Peritoneal dialysis clients are allowed 1.2 to 1.5 g of protein/kg/day because protein is lost with each exchange.
Which manifestation of an oncologic emergency requires the nurse to contact the health care provider immediately? A.) New onset of fatigue B.) Edema of arms and hands C.) Dry cough D.) Weight gain
Edema of arms and hands Edema of the arms and hands indicates worsening compression of the superior vena cava consistent with superior vena cava syndrome. The compression must be relieved immediately, often with radiation therapy, because death can result without timely intervention. New onset of fatigue may likely be an early manifestation of hypercalcemia, which usually develops slowly, but because it is an early manifestation, this is not the priority. Dry cough is not a manifestation that is specific to an oncologic emergency; however, it may be a side effect of chemotherapy. Weight gain could be an early sign of syndrome of inappropriate antidiuretic hormone; although this should be addressed, it is an early sign so it is not the priority.
A client with newly diagnosed irritable bowel syndrome (IBS) reports having five to six loose stools daily. What is the common psychological client response to this gastrointestinal health problem? A. Acceptance B. Embarrassment C. Euphoria D. Grief
Embarrassment The client who has a new onset of IBS with frequent stools most likely would be embarrassed. The client normally would not react to a new onset of IBS with acceptance or grief. It would be an abnormal reaction for the client to feel euphoria over a new onset of IBS.
A client is admitted to the hospital with severe right upper quadrant (RUQ) abdominal pain. Which assessment technique does the nurse use for this client? A. Assesses the abdomen in the following sequence: inspection, palpation, percussion, auscultation B. Examines the RUQ of the abdomen last C. Has the client lie in a supine position with legs straight and arms at the sides D. Views the abdomen by looking directly down while standing over the client's abdominal area
Examines the RUQ of the abdomen last If the client reports pain in the RUQ, the nurse would examine this area last in the examination sequence. This sequence prevents the client from tensing abdominal muscles because of the pain, which would make the examination difficult. The sequence for examining the abdomen is inspection, auscultation, percussion, and then palpation. This sequence prevents the increase in intestinal activity and bowel sounds caused by palpation and percussion. The client would be positioned supine with the knees bent, while keeping the arms at the sides to prevent tensing of the abdominal muscles. It is best to inspect the abdomen by standing at the side of the bed and then looking down on the abdomen, and also from the side at eye level.
Which potential side effects does the nurse include in the teaching plan for a client undergoing radiation therapy for laryngeal cancer? (Select all that apply.) A.) Fatigue B.) Changes in color of hair C.) Change in taste D.) Changes in skin of the neck E.) Difficulty swallowing
Fatigue Change in taste Changes in skin of the neck Difficulty swallowing Radiation therapy to any site produces fatigue in most clients, and may cause clients to report changes in taste. Radiation side effects are site-specific; the larynx is in the neck, so changes in the skin of the neck may occur. Dysphagia (difficulty swallowing) may occur from radiation to the throat area. Chemotherapy, which causes alopecia, may cause changes in the color or texture of hair; this does not normally occur with radiation therapy.
Which clients are at risk for acute kidney injury (AKI)? (Select all that apply.) Football player in preseason practice Client who underwent contrast dye radiology Accident victim recovering from a severe hemorrhage Accountant with diabetes Client in the intensive care unit on high doses of antibiotics Client recovering from gastrointestinal influenza
Football player in preseason practice Correct Client who underwent contrast dye radiology Correct Accident victim recovering from a severe hemorrhage Correct Client in the intensive care unit on high doses of antibiotics Correct Client recovering from gastrointestinal influenza Correct To prevent AKI, all people should be urged to avoid dehydration by drinking at least 2 to 3 liters of fluids daily, especially during strenuous exercise or work associated with diaphoresis, or when recovering from an illness that reduces kidney blood flow, such as influenza. Contrast media may cause acute renal failure, especially in older clients with reduced kidney function. Recent surgery or trauma, transfusions, or other factors that might lead to reduced kidney blood flow may cause AKI. Certain antibiotics may cause nephrotoxicity. Diabetes may cause acute kidney failure superimposed on chronic kidney failure.
A client has a routine sigmoidoscopy with a tissue biopsy. What complication is the nurse looking for in a postprocedure assessment? A. Excessive diarrhea B. Heavy bleeding C. Nausea and vomiting D. Severe rectal pain
Heavy bleeding Excessive or heavy bleeding is a possible complication following a sigmoidoscopy. It must be reported immediately to the health care provider. Excessive diarrhea, nausea, vomiting, and severe rectal pain are not common complications of sigmoidoscopy.
The oncology nurse is caring for a group of clients receiving chemotherapy. The client with which sign/symptom is displaying bone marrow suppression? A.) Hemoglobin of 7.4 and hematocrit of 21.8 B.) Potassium level of 2.9 mEq/L and diarrhea C.) 250,000 platelets/mm3 D.) 5000 white blood cells/mm3
Hemoglobin of 7.4 and hematocrit of 21.8 Bone marrow suppression causes anemia, leukopenia, and thrombocytopenia; the client with a hemoglobin of 7.4 and hematocrit of 21.8 has anemia demonstrated by low hemoglobin and hematocrit. The client with diarrhea and a potassium level of 2.9 mEq/L has hypokalemia and electrolyte imbalance. The client with 250,000 platelets/mm3 and the client with 5000 white blood cells/mm3 demonstrate normal values.
When monitoring a client with suspected syndrome of inappropriate antidiuretic hormone (SIADH), the nurse reviews the client's medical record, which contains the following information. The nurse notifies the health care provider for which signs and symptoms consistent with this syndrome? (Select all that apply.) Physical Assessment Findings Diagnostic Findings Medications Neuro: Episodes of confusion Cardiac: Pulse 88 and regular Musculoskeletal: Weakness, tremors Na: 115 K: 4.2 Creatinine: 0.8 ondansetron (Zofran) cyclophosphamide (Cytoxan) A.) Hyponatremia B.) Mental status changes C.) Azotemia D.) Bradycardia E.) Weakness
Hyponatremia Mental status changes Weakness Antidiuretic hormone (ADH) is secreted or produced ectopically, resulting in water retention and sodium dilution. Dilutional hyponatremia results from ADH secretion, causing confusion and changes in mental status. Weakness results from hyponatremia. Azotemia refers to buildup of nitrogenous waste products in the blood, typically from renal damage. Bradycardia is not part of the constellation of symptoms related to SIADH; tachycardia may result from fluid volume excess.
When caring for a client receiving chemotherapy, the nurse plans care during the nadir of bone marrow activity to prevent which complication? A.) Drug toxicity B.) Polycythemia C.) Infection D.) Dose-limiting side effects
Infection The lowest point of bone marrow function is referred to as the nadir; risk for infection is highest during this phase. Drug toxicity can develop when drug levels exceed peak concentrations. Polycythemia refers to an increase in the number of red blood cells; typically chemotherapy causes reduction of red blood cells or anemia. Dose limiting side effects occur when the dose or frequency of chemotherapy need to be altered or held, such as in the case of severe neutropenia or neurologic dysfunction .
When caring for a client with acute kidney injury and a temporary subclavian hemodialysis catheter, which assessment finding does the nurse report to the provider? Mild discomfort at the insertion site Temperature 100.8° F 1+ ankle edema Anorexia
Infection is a major complication of temporary catheters. All symptoms of infection, including fever, must be reported to the provider because the catheter may have to be removed. Mild discomfort at the insertion site is expected with a subclavian hemodialysis catheter. During acute injury, oliguria with resulting fluid retention is expected. Rising blood urea nitrogen may result in anorexia, nausea, and vomiting.
The nurse practitioner is performing an abdominal assessment on a newly admitted client. In which order should the nurse proceed with assessment technique? A. Auscultation, percussion, palpation, inspection B. Inspection, auscultation, percussion, palpation C. Palpation, percussion, inspection, auscultation D. Percussion, auscultation, palpation, inspection
Inspection, auscultation, percussion, palpation Abdominal examination usually begins at the client's right side and proceeds in a systematic fashion: RUQ, LUQ, LLQ, RLQ. However, if the client is experiencing pain in a specific quadrant, that area should be assessed last in the examination sequence to prevent the client from tensing abdominal muscles because of the pain, which would make the examination difficult. Therefore, the LLQ would be the last area assessed for this client.
The nurse is assessing a client who has come to the emergency department with acute abdominal pain. The client is very thin and the nurse observes visible peristaltic movements when inspecting the abdomen. What does the nurse suspect? A. Acute diarrhea B. Aortic aneurysm C. Intestinal obstruction D. Pancreatitis
Intestinal obstruction Peristaltic movements are rarely seen except in thin clients and should be reported since the finding may indicate an intestinal obstruction. Acute diarrhea does not cause visible peristaltic movements. Aortic aneurysm may cause a bulging, pulsatile mass. Pancreatitis is characterized by severe pain.
Which substance, produced in the stomach, facilitates the absorption of vitamin B12? A. Glucagon B. Hydrochloric acid C. Intrinsic factor D. Pepsinogen
Intrinsic factor Parietal cells in the stomach produce intrinsic factor, a substance that facilitates the absorption of vitamin B12. Absence of intrinsic factor causes pernicious anemia. Glucagon, which is produced by the alpha cells in the pancreas, is essential for the regulation of metabolism. Parietal cells secrete hydrochloric acid, but this does not facilitate the absorption of vitamin B12. Pepsinogen is secreted by the chief cells; pepsinogen is a precursor to pepsin, a digestive enzyme.
Which assessment finding represents a positive response to erythropoietin (Epogen, Procrit) therapy? Hematocrit of 26.7% Potassium within normal range Absence of spontaneous fractures Less fatigue
Less fatigue Treatment of anemia with erythropoietin will result in increased hemoglobin and hematocrit (H&H) and decreased shortness of breath and fatigue. A hematocrit value of 26.7% is low; erythropoietin should restore the hematocrit to at least 36% to be effective. Erythropoietin causes more red blood cells to be produced, increasing H&H, not potassium. Calcium supplements and phosphate binders prevent renal osteodystrophy; erythropoietin treats anemia.
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.
The nurse is caring for a client receiving chemotherapy who reports anorexia. Which measure does the nurse use to best monitor for cachexia? A.) Monitor weight B.) Trend red blood cells and hemoglobin and hematocrit C.) Monitor platelets D.) Observe for motor deficits
Monitor weight Cachexia results in extreme body wasting and malnutrition; severe weight loss is expected. Anemia and bleeding tendencies result from bone marrow suppression secondary to invasion of bone marrow by a cancer or a side effect of chemotherapy. Motor deficits result from spinal cord compression.
The nurse teaches a client who is recovering from acute kidney disease to avoid which type of medication? Nonsteroidal anti-inflammatory drugs (NSAIDs) Angiotensin-converting enzyme (ACE) inhibitors Opiates Calcium channel blockers
NSAIDs may be nephrotoxic to a client with acute kidney disease, and should be avoided. ACE inhibitors are used for treatment of hypertension and to protect the kidneys, especially in the diabetic client, from progression of kidney disease. Opiates may be used by clients with kidney disease if severe pain is present; however, excretion may be delayed. Calcium channel blockers can improve the glomerular filtration rate and blood flow within the kidney.
The nurse is assessing a client who comes to the emergency department with acute abdominal pain. The nurse notes a bulging, pulsating mass when inspecting the abdomen. Which action by the nurse is correct? A. Auscultate the abdomen to determine the presence of bowel sounds. B. Notify the provider about this finding immediately. C. Palpate the client's abdomen to determine the outlines of the mass. D. Question the client about recent stool habits.
Notify the provider about this finding immediately. A bulging, pulsating mass may indicate an abdominal aortic aneurysm, and the nurse should notify the provider immediately. Palpating the abdomen or even touching the abdomen with a stethoscope may cause this to rupture, which would be a life-threatening emergency. Because this is a potential life-threatening situation, questioning the client about stool habits is not appropriate.
While managing care for a client with chronic kidney disease, which actions does the registered nurse (RN) plan to delegate to unlicensed assistive personnel (UAP)? (Select all that apply.) Obtain the client's pre-hemodialysis weight. Check the arteriovenous (AV) fistula for a thrill and bruit. Document the amount the client drinks throughout the shift. Auscultate the client's lung sounds every 4 hours. Explain the components of a low-sodium diet.
Obtain the client's pre-hemodialysis weight. Correct Document the amount the client drinks throughout the shift. Correct Obtaining the client's weight and documenting oral fluid intake are routine tasks that can be performed by UAP. Assessment skills (checking the AV fistula and auscultating lung sounds) and client education (explaining special diet) require more education and are in the legal scope of practice of the RN.
Which medication does the nurse plan to administer to a client before chemotherapy to decrease the incidence of nausea and vomiting? A.) Morphine B.) Ondansetron (Zofran) C.) Naloxone (Narcan) D.) Diazepam (Valium)
Ondansetron (Zofran) Ondansetron is a 5-HT3 receptor blocker that blocks serotonin to prevent nausea and vomiting. Morphine is a narcotic analgesic or opiate; it may cause nausea. Naloxone is a narcotic antagonist used for opiate overdose. Diazepam, a benzodiazepine, is an antianxiety medication only; lorazepam, another benzodiazepine, may be used for nausea.
Your patient is the 68-year-old man from the previous Clinical Judgment Challenge who had shortness of breath (SOB) for the past 2 to 3 days. His clinical condition deteriorated further, requiring intubation. The health care provider orders a CT scan of the chest. 4. Your patient was extubated after the left thoracentesis. Within 12 hours he again develops respiratory distress, decreased breath sounds, and a trachea that appears deviated to the right. What is your assessment?
Pneumothorax, partial or complete, is a complication that can occur within 24 hours of a thoracentesis. Tracheal deviation results as the thoracic structures are shifted away from the collapsed lung.
A nurse cares for a client who is recovering from an open Whipple procedure. Which action should the nurse take? a. Clamp the nasogastric tube. b. Place the client in semi-Fowler's position. c. Assess vital signs once every shift. d. Provide oral rehydration.
Postoperative care for a client recovering from an open Whipple procedure should include placing the client in a semi-Fowler's position to reduce tension on the suture line and anastomosis sites, setting the nasogastric tube to low suction to remove free air buildup and pressure, assessing vital signs frequently to assess fluid and electrolyte complications, and providing intravenous fluids.
Which client problem does the nurse set as the priority for the client experiencing chemotherapy-induced peripheral neuropathy? A.) Potential for lack of understanding related to side effects of chemotherapy B.) Potential for injury related to sensory and motor deficits C.) Potential for ineffective coping strategies related to loss of motor control D.) Altered sexual function related to erectile dysfunction
Potential for injury related to sensory and motor deficits The highest priority is safety. Although knowing the side effects of chemotherapy may be helpful, the priority is the client's safety because of the lack of sensation or innervation to the extremities. The nurse should address the client's coping only after providing for safety. Erectile dysfunction may be a manifestation of peripheral neuropathy, but the priority is still the client's safety.
After a colonoscopy, a client reports severe abdominal pain. The nurse obtains these data: temperature 100.2° F (37.9° C), pulse 122 beats/min, blood pressure 100/45 mm Hg, respirations 44 breaths/min, and O2 saturation 89%. Which request from the health care provider does the nurse implement first? A. Give cefazolin (Ancef) 500 mg IV. B. Infuse normal saline at 200 mL/hr. C. Give morphine sulfate 2 mg IV. D. Provide oxygen at 6 L/min per nasal cannula.
Provide oxygen at 6 L/min per nasal cannula. Based on the data given, the client may be experiencing complications of colonoscopy such as bleeding or perforation. The most immediate concern involves respiratory status, so the client should be placed on oxygen first. An antibiotic request is important, but is not the first priority. Fluid supplementation is important, but the client's oxygen saturation level places the client's respiratory status as the priority. The client's need for analgesia should be delayed until respiratory status is addressed. Morphine depresses respiratory status and therefore might not be the right choice for this client.
When caring for the client with chemotherapy-induced mucositis, which intervention will be most helpful? A.) Administering a biological response modifier B.) Encouraging oral care with commercial mouthwash C.) Providing oral care with a disposable mouth swab D.) Maintaining NPO until the lesions have resolved
Providing oral care with a disposable mouth swab The client with mucositis would benefit most from oral care; mouth swabs are soft and disposable and therefore clean and appropriate to provide oral care. Biological response modifiers are used to stimulate bone marrow production of immune system cells; mucositis or sores in the mouth will not respond to these medications. Commercial mouthwashes should be avoided because they may contain alcohol or other drying agents that may further irritate the mucosa. Keeping the client NPO is not necessary because nutrition is important during cancer treatment; a local anesthetic may be prescribed for comfort.
A client admitted to the medical unit with a history of vomiting and diarrhea and an increased blood urea nitrogen requires 1 liter of normal saline infused over 2 hours. Which staff member should be assigned to care for the client? RN who has floated from pediatrics for this shift LPN/LVN with experience working on the medical unit RN who usually works on the general surgical unit New graduate RN who just finished a 6-week orientation
RN who usually works on the general surgical unit The nurse with experience in taking care of surgical clients will be most capable of monitoring the client receiving rapid fluid infusions, who is at risk for complications such as pulmonary edema and acute kidney failure. The pediatric float RN and the new graduate RN will have less experience in caring for this type of client. The LPN/LVN should not be assigned to a client requiring IV therapy and who is at high risk for complications.
A client arrives at the emergency department with acute abdominal pain in the left lower quadrant. In which order does the nurse examine and assess the client's left lower quadrant (LLQ), left upper quadrant (LUQ), right lower quadrant (RLQ), and right upper quadrant (RUQ)? A. LLQ, RLQ, LUQ, RUQ B. LUQ, LLQ, RUQ, RLQ C. RLQ, LLQ, RUQ, LUQ D. RUQ, LUQ, RLQ, LLQ
RUQ, LUQ, RLQ, LLQ Abdominal examination usually begins at the client's right side and proceeds in a systematic fashion: RUQ, LUQ, LLQ, RLQ. However, if the client is experiencing pain in a specific quadrant, that area should be assessed last in the examination sequence to prevent the client from tensing abdominal muscles because of the pain, which would make the examination difficult. Therefore, the LLQ would be the last area assessed for this client.
An outpatient client is receiving photodynamic therapy. Which environmental factor is a priority for the client to adjust for protection? A.) Storing drugs in dark locations at room temperature B.) Wearing soft clothing C.) Wearing a hat and sunglasses when going outside D.) Reducing all direct and indirect sources of light
Reducing all direct and indirect sources of light Lighting of all types must be kept to a minimum with clients receiving photodynamic therapy; it can lead to burns of the skin and damage to the eyes because these clients' eyes are sensitive to light. Any drug that the client is prescribed should be considered for its photosensitivity properties; drugs should be stored according to the recommendations, but this is not the primary concern for this client. Clothing must cover the skin to prevent burns from direct or indirect light; texture is not a concern for the client receiving this treatment. The client will be homebound for 1 to 3 months after the treatment and should not go outside.
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.
The nurse is caring for a client with end-stage ovarian cancer who needs clarification on the purpose of palliative surgery. Which outcome should the nurse teach the client is the goal of palliative surgery? A.) Cure of the cancer B.) Relief of symptoms or improved quality of life C.) Allowing other therapies to be more effective D.) Prolonging the client's survival time
Relief of symptoms or improved quality of life The focus of palliative surgery is to improve quality of life during the survival time. Curative surgery removes all cancer cells, visible and microscopic. Debulking is a procedure that removes some cancerous tissue, allowing other therapies to be more effective. Many therapies, such as surgery, chemotherapy, and biotherapy, increase the client's chance of cure and survival, but palliation improves quality of life.
The nurse assists a client with acute kidney injury (AKI) to modify the diet in which ways? (Select all that apply.) Restricted protein Liberal sodium Restricted fluids Low potassium Low fat
Restricted protein Correct Restricted fluids Correct Low potassium Correct Breakdown of protein leads to azotemia and increased blood urea nitrogen. Fluid is restricted during the oliguric stage. Potassium intoxication may occur, so dietary potassium is also restricted. Sodium is restricted during AKI because oliguria causes fluid retention. Fats may be used for needed calories when proteins are restricted.
Which problem excludes a client hoping to receive a kidney transplant from undergoing the procedure? History of hiatal hernia Presence of diabetes and glycosylated hemoglobin of 6.8% History of basal cell carcinoma on the nose 5 years ago Presence of tuberculosis
TB Long-standing pulmonary disease and chronic infection typically exclude clients from transplantation; these conditions worsen with the immune suppressants that are required to prevent rejection. A client with a history of hiatal hernia is not exempt from undergoing a kidney transplant. Good control of diabetes is a positive point, and would not exclude the client from transplantation. Basal cell carcinoma is considered curable and occurred 5 years ago, consistent with appropriate candidates for transplantation.
When caring for a client who receives peritoneal dialysis (PD), which finding does the nurse report to the provider immediately? Pulse oximetry reading of 95% Sinus bradycardia, rate of 58 beats/min Blood pressure of 148/90 mm Hg Temperature of 101.2° F (38.4°
Temperature of 101.2° F (38.4° Peritonitis is the major complication of PD, caused by intra-abdominal catheter site contamination; meticulous aseptic technique must be used when caring for PD equipment. A pulse oximetry reading of 95% is a normal saturation. Although a heart rate of 58 beats/min is slightly bradycardic, the provider can be informed upon visiting the client. Clients with kidney failure tend to have slightly higher blood pressures due to fluid retention; this is not as serious as a fever.
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." (Chp. 70, elsevier resources)
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. (Chp. 70, elsevier resources)
A client is receiving immune-suppressive therapy after kidney transplantation. Which measure for infection control is most important for the nurse to implement? Adherence to therapy Handwashing Monitoring for low-grade fever Strict clean technique
The most important infection control measure for the client receiving immune-suppressive therapy is handwashing. Adherence to therapy and monitoring for low-grade fever are important, but are not infection control measures. The nurse should practice aseptic technique for this client, not simply clean technique.
The nurse corrects the nursing student when caring for a client with neutropenia secondary to chemotherapy in which circumstance? A.) The student scrubs the hub of IV tubing before administering an antibiotic. B.) The nurse overhears the student explaining to the client the importance of handwashing. C.) The student teaches the client that symptoms of neutropenia include fatigue and weakness. D.) The nurse observes the student providing oral hygiene and perineal care.
The student teaches the client that symptoms of neutropenia include fatigue and weakness. Symptoms of neutropenia include low neutrophil count, fever, and signs and symptoms of infection; the student should be corrected. Asepsis with IV lines is an appropriate action. Handwashing is an essential component of client care, especially when the client is at risk for neutropenia. Hygiene and perineal care help prevent infection and sepsis.
The patient is a 68-year-old man who has had shortness of breath (SOB) for the past 2 to 3 days. His past medical history includes a 40-packyear smoking history, COPD, and heart failure. He reports that he became concerned when he woke from sleep because he could not breathe. Your physical assessment reveals crackles in the lower lobes bilaterally. His oxygen saturation (SpO2) is 84% without supplemental oxygen. 4. What additional referrals might be appropriate for this patient?
This patient would benefit from a respiratory therapy consult for additional instruction with breathing exercises, evaluation for home oxygen therapy, and evaluation for possible pulmonary rehabilitation.
While assisting a client during peritoneal dialysis, the nurse observes the drainage stop after 200 mL of peritoneal effluent drains into the bag. What action should the nurse implement first? Instruct the client to deep-breathe and cough. Document the effluent as output. Turn the client to the opposite side. Re-position the catheter.
Turn the client to the opposite side. With peritoneal dialysis, usually 1 to 2 L of dialysate is infused by gravity into the peritoneal space. The fluid dwells in the peritoneal cavity for a specified time, then drains by gravity into a drainage bag. The dialyzing fluid is called peritoneal effluent on outflow. The outflow should be a continuous stream after the clamp is completely open. Potential causes of flow difficulty include constipation, kinked or clamped connection tubing, the client's position, fibrin clot formation, and catheter displacement. If inflow or outflow drainage is inadequate, re-position the client to stimulate inflow or outflow. Turning the client to the other side or ensuring that he or she is in good body alignment may help. Instructing the client to deep-breathe and cough will not promote dialysate drainage. Increased abdominal pressure from coughing contributes to leakage at the catheter site. The nurse needs to measure and record the total amount of outflow after each exchange. However, the nurse should re-position the client first to assist with complete dialysate drainage. An x-ray is needed to identify peritoneal dialysis catheter placement. Only the physician re-positions a displaced catheter.
The oncology nurse should use which intervention to prevent disseminated intravascular coagulation (DIC)? A.) Monitoring platelets B.) Administering packed red blood cells C.) Using strict aseptic technique to prevent infection D.) Administering low-dose heparin therapy for clients on bedrest
Using strict aseptic technique to prevent infection Sepsis is a major cause of DIC, especially in the oncology client. Monitoring platelets will help detect DIC, but will not prevent it. Red blood cells are used for anemia, not for bleeding/coagulation disorders. Heparin may be administered to clients with DIC who have developed clotting, but this has not been proven to prevent the disorder.
Which factor represents a sign or symptom of digoxin toxicity? Serum digoxin level of 1.2 ng/mL Polyphagia Visual changes Serum potassium of 5.0 mEq/L
Visual changes, anorexia, nausea, and vomiting are symptoms of digoxin toxicity. A digoxin level of 1.2 ng/mL is normal (0.5 to 2.0 ng/mL). Polyphagia is a symptom of diabetes. Although hypokalemia may predispose to digoxin toxicity, this represents a normal, not low, potassium value.
a patient asks why it is essential that HAART meds be taken everyday at the same time. what is the nurses best response? a. missing or delaying doses of these drugs decreases blood conenctrations needed to inhibit viral replication b. missing or delayed doses of these drugs decreases the risk of developing infections c. missing or delaying doses of these drugs decreases the effectiveness missing or delaying doses can decrease the risk of developing HIV resistant mutations
a
a patient with PJP usually presents with which symptom? A. dyspnea, tachypnea, persistent dry cough, fever b. cough with copious thick sputum, fever, and dyspnea c. chest pain and difficulty swallowing D. fever, persistant cough and vomiting
a
an IV drug user who regularly shares needles is in the ER. what information does the nurse provide to decrease he patients risk of HIV through shared needles after each use? A. fill and flush syringe with clear water, fill with bleach and shake for 30-60 seconds and rinse with clear water B. fill and flush with water then soap and hot water, shake for 2 minutes and flush with cold water C. rinse needles with bleach and water solution and allow to air dry D. rinse needles after each use with rubbing alcohol and water, then rinse with water
a
which point are you sure to include when teaching a new RN to prevent HIV transmission from patients? A. wear gloves when in contact with patients mucous membrane or non-intact skin B. be sure to wear protective gear when providing any care to HIV positive patients C. always war a mask D. use PEP whether a patient is positive or not
a
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." (Chp. 70, elsevier resources)
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." 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. (Chp. 70, elsevier resources)
A client has undergone transurethral resection of the prostate (TURP). Which interventions does the nurse incorporate in this client's postoperative care? (Select all that apply.) a) Administer antispasmodic medications. b) Encourage the client to urinate around the catheter if pressure is felt. c) Perform intermittent urinary catheterization every 4 to 6 hours. d) Place the client in a supine position with his knees flexed. e) Assist the client to mobilize as soon as permitted. (Chp 72, elsevier resources)
a) Administer antispasmodic medications. e) Assist the client to mobilize as soon as permitted. Antispasmodic drugs can be administered to decrease the bladder spasms that may occur due to catheter use. Assisting the client to a chair as soon as permitted postoperatively will help to decrease the risk of complications from immobility. An indwelling catheter and continuous bladder irrigation are in place for about 24 hours after TURP. The client should not try to void around the catheter, which causes the bladder muscles to contract and may result in painful spasms. Intermittent urinary catheterization is not necessary. Typically, the catheter is taped to the client's thigh, so he should keep his leg straight. (Chp 72, elsevier resources)
The RN working in the hospital emergency department is assigned to care for these four clients. Which client does the nurse attend to first? a) Adolescent with an erection for "10 or 11 hours" who is reporting severe pain b) Young adult with a swollen, painful scrotum who has a recent history of mumps infection c) Middle-aged adult discharged 2 days ago after a transurethral resection of the prostate who has increased hematuria d) Older adult with a history of benign prostatic hyperplasia and palpable bladder distention (Chp 72, elsevier resources)
a) Adolescent with an erection for "10 or 11 hours" who is reporting severe pain The client who has had an erection for "10 or 11 hours" has symptoms of priapism, which is considered a urologic emergency because the circulation to the penis may be compromised and the client may not be able to void with an erect penis. The client with a swollen, painful scrotum; the client with hematuria; and the client with a history of benign prostatic hyperplasia do not require the nurse's immediate attention since these are not medical emergencies. (Chp 72, elsevier resources)
A client with prostate cancer asks the nurse for more information and counseling. Which resources does the nurse suggest? (Select all that apply.) a) American Cancer Society's Man to Man program b) Us TOO International c) American Prostate Cancer Society d) National Prostate Cancer Coalition e) Client's church, synagogue, or place of worship (Chp 72, elsevier resources)
a) American Cancer Society's Man to Man program b) Us TOO International d) National Prostate Cancer Coalition e) Client's church, synagogue, or place of worship The American Cancer Society's Man to Man program helps the client and partner cope with prostate cancer by providing one-on-one education, personal visits, education presentations, and the opportunity to engage in open and candid discussions. Us TOO International is a prostate cancer support group that is sponsored by the Prostate Cancer Education and Support Network. The National Prostate Cancer Coalition provides prostate cancer information. The client's church, synagogue, or place of worship is a community support service that may be important for many clients. There is no such organization as the American Prostate Cancer Society. (Chp 72, elsevier resources)
After returning from transurethral resection of the prostate, the client's urine in the continuous bladder irrigation system is a burgundy color. Which client needs does the nurse anticipate after the surgeon sees the client? (Select all that apply.) a) Antispasmodic drugs b) Emergency surgery c) Forced fluids d) Increased intermittent irrigation e) Monitoring for anemia (Chp 72, elsevier resources)
a) Antispasmodic drugs e) Monitoring for anemia Although not a common occurrence, bleeding may occur in the postoperative period. Venous bleeding is more common than arterial bleeding. The surgeon may apply traction on the catheter for a few hours to control the venous bleeding. Traction on the catheter is uncomfortable and increases the risk for bladder spasms, so analgesics or antispasmodics are usually prescribed. Hemoglobin and hematocrit should be monitored and trended for indications of anemia. Emergency surgery and increased intermittent irrigation would be indicated for an arterial bleed, which would be a brighter red color. Forced fluids are indicated after the catheter is removed. (Chp 72, elsevier resources)
A client with benign prostatic hyperplasia is being discharged with alpha-adrenergic blockers. Which information is important for the nurse to include when teaching the client about this type of pharmacologic management? (Select all that apply.) a) Avoid drugs used to treat erection problems. b) Be careful when changing positions. c) Keep all appointments for follow-up laboratory testing. d) Hearing tests will need to be conducted periodically. e) Take the medication in the afternoon. (Chp 72, elsevier resources)
a) Avoid drugs used to treat erection problems. b) Be careful when changing positions. c) Keep all appointments for follow-up laboratory testing. Drugs used to treat erectile dysfunction can worsen side effects, such as hypotension. Alpha-adrenergic blockers may cause orthostatic hypotension and can cause liver damage, so it is important to keep appointments for follow-up laboratory testing. These drugs do not affect hearing. Alpha-adrenergic blockers should be taken in the evening to decrease the risk of problems related to hypotension. (Chp 72, elsevier resources)
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" (Chp. 70, elsevier resources)
a) 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. (Chp. 70, elsevier resources)
When is the best time for the nurse to begin discharge planning and a community-based plan of care for a client with prostate cancer? a) Before surgery b) After surgery c) 2 days before being discharged d) The day of discharge (Chp 72, elsevier resources)
a) Before surgery Planning should begin as early as possible, on admission and before surgery. After surgery is not the correct time to begin planning. Planning should begin earlier than 2 days before discharge. (Chp 72, elsevier resources)
A young adult with testicular cancer is admitted for unilateral orchiectomy and retroperitoneal lymph node dissection. Which nursing action is best for the nurse to delegate to unlicensed assistive personnel (UAP)? a) Encourage the client to cough and deep-breathe after surgery. b) Discuss reproductive options with the client and significant other. c) Teach about the availability of a gel-filled silicone testicular prosthesis. d) Evaluate the client's understanding of chemotherapy and radiation treatment. (Chp 72, elsevier resources)
a) Encourage the client to cough and deep-breathe after surgery. Although teaching about routine postoperative client actions such as coughing and deep-breathing should be done by licensed nurses, reminding clients to perform these activities can be delegated to UAP. Client education and evaluation are more complex skills that should be done by licensed nurses. (Chp 72, elsevier resources)
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 (Chp. 70, elsevier resources)
a) 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. (Chp. 70, elsevier resources)
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. (Chp. 70, elsevier resources)
a) 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. (Chp. 70, elsevier resources)
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 (Chp. 70, elsevier resources)
a) 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. (Chp. 70, elsevier resources)
The nurse is caring for a client with erectile dysfunction who has not had success with other treatment modalities. The nurse anticipates that the health care provider will recommend which treatment for this client? a) Penile implants b) Penile injections c) Transurethral suppository d) Vacuum constriction device (Chp 72, elsevier resources)
a) Penile implants Penile implants (prostheses), which require surgery, are used when other modalities fail. Devices include semi-rigid, flexible, or hydraulic inflatable and multi-component or one-piece instruments. Penile injections are tried before using the option of last resort. Transurethral suppository is tried before using the option of last resort. A vacuum constriction device is easy to use, and is often the first option that is tried. (Chp 72, elsevier resources)
which conditions cause severe pain in HIV and AIDS (Select all that apply) a. enlarged organs b. peripheral neuropathy c. tumors d. high fever e. dry skin
a, b, c
an HIV positive women who is pregnant asks if her baby is at risk for HIV. which points must the nurse be sure to include when teaching? (Select all that apply) A. HIV can cross the placenta B. infant can contract HIV with exposure to blood and vaginal secretions during birth C. once your baby is born, you should be able to breastfeed D. there is a risk for perinatal transmission of HIV from you to your child. because you are on drug therapy, that risk is about 8% E. consider oral contraceptives o protect yourself from other STDs
a, b, d
what methods or agents are used to treat kaposi's sarcoma (Select all that apply) a. radiotherapy b. chemo c. antibiotics d. cryotherapy e. surgery
a, b, d
which actions are useful in helping orient a patient (Select all that apply) a. repeating person, place, time b. using clocks and calendars c. using MMSE screening test d. having familiar items present e. providing uninterrupted time
a, b, d
which descriptions are characteristic of a non progressor? (Select all that apply) A. has been infected for 10 years B. is asymptomatic C. has no CD4+ or t-lymphocytes D. is immunocompetent E. are functional antibodies
a, b, d
the nurse assesses a patient diagnosed with advanced AIDS for malnutirition. which findings does the nurse most likely assess (Select all that apply) a. pain b. anorexia c. urinary incontinence d. diarrhea e. vomiting
a, b, d, e
which methods or items are means of transmitting HIV (Select all that apply) a. sex b. household utensils c. breast milk d. toilet facilities e. mosquitoes
a, c
corticosteroids perform which actions (Select all that apply) a. block movement of neutrophils and monoctyes through cell membrane b. increase cell production in the bone marrow c. reduce number of circulating t cells, resulting in suppressed cell mediated immunity d. decrease ICP e. contrict blood vessels
a, c, d
where in the body can cytomegalovirus present with symptoms? (Select all that apply) a. eyes, causing visual impairment b. kidneys as glomerulonephritis c. respiratory tract causing pneumonia d. GI tract, causing diarrhea e. heart as cardiomyopathy
a, c, d
which actions can the nurse delegate to the UAP who will be giving mouth care to a patient with HIV/AIDS (Select all that apply) a. offer mouth rinses with sodium bicarb and sterile water several times a day b. assess mouth for increased presence of lesions c. encourage the patient to drink plenty of fluids d. provide a soft bristled toothbrush e. administer oral analgesic gel
a, c, d
which conditions may be the first signs of HIV in women? (Select all that apply) A. vaginal candidiasis B. bladder infections C. cervical caner D. PID E. mononucleosis
a, c, d
a patient presenting with toxicoplasmosis may have with s/s? (Select all that apply) A. speech difficulty B. Shortness of breath C. visual changes D. impaired gait E. mental status changes
a, c, d, e
which opportunistic infections can be observed in AIDS (Select all that apply) A. toxicoplasmosis B. gastroenteritis C. TB D. candidiasis E. cytomegalovirus
a, c, d, e
which practices are recommended to prevent transmission of HIV? (Select all that apply) A. latex condoms for genital and anal intercourse B. natural membrane condoms for genital and anal intercourse C. topical contraceptives D. antiviral meds E. latex barrier for genital and anal intercourse
a, e
A client has been prescribed lorcaserin (Belviq). What teaching is most appropriate? a. "Increase the fiber and water in your diet." b. "Reduce fat to less than 30% each day." c. "Report dry mouth and decreased sweating." d. "Lorcaserin may cause loose stools for a few days."
a. "Increase the fiber and water in your diet."
A client with unstable angina has received education about acute coronary syndrome. Which statement indicates that the client has understood the teaching? a. "This is a big warning; I must modify my lifestyle or risk having a heart attack in the next year." b. "Angina is just a temporary interruption of blood flow to my heart." c. "I need to tell my wife I've had a heart attack." d. "Because this was temporary, I will not need to take any medications for my heart."
a. "This is a big warning; I must modify my lifestyle or risk having a heart attack in the next year." Among people who have unstable angina, 10% to 30% have a myocardial infarction within 1 year. Although anginal pain is temporary, it reflects underlying coronary artery disease (CAD), which requires attention, including lifestyle modifications. Unstable angina reflects tissue ischemia, but infarction represents tissue necrosis. Clients with underlying CAD may need medications such as aspirin, lipid-lowering agents, anti-anginals, or antihypertensives.
A nurse is caring for a client receiving enteral feedings through a Dobhoff tube. What action by the nurse is best to prevent hyperosmolarity? a. Administer free-water boluses. b. Change the client's formula. c. Dilute the client's formula. d. Slow the rate of infusion.
a. Administer free-water boluses.
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.
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.
A client is in the family practice clinic. Today the client weighs 186.4 pounds (84.7 kg). Six months ago the client weighed 211.8 pounds (96.2 kg). What action by the nurse is best? a. Ask the client if the weight loss was intentional. b. Determine if there are food allergies or intolerances. c. Perform a comprehensive nutritional assessment. d. Perform a rapid bedside blood glucose test.
a. Ask the client if the weight loss was intentional.
A client is receiving total parenteral nutrition (TPN). On assessment, the nurse notes the client's pulse is 128 beats/min, blood pressure is 98/56 mm Hg, and skin turgor is dry. What action should the nurse perform next? a. Assess the 24-hour fluid balance. b. Assess the client's oral cavity. c. Prepare to hang a normal saline bolus. d. Turn up the infusion rate of the TPN.
a. Assess the 24-hour fluid balance.
A client is in the bariatric clinic 1 month after having gastric bypass surgery. The client is crying and says "I didn't know it would be this hard to live like this." What response by the nurse is best? a. Assess the client's coping and support systems. b. Inform the client that things will get easier. c. Re-educate the client on needed dietary changes. d. Tell the client lifestyle changes are always hard.
a. Assess the client's coping and support systems.
A nurse and a registered dietitian are assessing clients for partial parenteral nutrition (PPN). For which client would the nurse suggest another route of providing nutrition? a. Client with congestive heart failure b. Older client with dementia c. Client who has multiorgan failure d. Client who is post gastric resection
a. Client with congestive heart failure
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.
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.
When planning care for a client in the emergency department, which interventions are needed in the acute phase of myocardial infarction? (Select all that apply.) a. Morphine sulfate b. Oxygen c. Nitroglycerin d. Naloxone e. Acetaminophen f. Verapamil (Calan, Isoptin)
a. Morphine sulfate b. Oxygen c. Nitroglycerin Morphine is needed to reduce oxygen demand, preload, pain, and anxiety, and nitroglycerin is used to reduce preload and chest pain. Administering oxygen will increase available oxygen for the ischemic myocardium. Naloxone is a narcotic antagonist that is used for overdosage of opiates, not for MI. Acetaminophen may be used for headache related to nitroglycerin. Because of negative inotropic action, calcium channel blockers such as verapamil are used for angina, not for MI.
After receiving change-of-shift report in the coronary care unit, which client does the nurse assess first? a. The client with acute coronary syndrome who has a 3-pound weight gain and dyspnea b. The client with percutaneous coronary angioplasty who has a dose of heparin scheduled c. The client who had bradycardia after a myocardial infarction and now has a paced heart rate of 64 beats/min d. A client who has first-degree heart block, rate 68 beats/min, after having an inferior myocardial infarction
a. The client with acute coronary syndrome who has a 3-pound weight gain and dyspnea Dyspnea and weight gain are symptoms of left ventricular failure and pulmonary edema; this client needs prompt intervention. A scheduled heparin dose does not take priority over dyspnea; it can be administered after the client with dyspnea is taken care of. The client with a pacemaker and a normal heart rate is not in danger. First-degree heart block is rarely symptomatic, and the client has a normal heart rate; the client with dyspnea should be seen first.
The nurse is preparing to teach a client that metabolic syndrome can increase the risk for myocardial infarction (MI). Which signs of metabolic syndrome should the nurse include in the discussion? (Select all that apply.) a. Truncal obesity b. Hypercholesterolemia c. Elevated homocysteine levels d. Glucose intolerance e. Client taking losartan (Cozaar)
a. Truncal obesity b. Hypercholesterolemia d. Glucose intolerance e. Client taking losartan (Cozaar) A large waist size (excessive abdominal fat causing central obesity)—40 inches (102 cm) or greater for men, 35 inches (88 cm) or greater for women—is a sign of metabolic syndrome. Decreased high-density lipoprotein cholesterol (HDL-C) (usually with high low-density lipoprotein cholesterol)—HDL-C less than 40 mg/dL for men or less than 50 mg/dL for women—or taking an anticholesterol drug is a sign of metabolic syndrome. Increased fasting blood glucose (caused by diabetes, glucose intolerance, or insulin resistance) is included in the constellation of metabolic syndrome. Blood pressure greater than 130/85 mm Hg or taking antihypertensive medication indicates metabolic syndrome. Although elevated homocysteine levels may predispose to atherosclerosis, they are not part of metabolic syndrome.
HAART causes what effects? A. reversal of a patients antibody status B. decrease of the viral load C. increase of the viral load D. moe delectable HIV
b
What type of precautions should the nurse take for a patient suspected of having TB as a result of HIV? A. universal b. airborne c. enteric d. protective isolation
b
the nurse is teaching a patient about preventing infection through sex. which statement indicates effective teaching? a. latex condom with spermicide proves the best protection b. mutually monogamous sex with a non infected partner will best prevent HIV c. contraceptive methods like implants and injections are recommended to prevent HIV transmission d. if my partner and i are both HIV positive, unprotected sex is permitted
b
the patient with HIV/AIDS appears emaciated and has diarrhea, anorexia, mouth lesions, and peristent weight loss. what condition does the nurse suspect this patient is developing? a. AIDS dementia B. AIDS wasting syndrome C. AIDS GI opportunistic infection D. AIDS candidiasis opportunistic infection
b
what is the most important means of preventing HIV spread? A. engineering B. education C. isolation D. counseling
b
which definition of immunodeficiency is accurate? A. disease/deficiency acquired as a result of viral infection, contact with toxin, or medical therapy B. deficient immune response as a result of imapired or missing immune components C. chronic infection wih immunodeficiency virus D. disease/deficiency pesent since birth
b
A client with prostate cancer asks why he must have surgery instead of radiation, even if his cancer is the least-invasive type. What is the nurse's best response? a) "It is because your cancer growth is large." b) "Surgery is the most common intervention to cure the disease." c) "Surgery slows the spread of cancer." d) "The surgery is to promote urination." (Chp 72, elsevier resources)
b) "Surgery is the most common intervention to cure the disease." Because some localized prostate cancers are resistant to radiation, surgery is the most common intervention for a cure. The size of the tumor is not likely to be why the client is having surgery. A bilateral orchiectomy (removal of both testicles) is palliative surgery that slows the spread of cancer by removing the main source of testosterone. A transurethral resection of the prostate is done to promote urination for clients with advanced disease; it is not used as a curative treatment. (Chp 72, elsevier resources)
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. (Chp. 70, elsevier resources)
b) Ensure that the setting in which BSE is demonstrated is private and comfortable. d) 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. (Chp. 70, elsevier resources)
A client is having a radical prostatectomy. Which preoperative teaching specific to this surgery does the nurse emphasize? a) Incentive spirometry b) Kegel exercises c) Pain control d) Penile implants (Chp 72, elsevier resources)
b) Kegel exercises Kegel perineal exercises may reduce the severity of urinary incontinence after radical prostatectomy. The client is taught to contract and relax the perineal and gluteal muscles in several ways. Incentive spirometry and pain control are important for everyone who undergoes surgery; neither is specific to radical prostatectomy. Penile implants are not important to discuss during preoperative teaching; however, they may be necessary to discuss later. (Chp 72, elsevier resources)
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. (Chp. 70, elsevier resources)
b) 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. (Chp. 70, elsevier resources)
Why is prostate cancer screening often emphasized to the African-American population in the United States? a) Metastasis of prostate cancer is higher. b) Prostate cancer occurs at an earlier age. c) Prostate-specific antigen (PSA) is not sensitive to prostate disease. d) Clinical presentation is different. (Chp 72, elsevier resources)
b) Prostate cancer occurs at an earlier age. In the United States, prostate cancer affects African-American men the most and at an earlier age. There is no difference in prostate cancer metastasis, PSA sensitivity, or clinical presentation of prostate cancer in the African-American population as compared to other populations. (Chp 72, elsevier resources)
A client had an orchiectomy and laparoscopic radical retroperitoneal lymph node dissection this morning. What is the nurse's priority for care? a) assess the client's pain level and provide pain management b) ensure that the client's urinary catheter is draining clear yellow urine c) observe the client's incision for redness, swelling, and drainage d) apply oxygen therapy via nasal cannula at 2 L/min (Ignatavicius & Workman, p. 1515)
b) ensure that the client's urinary catheter is draining clear yellow urine (Ignatavicius & Workman, p. 1515)
A client had a transurethral resection of the prostate (TURP) with continuous bladder irrigation yesterday. The staff nurse notes that the urinary drainage is bright red and thick. What is the nurse's best action? a) notify the charge nurse as soon as possible b) increase the rate of bladder irrigation c) document the assessment in the medical record d) prepare the patient for a blood transfusion (Ignatavicius & Workman, p. 1506)
b) increase the rate of bladder irrigation (Ignatavicius & Workman, p. 1506)
which statement about the transmission of HIV is true? (Select all that apply) A. can only be transmitted during end stage B. those with recent HIV infection and high viral load are very infectious C. those with end stage HIV and no drug therapy are very infectious D. HIV is only transmitted with sexual contact E. all people infected with HIV will quickly progress to AIDS
b, c
how does HSV manifest itself in patients with HIV/AIDS (Select all that apply) a. maculopapular lesions that can spread b. chronic ulceration after vesicles rupture c. vesicles ocated in the perirectal, oral, and genital area d. numbness and tingling before vesicle forms e. itching localized to perianal area
b, c, d
where can candidiasis occur in the body (Select all that apply) a. nose b. esophagus c. vagina d. mouth e. ears
b, c, d
HIV is most commonly transmitted by which routes? (Select all that apply) A. oral B. sexual C. parenteral D. airborne E. perinatal
b, c, e
which statements are true about immunodeficiency? (Select all that apply) A. it causes a decrease in the patients risk for infection B. it may be acquired or congential C. it occurs when a persons body cannot recognize antigens D. it is the same as autoimmunity E. it may cause varied reactions from mild, localized health problems to total immune system failure
b, c, e
which statements about HIV are accurate? (Select all that apply) A. may be acquired or congenital B. it is retrovirus C. it always progresses to AIDS D. it is a virus that attacks the immune system E. it is a parasite that forces cells to make copies of itself
b, d, e
which immune function abnormalities are a result of HIV infection? (Select all that apply) A. lymphocytosis B. CD4+ depletion C. increased CD8+ activity D. long macrophage life span E. lymphocytopenia
b, 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 caring for a group of clients who have sustained myocardial infarction (MI). The nurse observes the client with which type of MI most carefully for the development of left ventricular heart failure? a. Inferior wall b. Anterior wall c. Lateral wall d. Posterior wall
b. Anterior wall Due to the large size of the anterior wall, the amount of tissue infarction may be large enough to decrease the force of contraction, leading to heart failure. The client with an inferior wall MI is more likely to develop right ventricular heart failure. Clients with obstruction of the circumflex artery may experience a lateral wall MI and sinus dysrhythmias or a posterior wall MI and sinus dysrhythmias.
A client is awaiting bariatric surgery in the morning. What action by the nurse is most important? a. Answering questions the client has about surgery b. Beginning venous thromboembolism prophylaxis c. Informing the client that he or she will be out of bed tomorrow d. Teaching the client about needed dietary changes
b. Beginning venous thromboembolism prophylaxis
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 client is receiving bolus feedings through a Dobhoff tube. What action by the nurse is most important? a. Auscultate lung sounds after each feeding. b. Check tube placement before each feeding. c. Check tube placement every 8 hours. d. Weigh the client daily on the same scale.
b. Check tube placement before each feeding.
A client has just returned from coronary artery bypass graft surgery. For which finding does the nurse contact the surgeon? a. Temperature 98.2° F b. Chest tube drainage 175 mL last hour c. Serum potassium 3.9 mEq/L d. Incisional pain 6 on a scale of 0 to 10
b. Chest tube drainage 175 mL last hour Some bleeding is expected after surgery; however, the nurse should report chest drainage over 150 mL/hr to the surgeon. Although hypothermia is a common problem after surgery, a temperature of 98.2° F is a normal finding. Serum potassium of 3.9 mEq/L is a normal finding. Incisional pain of 6 on a scale of 0 to 10 is expected immediately after major surgery; the nurse should administer prescribed analgesics.
A nurse is reviewing laboratory values for several clients. Which value causes the nurse to conduct nutritional assessments as a priority? a. Albumin: 3.5 g/dL b. Cholesterol: 142 mg/dL c. Hemoglobin: 9.8 mg/dL d. Prealbumin: 28 mg/dL
b. Cholesterol: 142 mg/dL A cholesterol level below 160 mg/dL is a possible indicator of malnutrition
The nurse in the coronary care unit is caring for a group of clients who have had myocardial infarction. Which client does the nurse see first? a. Client with dyspnea on exertion when ambulating to the bathroom b. Client with third-degree heart block on the monitor c. Client with normal sinus rhythm and PR interval of 0.28 second d. Client who refuses to take heparin or nitroglycerin
b. Client with third-degree heart block on the monitor Third-degree heart block is a serious complication that indicates that a large portion of the left ventricle and conduction system are involved, so the client with the third-degree heart block should be seen first. Third-degree heart block usually requires pacemaker insertion. A normal rhythm with prolonged PR interval indicates first-degree heart block, which usually does not require treatment. The client with dyspnea on exertion when ambulating to the bathroom is not at immediate risk. The client's uncooperative behavior when refusing to take heparin or nitroglycerin may indicate fear or denial; he should be seen after emergency situations have been handled.
The nurse is concerned that a client who had myocardial infarction (MI) has developed cardiogenic shock. Which findings indicate shock? (Select all that apply.) a. Bradycardia b. Cool, diaphoretic skin c. Crackles in the lung fields d. Respiratory rate of 12 breaths/min e. Anxiety and restlessness f. Temperature of 100.4° F
b. Cool, diaphoretic skin c. Crackles in the lung fields e. Anxiety and restlessness The client with shock has cool, moist skin. Because of extensive tissue necrosis, the left ventricle cannot forward blood adequately, resulting in pulmonary congestion and crackles. Because of poor tissue perfusion, a change in mental status, anxiety, and restlessness are expected. All types of shock (except neurogenic) present with tachycardia, not bradycardia. Due to pulmonary congestion, a client with cardiogenic shock typically has tachypnea. Cardiogenic shock does not present with low-grade fever; this would be more likely to occur in pericarditis.
The client in the cardiac care unit has had a large myocardial infarction. How does the nurse recognize onset of left ventricular failure? a. Urine output of 1500 mL on the preceding day b. Crackles in the lung fields c. Pedal edema d. Expectoration of yellow sputum
b. Crackles in the lung fields Manifestations of left ventricular failure and pulmonary edema are noted by listening for crackles and identifying their locations in the lung fields. A urine output of 1500 mL is normal. Edema is a sign of right ventricular heart failure. Yellow sputum indicates the presence of white blood cells and possible infection.
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.
Which atypical symptoms may be present in a female client experiencing myocardial infarction (MI)? (Select all that apply.) a. Sharp, inspiratory chest pain b. Dyspnea c. Dizziness d. Extreme fatigue e. Anorexia
b. Dyspnea c. Dizziness d. Extreme fatigue Many women who experience an MI present with dyspnea, light-headedness, and fatigue. Sharp, pleuritic pain is more consistent with pericarditis or pulmonary embolism. Anorexia is neither a typical nor an atypical sign of MI.
A morbidly obese client is admitted to a community hospital that does not typically care for bariatric-sized clients. What action by the nurse is most appropriate? a. Assess the client's readiness to make lifestyle changes. b. Ensure adequate staff when moving the client. c. Leave siderails down to prevent pressure ulcers. d. Reinforce the need to be sensitive to the client.
b. Ensure adequate staff when moving the client.
A nurse is caring for a morbidly obese client. What comfort measure is most important for the nurse to delegate to the unlicensed assistive personnel (UAP)? a. Designating "quiet time" so the client can rest b. Ensuring siderails are not causing excess pressure c. Providing oral care before and after meals and snacks d. Relaying any reports of pain to the registered nurse
b. Ensuring siderails are not causing excess pressure
After thrombolytic therapy, the nurse working in the cardiac catheterization laboratory would be alarmed to notice which sign? a. A 1-inch backup of blood in the IV tubing b. Facial drooping c. Partial thromboplastin time (PTT) 68 seconds d. Report of chest pressure during dye injection
b. Facial drooping During and after thrombolytic administration, the nurse observes for any indications of bleeding, including changes in neurologic status, which may indicate intracranial bleeding. A 1-inch backup of blood in the IV tubing may be related to IV positioning. If heparin is used, PTT reflects a therapeutic value. Reports of chest pressure during dye injection or stent deployment are considered an expected result of the procedure.
Which characteristics place women at high risk for myocardial infarction (MI)? (Select all that apply.) a. Premenopausal b. Increasing age c. Family history d. Abdominal obesity e. Breast cancer
b. Increasing age c. Family history d. Abdominal obesity Increasing age is a risk factor, especially after 70 years. Family history is a significant risk factor in both men and women. A large waist size and/or abdominal obesity are risk factors for both metabolic syndrome and MI. Premenopausal women are not at higher risk for MI, and breast cancer is not a risk factor for MI.
A client comes to the emergency department with chest discomfort. Which action does the nurse perform first? a. Administers oxygen therapy b. Obtains the client's description of the chest discomfort c. Provides pain relief medication d. Remains calm and stays with the client
b. Obtains the client's description of the chest discomfort A description of the chest discomfort must be obtained first, before further action can be taken. Neither oxygen therapy nor pain medication is the first priority in this situation; an assessment is needed first. Remaining calm and staying with the client are important, but are not matters of highest priority.
Prompt pain management with myocardial infarction is essential for which reason? a. The discomfort will increase client anxiety and reduce coping. b. Pain relief improves oxygen supply and decreases oxygen demand. c. Relief of pain indicates that the MI is resolving. d. Pain medication should not be used until a definitive diagnosis has been established.
b. Pain relief improves oxygen supply and decreases oxygen demand. The focus of pain relief is on reducing myocardial oxygen demand. Chest discomfort will increase anxiety, but it may not affect coping. Relief of pain is secondary to the use of opiates or indicates that the tissue infarction is complete. Although it used to be true that pain medication was not to be used for undiagnosed abdominal pain, this does not relate to MI.
Several nurses have just helped a morbidly obese client get out of bed. One nurse accesses the client's record because "I just have to know how much she weighs!" What action by the client's nurse is most appropriate? a. Make an anonymous report to the charge nurse. b. State "That is a violation of client confidentiality." c. Tell the nurse "Don't look; I'll tell you her weight." d. Walk away and ignore the other nurse's behavior.
b. State "That is a violation of client confidentiality."
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.
The HIV positive patient tells the nurse that his HIV negative partner will be using preexposure drugs (Truvada). which statement indicates the need for additional teaching? A. my partner will need to be tested q3m B. this drug will decrease the chances of my partner becoming positive C. once we start using Truvada I will no longer need a condom D. my partner will need to be monitored for any side effects on this drug
c
shingles results from VZV leaving the body by which route? a. mucous membrane b. pulmonary space c. body fluids and other tissues d. bone marrow
c
the HCP prescribes an integrase inhibitor for an HIV patient. the patient asks the nurse how this drug works. what is the nurses best response? A. it reduces how well HIV genetic material can be converted into human genetic material B. it reinforces the immune systems ability to fight off an infection C. it prevents viral DNA from integrating into hosts DNA D. prevent HIV infection from progressing to AIDS
c
the patient with HIV/AIDS tells the nurse that food tastes funny and is difficult to swallow. what is the nurses priority action at this time? a. Check the patients gag reflex b. ask about blood cultures c. examine the patient's mouth and throat d. collaborate with the dietitian to provide a soft diet
c
The nurse is assigned care for a client who has undergone a modified radical left mastectomy for breast cancer. When delegating care, which statement by the nursing assistant would require further teaching by the nurse? a) "I will report urine intake and output to you." b) "If the client appears to be in pain, I will tell you right away." c) "It is important for me to take blood pressure on the client's left arm." d) "When ambulating, I will assist the client to stand straight with arms hanging at the side." (Ignatavicius & Workman, p. 1474)
c) "It is important for me to take blood pressure on the client's left arm." (Ignatavicius & Workman, p. 1474)
With which male client does the nurse conduct prostate screening and education? a) Young adult with a history of urinary tract infections b) Client who has sustained an injury to the external genitalia c) Adult who is older than 50 years d) Sexually active client (Chp 72, elsevier resources)
c) Adult who is older than 50 years A man who is 50 years or older is at higher risk for prostate cancer. A history of urinary tract infections, injury to the external genitalia, and sexual activity are not risk factors for prostate cancer. (Chp 72, elsevier resources)
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 (Chp. 70, elsevier resources)
c) 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. (Chp. 70, elsevier resources)
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) (Chp. 70, elsevier resources)
c) 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. (Chp. 70, elsevier resources)
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 (Chp. 70, elsevier resources)
c) 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. (Chp. 70, elsevier resources)
Which assessment finding causes the nurse to suspect that a client may have testicular cancer? a) Hematuria b) Penile discharge c) Painless testicular lump d) Sudden increase in libido (Chp 72, elsevier resources)
c) Painless testicular lump A painless lump or swelling in the testicles is the most common manifestation of testicular cancer. Hematuria is not a symptom of testicular cancer, but could be indicative of other conditions such as bladder cancer. Penile discharge is not a symptom of testicular cancer, but could be indicative of another condition. A sudden increase in libido is not a symptom of testicular cancer. (Chp 72, elsevier resources)
The potential problem of grief is most relevant to a client after which procedure? a) Cystoscopy b) Transurethral microwave therapy c) Radical prostatectomy d) Sperm banking (Chp 72, elsevier resources)
c) Radical prostatectomy A radical prostatectomy may lead to erectile dysfunction, which could present a potential problem of grief at loss of function. Cystoscopy, a test to view the interior of the bladder, the bladder neck, and the urethra, does not affect sexuality. Transurethral microwave therapy is a minimally invasive procedure involving high temperatures that heat and destroy excess prostate tissue, and does not affect sexuality. The process of sperm banking would not result in a diagnosis of altered self-image; however, the diagnosis leading to the necessity of sperm banking might cause this. (Chp 72, elsevier resources)
Which method is a common complementary and alternative therapy for benign prostatic hyperplasia (BPH)? a) Acupuncture b) Calcium supplements c) Serenoa repens d) Yoga (Chp 72, elsevier resources)
c) Serenoa repens Serenoa repens (saw palmetto), a plant extract, is often used by men with early to moderate BPH. They believe that this agent relieves their symptoms and prefer this treatment over prescription drugs or surgery. (It should be noted, however, that studies on the effectiveness of Serenoa repens have not shown that it is effective.) Acupuncture, calcium, and yoga are not common alternative therapies for BPH. (Chp 72, elsevier resources)
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. (Chp. 70, elsevier resources)
c) 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. (Chp. 70, elsevier resources)
A client undergoing coronary artery bypass grafting asks why the surgeon has chosen to use the internal mammary artery for the surgery. Which response by the nurse is correct? a. "This way you will not need to have a leg incision." b. "The surgeon prefers this approach because it is easier." c. "These arteries remain open longer." d. "The surgeon has chosen this approach because of your age."
c. "These arteries remain open longer." Mammary arteries remain patent much longer than other grafts. Although no leg incision will be made with this approach, veins from the legs do not remain patent as long as the mammary artery graft does. Long-term patency, not ease of the procedure, is the primary concern. Age is not a determining factor in selection of these grafts.
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.
An LPN/LVN is scheduled to work on the inpatient "stepdown" cardiac unit. Which client does the charge nurse assign to the LPN/LVN? a. A 60-year-old who was admitted today for pacemaker insertion because of third-degree heart block and who is now reporting chest pain b. A 62-year-old who underwent open heart surgery 4 days ago for mitral valve replacement and who has a temperature of 38.2° C c. A 66-year-old who has a prescription for a nitroglycerin (Nitro-Dur) patch and is scheduled for discharge to a group home later today d. A 69-year-old who had a stent placed 2 hours ago in the left anterior descending artery and who has bursts of ventricular tachycardia
c. A 66-year-old who has a prescription for a nitroglycerin (Nitro-Dur) patch and is scheduled for discharge to a group home later today The LPN/LVN scope of practice includes administration of medications to stable clients. Third-degree heart block is characterized by a very low heart rate and usually by required pacemaker insertion; the skills of the RN are needed to care for this client. Fever after surgery requires collaboration with the health care provider, which is more consistent with the role of the RN. The client with a recent stent placement and having bursts of ventricular tachycardia is unstable and is showing ventricular irritability; he will need medications and monitoring beyond the scope of practice of the LPN/LVN.
An older adult client, 4 hours after coronary artery bypass graft (CABG), has a blood pressure of 80/50 mm Hg. What action does the nurse take? a. No action is required; low blood pressure is normal for older adults. b. No action is required for postsurgical CABG clients. c. Assess pulmonary artery wedge pressure (PAWP). d. Give ordered loop diuretics.
c. Assess pulmonary artery wedge pressure (PAWP). Decreased preload as exhibited by decreased PAWP could indicate hypovolemia secondary to hemorrhage or vasodilation; hypotension could cause the graft to collapse. Low blood pressure is not normal in older adults or postoperative clients. The cause of hypotension must be found and treated; further action is needed to determine additional interventions. Hypotension could be caused by hypovolemia; giving loop diuretics increases hypovolemia.
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.
The nurse is teaching a group of teens about prevention of heart disease. Which point should the nurse emphasize? a. Reduce abdominal fat. b. Avoid stress. c. Do not smoke or chew tobacco. d. Avoid alcoholic beverages.
c. Do not smoke or chew tobacco. Tobacco exposure, including secondhand smoke, reduces coronary blood flow; causes vasoconstriction, endothelial dysfunction, and thickening of the vessel walls; increases carbon monoxide; and decreases oxygen. Because it is highly addicting, beginning smoking in the teen years may lead to decades of exposure. Teens are not likely to experience metabolic syndrome from obesity, but are very likely to use tobacco. Avoiding stress is a less modifiable risk factor, which is less likely to cause heart disease in teens. The risk of smoking outweighs the risk of alcohol use. Tobacco exposure, including secondhand smoke, reduces coronary blood flow; causes vasoconstriction, endothelial dysfunction, and thickening of the vessel walls; increases carbon monoxide; and decreases oxygen. Because it is highly addicting, beginning smoking in the teen years may lead to decades of exposure. Teens are not likely to experience metabolic syndrome from obesity, but are very likely to use tobacco. Avoiding stress is a less modifiable risk factor, which is less likely to cause heart disease in teens. The risk of smoking outweighs the risk of alcohol use.
A client just returned to the surgical unit after a gastric bypass. What action by the nurse is the priority? a. Assess the client's pain. b. Check the surgical incision. c. Ensure an adequate airway. d. Program the morphine pump.
c. Ensure an adequate airway.
A nurse attempted to assist a morbidly obese client back to bed and had immediate pain in the lower back. What action by the nurse is most appropriate? a. Ask another nurse to help next time. b. Demand better equipment to use. c. Fill out and file a variance report. d. Refuse to assist the client again.
c. Fill out and file a variance report.
A client having a tube feeding begins vomiting. What action by the nurse is most appropriate? a. Administer an antiemetic. b. Check the client's gastric residual. c. Hold the feeding until the nausea subsides. d. Reduce the rate of the tube feeding by half.
c. Hold the feeding until the nausea subsides.
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
The visiting nurse is seeing a client postoperative for coronary artery bypass graft. Which nursing action should be performed first? a. Assess coping skills. b. Assess for postoperative pain at the client's incision site. c. Monitor for dysrhythmias. d. Monitor mental status.
c. Monitor for dysrhythmias. Dysrhythmias are the leading cause of prehospital death; the nurse should monitor the client's heart rhythm. Assessing mental status, coping skills, or postoperative pain is not the priority for this client.
The nurse is caring for a client in phase 1 cardiac rehabilitation. Which activity does the nurse suggest? a. The need to increase activities slowly at home b. Planning and participating in a walking program c. Placing a chair in the shower for independent hygiene d. Consultation with social worker for disability planning
c. Placing a chair in the shower for independent hygiene Phase 1 begins with the acute illness and ends with discharge from the hospital; it focuses on promoting rest and allowing clients to improve their activities of daily living based on their abilities. Phase 2 begins after discharge and continues through convalescence at home, including consultation with a social worker for long-term planning; it consists of achieving and maintaining a vital and productive life while remaining within the limits of the heart's ability to respond to increases in activity and stress. Phase 3 refers to long-term conditioning, such as a walking program.
A client tells the nurse about losing weight and regaining it multiple times. Besides eating and exercising habits, for what additional data should the nurse assess as the priority? a. Economic ability to join a gym b. Food allergies and intolerances c. Psychosocial influences on weight d. Reasons for wanting to lose weight
c. Psychosocial influences on weight
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 nursing student is studying nutritional problems and learns that kwashiorkor is distinguished from marasmus with which finding? a. Deficit of calories b. Lack of all nutrients c. Specific lack of protein d. Unknown cause of malnutrition
c. Specific lack of protein
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.
cryptosporidiosis is a form of intestinal infection in which diarrhea can amount to a loss of how many liters of fluid per day? A. 1-2 B. 3-5 c. 5-8 d. 15-20
d
which is the most common route for HCP to contract HIV: A. blood B. bodily fluids C. mucous membranes D. needle sticks
d
which malignancy is most common in patients with HIV/AIDS a. non-hodgkins B cell lymphoma b. anal cancer c. primary brain cancer d. kaposi's sarcoma
d
which statements regarding HIV/AIDS among older adults are true? A. the risk for HIV infection after exposure is minimal for older adults B. older men are more susceptible to HIV C. it is not necessary to assess an older adult for history of drug use D. older adults who participate in high-risk behaviors are susceptible to HIV
d
which treatments are intended to boost the immune system? a. protease inhibitors b. hematopoietic growth factors c. lymphocyte transfusion d. interleukin-2 infusion
d
The nurse is educating a group of young men about testicular self-examination (TSE). Which statement by a member of the group indicates teaching has been effective? a) "I will examine my testicles right before taking a shower." b) "I should squeeze each testicle in my hand to feel any lumps." c) "I should only report any large lumps to my health care provider." d) "I will look and feel for any lumps or changes to my testes." (Chp 72, elsevier resources)
d) "I will look and feel for any lumps or changes to my testes." With early detection by monthly TSE and treatment, testicular cancer can be successfully cured. In TSE, the client should look and feel for any lumps or changes to the testes. Any lumps that are detected should be immediately reported. A TSE should be performed immediately following a shower. The client should gently roll each testicle between the thumb and forefinger. All lumps should be reported to the provider, no matter the size. (Chp 72, elsevier resources)
The nurse is teaching a client about taking sildenafil (Viagra) for erectile dysfunction. Which statement by the client indicates a need for further teaching? a) "I should have sex within an hour after taking the drug." b) "I should avoid alcohol when on the drug or it might not work well." c) "I can expect to maybe get a stuffy nose or headache when I take the drug." d) "If I have chest pain during sex, I should take a nitroglycerin tablet." (Ignatavicius & Workman, p. 1513)
d) "If I have chest pain during sex, I should take a nitroglycerin tablet." (Ignatavicius & Workman, p. 1513)
A client receiving external beam radiation therapy calls the nurse to report rectal urgency, cramping, and passing of mucus and blood. What is the nurse's best response? a) "This is an emergency. Go directly to the emergency department." b) "This is normal and will resolve as soon as the treatment stops." c) "Avoid caffeine and continue drinking plenty of water and other fluids." d) "Limit spicy or fatty foods, caffeine, and dairy products." (Chp 72, elsevier resources)
d) "Limit spicy or fatty foods, caffeine, and dairy products." The client's symptoms indicate that he is experiencing radiation proctitis, a common complication of external beam radiation therapy. The nurse's instructions to limit spicy or fatty foods, caffeine, and dairy products describe what the client should do to alleviate these symptoms. The client's symptoms do not indicate an emergency, but they should be reported to the health care provider. The client's symptoms should resolve 4 to 6 weeks after the treatment stops. Avoiding caffeine and drinking water and other fluids describe what the client should do if he is experiencing radiation cystitis, which he is not. (Chp 72, elsevier resources)
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." (Chp. 70, elsevier resources)
d) "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. (Chp. 70, elsevier resources)
The nurse is caring for four clients. Which client does the nurse recognize as having the highest risk for development of breast cancer? a) 45-year-old male with gynecomastia b) 40-year-old female whose father had colon cancer c) 50-year-old male whose mother had ovarian cancer d) 65-year-old female with history of a prior episode of breast cancer (Ignatavicius & Workman, p. 1467)
d) 65-year-old female with history of a prior episode of breast cancer (Ignatavicius & Workman, p. 1467)
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 (Chp. 70, elsevier resources)
d) 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. (Chp. 70, elsevier resources)
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 (Chp. 70, elsevier resources)
d) 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. (Chp. 70, elsevier resources)
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 (Chp. 70, elsevier resources)
d) 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. (Chp. 70, elsevier resources)
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 (Chp. 70, elsevier resources)
d) 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. (Chp. 70, elsevier resources)
The issue that is often foremost in the minds of men who have been diagnosed with prostate cancer and must be addressed by the nurse is the alteration of which factor? a) Comfort because of surgical pain b) Mobility after treatment c) Nutrition because of radiation side effects d) Sexual function after treatment (Chp 72, elsevier resources)
d) Sexual function after treatment Altered sexual function is one of the biggest concerns of men after cancer treatment. Comfort, mobility, and nutrition are important, but are typically not the foremost concern in the minds of men with prostate cancer. (Chp 72, elsevier resources)
A client with testicular cancer is worried about sterility and the ability to conceive children later. Which resource does the nurse refer the client to before surgery takes place? a) American Cancer Society b) American Fertility Society c) RESOLVE: The National Infertility Association d) Sperm bank (Chp 72, elsevier resources)
d) Sperm bank After radiation therapy or chemotherapy has been started, the client is at increased risk for producing mutagenic sperm, which may not be viable or may result in fetal abnormalities. If the client is interested in having children, he should be encouraged to arrange for semen storage as soon as possible after diagnosis. Sperm collection should be completed before radiation therapy or chemotherapy is started. The client is referred to the American Cancer Society for more generalized information on testicular cancer. The American Fertility Society and RESOLVE: The National Infertility Association are appropriate referrals if permanent sterility occurs and sperm storage has not been feasible. (Chp 72, elsevier resources)
Hormone treatment for prostate cancer works by which action? a) Decreases blood flow to the tumor b) Destroys the tumor c) Shrinks the tumor d) Suppresses growth of the tumor (Chp 72, elsevier resources)
d) Suppresses growth of the tumor Hormone therapy, particularly antiandrogen drugs, inhibits tumor progression by blocking the uptake of testicular and adrenal androgens at the prostate tumor site. Antiandrogens may be used alone or in combination with luteinizing hormone-releasing hormone agonists for a total androgen blockade (hormone ablation). Hormone treatment for prostate cancer does not decrease blood flow to the tumor, destroy the tumor, or shrink the tumor. (Chp 72, elsevier resources)
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. (Chp. 70, elsevier resources)
d) 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. (Chp. 70, elsevier resources)
which groups are experiencing increased numbers of HIV infection? (Select all that apply) A. men having sex with other men B. IV drug users C. women having sex with men D. african americans E. hispanics
d, e
Which statement by a client scheduled for a percutaneous transluminal coronary angioplasty (PTCA) indicates a need for further preoperative teaching? a. "I will be awake during this procedure." b. "I will have a balloon in my artery to widen it." c. "I must lie still after the procedure." d. "My angina will be gone for good."
d. "My angina will be gone for good." Reocclusion is possible after PTCA. The client is typically awake, but drowsy, during this procedure. PTCA uses a balloon to widen the artery, and the client will have to lie still after the procedure because of the large-bore venous access. Time is necessary to allow the hole to heal and prevent hemorrhage.
A client asks the nurse about drugs for weight loss. What response by the nurse is best? a. "All weight-loss drugs can cause suicidal ideation." b. "No drugs are currently available for weight loss." c. "Only over-the-counter medications are available." d. "There are three drugs currently approved for this."
d. "There are three drugs currently approved for this."
During discharge planning after admission for a myocardial infarction, the client says, "I won't be able to increase my activity level. I live in an apartment, and there is no place to walk." What is the nurse's best response? a. "You are right. Work on your diet then." b. "You must find someplace to walk." c. "Walk around the edge of your apartment complex." d. "Where might you be able to walk?"
d. "Where might you be able to walk?" Asking the client where he or she might be able to walk calls for cooperation and participation from the client; increased activity is imperative for this client. Telling the client to work on diet is an inappropriate response. Telling the client to find someplace to walk is too demanding to be therapeutic. Telling the client to walk around the apartment complex is domineering and will not likely achieve cooperation from the client.
To validate that a client has had a myocardial infarction (MI), the nurse assesses for positive findings on which tests? a. Creatine kinase-MB fraction (CK-MB) and alkaline phosphatase b. Homocysteine and C-reactive protein c. Total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol d. CK-MB and troponin
d. CK-MB and troponin CK-MB and troponin are the cardiac markers used to determine whether MI has occurred. Alkaline phosphatase is often elevated in liver disease. Homocysteine and C-reactive protein are markers of inflammation, which may represent risk for MI, but they are not diagnostic for MI. Elevated cholesterol levels are risks for MI, but they do not validate that an MI has occurred.
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 client is receiving total parenteral nutrition (TPN). What action by the nurse is most important? a. Assessing blood glucose as directed b. Changing the IV dressing each day c. Checking the TPN with another nurse d. Performing appropriate hand hygiene
d. Performing appropriate hand hygiene
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 nurse is caring for a client 36 hours after coronary artery bypass grafting, with a priority problem of intolerance for activity related to imbalance of myocardial oxygen supply and demand. Which finding causes the nurse to terminate an activity and return the client to bed? a. Pulse 60 beats/min and regular b. Urinary frequency c. Incisional discomfort d. Respiratory rate 28 breaths/min
d. Respiratory rate 28 breaths/min Tachypnea and tachycardia reflect activity intolerance; activity should be terminated. Pulse 60 beats/min and regular is a normal finding. Urinary frequency may indicate infection or diuretic use, but not activity intolerance. Pain with activity after surgery is anticipated; pain medication should be available.
The nurse is assessing a client with chest pain to evaluate whether the client is suffering from angina or myocardial infarction (MI). Which symptom is indicative of an MI? a. Chest pain brought on by exertion or stress b. Substernal chest discomfort occurring at rest c. Substernal chest discomfort relieved by nitroglycerin or rest d. Substernal chest pressure relieved only by opioids
d. Substernal chest pressure relieved only by opioids Substernal chest pressure relieved only by opioids is typically indicative of MI. Substernal chest discomfort that occurs at rest is not necessarily indicative of MI; it could be a sign of unstable angina. Both chest pain brought on by exertion or stress and substernal chest discomfort relieved by nitroglycerin or rest are indicative of angina.
A nurse is weighing and measuring a client with severe kyphosis. What is the best method to obtain this client's height? a. Add the trunk and leg measurements. b. Ask the client how tall he or she is. c. Estimate by measuring clothing. d. Use knee-height calipers.
d. Use knee-height calipers.
A client in the progressive or intermediate stage of hypovolemic shock will exhibit which manifestation? 1 Polyuria 2 Metabolic alkalosis 3 Moist, warm skin 4 Feeling of impending doom
4. Feeling of impending doom Rationale: As shock progresses, tissue perfusion to the brain continues to be reduced, causing a sense of anxiety or that "something bad" is about to happen. Oliguria or anuria occurs in the nonprogressive stage rather than polyuria. A lack of perfusion to the skin results in cool, moist skin rather than warm skin. Due to decreased tissue perfusion, buildup of lactic or metabolic acid occurs; the arterial blood gases reflect metabolic acidosis at this time.
The nurse is preparing to administer a transfusion of packed red blood cells to a client with hemorrhagic shock. Which action is essential before initiating the transfusion? 1 Check the volume of blood in the bag. 2 Monitor the client for dark-colored urine. 3 Measure the client's blood pressure. 4 Initiate 0.9% saline solution infusion.
4. Initiate 0.9% saline solution infusion. Rationale: Isotonic solutions such as Ringer's lactate or normal saline may be used as volume expanders in hypovolemic shock. Red blood cells must be given with 0.9% saline to prevent clotting during infusion. While the volume of the blood in the bag is approximately 250 mL, it may vary; however, this is not essential to validate before initiating the transfusion. The nurse monitors for dark urine when an ABO transfusion reaction is suspected. Vital signs, especially a baseline temperature, are indicated prior to transfusion; a low blood pressure during shock states is expected.
In acute shock, which organ has the capacity to tolerate hypoxia and anoxia for 1 hour without sustaining permanent injury? 1 Liver 2 Heart 3 Brain 4 Kidney
4. Kidney Rationale: The kidney can tolerate hypoxia and anoxia for approximately 1hour without any permanent damage. The liver, heart, and brain use more oxygen and do not have the ability to function normally without adequate oxygen for more than a few minutes.
Which type of shock is often caused by pulmonary embolism? 1 Hypovolemic shock 2 Cardiogenic shock 3 Distributive shock 4 Obstructive shock
4. Obstructive shock Rationale: Pulmonary embolism can cause obstructive shock by blocking the circulation of blood in the lungs and heart, thus reducing overall cardiac output. Total body fluid is not affected, but central volume is decreased. Hypovolemic shock is characterized by a marked reduction in total blood volume. Cardiogenic shock is caused by failure of the heart to pump blood. Distributive shock is caused by a shift of blood from the vascular spaces to interstitial spaces. Pulmonary embolism does not directly affect total blood volume, myocardial function, or fluid levels in vascular and interstitial spaces.
A client with which problem or condition is at highest risk for septic shock? 1 Obese 2 Post-uncomplicated appendectomy 3 Post-myocardial infarction 4 On prednisone (Deltasone) therapy for rheumatoid arthritis
4. On prednisone (Deltasone) therapy for rheumatoid arthritis Rationale: Clients who do not have intact immune systems are at highest risk for sepsis and septic shock including those who have had organ transplants, with HIV/AIDS, kidney or liver disease, the very old, and those with invasive lines and procedures. Prednisone, taken for autoimmune diseases such as rheumatoid arthritis, suppresses the immune system and prevents further damage to the joints. While obesity, surgery, and hospitalization for MI pose some risk for infection and sepsis, the use of corticosteroid medications is an actual risk for the development of sepsis and septic shock.
Which organ is responsible for releasing myocardial depressant factor that leads to heart damage as a result of multiple organ dysfunction syndrome (MODS)? 1 Liver 2 Brain 3 Kidney 4 Pancreas
4. Pancreas Rationale: Myocardial depressant factor is secreted from the ischemic pancreas and is responsible for causing profound damage to the heart in MODS. The liver, brain, and kidneys, in addition to the heart, are severely damaged but they do not release myocardial depressant factors.
Which vasodilator drug is often helpful in managing hypovolemic shock? 1 Milrinone (Primacor) 2 Dobutamine (Dobutrex) 3 Phenylephrine HCl 4 Sodium nitroprusside (Nitropress)
4. Sodium nitroprusside (Nitropress) Rationale: Sodium nitroprusside dilates the coronary arteries, enhancing myocardial perfusion and improving hypovolemic shock. Milrinone and dobutamine are both inotropic agents that act by increasing the force of heart muscle contractions. Phenylephrine is vasoconstrictor, not a vasodilator.
The nurse is caring for postoperative clients at risk for hypovolemic shock. Which condition represents an early symptom of shock? 1 Hypotension 2 Bradypnea 3 Heart blocks 4 Tachycardia
4. Tachycardia Rationale: Heart and respiratory rates increased from the client's baseline level or a slight increase in diastolic blood pressure may be the only objective manifestation of this early stage of shock. Catecholamine release occurs early in shock as a compensation for fluid loss; blood pressure will be normal. Early in shock, the client displays rapid, not slow, respirations. Dysrhythmias are a late sign of shock; they are related to lack of oxygen to the heart.
Which nurse should be assigned to care for an intubated client who has septic shock as the result of a methicillin-resistant Staphylococcus aureus (MRSA) infection? 1 The LPN/LVN who has 20 years of experience 2 The new RN who recently finished orienting and is working independently with moderately complex clients 3 The RN who will also be caring for a client who had coronary artery bypass grafting (CABG) 12 hours ago 4 The RN with 2 years of experience in intensive care
4. The RN with 2 years of experience in intensive care Rationale: The RN with current intensive care experience who is not caring for a postoperative client would be an appropriate assignment. Care of the unstable client with intubation and mechanical ventilation is not within the scope of practice for the LPN/LVN. The client who is experiencing septic shock is too complex for the new RN. Although the RN is experienced, this assignment will put the post-CABG client at risk for MRSA infection.
Why are the clinical signs and symptoms of most types of shock the same, regardless of what condition caused the shock to occur? 1 An increase in heart rate is always the first physiologic adjustment the body makes to all stress states. 2 Because blood loss occurs with all types of shock, the most common first clinical symptom is hypotension. 3 Every type of shock interferes with cellular oxygenation in the same sequence. 4 The sympathetic nervous system is triggered by any type of shock and initiates the stress response.
4. The sympathetic nervous system is triggered by any type of shock and initiates the stress response. Rationale: Most manifestations of shock are similar regardless of what starts the process or which tissues are affected first. These common manifestations result from physiologic adjustments (compensatory mechanisms) in an attempt to ensure continued oxygenation of vital organs. These adjustment actions are performed by the sympathetic nervous system triggering the stress response and activating the endocrine and cardiovascular systems.
A client weighs 228 pounds (103.6 kg) and is 5'3" (160 cm) tall. What is this client's body mass index (BMI)? (Record your answer using a decimal rounded up to the nearest tenth.) _____
40.4
A client has a urinary catheter and continuous bladder irrigation after a transurethral resection of the prostate this morning. The amount of bladder irrigation solution that has infused over the past 12 hours is 1000 mL. The amount of fluid in the urinary drainage bag is 1725 mL. The nurse records that the client has had ____ mL urinary output in the past 12 hours. (Ignatavicius & Workman, p.1505)
725 mL (Ignatavicius & Workman, p.1505)
The medical-surgical unit nurse should call the Rapid Response Team to assess which of these clients? A. The client with a diagnosed pulmonary embolism who is receiving IV heparin and has bright red hemoptysis B. The client with deep vein thrombosis who is receiving low-molecular weight heparin and has ongoing calf pain C. The client with a right pneumothorax who is being treated with a chest tube and has a pulse oximetry of 94% D. The client who was extubated 3 days ago and has decreased breath sounds at the posterior bases of both lungs
A
The registered nurse is overseeing a nursing student who is administering medications to a group of clients with pulmonary disorders. Under which circumstance does the nurse correct the student? A. "You will receive enoxaparin (Lovenox) through the intravenous line for 3 days." B. "Therapy with warfarin (Coumadin) is effective when your INR is between 2 and 3." C. "Once the physician orders warfarin (Coumadin), we will discontinue the intravenous heparin." D. "If bleeding develops, we will give you aminocaproic acid to reverse the anticoagulant."
A
Which client has a higher risk for developing a pulmonary embolism (PE)? A. 25-year-old woman who frequently flies to different countries B. 67-year-old man who works on a farm C. 45-year-old man admitted for a heart attack D. 23-year-old woman with a bleeding disorder
A
Which intervention for the client in the intensive care unit will decrease the incidence of "ICU psychosis"? A. Decreasing nighttime disruptions B. Keeping the lights on to promote orientation C. Administering sedation D. Providing television or radio for stimulation
A
Which intervention will be most effective in reducing anxiety in the client with a pulmonary embolism (PE)? A. Remain with the client, and provide oxygen in a calm manner. B. Have the client breathe into a brown paper bag using pursed lips. C. Offer the client a mild sedative. Allow a family member to remain in the room
A
The tubing of the large-volume nebulizer for the client receiving humidified oxygen therapy is filled with water. What is your best action? A. Disconnect the tubing and drain the water from the tubing into a waste container. B. Turn off the nebulizer, empty the water from the nebulizer reservoir, and replace it with sterile saline. C. No action is needed because the water in the tubing is providing humidification to the oxygen delivered to the client. D. Move the tubing, placing it above the level of the nebulizer reservoir, so that water from the tubing flows into the nebulizer.
A Condensation fluid in the tubing disrupts oxygen flow to the client and must be removed. To prevent bacterial or fungal contamination, this condensation fluid/water is emptied into a waste container and is never emptied back into the reservoir.
What is the priority nursing diagnosis for the client receiving nonhumidified oxygen therapy of 40% (6 L/min) by simple mask? A. Risk for Injury B. Impaired Oral Mucous Membranes C. Risk for Infection D. Impaired Gas Exchange
A Oxygen therapy without humidification dries the mucous membranes of the nasal, oral, and respiratory passages, increasing the risk for tissue injury as well as for client discomfort.
Which manifestations in a client receiving oxygen therapy at 60% for more than 24 hours alerts you to the possibility of oxygen toxicity? A. Increased dyspnea B. Decreased rate and depth of respiration C. Wheezing on inhalation and exhalation D. Increased excretion of thick, white, frothy sputum
A Oxygen toxicity damages the alveolar membrane, stimulating the formation of a hyaline membrane and impairing gas exchange. Clients become increasingly more dyspneic and hypoxic.
During nasotracheal suctioning, the client's heart rate changes from 78 to 48 beats/min. What is your best first action? A. Stop suctioning. B. Administer oxygen by mask at 2 L/min. C. Gently pinch the client's cheek. D. Document the observation.
A The client is experiencing vagal stimulation and bradycardia from the presence of the suction catheter in the tracheopharyngeal area. Such stimulation can lead to severe hypotension, heart block, and asystole.
When you assess the client with a new tracheotomy at the beginning of your shift, you observe that the tracheostomy tube is pulsating in synchrony with the client's heartbeat. What is your best action? A. Notify the physician immediately. B. Stabilize the tube by reapplying the ties. C. Document the observation as the only action. D. Increase the inflation pressure of the tracheostomy cuff.
A The pulsation of the tracheostomy tube in synchrony with the client's heartbeat is one indication of a trachea-innominate artery fistula, a life-threatening complication of a tracheotomy. The tube needs to be removed and replaced in surgery as soon as possible. In the meantime, the tube should not be touched in any way as movement may increase the severity of the complication
Which nursing intervention would you use to prevent tracheal stenosis in a client after tracheostomy? A. Securing the tube in a midline position B. Assessing bilateral breath sounds every 2 hours C. Changing the tracheostomy ties every 24 hours D. Suctioning the tube with as small a catheter as possible
A Tracheal stenosis, a narrowed tracheal lumen, is the result of scar tissue formation from irritation. Two methods of preventing this complication are to keep the tube from moving in the trachea and to maintain proper cuff pressure
Which statement made by the client who will be undergoing a tracheotomy with placement of a fenestrated tracheostomy tube indicates correct knowledge of the features of this device? A. "I'm glad I will still be able to talk with this tube in place." B. "It is great that this tube does not have to be cleaned or suctioned." C. "I will miss going out to dinner and visiting in the homes of my friends." D. "Since I won't be able to swallow, will another tube be needed for eating?"
A When the inner cannula is removed, sufficient air passes through the fenestrations to permit the client to talk
Which client does the charge nurse assign to an experienced LPN/LVN working on the adult medical unit? A. A 32-year-old who needs a nasogastric tube inserted for gastric acid analysis B. A 36-year-old who needs teaching about an endoscopic retrograde cholangiopancreatography C. A 40-year-old who will need administration of IV midazolam hydrochloride (Versed) during an upper endoscopy D. A 46-year-old who was recently admitted with abdominal cramping and diarrhea of unknown causes
A 32-year-old who needs a nasogastric tube inserted for gastric acid analysis Nasogastric tube insertion is included in LPN/LVN education and is an appropriate task for an experienced LPN/LVN. Assessment and client teaching should be done by an RN. IV hypnotic medications should be administered by an RN.
Which client does the charge nurse on the adult medical unit assign to an RN who has floated from the outpatient gastrointestinal (GI) unit? A. A 38-year-old who needs discharge instructions after having an endoscopic retrograde cholangiopancreatography (ERCP) B. A 40-year-old who needs laxatives administered and effectiveness monitored before a colonoscopy C. A 43-year-old recently admitted with nausea, abdominal pain, and abdominal distention D. A 50-year-old with epigastric pain who needs conscious sedation during a scheduled endoscopy procedure
A 40-year-old who needs laxatives administered and effectiveness monitored before a colonoscopy A nurse who has experience with chronic GI problems will have experience and training in instructing clients on colonoscopy preparation. Discharge instructions following an ERCP, assessment of an admitted acutely ill client, and monitoring a client who is receiving conscious sedation would be accomplished best by nurses with experience in caring for adults with acute GI problems.
A newly graduated RN has just finished a 6-week orientation to the oncology unit. Which client is most appropriate to assign to the new graduate? A.) A 30-year-old with acute lymphocytic leukemia who will receive combination chemotherapy today B.) A 40-year-old with chemotherapy-induced nausea and vomiting who has had no urine output for 16 hours C.) A 45-year-old with pancytopenia who will require IV administration of erythropoietin (Procrit) D.) A 72-year-old with tumor lysis syndrome who is receiving normal saline IV at a rate of 250 mL/hr
A 45-year-old with pancytopenia who will require IV administration of erythropoietin (Procrit) A new nurse after a 6-week oncology orientation possesses the skills to care for clients with pancytopenia and with administration of medications to correct anemia. The clients with acute lymphocytic leukemia and chemotherapy-induced nausea are complex clients requiring a nurse certified in chemotherapy administration. The client with tumor lysis syndrome has complicated needs for assessment and care and should be cared for by an RN with more oncology experience.
While working in the outpatient procedure unit, the RN is assigned to these clients. Which client does the nurse assess first? A. A 51-year-old who recently had an endoscopic retrograde cholangiopancreatography (ERCP) B. A 54-year-old who is ready for discharge following a colonoscopy C. A 58-year-old who has just arrived for basal gastric secretion and gastric acid stimulation testing D. A 60-year-old with questions about an endoscopic ultrasound examination
A 51-year-old who recently had an endoscopic retrograde cholangiopancreatography (ERCP) ERCP requires conscious sedation, so the client needs immediate assessment of respiratory and cardiovascular status. The other clients are not at risk for depressed respiratory status.
A client admitted for sleep apnea asks the nurse, "Why does it seem like I wake up every 5 minutes?" What is the nurse's best response? A) "Because your body isn't getting rid of carbon dioxide. This is what stimulates your body to wake up and breathe." B) "Because your body isn't getting enough oxygen. Not getting enough oxygen is what stimulates you to wake up and breathe." C) "Because your tongue may be blocking your throat, and you wake up because you are choking." D) "It isn't really that often. It just feels that way." (Chp. 29; elsevier resources)
A) "Because your body isn't getting rid of carbon dioxide. This is what stimulates your body to wake up and breathe." (Chp. 29; elsevier resources)
A client has received packing for a posterior nosebleed. In reviewing the client's orders, which order does the nurse question? A) "Give ibuprofen 800 mg every 8 hours as needed for pain." B) "Encourage bedrest, with the head of the bed elevated 45 to 60 degrees." C) "Provide humidified air." D) "Suction at the bedside." (Chp. 29; elsevier resources)
A) "Give ibuprofen 800 mg every 8 hours as needed for pain." (Chp. 29; elsevier resources)
A 70-year-old client has a complicated medical history, including chronic obstructive pulmonary disease. Which client statement indicates the need for further teaching about the disease? A) "I am here to receive the yearly pneumonia shot again." B) "I am here to get my yearly flu shot again." C) "I should avoid large gatherings during cold and flu season." D) "I should cough into my upper sleeve instead of my hand." (Chp. 31; elsevier resources)
A) "I am here to receive the yearly pneumonia shot again." (Chp. 31; elsevier resources)
Which client has the highest risk for developing a pulmonary embolism (PE)? A) A 25-year-old woman who frequently flies to different countries B) A 67-year-old man who works on a farm C) A 45-year-old man admitted for a heart attack D) A 23-year-old woman with a bleeding disorder (Chp. 32, elsevier resources)
A) A 25-year-old woman who frequently flies to different countries (Chp. 32, elsevier resources)
While assessing a client who has been receiving heparin intravenously for the past 3 days, the nurse notes the IV pump is set at twice the required setting. What orders does the nurse anticipate from the prescriber? Select all that apply. A) Activated partial thromboplastin time B) International normalized ratio C) Prothrombin time D) Vitamin K E) Protamine sulfate (Chp. 32; p. 608)
A) Activated partial thromboplastin time E) Protamine sulfate (Chp. 32; p. 608)
A client has just been admitted to the intensive care unit after having a left lower lobectomy with a video-assisted thoracoscopic surgery. Which of these requests will the nurse implement first? A) Adjust oxygen flow rate to keep O2 saturation at 93% to 100%. B) Administer 2 g of cephalothin (Keflin) IV now. C) Give morphine sulfate 4 to 6 mg IV for pain. D) Infuse 1 unit of packed red blood cells (PRBCs) over the next 2 hours. (Chp. 30; elseview resources)
A) Adjust oxygen flow rate to keep O2 saturation at 93% to 100%. (Chp. 30; elseview resources)
A client with laryngeal cancer is admitted to the medical-surgical unit the morning before a scheduled total laryngectomy. Which preoperative intervention can be accomplished by an LPN/LVN working on the unit? A) Administering preoperative antibiotics and anxiolytics B) Assessing the client's nutritional status and need for nutrition supplements C) Having the client sign the operative consent form D) Teaching the client about the need for tracheal suctioning after surgery (Chp. 29; elsevier resources)
A) Administering preoperative antibiotics and anxiolytics (Chp. 29; elsevier resources)
A client with asthma has pneumonia, is reporting increased shortness of breath, and has inspiratory and expiratory wheezes. All of these medications are prescribed. Which medication should the nurse administer first? A) Albuterol (Proventil) 2 inhalations B) Fluticasone (Flovent) 2 inhalations C) Ipratropium (Atrovent) 2 inhalations D) Salmeterol (Serevent) 2 inhalations (Chp. 30; elseview resources)
A) Albuterol (Proventil) 2 inhalations (Chp. 30; elseview resources)
Which two factors in combination are the greatest risk factors for head and neck cancer? A) Alcohol and tobacco use B) Chronic laryngitis and voice abuse C) Marijuana use and exposure to industrial chemicals D) Poor oral hygiene and use of chewing tobacco (Chp. 29; elsevier resources)
A) Alcohol and tobacco use (Chp. 29; elsevier resources)
The community health nurse is planning tuberculosis treatment for a client who is homeless and heroin-addicted. Which action will be most effective in ensuring that the client completes treatment? A) Arrange for a health care worker to watch the client take the medication. B) Give the client written instructions about how to take prescribed medications. C) Have the client repeat medication names and side effects. D) Instruct the client about the possible consequences of nonadherence. (Chp. 31; elsevier resources)
A) Arrange for a health care worker to watch the client take the medication. (Chp. 31; elsevier resources)
A client with sleep apnea who has a new order for continuous positive airway pressure (CPAP) with a facemask returns to the outpatient clinic after 2 weeks with a report of ongoing daytime sleepiness. Which action should the nurse take first? A) Ask the client whether CPAP has been used consistently at night. B) Discuss the use of autotitrating positive airway pressure (APAP). C) Plan to teach the client about treatment with modafinil (Provigil). D) Suggest that a nasal mask be used instead of a full facemask. (Chp. 29; elsevier resources)
A) Ask the client whether CPAP has been used consistently at night. (Chp. 29; elsevier resources)
After surgery for placement of a chest tube, the client reports burning in the chest. What does the nurse do first? A) Assess the airway, breathing, and circulation. B) Call for the Rapid Response Team. C) Check the patency of the chest tubes. D) Listen for breath sounds. (Chp. 30; elseview resources)
A) Assess the airway, breathing, and circulation (Chp. 30; elseview resources)
Because clients with cystic fibrosis (CF) are at increased risk for infection, what will the nurse advise the client with CF who is infected with Burkholderia cepacia to do? A) Avoid Cystic Fibrosis Foundation-sponsored events. B) Avoid the hospital. C) Stay at home most of the time. D) Use an antiseptic hand gel. (Chp. 30; elseview resources)
A) Avoid Cystic Fibrosis Foundation-sponsored events. (Chp. 30; elseview resources)
Which assessment finding is associated with obstructive lung disease and not with interstitial lung disease? A) Barrel chest B) Cough C) Dyspnea D) Reduced gas exchange(Chp. 30; elseview resources)
A) Barrel chest (Chp. 30; elseview resources)
While the nurse is talking with the postoperative thoracic surgery client, the client coughs and the chest tube collection water seal chamber bubbles. What does the nurse do? A) Calmly continues talking B) Checks the tube for blocks or kinks C) Immediately calls the health care provider D) Strips the chest tube (Chp. 30; elseview resources)
A) Calmly continues talking (Chp. 30; elseview resources)
An older adult resident in a long-term-care facility becomes confused and agitated, telling the nurse, "Get out of here! You're going to kill me!" Which action will the nurse take first? A) Check the resident's oxygen saturation. B) Do a complete neurologic assessment. C) Give the prescribed PRN lorazepam (Ativan). D) Notify the resident's primary care provider. (Chp. 31; elsevier resources)
A) Check the resident's oxygen saturation. (Chp. 31; elsevier resources)
A newly hired RN with no previous emergency department (ED) experience has just completed a 1-month orientation. Which of these clients would be most appropriate to assign to this nurse? A) Client on warfarin (Coumadin) with epistaxis with profuse bleeding B) Client with facial burns caused by a mattress fire while sleeping C) Client with possible facial fractures after a motor vehicle collision (MVC) D) Client with suspected bilateral vocal cord paralysis and stridor (Chp. 29; elsevier resources)
A) Client on warfarin (Coumadin) with epistaxis with profuse bleeding (Chp. 29; elsevier resources)
The nurse is caring for a group of clients. Which clients should be monitored closely for respiratory failure? Select all that apply. A) Client with a brainstem tumor B) Client with acute pancreatitis C) Client with a T3 spinal cord injury D) Client using patient-controlled analgesia E) Client experiencing cocaine intoxication (Chp. 32, elsevier resources)
A) Client with a brainstem tumor B) Client with acute pancreatitis C) Client with a T3 spinal cord injury D) Client using patient-controlled analgesia (Chp. 32, elsevier resources)
The medical-surgical unit nurse should call the Rapid Response Team to assess which client? A) Client with a diagnosed pulmonary embolism who is receiving IV heparin and has bright-red hemoptysis B) Client with deep vein thrombosis who is receiving low-molecular-weight heparin and has ongoing calf pain C) Client with a right pneumothorax who is being treated with a chest tube and has a pulse oximetry of 94% D) Client who was extubated 3 days ago and has decreased breath sounds at the posterior bases of both lungs (Chp. 32, elsevier resources)
A) Client with a diagnosed pulmonary embolism who is receiving IV heparin and has bright-red hemoptysis (Chp. 32, elsevier resources)
All of these clients are being cared for on the intensive care stepdown unit. Which client should the charge nurse assign to an RN who has floated from the pediatric unit? A) Client with acute asthma episode who is receiving oxygen at FiO2 of 60% by non-rebreather mask. B) Client with chronic pleural effusions who is scheduled for a paracentesis in the next hour. C) Client with emphysema who requires instruction about correct use of oxygen at home. D) Client with lung cancer who has just been transferred from the intensive care unit after having a left lower lobectomy the previous day. (Chp. 30; elseview resources)
A) Client with acute asthma episode who is receiving oxygen at FiO2 of 60% by non-rebreather mask. (Chp. 30; elseview resources)
A client with tuberculosis (TB) who is homeless and has been living in shelters for the past 6 months asks the nurse why he must take so many medications. What information will the nurse provide in answering this question? Select all that apply. A) Combination drug therapy is effective in preventing transmission. B) Combination drug therapy is the most effective method of treating TB. C) Combination drug therapy will decrease the length of required treatment to 2 months. D) Multiple drug regimens destroy organisms as quickly as possible. E) The use of multiple drugs reduces the emergence of drug-resistant organisms. (Chp. 31; elsevier resources)
A) Combination drug therapy is effective in preventing transmission. B) Combination drug therapy is the most effective method of treating TB. D) Multiple drug regimens destroy organisms as quickly as possible. E) The use of multiple drugs reduces the emergence of drug-resistant organisms. (Chp. 31; elsevier resources)
The nursing assistant has taken vital signs of the ventilated postoperative client who has had radical neck surgery. What does the nurse tell the assistant to be especially vigilant for? A) Continuous oozing of bright-red blood B) Decreased level of consciousness C) Effective pain management D) Heart rate and blood pressure trending up over several hours (Chp. 29; elsevier resources)
A) Continuous oozing of bright-red blood (Chp. 29; elsevier resources)
An emergency nurse is preparing to care for a client arriving by ambulance after a motor vehicle crash. The client has severe facial and neck injuries and emergency airway measures have been taken. Which type of airway does the nurse prepare for? A) Cricothyroidotomy B) Endotracheal intubation C) Nasal bi-level positive airway pressure (BiPAP) D) Tracheotomy (Chp. 29; elsevier resources)
A) Cricothyroidotomy (Chp. 29; elsevier resources)
Which intervention for a client in the intensive care unit (ICU) will decrease the incidence of "ICU psychosis?" A) Decreasing nighttime disruptions B) Keeping the lights on to promote orientation C) Administering sedation D) Providing television or radio for stimulation (Chp. 32, elsevier resources)
A) Decreasing nighttime disruptions (Chp. 32, elsevier resources)
The nurse is assessing a client with possible pulmonary embolism (PE). For which symptoms should the nurse assess? Select all that apply. A) Dizziness and fainting B) Shortness of breath (SOB) worsening over the last 2 weeks C) Inspiratory chest pain D) Productive cough E) Pink, frothy sputum (Chp. 32, elsevier resources)
A) Dizziness and fainting C) Inspiratory chest pain (Chp. 32, elsevier resources)
A client is taking isoniazid, rifampin, pyrazinamide, and ethambutol for tuberculosis. The client calls to report visual changes, including blurred vision and reduced visual fields. Which medication may be causing these changes? A) Ethambutol B) Isoniazid C) Pyrazinamide D) Rifampin (Chp. 31; elsevier resources)
A) Ethambutol (Chp. 31; elsevier resources)
A client who has been homeless and has spent the past 6 months living in shelters has been diagnosed with confirmed tuberculosis (TB). Which medications does the nurse expect to be ordered for the client? A) Isoniazid (INH), rifampin (Rifadin), pyrazinamide (Zinamide), ethambutol (Myambutol) B) Metronidazole (Flagyl), acyclovir (Zovirax), flunisolide (AeroBid), rifampin (Rifadin) C) Prednisone (Prednisone), guaifenesin (Organidin), ketorolac (Toradol), pyrazinamide (Zinamide) D) Salmeterol (Serevent), cromolyn sodium (Intal), dexamethasone (Decadron), isoniazid (INH) (Chp. 31; elsevier resources)
A) Isoniazid (INH), rifampin (Rifadin), pyrazinamide (Zinamide), ethambutol (Myambutol) (Chp. 31; elsevier resources)
All of these nursing actions are included in the plan of care for a client who has just been extubated. Which action should the nurse delegate to unlicensed assistive personnel (UAP)? A) Keep the head of the bed elevated. B) Teach about incentive spirometer use. C) Monitor vital signs every 5 minutes. D) Adjust the nasal oxygen flow rate. (Chp. 32, elsevier resources)
A) Keep the head of the bed elevated. (Chp. 32, elsevier resources)
A client who has had a recent laryngectomy continues to report pain. Which medication would be best used as an adjunct to a narcotic once the client can take oral nutrition? A) Liquid nonsteroidal anti-inflammatory drugs (NSAIDs) B) Liquid steroids C) Opioid antagonists D) Oral diazepam (Chp. 29; elsevier resources)
A) Liquid nonsteroidal anti-inflammatory drugs (NSAIDs) (Chp. 29; elsevier resources)
A client has recently been released from prison and has just tested positive for tuberculosis (TB). What teaching points does the community health nurse want to stress for this client regarding medications? Select all that apply. A) Not taking the medication could lead to an infection that is difficult to treat or to total drug resistance. B) The medications may cause nausea. The client should take them at bedtime. C) The client is generally not contagious after 2 to 3 consecutive weeks of treatment. D) These medications must be taken for 2 years. E) These medications may cause kidney failure. (Chp. 31; elsevier resources)
A) Not taking the medication could lead to an infection that is difficult to treat or to total drug resistance. B) The medications may cause nausea. The client should take them at bedtime. (Chp. 31; elsevier resources)
The nurse caring for a client who is intubated and receiving mechanical ventilation notes that her oxygen saturation is 89%, her heart rate is 120 beats/min, and she is increasingly agitated and restless. On auscultation, the nurse finds that the lung sounds are diminished on one side. Which action does the nurse perform first? A) Notify the provider, and prepare for re-intubation or repositioning the tube. B) Document the findings, and request sedation from the provider. C) Call respiratory therapy to obtain a set of arterial blood gases. D) Reposition the tube, and call radiology for a stat chest x-ray. (Chp. 32; p. 616)
A) Notify the provider, and prepare for re-intubation or repositioning the tube. (Chp. 32; p. 616)
Which intervention will be most effective in reducing anxiety in a client with a pulmonary embolism (PE)? A) Remain with the client and provide oxygen in a calm manner. B) Have the client breathe into a brown paper bag using pursed lips. C) Offer the client a mild sedative. D) Allow a family member to remain in the room. (Chp. 32, elsevier resources)
A) Remain with the client and provide oxygen in a calm manner. (Chp. 32, elsevier resources)
A client has been admitted to the hospital with suspected TB. What drugs should the nurse plan to teach the client about before discharge? Select all that apply. A) Rifampin (Rifadin); contact lenses can become stained orange B) Isoniazid (INH); report yellowing of the skin or darkened urine C) Pyrazinamide (PZA); maintain a fluid restriction of 1200 mL/day D) Ethambutol (Myambutol); report any changes in vision E) Amoxicillin (Amoxil); take this drug with food or milk (Chp. 31; p. 598)
A) Rifampin (Rifadin); contact lenses can become stained orange B) Isoniazid (INH); report yellowing of the skin or darkened urine D) Ethambutol (Myambutol); report any changes in vision (Chp. 31; p. 598)
A nurse is caring for an 89-year-old client admitted with pneumonia. He has an IV of normal saline running at 100 mL/hr and antibiotics that were initiated in the emergency department 3 hours ago. He has oxygen at 2 liters/nasal cannula. What assessment finding by the nurse indicates that goals for a priority diagnosis have been met for this client? A) The client is alert and oriented to person, place, and time. B) Blood pressure is within normal limits and client's baseline. C) Skin behind the ears demonstrates no redness or irritation. D) Urine output has been >30 mL/hr per Foley catheter. (Chp. 31; p. 593)
A) The client is alert and oriented to person, place, and time. (Chp. 31; p. 593)
A client is being admitted for pneumonia. The sputum culture is positive for streptococcus, and the client asks about the length of the treatment. On what does the nurse base the answer? A) The client will be treated for 5 to 7 days. B) The client will require IV antibiotics for 7 to 10 days. C) The client will complete 6 days of therapy. D) The client must be afebrile for 24 hours. (Chp. 31; elsevier resources)
A) The client will be treated for 5 to 7 days. (Chp. 31; elsevier resources)
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 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.
The nurse is caring for a client with heart failure. For which symptoms should the nurse assess? Select all that apply. a. Chest discomfort or pain b. Tachycardia c. Expectorates thick, yellow sputum d. Sleeps on back without a pillow e. Shortness of breath with exertion
A, B, E: Decreased tissue perfusion may cause chest pain or discomfort. Tachycardia may occur as compensation for or as a result of decreased cardiac output. Dyspnea results as pulmonary venous congestion ensues. C - Incorrect: Thick, yellow sputum is indicative of infection; clients with acute heart failure have dry cough and, when severe, pink, frothy sputum. D - Incorrect: Orthopnea, the inability to lie flat, occurs in clients with heart failure.
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.
Indicate which interventions would help prevent aspiration during eating for a client with a temporary tracheostomy. (Select all that apply.) A. Avoid having the client eat a meal when he or she is fatigued. B. Add water or broth to foods to make them thinner and easier to swallow rapidly. C. Inflate the cuff of the tracheostomy tube to maximum pressure before initiating a feeding to mechanically block aspirated food from moving further down the airway. D. When feeding the client, allow the client to indicate when he or she is ready for the next bite. E. Encourage the client to tuck his or her chin downward and forward while swallowing. F. Urge the client to swallow 3 to 4 bites or mouthfuls in a row to reduce the time when he or she is at risk for aspiration. G. Place the client in lithotomy position for 30 minutes immediately following a meal.
A, D, E Rationale: Having the client eat or swallow when he or she is sleepy or fatigued decreases the full cooperation of the client and increases the risk for aspiration. Aspiration is less likely to occur when the client is alert. Thinner foods and fluids dramatically increase the risk for aspiration. Such substances can move quickly to the posterior pharynx without the client's volition. Inflating the cuff provides a false sense of security and can damage laryngeal and tracheal tissues. An excessively inflated cuff can balloon backward, pressing into the thin wall of the esophagus and interfering with the forward movement of food/fluid in the esophagus. Only the client can know when his or her mouth is completely empty and swallowing was successful. If feeding is attempted without this indication from the client, the mouth can become overfilled, increasing the risk for aspiration. The esophagus lies behind the trachea. Tucking the chin downward and forward allows the upper esophagus to be more prominent than the trachea, reducing the risk for aspiration. Allowing the client to eat rapidly or have successive swallows of food or liquids increases the amount of food in the client's mouth at any one time and increases the risk for aspiration. Clients should first swallow a bite or sip of food or fluid and then follow this with a "dry swallow" before more food or fluid is placed in the mouth. The lithotomy position is one in which the client's torso is nearly horizontal and his or her feet and legs are elevated. This position would increase abdominal pressure and allow gravity to allow substances in the stomach to reflux
A 32-year-old female with a urinary tract infection reports urinary frequency, urgency, and some discomfort upon urination. Her vital signs are stable except for a temperature of 100° F. What information does a nurse provide about taking her prescribed Bactrim? *Select all that apply*. A. "Be certain to wear sunscreen and protective clothing." B. "Drink at least 3 liters of fluids every day." C. "Take this drug with 8 ounces of water." D. "Try to urinate frequently to keep your bladder empty." E. "You will need to take all of this drug to get the benefits."
A,B,C,E: Wearing sunscreen and protective clothing is important to do while on this drug. Increased sensitivity to the sun can lead to severe sunburn. Sulfamethoxazole can form crystals that precipitate in the kidney tubules. Fluid intake prevents this complication. Clients should be cautioned to take all of the drug that is prescribed for them, even if their symptoms improve or disappear soon. Emptying the bladder is important-but not keeping it empty-as is stated here. The client should be advised to urinate every 3 to 4 hours or More often if he or she feels the urge
Which client with a long-term urinary problem does the nurse refer to community resources and support groups? Select all that apply. A. 32-year-old with a cystectomy B. 44-year-old with a Kock pouch C. 48-year-old with urinary calculi D. 78-year-old with urinary incontinence E. 80-year-old with dementia
A,B,D: The client with a cystectomy and a Kock pouch, and a urinary incontinence would benefit from community resources and support groups. Others who have had their bladders removed are good sources for information and for help in establishing coping mechanisms.
The client is scheduled for intravenous urography. During the assessment, the nurse notes a previous reaction of urticaria, itching, and sneezing to contrast dye. Which precautions does the nurse take? Select all that apply. A. Ensures that an antihistamine and a steroid are prescribed B. Documents the reaction on the chart C. Uses no contrast dye for the procedure D. Cancels the procedure E. Ensures that the health care provider is aware of the reaction
A,B,E: Suppression of immune and allergic responses should be undertaken. Allergies and suspected allergies must be documented in the medical record. The nurse must notify the provider of the previous response and obtain requests for antihistamine and corticosteroid. Contrast will give a more clear picture; if the provider believes it is necessary, suppression of the immune response is an acceptable intervention. The scope of practice for professional nursing does not include prescribing or canceling procedures.
Which client with an indwelling urinary catheter does a nurse re-assess to determine whether the catheterization needs to be continued or can be discontinued? Select all that apply. A. Three-day postoperative client B. Client in the step-down unit C. Comatose client with careful monitoring I/Os D. Incontinent client with perineal skin breakdown E. Incontinent long-term care older adult
A,B,E: Three days after surgery, the client probably should be able to urinate on his or her own. If the surgery was a bladder or urethral repair, then discontinuing the catheter might not be a consideration so soon. However, most clients do not need long-term catheterization after they have surgery. The incidence of complications (colonization of bacteria) begins to increase after 48 hours postinsertion.The client who is out of an intensive care situation is definitely one who should be considered for discontinuation of his or her catheter. He or she should be somewhat ambulatory and able to get to a bedside commode.The comatose client who is on strict I&O needs to have a urinary catheter in place to keep accurate account of his or her fluid balance.
A nurse is teaching a group of older adult women about the signs and symptoms of urinary tract infection (UTI). Which concepts does the nurse explain in the presentation? Select all that apply. A. Dysuria B. Enuresis C. Frequency D. Nocturia E. Urgency F. Polyuria
A,C,D, E: Dysuria, Frequency, Nocturia and urgency are symptoms of a UTI. Enuresis-bed-wetting and polyuria-are not signs of a UTI.
After receiving change-of-shift report about these four clients, which client does the nurse attend to first? A. Client with acute adrenal insufficiency who has a blood glucose of 36 mg/dL B. Client with diabetes insipidus who has a dose of desmopressin (DDAVP) due C. Client with hyperaldosteronism who has a serum potassium of 3.4 mEq/L D. Client with pituitary adenoma who is reporting a severe headache
A. A glucose level of 36 mg/dL is considered an emergency; this client must be assessed and treated immediately. Although it is important to maintain medications on schedule, the client requiring a dose of desmopressin is not the first client who needs to be seen. A serum potassium of 3.4 mEq/L in the client with hyperaldosteronism may be considered normal (or slightly hypokalemic), based on specific hospital levels. The client reporting a severe headache needs to be evaluated as soon as possible after the client with acute adrenal insufficiency. As an initial measure, the RN could delegate obtaining vital signs to unlicensed assistive personnel.
A client with iatrogenic Cushing's syndrome is a resident in a long-term care facility. Which nursing action included in the client's care would be best to delegate to unlicensed assistive personnel (UAP)? A. Assist with personal hygiene and skin care. B. Develop a plan of care to minimize risk for infection. C. Instruct the client on the reasons to avoid overeating. D. Monitor for signs and symptoms of fluid retention.
A. Assisting a client with bathing and skin care is included in UAP scope of practice. It is not within their scope of practice to develop a plan of care, although they will play a very important role in following the plan of care. Client teaching requires a broad education and should not be delegated to UAP. Monitoring for signs and symptoms of fluid retention is part of client assessment, which requires a higher level of education and clinical judgment.
A client has been admitted to the medical intensive care unit with a diagnosis of diabetes insipidus (DI) secondary to lithium overdose. Which medication is used to treat the DI? A. Desmopressin (DDAVP) B. Dopamine hydrochloride (Intropin) C. Prednisone D. Tolvaptan (Samsca)
A. Desmopressin is the drug of choice for treatment of severe DI. It may be administered orally, nasally, or by intramuscular or intravenous routes. Dopamine hydrochloride is a naturally occurring catecholamine and inotropic vasopressor; it would not be used to treat DI. Prednisone would not be used to treat DI. Tolvaptan is a selective competitive arginine vasopressin receptor 2 antagonist and is not used with DI.
A client with diabetes insipidus (DI) has dry lips and mucous membranes and poor skin turgor. Which intervention does the nurse provide first? A. Force fluids B. Offer lip balm C. Perform a 24-hour urine test D. Withhold desmopressin acetate (DDAVP)
A. Dry lips and mucous membranes and poor skin turgor are indications of dehydration, which can occur with DI. This is a serious condition that must be treated rapidly. Encouraging fluids is the initial step, provided the client is able to tolerate oral intake. Lip balm may make the client more comfortable, but does not address the problem of dehydration. A 24-hour urine test will identify loss of electrolytes and adrenal androgen metabolites, but will not correct the dehydration that this client is experiencing. Desmopressin acetate is a synthetic form of antidiuretic hormone that is given to reduce urine production; it improves DI and should not be withheld.
A client with pheochromocytoma is admitted for surgery. What does the nurse do for the admitting assessment? A. Avoids palpating the abdomen B. Monitors for pulmonary edema with a chest x-ray C. Obtains a 24-hour urine specimen on admission D. Places the client in a room with a roommate for distraction
A. The abdomen must not be palpated in a client with pheochromocytoma because this action could cause a sudden release of catecholamines and severe hypertension. The tumor on the adrenal gland causes sympathetic hyperactivity, increasing blood pressure and heart rate, not pulmonary edema. A 24-hour urine collection will already have been completed to determine the diagnosis of pheochromocytoma. A client diagnosed with a pheochromocytoma may feel anxious as part of the disease process; providing a roommate for distraction will not reduce the client's anxiety.
The nurse is teaching a client about how to monitor therapy effectiveness for syndrome of inappropriate antidiuretic hormone. What does the nurse tell the client to look for? A. Daily weight gain of less than 2 pounds B. Dry mucous membranes C. Increasing heart rate D. Muscle spasms
A. The client must monitor daily weights because this assesses the degree of fluid restriction needed. A weight gain of 2 pounds or more daily or a gradual increase over several days is cause for concern. Dry mucous membranes are a sign of dehydration and an indication that therapy is not effective. An increased heart rate indicates increased fluid retention or dehydration and hypovolemia, and either condition is an indication that therapy is not effective. Muscle spasms are associated with hyponatremia and are an indication of a change in the client's neurologic status. Untreated hyponatremia can lead to seizures and coma.
A client is being discharged with propylthiouracil (PTU). Which statement by the client indicates a need for further teaching by the nurse? A. "I can return to my job at the nursing home." B. "I must call if my urine is dark." C. "I must faithfully take the drug every 8 hours." D. "I need to report weight gain."
A. The client should avoid large crowds and people who are ill because PTU reduces blood cell counts and the immune response, which increases the risk for infection. The client does not, however, need to remain completely at home. Dark urine may indicate liver toxicity or failure, and the client must notify the provider immediately. Taking PTU regularly at the same time each day provides better drug levels and ensures better drug action. The client must notify the provider of weight gain because this may indicate hypothyroidism; a lower drug dose may be required.
A client with syndrome of inappropriate antidiuretic hormone is admitted with a serum sodium level of 105 mEq/L. Which request by the health care provider does the nurse address first? A. Administer infusion of 150 mL of 3% NaCl over 3 hours. B. Draw blood for hemoglobin and hematocrit. C. Insert retention catheter and monitor urine output. D. Weigh the client on admission and daily thereafter.
A. The client with a sodium level of 105 mEq/L is at high risk for seizures and coma. The priority intervention is to increase the sodium level to a more normal range. Ideally, 3% NaCl should be infused through a central line or with a small needle through a large vein to prevent irritation. Monitoring laboratory values for fluid balance and monitoring urine output are important, but are not the top priority. Monitoring client weight will help in the assessment of fluid balance; however, this is also not the top priority.
The nurse manager for the medical-surgical unit is making staff assignments. Which client will be most appropriate to assign to a newly graduated RN who has completed a 6-week unit orientation? A. Client with chronic hypothyroidism and dementia who takes levothyroxine (Synthroid) daily B. Client with follicular thyroid cancer who has vocal hoarseness and difficulty swallowing C. Client with Graves' disease who is experiencing increasing anxiety and diaphoresis D. Client with hyperparathyroidism who has just arrived on the unit after a parathyroidectomy
A. The client with chronic hypothyroidism and dementia is the most stable of the clients described and would be most appropriate to assign to an inexperienced RN. A client with vocal hoarseness and difficulty swallowing is at higher risk for complications and requires close observation by a more experienced nurse. Increasing anxiety and diaphoresis in a client with Graves' disease can be an indication of impending thyroid storm, which is an emergency; this is not a situation to be managed by a newly graduated RN. A client who has just arrived on the unit after a parathyroidectomy requires close observation for bleeding and airway compromise and requires assessment by an experienced nurse.
A client presents to the emergency department with a history of adrenal insufficiency. The following laboratory values are obtained: Na+ 130 mEq/L, K+ 5.6 mEq/L, and glucose 72 mg/dL. Which is the first request that the nurse anticipates? A. Administer insulin and dextrose in normal saline to shift potassium into cells. B. Give spironolactone (Aldactone) 100 mg orally. C. Initiate histamine2 (H2) blocker therapy with ranitidine for ulcer prophylaxis. D. Obtain arterial blood gases to assess for peaked T waves.
A. This client is hyperkalemic. The nurse should anticipate a request to administer 20 to 50 units of insulin with 20 to 50 mg of dextrose in normal saline as an IV infusion to shift potassium into the cells. Spironolactone is a potassium-sparing diuretic that helps the body keep potassium, which the client does not need. Although H2 blocker therapy would be appropriate for this client, it is not the first priority. Arterial blood gases are not used to assess for peaked T waves associated with hyperkalemia; an electrocardiogram needs to be obtained instead.
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.
When preparing the client who is undergoing urography with contrast, the nurse plans to administer which medication before the procedure? c/o flank pain, dysuria, bilat knee pain with BUN/Cr: 54/2.4 a. Acetylcysteine b. Metformin c. Captopril d. Acetaminophen
A. Acetylcysteine (an antioxidant) may be used to prevent contrast-induced nephrotoxic effects; this client has kidney impairment demonstrated by increased creatinine.
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.
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.
The nurse is preparing the room for the client returning from a thyroidectomy. Which items are important for the nurse to have available for this client? (Select all that apply.) A. Calcium gluconate B. Emergency tracheotomy kit C. Furosemide (Lasix) D. Hypertonic saline E. Oxygen F. Suction
A. B. E. F. Calcium gluconate should be available at the bedside to treat hypocalcemia and tetany that might occur if the parathyroid glands have been injured during the surgery. Equipment for an emergency tracheotomy must be kept at the bedside in the event that hemorrhage or edema should occlude the airway. Respiratory distress can result from swelling or damage to the laryngeal nerve leading to spasm, so it is important that the nurse work with respiratory therapy to have oxygen ready at the bedside for the client on admission. Because of the potential for increased secretions, it is important that a working suction device is present at the bedside for admission of the client from the operating room. Furosemide might be useful in the postoperative client to assist with urine output; however, this is not of added importance for this client. Hypertonic saline would not be of benefit to this client as the client is not hyponatremic.
The older adult woman who reports a change in bladder function says, "I feel like a child who sometimes pees her pants." What is the nurse's best response? A. "Have you tried using the toilet at least every couple of hours?" B. "How does that make you feel?" C. "We can fix that." D. "That happens when we get older."
A. By emptying the bladder on a regular basis, urinary incontinence from overflow may be avoided, which may give the client some sense of control.
When assessing a client with pyelonephritis, the nurse recognizes that which of these conditions may predispose the client to the problem? A. Spinal cord injury B. Cardiomyopathy C. Hepatic failure D.Glomerulonephritis
A. Chronic pyelonephritis occurs with spinal cord injury, bladder tumor, prostate enlargement, or urinary tract stones.
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.
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.
Which urinary assessment information indicates the potential need for increased fluids in the client? A. Increased blood urea nitrogen B. Increased creatinine C. Pale-colored urine D. Decreased sodium
A. Increased blood urea nitrogen (BUN) can indicate dehydration.
A client who is admitted with urolithiasis reports "spasms of intense flank pain, nausea, and severe dizziness." Which intervention does the nurse implement first? A. Administers morphine sulfate 4 mg IV B. Begins an infusion of metoclopramide (Reglan) 10 mg IV C. Obtains a urine specimen for urinalysis D. Starts an infusion of 0.9% normal saline at 100 mL/hr
A. Morphine administered IV will decrease the pain and the associated sympathetic nervous system reactions of nausea and hypotension.
When assessing the older adult, the nurse teaches the older adult that which age-related change causes nocturia? A. Decreased ability to concentrate urine B. Decreased production of antidiuretic hormone C. Increased production of erythropoietin D. Increased secretion of aldosterone
A. Nocturia may result from decreased kidney-concentrating ability associated with aging.
A 32-year-old female with a urinary tract infection reports urinary frequency, urgency, and some discomfort upon urination. Her vital signs are stable except for a temperature of 100° F. She is started on antibiotics and sent home. She returns to the clinic 3 days later-with the same symptoms. When asked about the previous UTI and medication regimen, she states, "I only took the first dose because after that, I felt better." How does the nurse respond? A. "Not completing your medication can lead to return of your infection." B. "That means your treatment will be prolonged with this new infection." C. "This means you will now have to take two drugs instead of one." D. "What you did was okay; however, let's get you started on something else."
A. Not completing the drug regimen can lead to recurrence of an infection and to bacterial drug resistance.
Which statement made by the client who is receiving intravesicular instillations of BCG for bladder cancer indicates to the nurse that more teaching is needed? A. "Holding my urine for at least 8 hours after the treatment keeps the drug in contact with my bladder." B. "Drinking plenty of fluids during the evening after the treatment helps get the drug out of my system." C. "Sitting to urinate for 24 hours after treatment prevents exposure of other people to the drug." D. "Avoiding intercourse for 24 hours after treatment reduces my wife's exposure to the drug."
A. Retaining urine for that long distends the bladder and increases the risk that the BCG will be absorbed systemically. In addition, the discomfort may cause the client to urinate rapidly, leading to more splashing and potentially exposing others to the BCG.
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.
The client has returned form a captopril renal scan. Which teaching should the nurse provide when the client returns? A."Arise slowly and call for assistance when ambulating." B. "I must measure your intake and output (I&O)." C. "We must save your urine because it is radioactive." D. "I must attach you to this cardiac monitor."
A. The drug can cause severe hypotension during and after the procedure. Warn him or her to avoid rapid position changes and of the risk for falling as a result of orthostatic (positional) hypotension.
Which assessments are most important for the nurse to perform when monitoring a client after a retrograde cystogram? A. Temperature and urine character B. Kidney tenderness and flank pain C. 24-hour urine volume, BUN and creatinine levels D. Angioedema and other indicators of systemic allergic response
A. The retrograde cystogram involves instilling a contrast dye directly into the bladder through the urethra. Infection is the primary concern from instruments entering the bladder. The dye does not enter the bloodstream, and systemic allergic responses do not occur. The kidneys are not involved in this imaging.
A nurse educates a group of women who have had frequent urinary tract infections (UTIs) about how to avoid recurrences of them. Which client statement shows correct understanding of what the nurse has taught? A. "I should be drinking at least 1.5 to 2.5 liters of fluids every day." B. "It is a good idea for me to reduce germs by taking a tub bath daily." C. "Trying to get to the bathroom to urinate every 6 hours is important for me." D. "Urinating 1000 mL on a daily basis is a good amount for me."
A. To reduce the number of UTIs, clients should be drinking a minimum of 1.5 to 2.5 liters of fluid (mostly water) each day.
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.
The nurse is providing discharge teaching to the client with heart failure, focusing on when to seek medical attention. Which statement by the client indicates understanding of the teaching? a. "I will call the provider if I have a cough lasting 3 or more days." b. "I will report to the provider weight loss of 2 to 3 pounds in a day." c. "I will try walking for 1 hour each day." d. "I should expect occasional chest pain."
A: Cough, a symptom of heart failure, is indicative of intra-alveolar edema; the provider should be notified. The client should call the provider for weight gain of 3 pounds in a week. The client should begin by walking 200 to 400 feet per day. Chest pain is indicative of myocardial ischemia and worsening of heart failure; the provider should be notified.
The nurse caring for a client discusses the importance of restricting sodium in the diet. Which statement made by the client indicates that he needs further teaching? a. "I should avoid grilling hamburgers." b. "I must cut out bacon and canned foods." c. "I shouldn't put the salt shaker on the table anymore." d. "I should avoid lunch meats but may cook my own turkey."
A: Cutting out beef or hamburgers made at home is not necessary; however, fast food hamburgers are to be avoided owing to higher sodium content. Bacon and canned foods are high in sodium, which promotes fluid retention; these are to be avoided. This client does not need further teaching. The client should avoid adding salt to food; he does not need further teaching. This client understands that all lunch meats and processed foods are high in sodium and are to be avoided.
The nurse is caring for an 82-year-old client admitted for exacerbation of heart failure. The nurse questions the client about the use of which medication because it raises an index of suspicion as to the cause of heart failure? a. Ibuprofen (Motrin) b. Hydrochlorothiazide (HydroDIURIL) c. NPH Insulin d. Levothyroxine (Synthroid)
A: Long-term use of NSAIDs, such as ibuprofen (Motrin), causes fluid and sodium retention. A diuretic may be used in the treatment of heart failure and hypertension. Although diabetes may be a risk factor for cardiovascular disease, it does not directly cause heart failure. In proper doses, Synthroid replaces thyroid hormone for those with hypothyroidism; it does not cause heart failure.
After receiving change-of-shift report about these four clients, which client should the nurse assess first? a. The 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset, frequent premature ventricular complexes b. The 55-year-old admitted with pulmonary edema who received furosemide (Lasix) and whose current O2 saturation is 94% c. The 68-year-old with pericarditis who is reporting sharp, stabbing chest pain when taking deep breaths d. The 79-year-old admitted for possible rejection of a heart transplant who has sinus tachycardia, rate 104
A: This client's premature ventricular complexes may be indicative of digoxin toxicity. Further assessment for clinical manifestations of digoxin toxicity should be done and the physician notified about the dysrhythmia. Option B: This client is stable. Option C: This type of pain is expected in pericarditis. Option D: Tachycardia is expected in this client because rejection will cause signs of decreased cardiac output, including tachycardia.
The nurse is caring for a group of clients. Which clients should be monitored closely for respiratory failure? Select all that apply. A. Client with a brainstem tumor B. Client with acute pancreatitis C. Client with a T3 spinal cord injury D. Client using patient-controlled analgesia E. Client experiencing cocaine intoxication
ABD
The nurse is assessing a client with possible pulmonary embolism. For which symptoms should the nurse assess? Select all that apply. A. Dizziness and fainting B. Shortness of breath (SOB) worsening over the last 2 weeks C. Inspiratory chest pain D. Productive cough E. Pink, frothy sputum
AC
Which medication is most effective in slowing the progression of kidney failure in a client with chronic kidney disease? Diltiazem (Cardizem) Lisinopril (Zestril) Clonidine (Catapres) Doxazosin (Cardura)
ACE Angiotensin-converting enzyme inhibitors such as lisinopril appear to be the most effective drugs to slow the progression of kidney failure. Calcium channel blockers such as diltiazem may indirectly prevent kidney disease by controlling hypertension, but are not specific to slowing progression of kidney disease. Vasodilators such as clonidine and doxazosin control blood pressure, but do not specifically protect from kidney disease.
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.
A client in the intensive care unit with acute kidney injury (AKI) must maintain a mean arterial pressure (MAP) of 65 mm Hg to promote kidney perfusion. What is the client's MAP if the blood pressure is 98/50 mm Hg? (Record your answer using a whole number.) _____ mm Hg
ANS: 66 mm Hg MAP= 98+(2x50)/3=66
10. 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)
ANS: A AFP is a glycoprotein that is elevated in testicular cancer. PSA and PAP testing is used in the screening of prostate cancer. CRP is diagnostic for inflammatory conditions.
1. 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
ANS: A Cloudy urine could indicate infection due to possible urine retention and should be a priority action. Common symptoms of benign prostatic hyperplasia are urinary hesitancy, post-void dribbling, and a weak urinary stream due to the enlarged prostate causing bladder outlet obstruction.
A nurse assesses a client who has a chronic wound. The client states, "I do not clean the wound and change the dressing every day because it costs too much for supplies." How should the nurse respond? a."You can use tap water instead of sterile saline to clean your wound." b."If you don't clean the wound properly, you could end up in the hospital." c."Sterile procedure is necessary to keep this wound from getting infected." d."Good hand hygiene is the only thing that really matters with wound care."
ANS: A For chronic wounds in the home, clean tap water and nonsterile supplies are acceptable and serve as cheaper alternatives to sterile supplies. Of course, if the wound becomes grossly infected, the client may end up in the hospital, but this response does not provide any helpful information. Good handwashing is important, but it is not the only consideration.
7. 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.
ANS: A Lupron, an LH-RH agonist, stimulates the pituitary gland to release luteinizing hormone (LH) to the point that the gland is depleted of LH and testosterone production is lessened. This may decrease the prostate cancer since it is hormone dependent. Lupron can cause osteoporosis, which results in the need for Aredia to prevent bone loss. Erectile dysfunction, decreased libido, and gynecomastia are side effects of the LH-RH medications. Antiandrogen drugs inhibit tumor progression by blocking androgens at the site of the prostate.
A nurse who manages client placements prepares to place four clients on a medical-surgical unit. Which client should be placed in isolation awaiting possible diagnosis of infection with methicillin-resistant Staphylococcus aureus(MRSA)? a.Client admitted from a nursing home with furuncles and folliculitis b.Client with a leg cut and other trauma from a motorcycle crash c.Client with a rash noticed after participating in sporting events d.Client transferred from intensive care with an elevated white blood cell count
ANS: A The client in long-term care and other communal environments is at high risk for MRSA. The presence of furuncles and folliculitis is also an indication that MRSA may be present. A client with an open wound from a motorcycle crash would have the potential to develop MRSA, but no signs are visible at present. The rash following participation in a sporting event could be caused by several different things. A client with an elevated white blood cell count has the potential for infection but should be at lower risk for MRSA than the client admitted from the communal environment.
A nurse assesses an older client who is scratching and rubbing white ridges on the skin between the fingers and on the wrists. Which action should the nurse take? a.Place the client in a single room. b.Administer an antihistamine. c.Assess the client's airway. d.Apply gloves to minimize friction.
ANS: A The client's presentation is most likely to be scabies, a contagious mite infestation. The client needs to be admitted to a single room and treated for the infestation. Secondary interventions may include medication to decrease the itching. This is not an allergic manifestation; therefore, antihistamine and airway assessments are not indicated. Gloves may decrease skin breakdown but would not address the client's infectious disorder.
13. The nurse is teaching an uncircumcised 65-year-old client about self-management of a urinary catheter in preparation for discharge to his home. What statement indicates a lack of understanding by the client? a. I only have to wash the outside of the catheter once a week. b. I should take extra time to clean the catheter site by pushing the foreskin back. c. The drainage bag needs to be changed at least once a week and as needed. d. I should pour a solution of vinegar and water through the tubing and bag.
ANS: A The first few inches of the catheter must be washed daily starting at the penis and washing outward with soap and water. The other options are correct for self-management of a urinary catheter in the home setting.
A nurse prepares to discharge a client who has a wound and is prescribed home health care. Which information should the nurse include in the hand-off report to the home health nurse? a.Recent wound assessment, including size and appearance b.Insurance information for billing and coding purposes c.Complete health history and physical assessment findings d.Resources available to the client for wound care supplies
ANS: A The hospital nurse should provide details about the wound, including size and appearance and any special wound needs, in a hand-off report to the home health nurse. Insurance information is important to the home health agency and manager, but this is not appropriate during this hand-off report. The nurse should report focused assessment findings instead of a complete health history and physical assessment. The home health nurse should work with the client to identify community resources.
4. 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.
ANS: A This client did not associate wine with the avoidance of alcohol, and requires additional teaching. The nurse must teach a client with BPH to avoid alcohol, caffeine, and large quantities of fluid in a short amount of time to prevent overdistention of the bladder. Decongestants also need to be avoided to lower the chance for urinary retention.
A nurse cares for a client who has a deep wound that is being treated with a wet-to-damp dressing. Which intervention should the nurse include in this client's plan of care? a.Change the dressing every 6 hours. b.Assess the wound bed once a day. c.Change the dressing when it is saturated. d.Contact the provider when the dressing leaks.
ANS: A Wet-to-damp dressings are changed every 4 to 6 hours to provide maximum débridement. The wound should be assessed each time the dressing is changed. Dry gauze dressings should be changed when the outer layer becomes saturated. Synthetic dressings can be left in place for extended periods of time but need to be changed if the seal breaks and the exudate leaks.
A nurse is caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first? a. Client with a Glasgow Coma Scale score that was 10 and is now is 8 b. Client with a Glasgow Coma Scale score that was 9 and is now is 12 c. Client with a moderate brain injury who is amnesic for the event d. Client who is requesting pain medication for a headache
ANS: A A 2-point decrease in the Glasgow Coma Scale score is clinically significant and the nurse needs to see this client first. An improvement in the score is a good sign. Amnesia is an expected finding with brain injuries, so this client is lower priority. The client requesting pain medication should be seen after the one with the declining Glasgow Coma Scale score.
A nurse prepares to discharge a client with chronic pancreatitis. Which question should the nurse ask to ensure safety upon discharge? a. "Do you have a one- or two-story home?" b. "Can you check your own pulse rate?" c. "Do you have any alcohol in your home?" d. "Can you prepare your own meals?"
ANS: A A client recovering from chronic pancreatitis should be limited to one floor until strength and activity increase. The client will need a bathroom on the same floor for frequent defecation. Assessing pulse rate and preparation of meals is not specific to chronic pancreatitis. Although the client should be encouraged to stop drinking alcoholic beverages, asking about alcohol availability is not adequate to assess this client's safety.
A nurse working with clients who experience alopecia knows that which is the best method of helping clients manage the psychosocial impact of this problem? a. Assisting the client to pre-plan for this event b. Reassuring the client that alopecia is temporary c. Teaching the client ways to protect the scalp d. Telling the client that there are worse side effects
ANS: A Alopecia does not occur for all clients who have cancer, but when it does, it can be devastating. The best action by the nurse is to teach the client about the possibility and to give the client multiple choices for preparing for this event. Not all clients will have the same reaction, but some possible actions the client can take are buying a wig ahead of time, buying attractive hats and scarves, and having a hairdresser modify a wig to look like the client's own hair. Teaching about scalp protection is important but does not address the psychosocial impact. Reassuring the client that hair loss is temporary and telling him or her that there are worse side effects are both patronizing and do not give the client tools to manage this condition.
The nurse is assessing clients on a cardiac unit. Which client does the nurse assess most carefully for developing left-sided heart failure? a. Middle-aged woman with aortic stenosis b. Middle-aged man with pulmonary hypertension c. Older woman who smokes cigarettes daily d. Older man who has had a myocardial infarction
ANS: A Although most people with heart failure will have failure that progresses from left to right, it is possible to have left-sided failure alone for a short period. It is also possible to have heart failure that progresses from right to left. Causes of left ventricular failure include mitral or aortic valve disease, coronary artery disease (CAD), and hypertension.
A client had an embolic stroke and is having an echocardiogram. When the client asks why the provider ordered "a test on my heart," how should the nurse respond? a. "Most of these types of blood clots come from the heart." b. "Some of the blood clots may have gone to your heart too." c. "We need to see if your heart is strong enough for therapy." d. "Your heart may have been damaged in the stroke too."
ANS: A An embolic stroke is caused when blood clots travel from one area of the body to the brain. The most common source of the clots is the heart. The other statements are inaccurate.
A client with heart failure is prescribed enalapril (Vasotec). What is the nurse's priority teaching for this client? a. "Avoid using salt substitutes." b. "Take your medication with food." c. "Avoid using aspirin-containing products." d. "Check your pulse daily."
ANS: A Angiotensin-converting enzyme (ACE) inhibitors inhibit the excretion of potassium. Hyperkalemia can be a life-threatening side effect, and clients should be taught to limit potassium intake. Salt substitutes are composed of potassium chloride.
The nurse working with oncology clients understands that which age-related change increases the older client's susceptibility to infection during chemotherapy? a. Decreased immune function b. Diminished nutritional stores c. Existing cognitive deficits d. Poor physical reserves
ANS: A As people age, there is an age-related decrease in immune function, causing the older adult to be more susceptible to infection than other clients. Not all older adults have diminished nutritional stores, cognitive dysfunction, or poor physical reserves.
A client has been admitted to the acute care unit for an exacerbation of heart failure. Which is the nurse's priority intervention? a. Assess respiratory status. b. Monitor electrolyte levels. c. Administer intravenous fluids. d. Insert a Foley catheter.
ANS: A Assessment of respiratory and oxygenation status is the priority nursing intervention for the prevention of complications. Monitoring electrolytes and inserting a catheter are important but do not take priority over assessing respiratory status. The client needs IV access, but fluids may need to be administered judiciously.
After a stroke, a client has ataxia. What intervention is most appropriate to include on the client's plan of care? a. Ambulate only with a gait belt. b. Encourage double swallowing. c. Monitor lung sounds after eating. d. Perform post-void residuals.
ANS: A Ataxia is a gait disturbance. For the client's safety, he or she should have assistance and use a gait belt when ambulating. Ataxia is not related to swallowing, aspiration, or voiding.
A client has a brain abscess and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying the client does not have a seizure disorder. What response by the nurse is best? a. "Increased pressure from the abscess can cause seizures." b. "Preventing febrile seizures with an abscess is important." c. "Seizures always occur in clients with brain abscesses." d. "This drug is used to sedate the client with an abscess."
ANS: A Brain abscesses can lead to seizures as a complication. The nurse should explain this to the spouse. Phenytoin is not used to prevent febrile seizures. Seizures are possible but do not always occur in clients with brain abscesses. This drug is not used for sedation.
A nurse in the oncology clinic is providing preoperative education to a client just diagnosed with cancer. The client has been scheduled for surgery in 3 days. What action by the nurse is best? a. Call the client at home the next day to review teaching. b. Give the client information about a cancer support group. c. Provide all the preoperative instructions in writing. d. Reassure the client that surgery will be over soon.
ANS: A Clients are often overwhelmed at a sudden diagnosis of cancer and may be more overwhelmed at the idea of a major operation so soon. This stress significantly impacts the client's ability to understand, retain, and recall information. The nurse should call the client at home the next day to review the teaching and to answer questions. The client may or may not be ready to investigate a support group, but this does not help with teaching. Giving information in writing is important (if the client can read it), but in itself will not be enough. Telling the client that surgery will be over soon is giving false reassurance and does nothing for teaching.
A nurse delegates care for a client with Parkinson disease to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this client's care? a. "Allow the client to be as independent as possible with activities." b. "Assist the client with frequent and meticulous oral care." c. "Assess the client's ability to eat and swallow before each meal." d. "Schedule appointments early in the morning to ensure rest in the afternoon."
ANS: A Clients with Parkinson disease do not move as quickly and can have functional problems. The client should be encouraged to be as independent as possible and provided time to perform activities without rushing. Although oral care is important for all clients, instructing the UAP to provide frequent and meticulous oral is not a priority for this client. This statement would be a priority if the client was immune-compromised or NPO. The nurse should assess the client's ability to eat and swallow; this should not be delegated. Appointments and activities should not be scheduled early in the morning because this may cause the client to be rushed and discourage the client from wanting to participate in activities of daily living.
A nurse assesses a client who is recovering from a Whipple procedure. Which assessment finding alerts the nurse to urgently contact the health care provider? a. Drainage from a fistula b. Absent bowel sounds c. Pain at the incision site d. Nasogastric (NG) tube drainage
ANS: A Complications of a Whipple procedure include secretions that drain from a fistula and peritonitis. Absent bowel sounds, pain at the incision site, and NG tube drainage are normal postoperative findings.
A client asks the nurse why it is important to be weighed every day if he has right-sided heart failure. What is the nurse's best response? a. "Weight is the best indication that you are gaining or losing fluid." b. "Daily weights will help us make sure that you're eating properly." c. "The hospital requires that all inpatients be weighed daily." d. "You need to lose weight to decrease the incidence of heart failure."
ANS: A Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2 pounds.
A client with a stroke has damage to Broca's area. What intervention to promote communication is best for this client? a. Assess whether or not the client can write. b. Communicate using "yes-or-no" questions. c. Reinforce speech therapy exercises. d. Remind the client not to use neologisms.
ANS: A Damage to Broca's area often leads to expressive aphasia, wherein the client can understand what is said but cannot express thoughts verbally. In some instances the client can write. The nurse should assess to see if that ability is intact. "Yes-or-no" questions are not good for this type of client because he or she will often answer automatically but incorrectly. Reinforcing speech therapy exercises is good for all clients with communication difficulties. Neologisms are made-up "words" often used by clients with sensory aphasia.
An older adult client with heart failure states, "I don't know what to do. I don't want to be a burden to my daughter, but I can't do it alone. Maybe I should die." What is the nurse's best response? a. "Would you like to talk about this more?" b. "You're lucky to have such a devoted daughter." c. "You must feel as though you are a burden." d. "Would you like an antidepressant medication?"
ANS: A Depression can occur in clients with heart failure, especially older adults. Having the client talk about his or her feelings will help the nurse focus on the actual problem. Open-ended statements allow the client to respond safely and honestly.
An older adult client is admitted with fluid volume excess. Which diagnostic study does the nurse facilitate as a priority? a. Echocardiography b. Chest x-ray c. T4 and thyroid-stimulating hormone (TSH) d. Arterial blood gas
ANS: A Echocardiography is considered the best tool for the diagnosis of heart failure. A chest x-ray probably will be done, and if the client has dyspnea, an arterial blood gas will be drawn, but the echocardiogram is the priority. T4 and TSH might be ordered to assess for a contributing cause of heart failure.
A nurse works on an oncology unit and delegates personal hygiene to an unlicensed assistive personnel (UAP). What action by the UAP requires intervention from the nurse? a. Allowing a very tired client to skip oral hygiene and sleep b. Assisting clients with washing the perianal area every 12 hours c. Helping the client use a soft-bristled toothbrush for oral care d. Reminding the client to rinse the mouth with water or saline
ANS: A Even though clients may be tired, they still need to participate in hygiene to help prevent infection. The other options are all appropriate.
A nurse promotes the prevention of lower back pain by teaching clients at a community center. Which instruction should the nurse include in this education? a. "Participate in an exercise program to strengthen muscles." b. "Purchase a mattress that allows you to adjust the firmness." c. "Wear flat instead of high-heeled shoes to work each day." d. "Keep your weight within 20% of your ideal body weight."
ANS: A Exercise can strengthen back muscles, reducing the incidence of low back pain. The other options will not prevent low back pain.
The nurse is teaching a client with chronic kidney disease (CKD) about the sodium restriction needed in the diet to prevent edema and hypertension. Which statement by the client indicates more teaching is needed? a. "I am thrilled that I can continue to eat fast food." b. "I will cut out bacon with my eggs every morning." c. "My cooking style will change by not adding salt." d. "I will probably lose weight by cutting out potato chips."
ANS: A Fast food restaurants usually serve food that is high in sodium. This statement indicates that more teaching needs to occur. The other statements show a correct understanding of the teaching.
12. A client is taking furosemide (Lasix) 40 mg/day for management of chronic kidney disease (CKD). To detect the positive effect of the medication, what action of the nurse is best? a. Obtain daily weights of the client. b. Auscultate heart and breath sounds. c. Palpate the client's abdomen. d. Assess the client's diet history.
ANS: A Furosemide (Lasix) is a loop diuretic that helps reduce fluid overload and hypertension in clients with early stages of CKD. One kilogram of weight equals about 1 liter of fluid retained in the client, so daily weights are necessary to monitor the response of the client to the medication. Heart and breath sounds should be assessed if there is fluid retention, as in heart failure. Palpation of the client's abdomen is not necessary, but the nurse should check for edema. The diet history of the client would be helpful to assess electrolyte replacement since potassium is lost with this diuretic, but this does not assess the effect of the medication.
A nurse is providing community screening for risk factors associated with stroke. Which client would the nurse identify as being at highest risk for a stroke? a. A 27-year-old heavy cocaine user b. A 30-year-old who drinks a beer a day c. A 40-year-old who uses seasonal antihistamines d. A 65-year-old who is active and on no medications
ANS: A Heavy drug use, particularly cocaine, is a risk factor for stroke. Heavy alcohol use is also a risk factor, but one beer a day is not considered heavy drinking. Antihistamines may contain phenylpropanolamine, which also increases the risk for stroke, but this client uses them seasonally and there is no information that they are abused or used heavily. The 65-year-old has only age as a risk factor.
A client in the intensive care unit is started on continuous venovenous hemofiltration (CVVH). Which finding is the cause of immediate action by the nurse? a. Blood pressure of 76/58 mm Hg b. Sodium level of 138 mEq/L c. Potassium level of 5.5 mEq/L d. Pulse rate of 90 beats/min
ANS: A Hypotension can be a problem with CVVH if replacement fluid does not provide enough volume to maintain blood pressure. The specially trained nurse needs to monitor for ongoing fluid and electrolyte replacement. The sodium level is normal and the potassium level is slightly elevated, which could be normal findings for someone with acute kidney injury. A pulse rate of 90 beats/min is normal.
The nurse is concerned that an older adult client with heart failure is developing pulmonary edema. What manifestation alerts the nurse to further assess the client for this complication? a. Confusion b. Dysphagia c. Sacral edema d. Irregular heart rate
ANS: A Impending pulmonary edema is characterized by a change in mental status, disorientation, and confusion, along with dyspnea and increasing fluid levels in the lungs. Dysphagia, sacral edema, and an irregular heart rate are not related to pulmonary edema.
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.
A nurse cares for a client who has obstructive jaundice. The client asks, "Why is my skin so itchy?" How should the nurse respond? a. "Bile salts accumulate in the skin and cause the itching." b. "Toxins released from an inflamed gallbladder lead to itching." c. "Itching is caused by the release of calcium into the skin." d. "Itching is caused by a hypersensitivity reaction."
ANS: A In obstructive jaundice, the normal flow of bile into the duodenum is blocked, allowing excess bile salts to accumulate on the skin. This leads to itching, or pruritus. The other statements are not accurate.
A client is receiving interleukins along with chemotherapy. What assessment by the nurse takes priority? a. Blood pressure b. Lung assessment c. Oral mucous membranes d. Skin integrity
ANS: A Interleukins can cause capillary leak syndrome and fluid shifting, leading to intravascular volume depletion. Although all assessments are important in caring for clients with cancer, blood pressure and other assessments of fluid status take priority
A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important? a. Assessing the IV site every hour b. Educating the client on side effects c. Monitoring the client for nausea d. Providing warm packs for comfort
ANS: A Intravenous chemotherapy can cause local tissue destruction if it extravasates into the surrounding tissues. Peripheral IV lines are more prone to this than centrally placed lines. The most important intervention is prevention, so the nurse should check hourly to ensure the IV site is patent, or frequently depending on facility policy. Education and monitoring for side effects such as nausea are important for all clients receiving chemotherapy. Warm packs may be helpful for comfort, but if the client reports that an IV site is painful, the nurse needs to assess further.
A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question should the nurse ask? a. "Do you live in a crowded residence?" b. "When was your last tetanus vaccination?" c. "Have you had any viral infections recently?" d. "Have you traveled out of the country in the last month?"
ANS: A Meningococcal meningitis tends to occur in multiple outbreaks. It is most likely to occur in areas of high-density population, such as college dormitories, prisons, and military barracks. A tetanus vaccination would not place the client at increased risk for meningitis or protect the client from meningitis. A viral infection would not lead to bacterial meningitis but could lead to viral meningitis. Simply knowing if the client traveled out of the country does not provide enough information. The nurse should ask about travel to specific countries in which the disease is common, for example, sub-Saharan Africa.
A client in severe heart failure has a heparin drip infusing. The health care provider prescribes nesiritide (Natrecor) to be given intravenously. Which intervention is essential before administration of this medication? a. Insert a separate IV access. b. Prepare a test bolus dose. c. Prepare the piggyback line. d. Administer furosemide (Lasix) first.
ANS: A Natrecor should be given through a separate IV access because it is incompatible with many medications, especially heparin. A test bolus is not needed, nor is Lasix. Because the medication should be given through a separate IV, it is not necessary to prepare a piggyback line.
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.
After teaching a client with a spinal cord injury, the nurse assesses the client's understanding. Which client statement indicates a correct understanding of how to prevent respiratory problems at home? a. "I'll use my incentive spirometer every 2 hours while I'm awake." b. "I'll drink thinned fluids to prevent choking." c. "I'll take cough medicine to prevent excessive coughing." d. "I'll position myself on my right side so I don't aspirate."
ANS: A Often, the person with a spinal cord injury will have weak intercostal muscles and is at higher risk for developing atelectasis and stasis pneumonia. Using an incentive spirometer every 2 hours helps the client expand the lungs more fully and prevents atelectasis. Clients should drink fluids that they can tolerate; usually thick fluids are easier to tolerate. The client should be encouraged to cough and clear secretions. Clients should be placed in high-Fowler's position to prevent aspiration.
A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The client's spouse is very frustrated, stating that the client's personality has changed and the situation is intolerable. What action by the nurse is best? a. Explain that personality changes are common following brain injuries. b. Ask the client why he or she is acting out and behaving differently. c. Refer the client and spouse to a head injury support group. d. Tell the spouse this is expected and he or she will have to learn to cope.
ANS: A Personality and behavior often change permanently after head injury. The nurse should explain this to the spouse. Asking the client about his or her behavior isn't useful because the client probably cannot help it. A referral might be a good idea, but the nurse needs to do something in addition to just referring the couple. Telling the spouse to learn to cope belittles the spouse's concerns and feelings.
A client with heart failure is experiencing acute shortness of breath. What is the nurse's priority action? a. Place the client in a high Fowler's position. b. Perform nasotracheal suctioning of the client. c. Auscultate the client's heart and lung sounds. d. Place the client on a 1000 mL fluid restriction.
ANS: A Placing a client in a high Fowler's position, especially with pillows under each arm, can maximize chest expansion and improve oxygenation. The nurse next should auscultate the client's heart and lungs. The client may or may not need fluid restriction to help manage heart failure, and suctioning is not needed.
The nurse is caring for a client with severe heart failure. What is the best position in which to place this client? a. High Fowler's, pillows under arms b. Semi-Fowler's, with legs elevated c. High Fowler's, with legs elevated d. Semi-Fowler's, on the left side
ANS: A Placing the client in high Fowler's position, with pillows under the arms, allows for maximum chest expansion.
A nurse assesses a client who is recovering from anterior cervical diskectomy and fusion. Which complication should alert the nurse to urgently communicate with the health care provider? a. Auscultated stridor b. Weak pedal pulses c. Difficulty swallowing d. Inability to shrug shoulders
ANS: A Postoperative swelling can narrow the trachea, cause a partial airway obstruction, and manifest as stridor. The client may also have trouble swallowing, but maintaining an airway takes priority. Weak pedal pulses and an inability to shrug the shoulders are not complications of this surgery.
A 70-kg adult with chronic renal failure is on a 40-g protein diet. The client has a reduced glomerular filtration rate and is not undergoing dialysis. Which result would give the nurse the most concern? a. Albumin level of 2.5 g/dL b. Phosphorus level of 5 mg/dL c. Sodium level of 135 mmol/L d. Potassium level of 5.5 mmol/L
ANS: A Protein restriction is necessary with chronic renal failure due to the buildup of waste products from protein breakdown. The nurse would be concerned with the low albumin level since this indicates that the protein in the diet is not enough for the client's metabolic needs. The electrolyte values are not related to the protein-restricted diet.
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
A nurse cares for a client with end-stage pancreatic cancer. The client asks, "Why is this happening to me?" How should the nurse respond? a. "I don't know. I wish I had an answer for you, but I don't." b. "It's important to keep a positive attitude for your family right now." c. "Scientists have not determined why cancer develops in certain people." d. "I think that this is a trial so you can become a better person because of it."
ANS: A The client is not asking the nurse to actually explain why the cancer has occurred. The client may be expressing his or her feelings of confusion, frustration, distress, and grief related to this diagnosis. Reminding the client to keep a positive attitude for his or her family does not address the client's emotions or current concerns. The nurse should validate that there is no easy or straightforward answer as to why the client has cancer. Telling a client that cancer is a trial is untrue and may diminish the client-nurse relationship.
A nurse reads on a hospitalized client's chart that the client is receiving teletherapy. What action by the nurse is best? a. Coordinate continuation of the therapy. b. Place the client on radiation precautions. c. No action by the nurse is needed at this time. d. Restrict visitors to only adults over age 18.
ANS: A The client needs to continue with radiation therapy, and the nurse can coordinate this with the appropriate department. The client is not radioactive, so radiation precautions and limiting visitors are not necessary.
A nurse cares for a client who is recovering from laparoscopic cholecystectomy surgery. The client reports pain in the shoulder blades. How should the nurse respond? a. "Ambulating in the hallway twice a day will help." b. "I will apply a cold compress to the painful area on your back." c. "Drinking a warm beverage can relieve this referred pain." d. "You should cough and deep breathe every hour."
ANS: A The client who has undergone a laparoscopic cholecystectomy may report free air pain due to retention of carbon dioxide in the abdomen. The nurse assists the client with early ambulation to promote absorption of the carbon dioxide. Cold compresses and drinking a warm beverage would not be helpful. Coughing and deep breathing are important postoperative activities, but they are not related to discomfort from carbon dioxide.
A client with a history of myocardial infarction calls the clinic to report the onset of a cough that is troublesome only at night. What direction does the nurse give to the client? a. "Please come into the clinic for an evaluation." b. "Increase your fluid intake during waking hours." c. "Use an over-the-counter cough suppressant." d. "Sleep on two pillows to facilitate postnasal drainage."
ANS: A The client with a history of myocardial infarction is at risk for developing heart failure. The onset of nocturnal cough is an early manifestation of heart failure, and the client needs to be evaluated as soon as possible.
A client has dumping syndrome after a partial gastrectomy. Which action by the nurse would be most helpful? a. Arrange a dietary consult. b. Increase fluid intake. c. Limit the client's foods. d. Make the client NPO.
ANS: A The client with dumping syndrome after a gastrectomy has multiple dietary needs. A referral to the registered dietitian will be extremely helpful. Food and fluid intake is complicated and needs planning. The client should not be NPO.
The nurse is providing care to a client with infective endocarditis. What infection control precautions does the nurse use? a. Standard Precautions b. Bleeding Precautions c. Reverse isolation d. Contact isolation
ANS: A The client with infective endocarditis does not pose any specific threat of transmitting the causative organism.
A client hospitalized for chemotherapy has a hemoglobin of 6.1 mg/dL. What medication should the nurse prepare to administer? a. Epoetin alfa (Epogen) b. Filgrastim (Neupogen) c. Mesna (Mesnex) d. Oprelvekin (Neumega)
ANS: A The client's hemoglobin is low, so the nurse should prepare to administer epoetin alfa, a colony-stimulating factor that increases production of red blood cells. Filgrastim is for neutropenia. Mesna is used to decrease bladder toxicity from some chemotherapeutic agents. Oprelvekin is used to increase platelet count.
. A male client with chronic kidney disease (CKD) is refusing to take his medication and has missed two hemodialysis appointments. What is the best initial action for the nurse? a. Discuss what the treatment regimen means to him. b. Refer the client to a mental health nurse practitioner. c. Reschedule the appointments to another date and time. d. Discuss the option of peritoneal dialysis.
ANS: A The initial action for the nurse is to assess anxiety, coping styles, and the client's acceptance of the required treatment for CKD. The client may be in denial of the diagnosis. While rescheduling hemodialysis appointments may help, and referral to a mental health practitioner and the possibility of peritoneal dialysis are all viable options, assessment of the client's acceptance of the treatment should come first.
A client with heart failure is due to receive enalapril (Vasotec) and has a blood pressure of 98/50 mm Hg. What is the nurse's best action? a. Administer the Vasotec. b. Recheck the blood pressure. c. Hold the Vasotec. d. Notify the health care provider.
ANS: A The nurse should administer the medication. Generally, the health care provider will maintain the client's blood pressure between 90 and 110 mm Hg.
A client in the emergency department is having a stroke and needs a carotid artery angioplasty with stenting. The client's mental status is deteriorating. What action by the nurse is most appropriate? a. Attempt to find the family to sign a consent. b. Inform the provider that the procedure cannot occur. c. Nothing; no consent is needed in an emergency. d. Sign the consent form for the client.
ANS: A The nurse should attempt to find the family to give consent. If no family is present or can be found, under the principle of emergency consent, a life-saving procedure can be performed without formal consent. The nurse should not just sign the consent form.
The nurse assesses a client and notes the presence of an S3 gallop. What is the nurse's best intervention? a. Assess for symptoms of left-sided heart failure. b. Document this as a normal finding. c. Call the health care provider immediately. d. Transfer the client to the intensive care unit.
ANS: A The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. The other actions are not warranted.
A client has a serum potassium level of 6.5 mmol/L, a serum creatinine level of 2 mg/dL, and a urine output of 350 mL/day. What is the best action by the nurse? a. Place the client on a cardiac monitor immediately. b. Teach the client to limit high-potassium foods. c. Continue to monitor the client's intake and output. d. Ask to have the laboratory redraw the blood specimen.
ANS: A The priority action by the nurse should be to check the cardiac status with a monitor. High potassium levels can lead to dysrhythmias. The other choices are logical nursing interventions for acute kidney injury but not the best immediate action.
3. A male client comes into the emergency department with a serum creatinine of 2.2 mg/dL and a blood urea nitrogen (BUN) of 24 mL/dL. What question should the nurse ask first when taking this client's history? a. "Have you been taking any aspirin, ibuprofen, or naproxen recently?" b. "Do you have anyone in your family with renal failure?" c. "Have you had a diet that is low in protein recently?" d. "Has a relative had a kidney transplant lately?"
ANS: A There are some medications that are nephrotoxic, such as the nonsteroidal anti-inflammatory drugs ibuprofen, aspirin, and naproxen. This would be a good question to initially ask the client since both the serum creatinine and BUN are elevated, indicating some renal problems. A family history of renal failure and kidney transplantation would not be part of the questioning and could cause anxiety in the client. A diet high in protein could be a factor in an increased BUN.
A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beats/min, pulse pressure increase from 26 to 40 mm Hg, and respiratory irregularities. What action by the nurse takes priority? a. Call the provider or Rapid Response Team. b. Increase the rate of the IV fluid administration. c. Notify respiratory therapy for a breathing treatment. d. Prepare to give IV pain medication.
ANS: A These manifestations indicate Cushing's syndrome, a potentially life-threatening increase in intracranial pressure (ICP), which is an emergency. Immediate medical attention is necessary, so the nurse notifies the provider or the Rapid Response Team. Increasing fluids would increase the ICP. The client does not need a breathing treatment or pain medication.
A client with chronic kidney disease (CKD) is experiencing nausea, vomiting, visual changes, and anorexia. Which action by the nurse is best? a. Check the client's digoxin (Lanoxin) level. b. Administer an anti-nausea medication. c. Ask if the client is able to eat crackers. d. Get a referral to a gastrointestinal provider.
ANS: A These signs and symptoms are indications of digoxin (Lanoxin) toxicity. The nurse should check the level of this medication. Administering antiemetics, asking if the client can eat, and obtaining a referral to a specialist all address the client's symptoms but do not lead to the cause of the symptoms.
A marathon runner comes into the clinic and states "I have not urinated very much in the last few days." The nurse notes a heart rate of 110 beats/min and a blood pressure of 86/58 mm Hg. Which action by the nurse is the priority? a. Give the client a bottle of water immediately. b. Start an intravenous line for fluids. c. Teach the client to drink 2 to 3 liters of water daily. d. Perform an electrocardiogram.
ANS: A This athlete is mildly dehydrated as evidenced by the higher heart rate and lower blood pressure. The nurse can start hydrating the client with a bottle of water first, followed by teaching the client to drink 2 to 3 liters of water each day. An intravenous line may be ordered later, after the client's degree of dehydration is assessed. An electrocardiogram is not necessary at this time.
A client who had a severe traumatic brain injury is being discharged home, where the spouse will be a full-time caregiver. What statement by the spouse would lead the nurse to provide further education on home care? a. "I know I can take care of all these needs by myself." b. "I need to seek counseling because I am very angry." c. "Hopefully things will improve gradually over time." d. "With respite care and support, I think I can do this."
ANS: A This caregiver has unrealistic expectations about being able to do everything without help. Acknowledging anger and seeking counseling show a realistic outlook and plans for accomplishing goals. Hoping for improvement over time is also realistic, especially with the inclusion of the word "hopefully." Realizing the importance of respite care and support also is a realistic outlook.
A client with a history of prostate cancer is in the clinic and reports new onset of severe low back pain. What action by the nurse is most important? a. Assess the client's gait and balance. b. Ask the client about the ease of urine flow. c. Document the report completely. d. Inquire about the client's job risks.
ANS: A This client has manifestations of spinal cord compression, which can be seen with prostate cancer. This may affect both gait and balance and urinary function. For client safety, assessing gait and balance is the priority. Documentation should be complete. The client may or may not have occupational risks for low back pain, but with his history of prostate cancer, this should not be where the nurse starts investigating.
A nurse witnesses a client with late-stage Alzheimer's disease eat breakfast. Afterward the client states, "I am hungry and want breakfast." How should the nurse respond? a. "I see you are still hungry. I will get you some toast." b. "You ate your breakfast 30 minutes ago." c. "It appears you are confused this morning." d. "Your family will be here soon. Let's get you dressed."
ANS: A Use of validation therapy with clients who have Alzheimer's disease involves acknowledgment of the client's feelings and concerns. This technique has proved more effective in later stages of the disease, when using reality orientation only increases agitation. Telling the client that he or she already ate breakfast may agitate the client. The other statements do not validate the client's concerns.
A nurse assesses a client who is recovering from an open Whipple procedure. Which action should the nurse perform first? a. Assess the client's endotracheal tube with 40% FiO2. b. Insert an indwelling Foley catheter to gravity drainage. c. Place the client's nasogastric tube to low intermittent suction. d. Start lactated Ringer's solution through an intravenous catheter.
ANS: A Using the ABCs, airway and oxygenation status should always be assessed first, so checking the endotracheal tube is the first action. Next, the nurse should start the IV line (circulation). After that, the Foley catheter can be inserted and the nasogastric tube can be set.
A nurse delegates care for a client who has open skin lesions. Which statements should the nurse include when delegating this client's hygiene care to an unlicensed assistive personnel (UAP)? (Select all that apply.) a."Wash your hands before touching the client." b."Wear gloves when bathing the client." c."Assess skin for breakdown during the bath." d."Apply lotion to lesions while the skin is wet." e."Use a damp cloth to scrub the lesions."
ANS: A, B All health care providers should follow Standard Precautions when caring for clients who have any open skin areas. This includes hand hygiene and wearing gloves when in contact with the lesions. The UAP is not qualified to assess the client's skin. The other statements are not appropriate for the care of open skin lesions.
A nurse is seeing many clients in the neurosurgical clinic. With which clients should the nurse plan to do more teaching? (Select all that apply.) a. Client with an aneurysm coil placed 2 months ago who is taking ibuprofen (Motrin) for sinus headaches b. Client with an aneurysm clip who states that his family is happy there is no chance of recurrence c. Client who had a coil procedure who says that there will be no problem following up for 1 year d. Client who underwent a flow diversion procedure 3 months ago who is taking docusate sodium (Colace) for constipation e. Client who underwent surgical aneurysm ligation 3 months ago who is planning to take a Caribbean cruise
ANS: A, B After a coil procedure, up to 20% of clients experience re-bleeding in the first year. The client with this coil should not be taking drugs that interfere with clotting. An aneurysm clip can move up to 5 years after placement, so this client and family need to be watchful for changing neurologic status. The other statements show good understanding.
A nurse cares for a client who presents with tachycardia and prostration related to biliary colic. Which actions should the nurse take? (Select all that apply.) a. Contact the provider immediately. b. Lower the head of the bed. c. Decrease intravenous fluids. d. Ask the client to bear down. e. Administer prescribed opioids.
ANS: A, B Clients who are experiencing biliary colic may present with tachycardia, pallor, diaphoresis, prostration, or other signs of shock. The nurse should stay with the client, lower the client's head, and contact the provider or Rapid Response Team for immediate assistance. Treatment for shock usually includes intravenous fluids; therefore, decreasing fluids would be an incorrect intervention. The client's tachycardia is a result of shock, not pain. Performing the vagal maneuver or administering opioids could knock out the client's compensation mechanism.
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.
A nurse assesses clients on a medical-surgical unit. Which clients should the nurse identify as at risk for secondary seizures? (Select all that apply.) a. A 26-year-old woman with a left temporal brain tumor b. A 38-year-old male client in an alcohol withdrawal program c. A 42-year-old football player with a traumatic brain injury d. A 66-year-old female client with multiple sclerosis e. A 72-year-old man with chronic obstructive pulmonary disease
ANS: A, B, C Clients at risk for secondary seizures include those with a brain lesion from a tumor or trauma, and those who are experiencing a metabolic disorder, acute alcohol withdrawal, electrolyte disturbances, and high fever. Clients with a history of stroke, heart disease, and substance abuse are also at risk. Clients with multiple sclerosis or chronic obstructive pulmonary disease are not at risk for secondary seizures.
A nurse is preparing to administer IV chemotherapy. What supplies does this nurse need? (Select all that apply.) a. "Chemo" gloves b. Facemask c. Isolation gown d. N95 respirator e. Shoe covers
ANS: A, B, C The Occupational Safety and Health Administration (OSHA) and the Oncology Nurses Society have developed safety guidelines for those preparing or administering IV chemotherapy. These include double gloves (or "chemo" gloves), a facemask, and a gown. An N95 respirator and shoe covers are not required.
A client's family members are concerned that telling the client about a new finding of cancer will cause extreme emotional distress. They approach the nurse and ask if this can be kept from the client. What actions by the nurse are most appropriate? (Select all that apply.) a. Ask the family to describe their concerns more fully. b. Consult with a social worker, chaplain, or ethics committee. c. Explain the client's right to know and ask for their assistance. d. Have the unit manager take over the care of this client and family. e. Tell the family that this secret will not be kept from the client.
ANS: A, B, C The client's right of autonomy means that the client must be fully informed as to his or her diagnosis and treatment options. The nurse cannot ethically keep this information from the client. The nurse can ask the family to explain their concerns more fully so everyone understands the concerns. A social worker, chaplain, or ethics committee can become involved to assist the nurse, client, and family. The nurse should explain the client's right to know and ask the family how best to proceed. The nurse should not abdicate responsibility for this difficult situation by transferring care to another nurse. Simply telling the family that he or she will not keep this secret sets up an adversarial relationship. Explaining this fact along with the concept of autonomy would be acceptable, but this by itself is not.
The nurse is caring for five clients on the medical-surgical unit. Which clients would the nurse consider to be at risk for post-renal acute kidney injury (AKI)? (Select all that apply.) a. Man with prostate cancer b. Woman with blood clots in the urinary tract c. Client with ureterolithiasis d. Firefighter with severe burns e. Young woman with lupus
ANS: A, B, C Urine flow obstruction, such as prostate cancer, blood clots in the urinary tract, and kidney stones (ureterolithiasis), causes post-renal AKI. Severe burns would be a pre-renal cause. Lupus would be an intrarenal cause for AKI.
A client has a small-bore feeding tube (Dobhoff tube) inserted for continuous enteral feedings while recovering from a traumatic brain injury. What actions should the nurse include in the client's care? (Select all that apply.) a. Assess tube placement per agency policy. b. Keep the head of the bed elevated at least 30 degrees. c. Listen to lung sounds at least every 4 hours. d. Run continuous feedings on a feeding pump. e. Use blue dye to determine proper placement.
ANS: A, B, C, D All of these options are important for client safety when continuous enteral feedings are in use. Blue dye is not used because it can cause lung injury if aspirated.
A client has meningitis following brain surgery. What comfort measures may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Applying a cool washcloth to the head b. Assisting the client to a position of comfort c. Keeping voices soft and soothing d. Maintaining low lighting in the room e. Providing antipyretics for fever
ANS: A, B, C, D The client with meningitis often has high fever, pain, and some degree of confusion. Cool washcloths to the forehead are comforting and help with pain. Allowing the client to assume a position of comfort also helps manage pain. Keeping voices low and lights dimmed also helps convey caring in a nonthreatening manner. The nurse provides antipyretics for fever.
When working with older adults to promote good nutrition, what actions by the nurse are most appropriate? (Select all that apply.) a. Allow uninterrupted time for eating. b. Assess dentures for appropriate fit. c. Ensure the client has glasses on when eating. d. Provide salty foods that the client can taste. e. Serve high-calorie, high-protein snacks.
ANS: A, B, C, E NO SALTY FOOD!
3. A client came to the clinic with erectile dysfunction. What are some possible causes of this condition that the nurse could discuss with the client during history taking? (Select all that apply.) a. Recent prostatectomy b. Long-term hypertension c. Diabetes mellitus d. Hour-long exercise sessions e. Consumption of beer each night
ANS: A, B, C, E Organic erectile dysfunction can be caused by surgical procedures, hypertension and its treatment, diabetes mellitus, and alcohol consumption. There is no evidence that exercise is related to this problem.
The student nurse learns about risk factors for gastric cancer. Which factors does this include? (Select all that apply.) a. Achlorhydria b. Chronic atrophic gastritis c. Helicobacter pylori infection d. Iron deficiency anemia e. Pernicious anemia
ANS: A, B, C, E Achlorhydria, chronic atrophic gastritis, H. pylori infection, and pernicious anemia are all risk factors for developing gastric cancer. Iron deficiency anemia is not a risk factor.
The student nurse studying stomach disorders learns that the risk factors for acute gastritis include which of the following? (Select all that apply.) a. Alcohol b. Caffeine c. Corticosteroids d. Fruit juice e. Nonsteroidal anti-inflammatory drugs (NSAIDs)
ANS: A, B, C, E Risk factors for acute gastritis include alcohol, caffeine, corticosteroids, and chronic NSAID use. Fruit juice is not a risk factor, although in some people it does cause distress.
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.
A client has thrombocytopenia. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Apply the client's shoes before getting the client out of bed. b. Assist the client with ambulation. c. Shave the client with a safety razor only. d. Use a lift sheet to move the client up in bed. e. Use the Waterpik on a low setting for oral care.
ANS: A, B, D Clients with thrombocytopenia are at risk of significant bleeding even with minor injuries. The nurse instructs the UAP to put the client's shoes on before getting the client out of bed, assist with ambulation, shave the client with an electric razor, use a lift sheet when needed to reposition the client, and use a soft-bristled toothbrush for oral care.
A client is undergoing hemodialysis. The client's blood pressure at the beginning of the procedure was 136/88 mm Hg, and now it is 110/54 mm Hg. What actions should the nurse perform to maintain blood pressure? (Select all that apply.) a. Adjust the rate of extracorporeal blood flow. b. Place the client in the Trendelenburg position. c. Stop the hemodialysis treatment. d. Administer a 250-mL bolus of normal saline. e. Contact the health care provider for orders.
ANS: A, B, D Hypotension occurs often during hemodialysis treatments as a result of vasodilation from the warmed dialysate. Modest decreases in blood pressure, as is the case with this client, can be maintained with rate adjustment, Trendelenburg positioning, and a fluid bolus. If the blood pressure drops considerably after two boluses and cooling dialysate, the hemodialysis can be stopped and the health care provider contacted.
A client is unsure of the decision to undergo peritoneal dialysis (PD) and wishes to discuss the advantages of this treatment with the nurse. Which statements by the nurse are accurate regarding PD? (Select all that apply.) a. "You will not need vascular access to perform PD." b. "There is less restriction of protein and fluids." c. "You will have no risk for infection with PD." d. "You have flexible scheduling for the exchanges." e. "It takes less time than hemodialysis treatments."
ANS: A, B, D PD is based on exchanges of waste, fluid, and electrolytes in the peritoneal cavity. There is no need for vascular access. Protein is lost in the exchange, which allows for more protein and fluid in the diet. There is flexibility in the time for exchanges, but the treatment takes a longer period of time compared to hemodialysis. There still is risk for infection with PD, especially peritonitis.
A nurse is working with many stroke clients. Which clients would the nurse consider referring to a mental health provider on discharge? (Select all that apply.) a. Client who exhibits extreme emotional lability b. Client with an initial National Institutes of Health (NIH) Stroke Scale score of 38 c. Client with mild forgetfulness and a slight limp d. Client who has a past hospitalization for a suicide attempt e. Client who is unable to walk or eat 3 weeks post-stroke
ANS: A, B, D, E Clients most at risk for post-stroke depression are those with a previous history of depression, severe stroke (NIH Stroke Scale score of 38 is severe), and post-stroke physical or cognitive impairment. The client with mild forgetfulness and a slight limp would be a low priority for this referral.
A client has mucositis. What actions by the nurse will improve the client's nutrition? (Select all that apply.) a. Assist with rinsing the mouth with saline frequently. b. Encourage the client to eat room-temperature foods. c. Give the client hot liquids to hold in the mouth. d. Provide local anesthetic medications to swish and spit. e. Remind the client to brush teeth gently after each meal.
ANS: A, B, D, E Mucositis can interfere with nutrition. The nurse can help with rinsing the mouth frequently with water or saline; encouraging the client to eat cool, slightly warm, or room-temperature foods; providing swish-and-spit anesthetics; and reminding the client to keep the mouth clean by brushing gently after each meal. Hot liquids would be painful for the client.
A client has a gastrointestinal hemorrhage and is prescribed two units of packed red blood cells. What actions should the nurse perform prior to hanging the blood? (Select all that apply.) a. Ask a second nurse to double-check the blood. b. Prime the IV tubing with normal saline. c. Prime the IV tubing with dextrose in water. d. Take and record a set of vital signs. e. Teach the client about reaction manifestations.
ANS: A, B, D, E Prior to starting a blood transfusion, the nurse asks another nurse to double-check the blood (and client identity), primes the IV tubing with normal saline, takes and records a baseline set of vital signs, and teaches the client about manifestations to report. The IV tubing is not primed with dextrose in water.
1. The nurse is administering finasteride (Proscar) and doxazosin (Cardura) to a 67-year-old client with benign prostatic hyperplasia. What precautions are related to the side effects of these medications? (Select all that apply.) a.Assessing for blood pressure changes when lying, sitting, and arising from the bed b.Immediately reporting any change in the alanine aminotransferase laboratory test c.Teaching the client about the possibility of increased libido with these medications d.Taking the clients pulse rate for a minute in anticipation of bradycardia e.Asking the client to report any weakness, light-headedness, or dizziness
ANS: A, B, E Both the 5-alpha-reductase inhibitor (5-ARI) and the alpha1-selective blocking agents can cause orthostatic (postural) hypotension and liver dysfunction. The 5-ARI agent (Proscar) can cause a decreased libido rather than an increased sexual drive. The alpha-blocking drug (Cardura) can cause tachycardia rather than bradycardia.
A nurse cares for older adult clients in a long-term acute care facility. Which interventions should the nurse implement to prevent skin breakdown in these clients? (Select all that apply.) a.Use a lift sheet when moving the client in bed. b.Avoid tape when applying dressings. c.Avoid whirlpool therapy. d.Use loose dressing on all wounds. e.Implement pressure-relieving devices.
ANS: A, B, E Using a lift sheet will prevent shearing forces from tearing skin. Tape should be avoided so that the skin won't tear. Using pressure-relieving devices for clients who are at risk for pressure ulcer formation, including older adults, is a proactive approach to prevent skin breakdown. No contraindication to using whirlpool therapy for the older client is known. Dressings should be applied as prescribed, not so loose that they do not provide required treatment, and not so tight that they decrease blood flow to tissues.
A nurse plans care for a client with a halo fixator. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Tape a halo wrench to the client's vest. b. Assess the pin sites for signs of infection. c. Loosen the pins when sleeping. d. Decrease the client's oral fluid intake. e. Assess the chest and back for skin breakdown.
ANS: A, B, E A special halo wrench should be taped to the client's vest in case of a cardiopulmonary emergency. The nurse should assess the pin sites for signs of infection or loose pins and for complications from the halo. The nurse should also increase fluids and fiber to decrease bowel straining and assess the client's chest and back for skin breakdown from the halo vest.
After teaching a client with a spinal cord tumor, the nurse assesses the client's understanding. Which statements by the client indicate a correct understanding of the teaching? (Select all that apply.) a. "Even though turning hurts, I will remind you to turn me every 2 hours." b. "Radiation therapy can shrink the tumor but also can cause more problems." c. "Surgery will be scheduled to remove the tumor and reverse my symptoms." d. "I put my affairs in order because this type of cancer is almost always fatal." e. "My family is moving my bedroom downstairs for when I am discharged home."
ANS: A, B, E Although surgery may relieve symptoms by reducing pressure on the spine and debulking the tumor, some motor and sensory deficits may remain. Spinal tumors usually cause disability but are not usually fatal. Radiation therapy is often used to shrink spinal tumors but can cause progressive spinal cord degeneration and neurologic deficits. The client should be turned every 2 hours to prevent skin breakdown and arrangements should be made at home so that the client can complete activities of daily living without needing to go up and down stairs.
A nurse assesses a client who is experiencing a cluster headache. Which clinical manifestations should the nurse expect to find? (Select all that apply.) a. Ipsilateral tearing of the eye b. Miosis c. Abrupt loss of consciousness d. Neck and shoulder tenderness e. Nasal congestion f. Exophthalmos
ANS: A, B, E Cluster headache is usually accompanied by ipsilateral tearing, miosis, rhinorrhea or nasal congestion, ptosis, eyelid edema, and facial sweating. Abrupt loss of consciousness, neck and shoulder tenderness, and exophthalmos are not associated with cluster headaches.
The nurse is assessing a client with left-sided heart failure. What conditions does the nurse assess for? (Select all that apply.) a. Pulmonary crackles b. Confusion, restlessness c. Pulmonary hypertension d. Dependent edema e. S3/S4 summation gallop f. Cough worsens at night
ANS: A, B, E, F Left-sided failure occurs with a decrease in contractility of the heart or an increase in afterload. Most of the signs will be noted in the respiratory system. Right-sided failure occurs with problems from the pulmonary vasculature onward. Signs will be noted before the right atrium or ventricle.
The nurse is evaluating the laboratory results for a client with heart failure. What results does the nurse expect? (Select all that apply.) a. Hematocrit (Hct), 32.8% b. Serum sodium, 130 mEq/L c. Serum potassium, 4.0 mEq/L d. Serum creatinine, 1.0 mg/dL e. Proteinuria f. Microalbuminuria
ANS: A, B, E, F The hematocrit is low (should be 42.6%), indicating a dilutional ratio of red blood cells (RBCs) to fluid. The serum sodium is low because of hemodilution. Microalbuminuria and proteinuria are present, indicating a decrease in renal filtration. This is an early warning sign of decreased compliance of the heart.
A nurse is caring for a client with meningitis. Which laboratory values should the nurse monitor to identify potential complications of this disorder? (Select all that apply.) a. Sodium level b. Liver enzymes c. Clotting factors d. Cardiac enzymes e. Creatinine level
ANS: A, C Inflammation associated with meningitis can stimulate the hypothalamus and result in excessive production of antidiuretic hormone. The nurse should monitor sodium levels for early identification of syndrome of inappropriate antidiuretic hormone. A systemic inflammatory response (SIR) can also occur with meningitis. A SIR can result in a coagulopathy that leads to disseminated intravascular coagulation. The nurse should monitor clotting factors to identify this complication. The other laboratory values are not specific to complications of meningitis.
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.
A client on interferon therapy is reporting severe skin itching and irritation. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Apply moisturizers to dry skin. b. Apply steroid creams to the skin. c. Bathe the client using mild soap. d. Help the client with a hot water bath. e. Teach the client to avoid sunlight.
ANS: A, C The nurse can delegate applying unscented moisturizer and using mild soap for bathing. Steroid creams are not used for this condition. Hot water will worsen the irritation. Client teaching is a nursing function.
A nurse evaluates the results of diagnostic tests on a client's cerebrospinal fluid (CSF). Which fluid results alerts the nurse to possible viral meningitis? (Select all that apply.) a. Clear b. Cloudy c. Increased protein level d. Normal glucose level e. Bacterial organisms present f. Increased white blood cells
ANS: A, C, D In viral meningitis, CSF fluid is clear, protein levels are slightly increased, and glucose levels are normal. Viral meningitis does not cause cloudiness or increased turbidity of CSF. In bacterial meningitis, the presence of bacteria and white blood cells causes the fluid to be cloudy.
A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.) a. Heart rate of 34 beats/min b. Blood pressure of 185/65 mm Hg c. Urine output less than 30 mL/hr d. Decreased level of consciousness e. Increased oxygen saturation
ANS: A, C, D Neurogenic shock with acute spinal cord injury manifests with decreased oxygen saturation, symptomatic bradycardia, decreased level of consciousness, decreased urine output, and hypotension.
A nurse cares for older clients who have traumatic brain injury. What should the nurse understand about this population? (Select all that apply.) a. Admission can overwhelm the coping mechanisms for older clients. b. Alcohol is typically involved in most traumatic brain injuries for this age group. c. These clients are more susceptible to systemic and wound infections. d. Other medical conditions can complicate treatment for these clients. e. Very few traumatic brain injuries occur in this age group.
ANS: A, C, D Older clients often tolerate stress poorly, which includes being admitted to a hospital that is unfamiliar and noisy. Because of decreased protective mechanisms, they are more susceptible to both local and systemic infections. Other medical conditions can complicate their treatment and recovery. Alcohol is typically not related to traumatic brain injury in this population; such injury is most often from falls and motor vehicle crashes. The 65- to 76-year-old age group has the second highest rate of brain injuries compared to other age groups.
The nurse understands that malnutrition can occur in hospitalized clients for several reasons. Which are possible reasons for this to occur? (Select all that apply.) a. Cultural food preferences b. Family bringing snacks c. Increased need for nutrition d. Need for NPO status e. Staff shortages
ANS: A, C, D, E FAM NO SNACKS!
The nurse working in the emergency department assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess? (Select all that apply.) a. Alcohol intake b. Diabetes c. High-fat diet d. Obesity e. Smoking
ANS: A, C, D, E Alcohol intake, a high-fat diet, obesity, and smoking are all modifiable risk factors for stroke. Diabetes is not modifiable but is a risk factor that can be controlled with medical intervention.
A client receiving chemotherapy has a white blood cell count of 1000/mm3. What actions by the nurse are most appropriate? (Select all that apply.) a. Assess all mucous membranes every 4 to 8 hours. b. Do not allow the client to eat meat or poultry. c. Listen to lung sounds and monitor for cough. d. Monitor the venous access device appearance with vital signs. e. Take and record vital signs every 4 to 8 hours.
ANS: A, C, D, E Depending on facility protocol, the nurse should assess this client for infection every 4 to 8 hours by assessing all mucous membranes, listening to lung sounds, monitoring for cough, monitoring the appearance of the venous access device, and recording vital signs. Eating meat and poultry is allowed.
A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which assessment data should the nurse obtain to assess the client's coping strategies? (Select all that apply.) a. Spiritual beliefs b. Level of pain c. Family support d. Level of independence e. Annual income f. Previous coping strategies
ANS: A, C, D, F Information about the client's preinjury psychosocial status, usual methods of coping with illness, difficult situations, and disappointments should be obtained. Determine the client's level of independence or dependence and his or her comfort level in discussing feelings and emotions with family members or close friends. Clients who are emotionally secure and have a positive self-image, a supportive family, and financial and job security often adapt to their injury. Information about the client's spiritual and religious beliefs or cultural background also assists the nurse in developing the plan of care. The other options do not supply as much information about coping.
A nurse plans care for a client who has acute pancreatitis and is prescribed nothing by mouth (NPO). With which health care team members should the nurse collaborate to provide appropriate nutrition to this client? (Select all that apply.) a. Registered dietitian b. Nursing assistant c. Clinical pharmacist d. Certified herbalist e. Health care provider
ANS: A, C, E Clients who are prescribed NPO while experiencing an acute pancreatitis episode may need enteral or parenteral nutrition. The nurse should collaborate with the registered dietitian, clinical pharmacist, and health care provider to plan and implement the more appropriate nutritional interventions. The nursing assistant and certified herbalist would not assist with this clinical decision.
. A client is hospitalized in the oliguric phase of acute kidney injury (AKI) and is receiving tube feedings. The nurse is teaching the client's spouse about the kidney-specific formulation for the enteral solution compared to standard formulas. What components should be discussed in the teaching plan? (Select all that apply.) a. Lower sodium b. Higher calcium c. Lower potassium d. Higher phosphorus e. Higher calories
ANS: A, C, E Many clients with AKI are too ill to meet caloric goals and require tube feedings with kidney-specific formulas that are lower in sodium, potassium, and phosphorus, and higher in calories than are standard formulas.
A nurse is caring for a postoperative 70-kg client who had major blood loss during surgery. Which findings by the nurse should prompt immediate action to prevent acute kidney injury? (Select all that apply.) a. Urine output of 100 mL in 4 hours b. Urine output of 500 mL in 12 hours c. Large amount of sediment in the urine d. Amber, odorless urine e. Blood pressure of 90/60 mm Hg
ANS: A, C, E The low urine output, sediment, and blood pressure should be reported to the provider. Postoperatively, the nurse should measure intake and output, check the characteristics of the urine, and report sediment, hematuria, and urine output of less than 0.5 mL/kg/hour for 3 to 4 hours. A urine output of 100 mL is low, but a urine output of 500 mL in 12 hours should be within normal limits. Perfusion to the kidneys is compromised with low blood pressure. The amber odorless urine is normal.
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.
A client has dumping syndrome. What menu selections indicate the client understands the correct diet to manage this condition? (Select all that apply.) a. Canned unsweetened apricots b. Coffee cake c. Milk shake d. Potato soup e. Steamed broccoli
ANS: A, D Canned apricots and potato soup are appropriate selections as they are part of a high-protein, high-fat, low- to moderate-carbohydrate diet. Coffee cake and other sweets must be avoided. Milk products and sweet drinks such as shakes must be avoided. Gas-forming foods such as broccoli must also be avoided.
A nursing student studying traumatic brain injuries (TBIs) should recognize which facts about these disorders? (Select all that apply.) a. A client with a moderate trauma may need hospitalization. b. A Glasgow Coma Scale score of 10 indicates a mild brain injury. c. Only open head injuries can cause a severe TBI. d. A client with a Glasgow Coma Scale score of 3 has severe TBI. e. The terms "mild TBI" and "concussion" have similar meanings.
ANS: A, D, E "Mild TBI" is a term used synonymously with the term "concussion." A moderate TBI has a Glasgow Coma Scale (GCS) score of 9 to 12, and these clients may need to be hospitalized. Both open and closed head injuries can cause a severe TBI, which is characterized by a GCS score of 3 to 8.
2. 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
ANS: A, D, E, F Advanced family history of prostate cancer, age, a diet high in animal fat, and race are all risk factors for prostate cancer. Smoking and obesity are not known risk factors.
A nurse plans care for a client who is immobile. Which interventions should the nurse include in this client's plan of care to prevent pressure sores? (Select all that apply.) a.Place a small pillow between bony surfaces. b.Elevate the head of the bed to 45 degrees. c.Limit fluids and proteins in the diet. d.Use a lift sheet to assist with re-positioning. e.Re-position the client who is in a chair every 2 hours. f.Keep the client's heels off the bed surfaces. g.Use a rubber ring to decrease sacral pressure when up in the chair.
ANS: A, D, F A small pillow decreases the risk for pressure between bony prominences, a lift sheet decreases friction and shear, and heels have poor circulation and are at high risk for pressure sores, so they should be kept off hard surfaces. Head-of-the-bed elevation greater than 30 degrees increases pressure on pelvic soft tissues. Fluids and proteins are important for maintaining tissue integrity. Clients should be repositioned every hour while sitting in a chair. A rubber ring impairs capillary blood flow, increasing the risk for a pressure sore.
A nurse assesses a client with cholelithiasis. Which assessment findings should the nurse identify as contributors to this client's condition? (Select all that apply.) a. Body mass index of 46 b. Vegetarian diet c. Drinking 4 ounces of red wine nightly d. Pregnant with twins e. History of metabolic syndrome f. Glycosylated hemoglobin level of 15%
ANS: A, D, F Obesity, pregnancy, and diabetes are all risk factors for the development of cholelithiasis. A diet low in saturated fats and moderate alcohol intake may decrease the risk. Although metabolic syndrome is a precursor to diabetes, it is not a risk factor for cholelithiasis. The client should be informed of the connection.
A nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Have suction equipment at the bedside. b. Place a padded tongue blade at the bedside. c. Permit only clear oral fluids. d. Keep bed rails up at all times. e. Maintain the client on strict bedrest. f. Ensure that the client has IV access.
ANS: A, D, F Oxygen and suctioning equipment with an airway must be readily available. The bed rails should be up at all times while the client is in the bed to prevent injury from a fall if the client has a seizure. If the client does not have an IV access, insert a saline lock, especially for those clients who are at significant risk for generalized tonic-clonic seizures. The saline lock provides ready access if IV drug therapy must be given to stop the seizure. Padded tongue blades may pose a danger to the client during a seizure and should not be used. Dietary restrictions and strict bedrest are not interventions associated with epilepsy. The client should be encouraged to eat a well-balanced diet and ambulate while in the hospital.
A nurse assesses a wife who is caring for her husband. She has a Braden Scale score of 9. Which question should the nurse include in this assessment? a."Do you have a bedpan at home?" b."How are you coping with providing this care?" c."What are you doing to prevent pediculosis?" d."Are you sharing a bed with your husband?"
ANS: B A client with a Braden Scale score of 9 is at high risk for skin breakdown and requires moderate to maximum assistance to prevent further breakdown. Family members who care for clients at home may experience a disruption in family routines and added stress. The nurse should assess the wife's feelings and provide support for coping with changes. Asking about the client's toileting practices, prevention of pediculosis, and sleeping arrangements do not provide information about the caregiver's support and coping mechanisms and ability to continue to care for her husband.
8. 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
ANS: B Before administering sulfamethoxazole-trimethoprim, the nurse must assess if the client is allergic to sulfa drugs. Urinary tract infection, hematuria, and elevated serum white blood cells are common problems associated with bacterial prostatitis that require long-term antibiotic therapy.
5. 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.
ANS: B Bright red urinary drainage with clots may indicate arterial bleeding. Vital signs should be taken and the surgeon notified. The traction on the three-way catheter should not be released since it places pressure at the surgical site to avoid bleeding. The nurses review of hemoglobin and hematocrit and reminding the client not to pull on the catheter are good choices, but not the priority at this time.
A nurse assesses a client who has psoriasis. Which action should the nurse take first? a.Don gloves and an isolation gown. b.Shake the client's hand and introduce self. c.Assess for signs and symptoms of infections. d.Ask the client if she might be pregnant.
ANS: B Clients with psoriatic lesions are often self-conscious of their skin. The nurse should first provide direct contact and touch without gloves to establish a good report with the client. Psoriasis is not an infectious disease, nor is it contagious. The nurse would not need to wear gloves or an isolation gown. Obtaining a health history and assessing for an infection and pregnancy should be completed after establishing a report with the client.
After educating a caregiver of a home care client, a nurse assesses the caregiver's understanding. Which statement indicates that the caregiver needs additional education? a."I can help him shift his position every hour when he sits in the chair." b."If his tailbone is red and tender in the morning, I will massage it with baby oil." c."Applying lotion to his arms and legs every evening will decrease dryness." d."Drinking a nutritional supplement between meals will help maintain his weight."
ANS: B Massage of reddened areas over bony prominences such as the coccyx, or tailbone, is contraindicated because the pressure of the massage can cause damage to the skin and subcutaneous tissue layers. The other statements are appropriate for the care of a client at home.
After teaching a client who has psoriasis, a nurse assesses the client's understanding. Which statement indicates the client needs additional teaching? a."At the next family reunion, I'm going to ask my relatives if they have psoriasis." b."I have to make sure I keep my lesions covered, so I do not spread this to others." c."I expect that these patches will get smaller when I lie out in the sun." d."I should continue to use the cortisone ointment as the patches shrink and dry out."
ANS: B Psoriasis is not a contagious disorder. The client does not have to worry about spreading the condition to others. It is a condition that has hereditary links, the patches will decrease in size with ultraviolet light exposure, and cortisone ointment should be applied directly to lesions to suppress cell division.
After teaching a client who is at risk for the formation of pressure ulcers, a nurse assesses the client's understanding. Which dietary choice by the client indicates a good understanding of the teaching? a.Low-fat diet with whole grains and cereals and vitamin supplements b.High-protein diet with vitamins and mineral supplements c.Vegetarian diet with nutritional supplements and fish oil capsules d.Low-fat, low-cholesterol, high-fiber, low-carbohydrate diet
ANS: B The preferred diet is high in protein to assist in wound healing and prevention of new wounds. Fat is also needed to ensure formation of cell membranes, so any of the options with low fat would not be good choices. A vegetarian diet would not provide fat and high levels of protein
12. 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 cell count 4.5 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.
ANS: B The serum sodium is decreased due to large-volume bladder irrigation (normal is 136 to 145 mEq/L). By slowing the irrigation, there will be less fluid overload and sodium dilution. The hemoglobin and hematocrit values are a low normal, with a slight decrease in the red blood cell count. Therefore, a blood transfusion or frequent vital signs should not be necessary. Immediate report to the surgeon is not necessary.
A nurse performs a skin screening for a client who has numerous skin lesions. Which lesion does the nurse evaluate first? a.Beige freckles on the backs of both hands b.Irregular blue mole with white specks on the lower leg c.Large cluster of pustules in the right axilla d.Thick, reddened papules covered by white scales
ANS: B This mole fits two of the criteria for being cancerous or precancerous: variation of color within one lesion, and an indistinct or irregular border. Melanoma is an invasive malignant disease with the potential for a fatal outcome. Freckles are a benign condition. Pustules could mean an infection, but it is more important to take care of the potentially cancerous lesion first. Psoriasis vulgaris manifests as thick reddened papules covered by white scales. This is a chronic disorder and is not the priority.
A client has a platelet count of 9800/mm3. What action by the nurse is most appropriate? a. Assess the client for calf pain, warmth, and redness. b. Instruct the client to call for help to get out of bed. c. Obtain cultures as per the facility's standing policy. d. Place the client on protective isolation precautions.
ANS: B A client with a platelet count this low is at high risk for serious bleeding episodes. To prevent injury, the client should be instructed to call for help prior to getting out of bed. Calf pain, warmth, and redness might indicate a deep vein thrombosis, not associated with low platelets. Cultures and isolation relate to low white cell counts.
The nurse is administering captopril (Capoten) to a client with heart failure. What is the priority intervention for this client? a. Administer this medication before meals to aid absorption. b. Instruct the client to ask for assistance when arising from bed. c. Give the medication with milk to prevent stomach upset. d. Monitor the potassium level and check for symptoms of hypokalemia.
ANS: B Administration of the first dose of angiotensin-converting enzyme (ACE) inhibitors is often associated with hypotension, usually termed first-dose effect. The nurse should instruct the client to seek assistance before arising from bed to prevent injury from postural hypotension.
A nurse assesses a client after administering prescribed levetiracetam (Keppra). Which laboratory tests should the nurse monitor for potential adverse effects of this medication? a. Serum electrolyte levels b. Kidney function tests c. Complete blood cell count d. Antinuclear antibodies
ANS: B Adverse effects of levetiracetam include coordination problems and renal toxicity. The other laboratory tests are not affected by levetiracetam.
After teaching a client who is recovering from laparoscopic cholecystectomy surgery, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? a. "Drinking at least 2 liters of water each day is suggested." b. "I will decrease the amount of fatty foods in my diet." c. "Drinking fluids with my meals will increase bloating." d. "I will avoid concentrated sweets and simple carbohydrates."
ANS: B After cholecystectomy, clients need a nutritious diet without a lot of excess fat; otherwise a special diet is not recommended for most clients. Good fluid intake is healthy for all people but is not related to the surgery. Drinking fluids between meals helps with dumping syndrome, which is not seen with this procedure. Restriction of sweets is not required.
A client has an intraventricular catheter. What action by the nurse takes priority? a. Document intracranial pressure readings. b. Perform hand hygiene before client care. c. Measure intracranial pressure per hospital policy. d. Teach the client and family about the device.
ANS: B All of the actions are appropriate for this client. However, performing hand hygiene takes priority because it prevents infection, which is a possibly devastating complication.
An older female client has been prescribed esomeprazole (Nexium) for treatment of chronic gastric ulcers. What teaching is particularly important for this client? a. Check with the pharmacist before taking other medications. b. Increase intake of calcium and vitamin D. c. Report any worsening of symptoms to the provider. d. Take the medication as prescribed by the provider.
ANS: B All of this advice is appropriate for any client taking this medication. However, long-term use is associated with osteoporosis and osteoporosis-related fractures. This client is already at higher risk for this problem and should be instructed to increase calcium and vitamin D intake. The other options are appropriate for any client taking any medication and are not specific to the use of esomeprazole.
A nurse assesses a client with Huntington disease. Which motor changes should the nurse monitor for in this client? a. Shuffling gait b. Jerky hand movements c. Continuous chewing motions d. Tremors of the hands
ANS: B An imbalance between excitatory and inhibitory neurotransmitters leads to uninhibited motor movements, such as brisk, jerky, purposeless movements of the hands, face, tongue, and legs. Shuffling gait, continuous chewing motions, and tremors are associated with Parkinson disease.
A client is having a peritoneal dialysis treatment. The nurse notes an opaque color to the effluent. What is the priority action by the nurse? a. Warm the dialysate solution in a microwave before instillation. b. Take a sample of the effluent and send to the laboratory. c. Flush the tubing with normal saline to maintain patency of the catheter. d. Check the peritoneal catheter for kinking and curling.
ANS: B An opaque or cloudy effluent is the first sign of peritonitis. A sample of the effluent would need to be sent to the laboratory for culture and sensitivity in order to administer the correct antibiotic. Warming the dialysate in a microwave and flushing the tubing are not safe actions by the nurse. Checking the catheter for obstruction is a viable option but will not treat the peritonitis.
A nurse is teaching a client who experiences migraine headaches and is prescribed a beta blocker. Which statement should the nurse include in this client's teaching? a. "Take this drug only when you have prodromal symptoms indicating the onset of a migraine headache." b. "Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches." c. "This drug will relieve the pain during the aura phase soon after a headache has started." d. "This medication will have no effect on your heart rate or blood pressure because you are taking it for migraines."
ANS: B Beta blockers are prescribed as prophylactic treatment to prevent the vascular changes that initiate migraine headaches. Heart rate and blood pressure will also be affected, and the client should monitor these side effects. The other responses do not discuss appropriate uses of the medication.
A client is recovering from a kidney transplant. The client's urine output was 1500 mL over the last 12-hour period since transplantation. What is the priority assessment by the nurse? a. Checking skin turgor b. Taking blood pressure c. Assessing lung sounds d. Weighing the client
ANS: B By taking blood pressure, the nurse is assessing for hypotension that could compromise perfusion to the new kidney. The nurse then should notify the provider immediately. Skin turgor, lung sounds, and weight could give information about the fluid status of the client, but they are not the priority assessment.
A nurse assesses the health history of a client who is prescribed ziconotide (Prialt) for chronic back pain. Which assessment question should the nurse ask? a. "Are you taking a nonsteroidal anti-inflammatory drug?" b. "Do you have a mental health disorder?" c. "Are you able to swallow medications?" d. "Do you smoke cigarettes or any illegal drugs?"
ANS: B Clients who have a mental health or behavioral health problem should not take ziconotide. The other questions do not identify a contraindication for this medication.
The nurse is discharging a client home following mitral valve replacement. What statement indicates that the client requires further education? a. "I will be able to carry heavy loads after 6 months of rest." b. "I will have my teeth cleaned by the dentist in 2 weeks." c. "I will avoid eating foods high in vitamin K, like spinach." d. "I will use an electric razor instead of a straight razor to shave."
ANS: B Clients who have defective or repaired valves are at high risk for endocarditis. The client who has had valve surgery should avoid dental procedures for 6 months because of the risk for endocarditis. When undergoing any invasive procedure, the client needs to be placed on prophylactic antibiotics.
A nurse teaches a client who is recovering from a spinal fusion. Which statement should the nurse include in this client's postoperative instructions? a. "Only lift items that are 10 pounds or less." b. "Wear your brace whenever you are out of bed." c. "You must remain in bed for 3 weeks after surgery." d. "You are prescribed medications to prevent rejection."
ANS: B Clients who undergo spinal fusion are fitted with a brace that they must wear throughout the healing process (usually 3 to 6 months) whenever they are out of bed. The client should not lift anything. The client does not need to remain in bed. Medications for rejection prevention are not necessary for this procedure.
A client had an upper gastrointestinal hemorrhage and now has a nasogastric (NG) tube. What comfort measure may the nurse delegate to the unlicensed assistive personnel (UAP)? a. Lavaging the tube with ice water b. Performing frequent oral care c. Re-positioning the tube every 4 hours d. Taking and recording vital signs
ANS: B Clients with NG tubes need frequent oral care both for comfort and to prevent infection. Lavaging the tube is done by the nurse. Re-positioning the tube, if needed, is also done by the nurse. The UAP can take vital signs, but this is not a comfort measure.
The nurse is assessing a client with a history of heart failure. What priority question assists the nurse to assess the client's activity level? a. "Do you have trouble breathing or chest pain?" b. "Are you able to walk upstairs without fatigue?" c. "Do you awake with breathlessness during the night?" d. "Do you have new-onset heaviness in your legs?"
ANS: B Clients with a history of heart failure generally have negative findings, such as shortness of breath. The nurse needs to determine whether the client's activity is the same or worse, or whether the client identifies a decrease in activity level.
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.
The nurse is teaching the main principles of hemodialysis to a client with chronic kidney disease. Which statement by the client indicates a need for further teaching by the nurse? a. "My sodium level changes by movement from the blood into the dialysate." b. "Dialysis works by movement of wastes from lower to higher concentration." c. "Extra fluid can be pulled from the blood by osmosis." d. "The dialysate is similar to blood but without any toxins."
ANS: B Dialysis works using the passive transfer of toxins by diffusion. Diffusion is the movement of molecules from an area of higher concentration to an area of lower concentration. The other statements show a correct understanding about hemodialysis.
The nurse is caring for a client with mitral valve stenosis. What clinical manifestation alerts the nurse to the possibility that the client's stenosis has progressed? a. Oxygen saturation of 92% b. Dyspnea on exertion c. Muted systolic murmur d. Upper extremity weakness
ANS: B Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs increases.
A client with cancer has anorexia and mucositis, and is losing weight. The client's family members continually bring favorite foods to the client and are distressed when the client won't eat them. What action by the nurse is best? a. Explain the pathophysiologic reasons behind the client not eating. b. Help the family show other ways to demonstrate love and caring. c. Suggest foods and liquids the client might be willing to try to eat. d. Tell the family the client isn't able to eat now no matter what they bring.
ANS: B Families often become distressed when their loved ones won't eat. Providing food is a universal sign of caring, and to some people the refusal to eat signifies worsening of the condition. The best option for the nurse is to help the family find other ways to demonstrate caring and love, because with treatment-related anorexia and mucositis, the client is not likely to eat anything right now. Explaining the rationale for the problem is a good idea but does not suggest to the family anything that they can do for the client. Simply telling the family the client is not able to eat does not give them useful information and is dismissive of their concerns.
A client is being prepared for a mechanical embolectomy. What action by the nurse takes priority? a. Assess for contraindications to fibrinolytics. b. Ensure that informed consent is on the chart. c. Perform a full neurologic assessment. d. Review the client's medication lists.
ANS: B For this invasive procedure, the client needs to give informed consent. The nurse ensures that this is on the chart prior to the procedure beginning. Fibrinolytics are not used. A neurologic assessment and medication review are important, but the consent is the priority.
The nurse is instructing a client with heart failure about energy conservation. Which is the best instruction? a. "Walk until you become short of breath and then walk back home." b. "Gather everything you need for a chore before you begin." c. "Pull rather than push or carry items heavier than 5 pounds." d. "Take a walk after dinner every day to build up your strength."
ANS: B Gathering all supplies needed for a chore at one time decreases the amount of energy needed.
A nurse is caring for four clients who might be brain dead. Which client would best meet the criteria to allow assessment of brain death? a. Client with a core temperature of 95° F (35° C) for 2 days b. Client in a coma for 2 weeks from a motor vehicle crash c. Client who is found unresponsive in a remote area of a field by a hunter d. Client with a systolic blood pressure of 92 mm Hg since admission
ANS: B In order to determine brain death, clients must meet four criteria: 1) coma from a known cause, 2) normal or near-normal core temperature, 3) normal systolic blood pressure, and 4) at least one neurologic examination. The client who was in the car crash meets two of these criteria. The clients with the lower temperature and lower blood pressure have only one of these criteria. There is no data to support assessment of brain death in the client found by the hunter.
A client with systolic dysfunction has an ejection fraction of 38%. The nurse assesses for which physiologic change? a. Increase in stroke volume b. Decrease in tissue perfusion c. Increase in oxygen saturation d. Decrease in arterial vasoconstriction
ANS: B In systolic dysfunction, the ventricle is unable to contract with enough force to eject blood effectively during systole. As the ejection fraction decreases (50% to 70% is normal), tissue perfusion decreases and the client develops activity intolerance. Stroke volume and oxygen saturation do not increase with a low ejection fraction.
A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication should the nurse prepare to administer? a. Atenolol (Tenormin) b. Lorazepam (Ativan) c. Phenytoin (Dilantin) d. Lisinopril (Prinivil)
ANS: B Initially, intravenous lorazepam is administered to stop motor movements. This is followed by the administration of phenytoin. Atenolol, a beta blocker, and lisinopril, an angiotensin-converting enzyme inhibitor, are not administered for seizure activity. These medications are typically administered for hypertension and heart failure.
The client with heart failure has been prescribed intravenous nitroglycerin and furosemide (Lasix) for pulmonary edema. Which is the priority nursing intervention? a. Insert an indwelling urinary catheter. b. Monitor the client's blood pressure. c. Place the nitroglycerin under the client's tongue. d. Monitor the client's serum glucose level.
ANS: B Intravenous nitroglycerin and morphine will decrease the client's blood pressure, so it is important to monitor closely for hypotension. Intravenous medications are not administered under the tongue. Although the client may need an indwelling urinary catheter to monitor output, it is not the priority. The client's glucose levels should not be affected by these medications.
The nurse is caring for four clients with chronic kidney disease. Which client should the nurse assess first upon initial rounding? a. Woman with a blood pressure of 158/90 mm Hg b. Client with Kussmaul respirations c. Man with skin itching from head to toe d. Client with halitosis and stomatitis
ANS: B Kussmaul respirations indicate a worsening of chronic kidney disease (CKD). The client is increasing the rate and depth of breathing to excrete carbon dioxide through the lungs. Hypertension is common in most clients with CKD, and skin itching increases with calcium-phosphate imbalances, another common finding in CKD. Uremia from CKD causes ammonia to be formed, resulting in the common findings of halitosis and stomatitis
An emergency department nurse cares for a client who experienced a spinal cord injury 1 hour ago. Which prescribed medication should the nurse prepare to administer? a. Intrathecal baclofen (Lioresal) b. Methylprednisolone (Medrol) c. Atropine sulfate d. Epinephrine (Adrenalin)
ANS: B Methylprednisolone (Medrol) should be given within 8 hours of the injury. Clients who receive this therapy usually show improvement in motor and sensory function. The other medications are inappropriate for this client.
After receiving the hand-off report, which client should the oncology nurse see first? a. Client who is afebrile with a heart rate of 108 beats/min b. Older client on chemotherapy with mental status changes c. Client who is neutropenic and in protective isolation d. Client scheduled for radiation therapy today
ANS: B Older clients often do not exhibit classic signs of infection, and often mental status changes are the first observation. Clients on chemotherapy who become neutropenic also often do not exhibit classic signs of infection. The nurse should assess the older client first. The other clients can be seen afterward.
A client has received a dose of ondansetron (Zofran) for nausea. What action by the nurse is most important? a. Assess the client for a headache. b. Assist the client in getting out of bed. c. Instruct the client to reduce salt intake. d. Weigh the client daily before the client eats.
ANS: B Ondansetron side effects include postural hypotension, vertigo, and bradycardia, all of which increase the client's risk for injury. The nurse should assist the client when getting out of bed. Headache and fluid retention are not side effects of this drug.
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.
The nurse is assessing a client with a diagnosis of pre-renal acute kidney injury (AKI). Which condition would the nurse expect to find in the client's recent history? a. Pyelonephritis b. Myocardial infarction c. Bladder cancer d. Kidney stones
ANS: B Pre-renal causes of AKI are related to a decrease in perfusion, such as with a myocardial infarction. Pyelonephritis is an intrinsic or intrarenal cause of AKI related to kidney damage. Bladder cancer and kidney stones are post-renal causes of AKI related to urine flow obstruction.
A client has a pyloric obstruction and reports sudden muscle weakness. What action by the nurse takes priority? a. Document the findings in the chart. b. Request an electrocardiogram (ECG). c. Facilitate a serum potassium test. d. Place the client on bedrest.
ANS: B Pyloric stenosis can lead to hypokalemia, which is manifested by muscle weakness. The nurse first obtains an ECG because potassium imbalances can lead to cardiac dysrhythmias. A potassium level is also warranted, as is placing the client on bedrest for safety. Documentation should be thorough, but none of these actions takes priority over the ECG.
A client in the oncology clinic reports her family is frustrated at her ongoing fatigue 4 months after radiation therapy for breast cancer. What response by the nurse is most appropriate? a. "Are you getting adequate rest and sleep each day?" b. "It is normal to be fatigued even for years afterward." c. "This is not normal and I'll let the provider know." d. "Try adding more vitamins B and C to your diet."
ANS: B Regardless of the cause, radiation-induced fatigue can be debilitating and may last for months or years after treatment has ended. Rest and adequate nutrition can affect fatigue, but it is most important that the client understands this is normal.
A nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How should the nurse document this activity? a. Atonic seizure b. Tonic-clonic seizure c. Myoclonic seizure d. Absence seizure
ANS: B Seizure activity that begins with stiffening of the arms and legs, followed by loss of consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure. An atonic seizure presents as a sudden loss of muscle tone followed by postictal confusion. A myoclonic seizure presents with a brief jerking or stiffening of extremities that may occur singly or in groups. Absence seizures present with automatisms, and the client is unaware of his or her environment.
A nurse cares for a client with advanced Alzheimer's disease. The client's caregiver states, "She is always wandering off. What can I do to manage this restless behavior?" How should the nurse respond? a. "This is a sign of fatigue. The client would benefit from a daily nap." b. "Engage the client in scheduled activities throughout the day." c. "It sounds like this is difficult for you. I will consult the social worker." d. "The provider can prescribe a mild sedative for restlessness."
ANS: B Several strategies may be used to cope with restlessness and wandering. One strategy is to engage the client in structured activities. Another is to take the client for frequent walks. Daily naps and a mild sedative will not be as effective in the management of restless behavior. Consulting the social worker does not address the caregiver's concern.
The nurse is assessing a client admitted to the cardiac unit. What statement made by the client alerts the nurse to the possibility of right-sided heart failure? a. "I sleep with four pillows at night." b. "My shoes fit really tight lately." c. "I wake up coughing every night." d. "I have trouble catching my breath."
ANS: B Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Left-sided heart failure symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty breathing all could be results of left-sided heart failure.
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.
A student nurse is preparing morning medications for a client who had a stroke. The student plans to hold the docusate sodium (Colace) because the client had a large stool earlier. What action by the supervising nurse is best? a. Have the student ask the client if it is desired or not. b. Inform the student that the docusate should be given. c. Tell the student to document the rationale. d. Tell the student to give it unless the client refuses.
ANS: B Stool softeners should be given to clients with neurologic disorders in order to prevent an elevation in intracranial pressure that accompanies the Valsalva maneuver when constipated. The supervising nurse should instruct the student to administer the docusate. The other options are not appropriate. The medication could be held for diarrhea.
A nurse obtains a health history on a client prior to administering prescribed sumatriptan succinate (Imitrex) for migraine headaches. Which condition should alert the nurse to hold the medication and contact the health care provider? a. Bronchial asthma b. Prinzmetal's angina c. Diabetes mellitus d. Chronic kidney disease
ANS: B Sumatriptan succinate effectively reduces pain and other associated symptoms of migraine headache by binding to serotonin receptors and triggering cranial vasoconstriction. Vasoconstrictive effects are not confined to the cranium and can cause coronary vasospasm in clients with Prinzmetal's angina. The other conditions would not affect the client's treatment.
A client who has had a prosthetic valve replacement asks the nurse why he must take anticoagulants for the rest of his life. What is the nurse's best response? a. "The prosthetic valve places you at greater risk for a heart attack." b. "Blood clots form more easily in artificial replacement valves." c. "The vein taken from your leg reduces circulation in the leg." d. "The surgery left a lot of small clots in your heart and lungs."
ANS: B Synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate easily and initiate the formation of blood clots.
A nurse plans care for a client with acute pancreatitis. Which intervention should the nurse include in this client's plan of care to reduce discomfort? a. Administer morphine sulfate intravenously every 4 hours as needed. b. Maintain nothing by mouth (NPO) and administer intravenous fluids. c. Provide small, frequent feedings with no concentrated sweets. d. Place the client in semi-Fowler's position with the head of bed elevated.
ANS: B The client should be kept NPO to reduce GI activity and reduce pancreatic enzyme production. IV fluids should be used to prevent dehydration. The client may need a nasogastric tube. Pain medications should be given around the clock and more frequently than every 4 to 6 hours. A fetal position with legs drawn up to the chest will promote comfort.
A nurse is teaching a client with multiple sclerosis who is prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol). Which statement should the nurse include in this client's discharge teaching? a. "Take warm baths to promote muscle relaxation." b. "Avoid crowds and people with colds." c. "Relying on a walker will weaken your gait." d. "Take prescribed medications when symptoms occur."
ANS: B The client should be taught to avoid people with any type of upper respiratory illness because these medications are immunosuppressive. Warm baths will exacerbate the client's symptoms. Assistive devices may be required for safe ambulation. Medication should be taken at all times and should not be stopped.
The nurse notes that the client's apical pulse is displaced to the left. What conclusion can be drawn from this assessment? a. This is a normal finding. b. The heart is hypertrophied. c. The left ventricle is contracted. d. The client has pulsus alternans.
ANS: B The client with heart failure typically has an enlarged heart that displaces the apical pulse to the left.
A client with pericarditis is admitted to the cardiac unit. What assessment finding does the nurse expect in this client? a. Heart rate that speeds up and slows down b. Friction rub at the left lower sternal border c. Presence of a regularly gallop rhythm d. Coarse crackles in bilateral lung bases
ANS: B The client with pericarditis may present with a pericardial friction rub at the left lower sternal border. This sound is the result of friction from inflamed pericardial layers when they rub together. The other assessments are not relate
A client has a recurrence of gastric cancer and is in the gastrointestinal clinic crying. What response by the nurse is most appropriate? a. "Do you have family or friends for support?" b. "I'd like to know what you are feeling now." c. "Well, we knew this would probably happen." d. "Would you like me to refer you to hospice?"
ANS: B The nurse assesses the client's emotional state with open-ended questions and statements and shows a willingness to listen to the client's concerns. Asking about support people is very limited in nature, and "yes-or-no" questions are not therapeutic. Stating that this was expected dismisses the client's concerns. The client may or may not be ready to hear about hospice, and this is another limited, yes-or-no question.
A nurse cares for a client who is prescribed patient-controlled analgesia (PCA) after a cholecystectomy. The client states, "When I wake up I am in pain." Which action should the nurse take? a. Administer intravenous morphine while the client sleeps. b. Encourage the client to use the PCA pump upon awakening. c. Contact the provider and request a different analgesic. d. Ask a family member to initiate the PCA pump for the client
ANS: B The nurse should encourage the client to use the PCA pump prior to napping and upon awakening. Administering additional intravenous morphine while the client sleeps places the client at risk for respiratory depression. The nurse should also evaluate dosages received compared with dosages requested and contact the provider if the dose or frequency is not adequate. Only the client should push the pain button on a PCA pump.
A nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. Which action should the nurse take? a. Start fluids via a large-bore catheter. b. Turn the client's head to the side. c. Administer IV push diazepam. d. Prepare to intubate the client.
ANS: B The nurse should turn the client's head to the side to prevent aspiration and allow drainage of secretions. Anticonvulsants are administered on a routine basis if a seizure is sustained. If the seizure is sustained (status epilepticus), the client must be intubated and should be administered oxygen, 0.9% sodium chloride, and IV push lorazepam or diazepam.
A client tells the oncology nurse about an upcoming vacation to the beach to celebrate completing radiation treatments for cancer. What response by the nurse is most appropriate? a. "Avoid getting salt water on the radiation site." b. "Do not expose the radiation area to direct sunlight." c. "Have a wonderful time and enjoy your vacation!" d. "Remember you should not drink alcohol for a year."
ANS: B The skin overlying the radiation site is extremely sensitive to sunlight after radiation therapy has been completed. The nurse should inform the client to avoid sun exposure to this area. This advice continues for 1 year after treatment has been completed. The other statements are not appropriate.
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.
A client is being discharged home after a heart transplant with a prescription for cyclosporine (Sandimmune). What priority education does the nurse provide with the client's discharge instructions? a. "Use a soft-bristled toothbrush and avoid flossing." b. "Avoid large crowds and people who are sick." c. "Change positions slowly to avoid hypotension." d. "Check your heart rate before taking the medication."
ANS: B These agents cause immune suppression, leaving the client more vulnerable to infection.
The nurse is caring for a client with peptic ulcer disease who reports sudden onset of sharp abdominal pain. On palpation, the client's abdomen is tense and rigid. What action takes priority? a. Administer the prescribed pain medication. b. Notify the health care provider immediately. c. Percuss all four abdominal quadrants. d. Take and document a set of vital signs.
ANS: B This client has manifestations of a perforated ulcer, which is an emergency. The priority is to get the client medical attention. The nurse can take a set of vital signs while someone else calls the provider. The nurse should not percuss the abdomen or give pain medication since the client may need to sign consent for surgery.
After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse is best? a. Assess the client's magnesium level. b. Assess the client's sodium level. c. Increase the rate of the IV infusion. d. Provide oral care every hour.
ANS: B This client has manifestations of hypernatremia, which is a possible complication after craniotomy. The nurse should assess the client's serum sodium level. Magnesium level is not related. The nurse does not independently increase the rate of the IV infusion. Providing oral care is also a good option but does not take priority over assessing laboratory results.
A client is admitted with acute kidney injury (AKI) and a urine output of 2000 mL/day. What is the major concern of the nurse regarding this client's care? a. Edema and pain b. Electrolyte and fluid imbalance c. Cardiac and respiratory status d. Mental health status
ANS: B This client may have an inflammatory cause of AKI with proteins entering the glomerulus and holding the fluid in the filtrate, causing polyuria. Electrolyte loss and fluid balance is essential. Edema and pain are not usually a problem with fluid loss. There could be changes in the client's cardiac, respiratory, and mental health status if the electrolyte imbalance is not treated.
A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt like his legs were very heavy. Currently the client's neurologic examination is normal. About what drug should the nurse plan to teach the client? a. Alteplase (Activase) b. Clopidogrel (Plavix) c. Heparin sodium d. Mannitol (Osmitrol)
ANS: B This client's manifestations are consistent with a transient ischemic attack, and the client would be prescribed aspirin or clopidogrel on discharge. Alteplase is used for ischemic stroke. Heparin and mannitol are not used for this condition.
A client is having a catheter placed in the femoral artery to deliver yttrium-90 beads into a liver tumor. What action by the nurse is most important? a. Assessing the client's abdomen beforehand b. Ensuring that informed consent is on the chart c. Marking the client's bilateral pedal pulses d. Reviewing client teaching done previously
ANS: B This is an invasive procedure requiring informed consent. The nurse should ensure that consent is on the chart. The other actions are also appropriate but not the priority.
A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client who is in the healing phase of acute pancreatitis. Which statements focused on nutritional requirements should the nurse include when delegating care for this client? (Select all that apply.) a. "Do not allow the client to eat between meals." b. "Make sure the client receives a protein shake." c. "Do not allow caffeine-containing beverages." d. "Make sure the foods are bland with little spice." e. "Do not allow high-carbohydrate food items."
ANS: B, C, D During the healing phase of pancreatitis, the client should be provided small, frequent, moderate- to high-carbohydrate, high-protein, low-fat meals. Protein shakes can be provided to supplement the diet. Foods and beverages should not contain caffeine and should be bland.
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.
A nurse cares for a client with pancreatic cancer who is prescribed implanted radioactive iodine seeds. Which actions should the nurse take when caring for this client? (Select all that apply.) a. Dispose of dirty linen in a red "biohazard" bag. b. Place the client in a private room. c. Wear a lead apron when providing client care. d. Bundle care to minimize exposure to the client. e. Initiate Transmission-Based Precautions.
ANS: B, C, D The client should be placed in a private room and dirty linens kept in the client's room until the radiation source is removed. The nurse should wear a lead apron while providing care, ensuring that the apron always faces the client. The nurse should also bundle care to minimize exposure to the client. Transmission-Based Precautions will not protect the nurse from the implanted radioactive iodine seeds.
A nurse is giving discharge instructions to a client recently diagnosed with chronic kidney disease (CKD). Which statements made by the client indicate a correct understanding of the teaching? (Select all that apply.) a. "I can continue to take antacids to relieve heartburn." b. "I need to ask for an antibiotic when scheduling a dental appointment." c. "I'll need to check my blood sugar often to prevent hypoglycemia." d. "The dose of my pain medication may have to be adjusted." e. "I should watch for bleeding when taking my anticoagulants."
ANS: B, C, D, E In discharge teaching, the nurse must emphasize that the client needs to have an antibiotic prophylactically before dental procedures to prevent infection. There may be a need for dose reduction in medications if the kidney is not excreting them properly (antacids with magnesium, antibiotics, antidiabetic drugs, insulin, opioids, and anticoagulants).
A nurse assesses a client who is recovering from a Whipple procedure. Which clinical manifestations alert the nurse to a complication from this procedure? (Select all that apply.) a. Clay-colored stools b. Substernal chest pain c. Shortness of breath d. Lack of bowel sounds or flatus e. Urine output of 20 mL/6 hr
ANS: B, C, D, E Myocardial infarction (chest pain), pulmonary embolism (shortness of breath), adynamic ileus (lack of bowel sounds or flatus), and renal failure (urine output of 20 mL/6 hr) are just some of the complications for which the nurse must assess the client after the Whipple procedure. Clay-colored stools are associated with cholecystitis and are not a complication of a Whipple procedure.
The student nurse caring for clients who have cancer understands that the general consequences of cancer include which client problems? (Select all that apply.) a. Clotting abnormalities from thrombocythemia b. Increased risk of infection from white blood cell deficits c. Nutritional deficits such as early satiety and cachexia d. Potential for reduced gas exchange e. Various motor and sensory deficits
ANS: B, C, D, E The general consequences of cancer include reduced immunity and blood-producing functions, altered GI structure and function, decreased respiratory function, and motor and sensory deficits. Clotting problems often occur due to thrombocytopenia (not enough platelets), not thrombocythemia (too many platelets).
A nurse prepares to admit a client who has herpes zoster. Which actions should the nurse take? (Select all that apply.) a.Prepare a room for reverse isolation. b.Assess staff for a history of or vaccination for chickenpox. c.Check the admission orders for analgesia. d.Choose a roommate who also is immune suppressed. e.Ensure that gloves are available in the room.
ANS: B, C, E Herpes zoster (shingles) is caused by reactivation of the same virus, varicella zoster, in clients who have previously had chickenpox. Anyone who has not had the disease or has not been vaccinated for it is at high risk for getting chickenpox. Herpes zoster is very painful and requires analgesia. Use of gloves and good handwashing are sufficient to prevent spread. It is best to put this client in a private room. Herpes zoster is a disease of immune suppression, so no one who is immune-suppressed should be in the same room.
A client's small-bore feeding tube has become occluded after the nurse administered medications. What actions by the nurse are best? (Select all that apply.) a. Attempt to dissolve the clog by instilling a cola product. b. Determine if any of the medications come in liquid form. c. Flush the tube before and after administering medications. d. Mix all medications in the formula and use a feeding pump. e. Try to flush the tube with 30 mL of water and gentle pressure.
ANS: B, C, E LIQUID FLUSH FLUSH
A nurse is designing a community education program to meet the Healthy People 2020 objectives for nutrition and weight status. What information about these goals does the nurse use to plan this event? (Select all that apply.) a. Decrease the amount of fruit to 1.1 cups/1000 calories. b. Increase the amount of vegetables to 1.1 cups/1000 calories. c. Increase the number of adults at a healthy weight by 25%. d. Reduce the number of adults who are obese by 10%. e. Reduce the consumption of saturated fat by nearly 10%.
ANS: B, D, E Take Healthy People to BED
A nurse is dismissing a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management? (Select all that apply.) a. Does not want to purchase a thermometer b. Is allergic to acetaminophen (Tylenol) c. Laughing, says "Strenuous? What's that?" d. Lives alone and is new in town with no friends e. Plans to have a beer and go to bed once home
ANS: B, D, E Clients should take acetaminophen for headache. An allergy to this drug may mean the client takes aspirin or ibuprofen (Motrin), which should be avoided. The client needs neurologic checks every 1 to 2 hours, and this client does not seem to have anyone available who can do that. Alcohol needs to be avoided for at least 24 hours. A thermometer is not needed. The client laughing at strenuous activity probably does not engage in any kind of strenuous activity, but the nurse should confirm this.
A nurse assesses a client who has encephalitis. Which manifestations should the nurse recognize as signs of increased intracranial pressure (ICP), a complication of encephalitis? (Select all that apply.) a. Photophobia b. Dilated pupils c. Headache d. Widened pulse pressure e. Bradycardia
ANS: B, D, E Increased ICP is a complication of encephalitis. The nurse should monitor for signs of increased ICP, including dilated pupils, widened pulse pressure, bradycardia, irregular respirations, and less responsive pupils. Photophobia and headache are not related to increased ICP.
A nurse is teaching a client who has chronic headaches. Which statements about headache triggers should the nurse include in this client's plan of care? (Select all that apply.) a. "Increase your intake of caffeinated beverages." b. "Incorporate physical exercise into your daily routine." c. "Avoid all alcoholic beverages." d. "Participate in a smoking cessation program." e. "Increase your intake of fruits and vegetables."
ANS: B, D, E Triggers for headaches include caffeine, smoking, and ingestion of pickled foods, so these factors should be avoided. Clients are taught to eat a balanced diet and to get adequate exercise and rest. Alcohol does not trigger chronic headaches but can enhance headaches during the headache period.
The nurse is teaching a client with diabetes mellitus how to prevent or delay chronic kidney disease (CKD). Which client statements indicate a lack of understanding of the teaching? (Select all that apply.) a. "I need to decrease sodium, cholesterol, and protein in my diet." b. "My weight should be maintained at a body mass index of 30." c. "Smoking should be stopped as soon as I possibly can." d. "I can continue to take an aspirin every 4 to 8 hours for my pain." e. "I really only need to drink a couple of glasses of water each day."
ANS: B, D, E Weight should be maintained at a body mass index (BMI) of 22 to 25. A BMI of 30 indicates obesity. The use of nonsteroidal anti-inflammatory drugs such as aspirin should be limited to the lowest time at the lowest dose due to interference with kidney blood flow. The client should drink at least 2 liters of water daily. Diet adjustments should be made by restricting sodium, cholesterol, and protein. Smoking causes constriction of blood vessels and decreases kidney perfusion, so the client should stop smoking.
A nurse cares for a client with a lower motor neuron injury who is experiencing a flaccid bowel elimination pattern. Which actions should the nurse take to assist in relieving this client's constipation? (Select all that apply.) a. Pour warm water over the perineum. b. Provide a diet high in fluids and fiber. c. Administer daily tap water enemas. d. Implement a consistent daily time for elimination. e. Massage the abdomen from left to right. f. Perform manual disimpaction.
ANS: B, D, F For the client with a lower motor neuron injury, the resulting flaccid bowel may require a bowel program for the client that includes stool softeners, increased fluid intake, a high-fiber diet, and a consistent elimination time. If the client becomes impacted, the nurse would need to perform manual disimpaction. Pouring warm water over the perineum, administering daily enemas, and massaging the abdomen would not assist this client.
A nurse teaches a client who is recovering from acute pancreatitis. Which statements should the nurse include in this client's teaching? (Select all that apply.) a. "Take a 20-minute walk at least 5 days each week." b. "Attend local Alcoholics Anonymous (AA) meetings weekly." c. "Choose whole grains rather than foods with simple sugars." d. "Use cooking spray when you cook rather than margarine or butter." e. "Stay away from milk and dairy products that contain lactose." f. "We can talk to your doctor about a prescription for nicotine patches."
ANS: B, D, F The client should be advised to stay sober, and AA is a great resource. The client requires a low-fat diet, and cooking spray is low in fat compared with butter or margarine. If the client smokes, he or she must stop because nicotine can precipitate an exacerbation. A nicotine patch may help the client quit smoking. The client must rest until his or her strength returns. The client requires high carbohydrates and calories for healing; complex carbohydrates are not preferred over simple ones. Dairy products do not cause a problem.
A nurse is caring for a client after a stroke. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assess neurologic status with the Glasgow Coma Scale. b. Check and document oxygen saturation every 1 to 2 hours. c. Cluster client care to allow periods of uninterrupted rest. d. Elevate the head of the bed to 45 degrees to prevent aspiration. e. Position the client supine with the head in a neutral midline position.
ANS: B, E The UAP can take and document vital signs, including oxygen saturation, and keep the client's head in a neutral, midline position with correct direction from the nurse. The nurse assesses the Glasgow Coma Scale score. The nursing staff should not cluster care because this can cause an increase in the intracranial pressure. The head of the bed should be minimally elevated, up to 30 degrees.
A nurse assesses a client who presents with an increase in psoriatic lesions. Which questions should the nurse ask to identify a possible trigger for worsening of this client's psoriatic lesions? (Select all that apply.) a."Have you eaten a large amount of chocolate lately?" b."Have you been under a lot of stress lately?" c."Have you recently used a public shower?" d."Have you been out of the country recently?" e."Have you recently had any other health problems?" f."Have you changed any medications recently?"
ANS: B, E, F Systemic factors, hormonal changes, psychological stress, medications, and general health factors can aggravate psoriasis. Psoriatic lesions are not triggered by chocolate, public showers, or international travel.
A nurse assesses a client who is experiencing an absence seizure. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Intermittent rigidity b. Lip smacking c. Sudden loss of muscle tone d. Brief jerking of the extremities e. Picking at clothing f. Patting of the hand on the leg
ANS: B, E, F Automatisms are characteristic of absence seizures. These behaviors consist of lip smacking, picking at clothing, and patting. Rigidity of muscles is associated with the tonic phase of a seizure, and jerking of the extremities is associated with the clonic phase of a seizure. Loss of muscle tone occurs with atonic seizures.
When transferring a client into a chair, a nurse notices that the pressure-relieving mattress overlay has deep imprints of the client's buttocks, heels, and scapulae. Which action should the nurse take next? a.Turn the mattress overlay to the opposite side. b.Do nothing because this is an expected occurrence. c.Apply a different pressure-relieving device. d.Reinforce the overlay with extra cushions.
ANS: C "Bottoming out," as evidenced by deep imprints in the mattress overlay, indicates that this device is not appropriate for this client, and a different device or strategy should be implemented to prevent pressure ulcer formation.
A nurse assesses clients on a medical-surgical unit. Which client should the nurse evaluate for a wound infection? a.Client with blood cultures pending b.Client who has thin, serous wound drainage c.Client with a white blood cell count of 23,000/mm3 d.Client whose wound has decreased in size
ANS: C A client with an elevated white blood cell count should be evaluated for sources of infection. Pending cultures, thin drainage, and a decrease in wound size are not indications that the client may have an infection.
A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure ulcer development? a.A 44-year-old prescribed IV antibiotics for pneumonia b.A 26-year-old who is bedridden with a fractured leg c.A 65-year-old with hemi-paralysis and incontinence d.A 78-year-old requiring assistance to ambulate with a walker
ANS: C Being immobile and being incontinent are two significant risk factors for the development of pressure ulcers. The client with pneumonia does not have specific risk factors. The young client who has a fractured leg and the client who needs assistance with ambulation might be at moderate risk if they do not move about much, but having two risk factors makes the 65-year-old the person at highest risk.
A nurse assesses a young female client who is prescribed isotretinoin (Accutane). Which question should the nurse ask prior to starting this therapy? a."Do you spend a great deal of time in the sun?" b."Have you or any family members ever had skin cancer?" c."Which method of contraception are you using?" d."Do you drink alcoholic beverages?"
ANS: C Isotretinoin has many side effects. It is a known teratogen and can cause severe birth defects. A pregnancy test is required before therapy is initiated, and strict birth control measures must be used during therapy. Sun exposure, alcohol ingestion, and family history of cancer are contraindications for isotretinoin.
9. A 55-year-old male client is admitted to the emergency department with symptoms of a myocardial infarction. Which question by the nurse is the most appropriate before administering nitroglycerin? a. On a scale from 0 to 10, what is the rating of your chest pain? b. Are you allergic to any food or medications? c. Have you taken any drugs like Viagra recently? d. Are you light-headed or dizzy right now?
ANS: C Phosphodiesterase-5 inhibitors such as sildenafil (Viagra) relax smooth muscles to increase blood flow to the penis for treatment of erectile dysfunction. In combination with nitroglycerin, there can be extreme hypotension with reduction of blood flow to vital organs. The other questions are appropriate but not the highest priority before administering nitroglycerin.
11. 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.
ANS: C Sperm collection is a viable option for a client diagnosed with testicular cancer and should be completed before radiation therapy, chemotherapy, or radical lymph node dissection. The other options would promote psychosocial support but are not the priority intervention.
3. 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
ANS: C The prostate-specific antigen test should be discussed as an option for prostate cancer screening. A complete blood count and culture and sensitivity laboratory test will be ordered if infection is suspected. A cystoscopy would be performed to assess the effect of a bladder neck obstruction.
A nurse cares for a client who is prescribed vancomycin (Vancocin) 500 mg IV every 6 hours for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which action should the nurse take? a.Administer it over 30 minutes using an IV pump. b.Give the client diphenhydramine (Benadryl) before the drug. c.Assess the IV site at least every 2 hours for thrombophlebitis. d.Ensure that the client has increased oral intake during therapy.
ANS: C Vancomycin is very irritating to the veins and can easily cause thrombophlebitis. This drug is given over at least 60 minutes; although it can cause histamine release (leading to "red man syndrome"), it is not customary to administer diphenhydramine before starting the infusion. Increasing oral intake is not specific to vancomycin therapy.
The rehabilitation nurse is assisting a client with heart failure to increase activity tolerance. During ambulation of the client, identification of what symptom causes the nurse to stop the client's activity? a. Decrease in oxygen saturation from 98% to 95% b. Respiratory rate change from 22 to 28 breaths/min c. Systolic blood pressure change from 136 to 96 mm Hg d. Increase in heart rate from 86 to 100 beats/min
ANS: C A blood pressure change (increase or decrease) of greater than 20 mm Hg during or after activity indicates poor cardiac tolerance of the activity. A significant decrease (>20%) in blood pressure during or after activity is especially ominous, because it indicates an inability of the left ventricle to maintain sufficient cardiac output.
A nurse cares for several clients on a neurologic unit. Which prescription for a client should direct the nurse to ensure that an informed consent has been obtained before the test or procedure? a. Sensation measurement via the pinprick method b. Computed tomography of the cranial vault c. Lumbar puncture for cerebrospinal fluid sampling d. Venipuncture for autoantibody analysis
ANS: C A lumbar puncture is an invasive procedure with many potentially serious complications. The other assessments or tests are considered noninvasive and do not require an informed consent.
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.
A client with a bleeding gastric ulcer is having a nuclear medicine scan. What action by the nurse is most appropriate? a. Assess the client for iodine or shellfish allergies. b. Educate the client on the side effects of sedation. c. Inform the client a second scan may be needed. d. Teach the client about bowel preparation for the scan.
ANS: C A second scan may be performed in 1 to 2 days to see if interventions have worked. The nuclear medicine scan does not use iodine-containing contrast dye or sedation. There is no required bowel preparation.
A nurse assesses a client with Alzheimer's disease who is recently admitted to the hospital. Which psychosocial assessment should the nurse complete? a. Assess religious and spiritual needs while in the hospital. b. Identify the client's ability to perform self-care activities. c. Evaluate the client's reaction to a change of environment. d. Ask the client about relationships with family members.
ANS: C As Alzheimer's disease progresses, the client experiences changes in emotional and behavioral affect. The nurse should be alert to the client's reaction to a change in environment, such as being hospitalized, because the client may exhibit an exaggerated response, such as aggression, to the event. The other assessments should be completed but are not as important as assessing the client's reaction to environmental change.
A nurse is teaching a client with chronic migraine headaches. Which statement related to complementary therapy should the nurse include in this client's teaching? a. "Place a warm compress on your forehead at the onset of the headache." b. "Wear dark sunglasses when you are in brightly lit spaces." c. "Lie down in a darkened room when you experience a headache." d. "Set your alarm to ensure you do not sleep longer than 6 hours at one time."
ANS: C At the onset of a migraine attack, the client may be able to alleviate pain by lying down and darkening the room. He or she may want both eyes covered and a cool cloth on the forehead. If the client falls asleep, he or she should remain undisturbed until awakening. The other options are not recognized therapies for migraines.
The nurse reminds the client who has received a heart transplant to change positions slowly. Why is this instruction a priority? a. Rapid position changes can create shear and friction forces, which can tear out internal vascular sutures. b. The new vascular connections are more sensitive to position changes, leading to increased intravascular pressure. c. The new heart is denervated and is unable to respond to decreases in blood pressure caused by position changes. d. The recovering heart diverts blood flow away from the brain when the client stands, increasing the risk for stroke.
ANS: C Because the new heart is denervated, the baroreceptor and other mechanisms that compensate for blood pressure drops caused by position changes do not function. This allows orthostatic hypotension to persist in the postoperative period.
A nurse prepares to assess the emotional state of a client with end-stage pancreatic cancer. Which action should the nurse take first? a. Bring the client to a quiet room for privacy. b. Pull up a chair and sit next to the client's bed. c. Determine whether the client feels like talking about his or her feelings. d. Review the health care provider's notes about the prognosis for the client.
ANS: C Before conducting an assessment about the client's feelings, the nurse should determine whether he or she is willing and able to talk about them. If the client is open to the conversation and his or her room is not appropriate, an alternative meeting space may be located. The nurse should be present for the client during this time, and pulling up a chair and sitting with the client indicates that presence. Because the nurse is assessing the client's response to a terminal diagnosis, it is not necessary to have detailed information about the projected prognosis; the nurse knows that the client is facing an end-of-life illness.
A nurse delegates care for a client with early-stage Alzheimer's disease to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this client's care? a. "If she is confused, play along and pretend that everything is okay." b. "Remove the clock from her room so that she doesn't get confused." c. "Reorient the client to the day, time, and environment with each contact." d. "Use validation therapy to recognize and acknowledge the client's concerns."
ANS: C Clients who have early-stage Alzheimer's disease should be reoriented frequently to person, place, and time. The UAP should reorient the client and not encourage the client's delusions. The room should have a clock and white board with the current date written on it. Validation therapy is used with late-stage Alzheimer's disease.
A nurse prepares to discharge a client with Alzheimer's disease. Which statement should the nurse include in the discharge teaching for this client's caregiver? a. "Allow the client to rest most of the day." b. "Place a padded throw rug at the bedside." c. "Install deadbolt locks on all outside doors." d. "Provide a high-calorie and high-protein diet."
ANS: C Clients with Alzheimer's disease have a tendency to wander, especially at night. If possible, alarms should be installed on all outside doors to alert family members if the client leaves. At a minimum, all outside doors should have deadbolt locks installed to prevent the client from going outdoors unsupervised. The client should be allowed to exercise within his or her limits. Throw rugs are a slip and fall hazard and should be removed. The client should eat a well-balanced diet. There is no need for a high-calorie or high-protein diet.
The nurse is assessing a client in an outpatient clinic. Which client statement alerts the nurse to possible left-sided heart failure? a. "I have been drinking more water than usual." b. "I have been awakened by the need to urinate at night." c. "I have to stop halfway up the stairs to catch my breath." d. "I have experienced blurred vision on several occasions."
ANS: C Clients with left-sided heart failure report weakness or fatigue while performing normal activities of daily living, as well as difficulty breathing, or "catching their breath." This occurs as fluid moves into the alveoli. Nocturia is often seen with right-sided heart failure. Thirst and blurred vision are not related to heart failure.
A nurse is teaching the daughter of a client who has Alzheimer's disease. The daughter asks, "Will the medication my mother is taking improve her dementia?" How should the nurse respond? a. "It will allow your mother to live independently for several more years." b. "It is used to halt the advancement of Alzheimer's disease but will not cure it." c. "It will not improve her dementia but can help control emotional responses." d. "It is used to improve short-term memory but will not improve problem solving."
ANS: C Drug therapy is not effective for treating dementia or halting the advancement of Alzheimer's disease. However, certain drugs may help suppress emotional disturbances and psychiatric manifestations. Medication therapy may not allow the client to safely live independently.
The nurse is taking the vital signs of a client after hemodialysis. Blood pressure is 110/58 mm Hg, pulse 66 beats/min, and temperature is 99.8° F (37.6° C). What is the most appropriate action by the nurse? a. Administer fluid to increase blood pressure. b. Check the white blood cell count. c. Monitor the client's temperature. d. Connect the client to an electrocardiographic (ECG) monitor.
ANS: C During hemodialysis, the dialysate is warmed to increase diffusion and prevent hypothermia. The client's temperature could reflect the temperature of the dialysate. There is no indication to check the white blood cell count or connect the client to an ECG monitor. The other vital signs are within normal limits.
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.
A nurse assesses a client with early-onset multiple sclerosis (MS). Which clinical manifestation should the nurse expect to find? a. Hyperresponsive reflexes b. Excessive somnolence c. Nystagmus d. Heat intolerance
ANS: C Early signs and symptoms of MS include changes in motor skills, vision, and sensation. Hyperresponsive reflexes, excessive somnolence, and heat intolerance are later manifestations of MS.
A nurse assesses a client who has a history of migraines. Which clinical manifestation should the nurse identify as an early sign of a migraine with aura? a. Vertigo b. Lethargy c. Visual disturbances d. Numbness of the tongue
ANS: C Early warning of impending migraine with aura usually consists of visual changes, flashing lights, or diplopia. The other manifestations are not associated with an impending migraine with aura.
A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod (Gilenya). For which adverse effect should the nurse monitor? a. Peripheral edema b. Black tarry stools c. Bradycardia d. Nausea and vomiting
ANS: C Fingolimod (Gilenya) is an antineoplastic agent that can cause bradycardia, especially within the first 6 hours after administration. Peripheral edema, black and tarry stools, and nausea and vomiting are not adverse effects of fingolimod.
A nurse plans care for a client with lower back pain from a work-related injury. Which intervention should the nurse include in this client's plan of care? a. Encourage the client to stretch the back by reaching toward the toes. b. Massage the affected area with ice twice a day. c. Apply a heating pad for 20 minutes at least four times daily. d. Advise the client to avoid warm baths or showers.
ANS: C Heat increases blood flow to the affected area and promotes healing of injured nerves. Stretching and ice will not promote healing, and there is no need to avoid warm baths or showers.
A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that a priority goal for this problem has been met? a. Chooses preferred items from the menu b. Eats 75% to 100% of all meals and snacks c. Has clear lung sounds on auscultation d. Gains 2 pounds after 1 week
ANS: C Impaired swallowing can lead to aspiration, so the priority goal for this problem is no aspiration. Clear lung sounds is the best indicator that aspiration has not occurred. Choosing menu items is not related to this problem. Eating meals does not indicate the client is not still aspirating. A weight gain indicates improved nutrition but still does not show a lack of aspiration.
The nurse is caring for a client diagnosed with aortic stenosis. What assessment finding does the nurse expect in this client? a. Bounding arterial pulse b. Slow, faint arterial pulse c. Narrowed pulse pressure d. Elevated systolic pressure
ANS: C In aortic stenosis, the client presents with narrowed pulse pressure when blood pressure (BP) is assessed.
A client is admitted with early-stage heart failure. Which assessment finding does the nurse expect? a. A decrease in blood pressure and urine output b. An increase in creatinine and extremity edema c. An increase in heart rate and respiratory rate d. A decrease in respirations and oxygen saturation
ANS: C In heart failure, stimulation of the sympathetic nervous system represents the most immediate response. Adrenergic receptor stimulation causes an increase in heart rate and respiratory rate. Blood pressure will remain the same or will elevate slightly. Changes in creatinine occur when kidney damage has occurred, which is a later manifestation. Other later manifestations may include edema, increased respiratory rate, and lowered oxygen saturation readings.
The nurse is teaching a client how to increase the flow of dialysate into the peritoneal cavity during dialysis. Which statement by the client demonstrates a correct understanding of the teaching? a. "I should leave the drainage bag above the level of my abdomen." b. "I could flush the tubing with normal saline if the flow stops." c. "I should take a stool softener every morning to avoid constipation." d. "My diet should have low fiber in it to prevent any irritation."
ANS: C Inflow and outflow problems of the dialysate are best controlled by preventing constipation. A daily stool softener is the best option for the client. The drainage bag should be below the level of the abdomen. Flushing the tubing will not help with the flow. A diet high in fiber will also help with a constipation problem.
A nurse assesses a client who has cholecystitis. Which clinical manifestation indicates that the condition is chronic rather than acute? a. Temperature of 100.1° F (37.8° C) b. Positive Murphy's sign c. Light-colored stools d. Upper abdominal pain after eating
ANS: C Jaundice, clay-colored stools, and dark urine are more commonly seen with chronic cholecystitis. The other symptoms are seen equally with both chronic and acute cholecystitis.
A nurse assesses clients at a community health center. Which client is at highest risk for pancreatic cancer? a. A 32-year-old with hypothyroidism b. A 44-year-old with cholelithiasis c. A 50-year-old who has the BRCA2 gene mutation d. A 68-year-old who is of African-American ethnicity
ANS: C Mutations in both the BRCA2 and p16 genes increase the risk for developing pancreatic cancer in a small number of cases. The other factors do not appear to be linked to increased risk.
A nurse assesses clients at a community center. Which client is at greatest risk for lower back pain? a. A 24-year-old female who is 25 weeks pregnant b. A 36-year-old male who uses ergonomic techniques c. A 45-year-old male with osteoarthritis d. A 53-year-old female who uses a walker
ANS: C Osteoarthritis causes changes to support structures, increasing the client's risk for low back pain. The other clients are not at high risk.
A nurse cares for a client with acute pancreatitis. The client states, "I am hungry." How should the nurse reply? a. "Is your stomach rumbling or do you have bowel sounds?" b. "I need to check your gag reflex before you can eat." c. "Have you passed any flatus or moved your bowels?" d. "You will not be able to eat until the pain subsides."
ANS: C Paralytic ileus is a common complication of acute pancreatitis. The client should not eat until this has resolved. Bowel sounds and decreased pain are not reliable indicators of peristalsis. Instead, the nurse should assess for passage of flatus or bowel movement.
A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program. The client states, "I do not understand the need for rehabilitation; the paralysis will not go away and it will not get better." How should the nurse respond? a. "If you don't want to participate in the rehabilitation program, I'll let the provider know." b. "Rehabilitation programs have helped many clients with your injury. You should give it a chance." c. "The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability." d. "When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first."
ANS: C Participation in rehabilitation programs has many purposes, including prevention of disability, maintenance of functional ability, and restoration of function. The other responses do not meet this client's needs.
A client is receiving rituximab (Rituxan) and asks how it works. What response by the nurse is best? a. "It causes rapid lysis of the cancer cell membranes." b. "It destroys the enzymes needed to create cancer cells." c. "It prevents the start of cell division in the cancer cells." d. "It sensitizes certain cancer cells to chemotherapy."
ANS: C Rituxan prevents the initiation of cancer cell division. The other statements are not accurate.
A client is admitted with superior vena cava syndrome. What action by the nurse is most appropriate? a. Administer a dose of allopurinol (Aloprim). b. Assess the client's serum potassium level. c. Gently inquire about advance directives. d. Prepare the client for emergency surgery.
ANS: C Superior vena cava syndrome is often a late-stage manifestation. After the client is stabilized and comfortable, the nurse should initiate a conversation about advance directives. Allopurinol is used for tumor lysis syndrome. Potassium levels are important in tumor lysis syndrome, in which cell destruction leads to large quantities of potassium being released into the bloodstream. Surgery is rarely done for superior vena cava syndrome.
Four clients are receiving tyrosine kinase inhibitors (TKIs). Which of these four clients should the nurse assess first? a. Client with dry, itchy, peeling skin b. Client with a serum calcium of 9.2 mg/dL c. Client with a serum potassium of 2.8 mEq/L d. Client with a weight gain of 0.5 pound (1.1 kg) in 1 day
ANS: C TKIs can cause electrolyte imbalances. This potassium level is very low, so the nurse should assess this client first. Dry, itchy, peeling skin can be a problem in clients receiving biologic response modifiers, and the nurse should assess that client next because of the potential for discomfort and infection. This calcium level is normal. TKIs can also cause weight gain, but the client with the low potassium level is more critical.
A client is placed on fluid restrictions because of chronic kidney disease (CKD). Which assessment finding would alert the nurse that the client's fluid balance is stable at this time? a. Decreased calcium levels b. Increased phosphorus levels c. No adventitious sounds in the lungs d. Increased edema in the legs
ANS: C The absence of adventitious sounds upon auscultation of the lungs indicates a lack of fluid overload and fluid balance in the client's body. Decreased calcium levels and increased phosphorus levels are common findings with CKD. Edema would indicate a fluid imbalance.
The charge nurse of the medical-surgical unit is making staff assignments. Which staff member should be assigned to a client with chronic kidney disease who is exhibiting a low-grade fever and a pericardial friction rub? a. Registered nurse who just floated from the surgical unit b. Registered nurse who just floated from the dialysis unit c. Registered nurse who was assigned the same client yesterday d. Licensed practical nurse with 5 years' experience on this floor
ANS: C The client is exhibiting symptoms of pericarditis, which can occur with chronic kidney disease. Continuity of care is important to assess subtle differences in clients. Therefore, the registered nurse (RN) who was assigned to this client previously should again give care to this client. The float nurses would not be as knowledgeable about the unit and its clients. The licensed practical nurse may not have the education level of the RN to assess for pericarditis.
A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first? a. Initiate oxygen via a nasal cannula. b. Place the client in a supine position. c. Palpate the bladder for distention. d. Administer a prescribed beta blocker
ANS: C The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury. Precipitating conditions should be eliminated and the physician notified. The other actions would not be appropriate.
A nurse reviews these laboratory values of a client who returned from kidney transplantation 12 hours ago: Sodium 136 mEq/L Potassium 5 mEq/L Blood urea nitrogen (BUN) 44 mg/dL Serum creatinine 2.5 mg/dL What initial intervention would the nurse anticipate? a. Start hemodialysis immediately. b. Discuss the need for peritoneal dialysis. c. Increase the dose of immunosuppression. d. Return the client to surgery for exploration.
ANS: C The client may need a higher dose of immunosuppressive medication as evidenced by the elevated BUN and serum creatinine levels. This increased dose may reverse the possible acute rejection of the transplanted kidney. The client does not need hemodialysis, peritoneal dialysis, or further surgery at this point.
A nurse is caring for four clients in the neurologic/neurosurgical intensive care unit. Which client should the nurse assess first? a. Client who has been diagnosed with meningitis with a fever of 101° F (38.3° C) b. Client who had a transient ischemic attack and is waiting for teaching on clopidogrel (Plavix) c. Client receiving tissue plasminogen activator (t-PA) who has a change in respiratory pattern and rate d. Client who is waiting for subarachnoid bolt insertion with the consent form already signed
ANS: C The client receiving t-PA has a change in neurologic status while receiving this fibrinolytic therapy. The nurse assesses this client first as he or she may have an intracerebral bleed. The client with meningitis has expected manifestations. The client waiting for discharge teaching is a lower priority. The client waiting for surgery can be assessed quickly after the nurse sees the client who is receiving t-PA, or the nurse could delegate checking on this client to another nurse.
The nurse is providing discharge education to a client with hypertrophic cardiomyopathy (HCM). What priority instruction will the nurse include? a. "Take your digoxin at the same time every day." b. "You should begin an aerobic exercise program." c. "You should report episodes of dizziness or fainting." d. "You may have only two alcoholic drinks daily."
ANS: C The client with HCM is instructed to notify the health care provider if episodes of fainting, dizziness, or palpitations occur because these may signal the onset of deadly dysrhythmias. Clients with HCM are instructed to avoid strenuous exercise and alcohol. Cardiac glycosides are contraindicated in obstructive HCM.
After teaching a client who is prescribed pancreatic enzyme replacement therapy, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "The capsules can be opened and the powder sprinkled on applesauce if needed." b. "I will wipe my lips carefully after I drink the enzyme preparation." c. "The best time to take the enzymes is immediately after I have a meal or a snack." d. "I will not mix the enzyme powder with food or liquids that contain protein."
ANS: C The enzymes should be taken immediately before eating meals or snacks. If the client cannot swallow the capsules whole, they can be opened up and the powder sprinkled on applesauce, mashed fruit, or rice cereal. The client should wipe his or her lips carefully after drinking the enzyme preparation because the liquid could damage the skin. Protein items will be dissolved by the enzymes if they are mixed together.
The charge nurse is orienting a float nurse to an assigned client with an arteriovenous (AV) fistula for hemodialysis in her left arm. Which action by the float nurse would be considered unsafe? a. Palpating the access site for a bruit or thrill b. Using the right arm for a blood pressure reading c. Administering intravenous fluids through the AV fistula d. Checking distal pulses in the left arm
ANS: C The nurse should not use the arm with the AV fistula for intravenous infusion, blood pressure readings, or venipuncture. Compression and infection can result in the loss of the AV fistula. The AV fistula should be monitored by auscultating or palpating the access site. Checking the distal pulse would be an appropriate assessment.
A nurse cares for a client with a spinal cord injury. With which interdisciplinary team member should the nurse consult to assist the client with activities of daily living? a. Social worker b. Physical therapist c. Occupational therapist d. Case manager
ANS: C The occupational therapist instructs the client in the correct use of all adaptive equipment. In collaboration with the therapist, the nurse instructs family members or the caregiver about transfer skills, feeding, bathing, dressing, positioning, and skin care. The other team members are consulted to assist the client with unrelated issues.
A client has a traumatic brain injury and a positive halo sign. The client is in the intensive care unit, sedated and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time? a. Inability to communicate b. Nutritional deficit c. Risk for acquiring an infection d. Risk for skin breakdown
ANS: C The positive halo sign indicates a leak of cerebrospinal fluid. This places the client at high risk of acquiring an infection. Communication and nutrition are not priorities compared with preventing a brain infection. The client has a definite risk for a skin breakdown, but it is not the immediate danger a brain infection would be.
A client with peptic ulcer disease is in the emergency department and reports the pain has gotten much worse over the last several days. The client's blood pressure when lying down was 122/80 mm Hg and when standing was 98/52 mm Hg. What action by the nurse is most appropriate? a. Administer ibuprofen (Motrin). b. Call the Rapid Response Team. c. Start a large-bore IV with normal saline. d. Tell the client to remain lying down.
ANS: C This client has orthostatic changes to the blood pressure, indicating fluid volume loss. The nurse should start a large-bore IV with isotonic solution. Ibuprofen will exacerbate the ulcer. The Rapid Response Team is not needed at this point. The client should be put on safety precautions, which includes staying in bed, but this is not the priority.
A client is diagnosed with chronic kidney disease (CKD). What is an ideal goal of treatment set by the nurse in the care plan to reduce the risk of pulmonary edema? a. Maintaining oxygen saturation of 89% b. Minimal crackles and wheezes in lung sounds c. Maintaining a balanced intake and output d. Limited shortness of breath upon exertion
ANS: C With an optimal fluid balance, the client will be more able to eject blood from the left ventricle without increased pressure in the left ventricle and pulmonary vessels. Other ideal goals are oxygen saturations greater than 92%, no auscultated crackles or wheezes, and no demonstrated shortness of breath.
A nurse assesses a client who is recovering from the implantation of a vagal nerve stimulation device. For which clinical manifestations should the nurse assess as common complications of this procedure? (Select all that apply.) a. Bleeding b. Infection c. Hoarseness d. Dysphagia e. Seizures
ANS: C, D Complications of surgery to implant a vagal nerve stimulation device include hoarseness (most common), dyspnea, neck pain, and dysphagia. The device is tunneled under the skin with an electrode connected to the vagus nerve to control simple or complex partial seizures. Bleeding is not a common complication of this procedure, and infection would not occur during the recovery period.
A nurse working with a client who has possible gastritis assesses the client's gastrointestinal system. Which findings indicate a chronic condition as opposed to acute gastritis? (Select all that apply.) a. Anorexia b. Dyspepsia c. Intolerance of fatty foods d. Pernicious anemia e. Nausea and vomiting
ANS: C, D Intolerance of fatty or spicy foods and pernicious anemia are signs of chronic gastritis. Anorexia and nausea/vomiting can be seen in both conditions. Dyspepsia is seen in acute gastritis.
A nurse has delegated feeding a client to an unlicensed assistive personnel (UAP). What actions does the nurse include in the directions to the UAP? (Select all that apply.) a. Allow 30 minutes for eating so food doesn't get spoiled. b. Assess the client's mouth while providing premeal oral care. c. Ensure warm and cold items stay at appropriate temperatures. d. Remove bedpans, soiled linens, and other unpleasant items. e. Sit with the client, making the atmosphere more relaxed.
ANS: C, D, E UAP RES!
A nurse assesses a client who is recovering from a lumbar laminectomy. Which complications should alert the nurse to urgently communicate with the health care provider? (Select all that apply.) a. Surgical discomfort b. Redness and itching at the incision site c. Incisional bulging d. Clear drainage on the dressing e. Sudden and severe headache
ANS: C, D, E Bulging at the incision site or clear fluid on the dressing after a laminectomy strongly suggests a cerebrospinal fluid leak, which constitutes an emergency. Loss of cerebral spinal fluid may cause a sudden and severe headache, which is also an emergency situation. Pain, redness, and itching at the site are normal.
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.
After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the client's understanding. Which client statements indicate a correct understanding of the teaching related to sexual effects of this injury? (Select all that apply.) a. "I will explore other ways besides intercourse to please my partner." b. "I will not be able to have an erection because of my injury." c. "Ejaculation may not be as predictable as before." d. "I may urinate with ejaculation but this will not cause infection." e. "I should be able to have an erection with stimulation."
ANS: C, D, E Men with injuries above T6 often are able to have erections by stimulating reflex activity. For example, stroking the penis will cause an erection. Ejaculation is less predictable and may be mixed with urine. However, urine is sterile, so the client's partner will not get an infection.
A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the client's hips and sacrum. Which actions should the nurse take? (Select all that apply.) a. Apply a barrier cream to protect the skin from excoriation. b. Perform range-of-motion (ROM) exercises for the hip joint. c. Re-position the client off of the reddened areas. d. Get the client out of bed and into a chair once a day. e. Obtain a low-air-loss mattress to minimize pressure.
ANS: C, E Appropriate interventions to relieve pressure on these areas include frequent re-positioning and a low-air-loss mattress. Reddened areas should not be rubbed because this action could cause more extensive damage to the already fragile capillary system. Barrier cream will not protect the skin from pressure wounds. ROM exercises are used to prevent contractures. Sitting the client in a chair once a day will decrease the client's risk of respiratory complications but will not decrease pressure on the client's hips and sacrum.
A nurse is caring for a client who has a pressure ulcer on the right ankle. Which action should the nurse take first? a.Draw blood for albumin, prealbumin, and total protein. b.Prepare for and assist with obtaining a wound culture. c.Place the client in bed and instruct the client to elevate the foot. d.Assess the right leg for pulses, skin color, and temperature.
ANS: D A client with an ulcer on the foot should be assessed for interruption in arterial flow to the area. This begins with the assessment of pulses and color and temperature of the skin. The nurse can also assess for pulses noninvasively with a Doppler flowmeter if unable to palpate with his or her fingers. Tests to determine nutritional status and risk assessment would be completed after the initial assessment is done. Wound cultures are done after it has been determined that drainage, odor, and other risks for infection are present. Elevation of the foot would impair the ability of arterial blood to flow to the area.
After teaching a client how to care for a furuncle in the axilla, a nurse assesses the client's understanding. Which statement indicates the client correctly understands the teaching? a."I'll apply cortisone cream to reduce the inflammation." b."I'll apply a clean dressing after squeezing out the pus." c."I'll keep my arm down at my side to prevent spread." d."I'll cleanse the area prior to applying antibiotic cream."
ANS: D Cleansing and topical antibiotics can eliminate the infection. Warm compresses enhance comfort and open the lesion, allowing better penetration of the topical antibiotic. Cortisone cream reduces the inflammatory response but increases the infectious process. Squeezing the lesion may introduce infection to deeper tissues and cause cellulitis. Keeping the arm down increases moisture in the area and promotes bacterial growth.
2. 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.
ANS: D Frequent visits to the bathroom during the night could cause sleep interruptions and affect the clients mood and mental status. Incontinence could cause the client to feel embarrassment and cause him to limit his activities outside the home. The social isolation could lead to clinical depression and should be treated professionally. The nurse should not give advice before exploring the clients response to his change in behavior. The statement about age has no validity.
A nurse cares for clients who have various skin infections. Which infection is paired with the correct pharmacologic treatment? a.Viral infection - Clindamycin (Cleocin) b.Bacterial infection - Acyclovir (Zovirax) c.Yeast infection - Linezolid (Zyvox) d.Fungal infection - Ketoconazole (Nizoral)
ANS: D Ketoconazole is an antifungal. Clindamycin and linezolid are antibiotics. Acyclovir is an antiviral drug.
6. 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
ANS: D The UAP could aid the client in transferring from the bed to the chair and with ambulation. The nurse would be responsible for medication administration, assessment of swelling, and the application of ice if needed.
A nurse teaches a client who has very dry skin. Which statement should the nurse include in this client's education? a."Use lots of moisturizer several times a day to minimize dryness." b."Take a cold shower instead of soaking in the bathtub." c."Use antimicrobial soap to avoid infection of cracked skin." d."After you bathe, put lotion on before your skin is totally dry."
ANS: D The client should bathe in warm water for at least 20 minutes and then apply lotion immediately because this will keep the moisture in the skin. Just using moisturizer will not be as helpful because the moisturizer is not what rehydrates the skin; it is the water. Bathing in warm water will rehydrate skin more effectively than a cold shower, and antimicrobial soaps are actually more drying than other kinds of soap.
A nurse assesses a client who is recovering from a diskectomy 6 hours ago. Which assessment finding should the nurse address first? a. Sleepy but arouses to voice b. Dry and cracked oral mucosa c. Pain present in lower back d. Bladder palpated above pubis
ANS: D A distended bladder may indicate damage to the sacral spinal nerves. The other findings require the nurse to provide care but are not the priority or a complication of the procedure.
The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first? a. Client with cerebral perfusion pressure of 72 mm Hg b. Client who has a Glasgow Coma Scale score of 12 c. Client with a PaCO2 of 36 mm Hg who is on a ventilator d. Client who has a temperature of 102° F (38.9° C)
ANS: D A fever is a poor prognostic indicator in clients with brain injuries. The nurse should see this client first. A Glasgow Coma Scale score of 12, a PaCO2 of 36, and cerebral perfusion pressure of 72 mm Hg are all desired outcomes.
A client has a long history of hypertension. Which category of medications would the nurse expect to be ordered to avoid chronic kidney disease (CKD)? a. Antibiotic b. Histamine blocker c. Bronchodilator d. Angiotensin-converting enzyme (ACE) inhibitor
ANS: D ACE inhibitors stop the conversion of angiotensin I to the vasoconstrictor angiotensin II. This category of medication also blocks bradykinin and prostaglandin, increases renin, and decreases aldosterone, which promotes vasodilation and perfusion to the kidney. Antibiotics fight infection, histamine blockers decrease inflammation, and bronchodilators increase the size of the bronchi; none of these medications helps slow the progression of CKD in clients with hypertension.
A nurse cares for a client with amyotrophic lateral sclerosis (ALS). The client states, "I do not want to be placed on a mechanical ventilator." How should the nurse respond? a. "You should discuss this with your family and health care provider." b. "Why are you afraid of being placed on a breathing machine?" c. "Using the incentive spirometer each hour will delay the need for a ventilator." d. "What would you like to be done if you begin to have difficulty breathing?"
ANS: D ALS is an adult-onset upper and lower motor neuron disease characterized by progressive weakness, muscle wasting, and spasticity, eventually leading to paralysis. Once muscles of breathing are involved, the client must indicate in the advance directive what is to be done when breathing is no longer possible without intervention. The other statements do not address the client's needs.
A nurse is assessing a female client who is taking progestins. What assessment finding requires the nurse to notify the provider immediately? a. Irregular menses b. Edema in the lower extremities c. Ongoing breast tenderness d. Red, warm, swollen calf
ANS: D All clients receiving progestin therapy are at risk for thromboembolism. A red, warm, swollen calf is a manifestation of deep vein thrombosis and should be reported to the provider. Irregular menses, edema in the lower extremities, and breast tenderness are common side effects of the therapy.
A nurse works with clients who have alopecia from chemotherapy. What action by the nurse takes priority? a. Helping clients adjust to their appearance b. Reassuring clients that this change is temporary c. Referring clients to a reputable wig shop d. Teaching measures to prevent scalp injury
ANS: D All of the actions are appropriate for clients with alopecia. However, the priority is client safety, so the nurse should first teach ways to prevent scalp injury.
A client is scheduled for a total gastrectomy for gastric cancer. What preoperative laboratory result should the nurse report to the surgeon immediately? a. Albumin: 2.1 g/dL b. Hematocrit: 28% c. Hemoglobin: 8.1 mg/dL d. International normalized ratio (INR): 4.2
ANS: D An INR as high as 4.2 poses a serious risk of bleeding during the operation and should be reported. The albumin is low and is an expected finding. The hematocrit and hemoglobin are also low, but this is expected in gastric cancer.
After teaching the wife of a client who has Parkinson disease, the nurse assesses the wife's understanding. Which statement by the client's wife indicates she correctly understands changes associated with this disease? a. "His masklike face makes it difficult to communicate, so I will use a white board." b. "He should not socialize outside of the house due to uncontrollable drooling." c. "This disease is associated with anxiety causing increased perspiration." d. "He may have trouble chewing, so I will offer bite-sized portions."
ANS: D Because chewing and swallowing can be problematic, small frequent meals and a supplement are better for meeting the client's nutritional needs. A masklike face and drooling are common in clients with Parkinson disease. The client should be encouraged to continue to socialize and communicate as normally as possible. The wife should understand that the client's masklike face can be misinterpreted and additional time may be needed for the client to communicate with her or others. Excessive perspiration is also common in clients with Parkinson disease and is associated with the autonomic nervous system's response.
23. A nurse is caring for a client who is scheduled for a dose of cefazolin and vitamins at this time. Hemodialysis for this client is also scheduled in 60 minutes. Which action by the nurse is best? a. Administer cefazolin since the level of the antibiotic must be maintained. b. Hold the vitamins but administer the cefazolin. c. Hold the cefazolin but administer the vitamins. d. Hold all medications since both cefazolin and vitamins are dialyzable.
ANS: D Both the cefazolin and the vitamins should be held until after the hemodialysis is completed because they would otherwise be removed by the dialysis process.
The nurse has taught a client with cancer ways to prevent infection. What statement by the client indicates that more teaching is needed? a. "I should take my temperature daily and when I don't feel well." b. "I will wash my toothbrush in the dishwasher once a week." c. "I won't let anyone share any of my personal items or dishes." d. "It's alright for me to keep my pets and change the litter box."
ANS: D Clients should wash their hands after touching their pets and should not empty or scoop the cat litter box. The other statements are appropriate for self-management.
After teaching a client who has a history of cholelithiasis, the nurse assesses the client's understanding. Which menu selection made by the client indicates the client clearly understands the dietary teaching? a. Lasagna, tossed salad with Italian dressing, and low-fat milk b. Grilled cheese sandwich, tomato soup, and coffee with cream c. Cream of potato soup, Caesar salad with chicken, and a diet cola d. Roasted chicken breast, baked potato with chives, and orange juice
ANS: D Clients with cholelithiasis should avoid foods high in fat and cholesterol, such as whole milk, butter, and fried foods. Lasagna, low-fat milk, grilled cheese, cream, and cream of potato soup all have high levels of fat. The meal with the least amount of fat is the chicken breast dinner.
A client with a history of heart failure is being discharged. Which priority instruction will assist the client in the prevention of complications associated with heart failure? a. "Avoid drinking more than 3 quarts of liquids each day." b. "Eat six small meals daily instead of three larger meals." c. "When you feel short of breath, take an additional diuretic." d. "Weigh yourself daily while wearing the same amount of clothing."
ANS: D Clients with heart failure are instructed to weigh themselves daily to detect worsening heart failure early, and thus avoid complications. Other signs of worsening heart failure include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia.
After teaching a client who is diagnosed with new-onset status epilepticus and prescribed phenytoin (Dilantin), the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching? a. "To prevent complications, I will drink at least 2 liters of water daily." b. "This medication will stop me from getting an aura before a seizure." c. "I will not drive a motor vehicle while taking this medication." d. "Even when my seizures stop, I will continue to take this drug."
ANS: D Discontinuing antiepileptic drugs can lead to the recurrence of seizures or status epilepticus. The client does not need to drink more water and can drive while taking this medication. The medication will not stop an aura before a seizure.
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.
A client with cancer is admitted to a short-term rehabilitation facility. The nurse prepares to administer the client's oral chemotherapy medications. What action by the nurse is most appropriate? a. Crush the medications if the client cannot swallow them. b. Give one medication at a time with a full glass of water. c. No special precautions are needed for these medications. d. Wear personal protective equipment when handling the medications.
ANS: D During the administration of oral chemotherapy agents, nurses must take the same precautions that are used when administering IV chemotherapy. This includes using personal protective equipment. These medications cannot be crushed, split, or chewed. Giving one at a time is not needed.
A nurse plans care for a client with Parkinson disease. Which intervention should the nurse include in this client's plan of care? a. Ambulate the client in the hallway twice a day. b. Ensure a fluid intake of at least 3 liters per day. c. Teach the client pursed-lip breathing techniques. d. Keep the head of the bed at 30 degrees or greater
ANS: D Elevation of the head of the bed will help prevent aspiration. The other options will not prevent aspiration, which is the greatest respiratory complication of Parkinson disease, nor do these interventions address any of the complications of Parkinson disease. Ambulation in the hallway is usually implemented to prevent venous thrombosis. Increased fluid intake flushes out toxins from the client's blood. Pursed-lip breathing increases exhalation of carbon dioxide.
The nurse is starting a client on digoxin (Lanoxin) therapy. What intervention is essential to teach this client? a. "Avoid taking aspirin or aspirin-containing products." b. "Increase your intake of foods high in potassium." c. "Hold this medication if your pulse rate is below 80 beats/min." d. "Do not take this medication within 1 hour of taking an antacid."
ANS: D Gastrointestinal absorption of digoxin is erratic. Many medications, especially antacids, interfere with its absorption. Clients are taught to hold their digoxin for bradycardia; a heart rate of 80 is too high for this cutoff.
A client is assessed by the nurse after a hemodialysis session. The nurse notes bleeding from the client's nose and around the intravenous catheter. What action by the nurse is the priority? a. Hold pressure over the client's nose for 10 minutes. b. Take the client's pulse, blood pressure, and temperature. c. Assess for a bruit or thrill over the arteriovenous fistula. d. Prepare protamine sulfate for administration.
ANS: D Heparin is used with hemodialysis treatments. The bleeding alerts the nurse that too much anticoagulant is in the client's system and protamine sulfate should be administered. Pressure, taking vital signs, and assessing for a bruit or thrill are not as important as medication administration.
A client is taking triamterene-hydrochlorothiazide (Dyazide) and furosemide (Lasix). What assessment finding requires action by the nurse? a. Cough b. Headache c. Pulse of 62 beats/min d. Potassium of 2.9 mEq/L
ANS: D Hypokalemia is a side effect of both thiazide and loop diuretics. The client loses electrolytes with fluid. Coughing is not a typical side effect of this medication. Headache may occur with any medication and is not a serious side effect. Bradycardia is not likely to occur with this medication.
A nurse assesses a client with a neurologic disorder. Which assessment finding should the nurse identify as a late manifestation of amyotrophic lateral sclerosis (ALS)? a. Dysarthria b. Dysphagia c. Muscle weakness d. Impairment of respiratory muscles
ANS: D In ALS, progressive muscle atrophy occurs until a flaccid quadriplegia develops. Eventually, the respiratory muscles are involved, which leads to respiratory compromise. Dysarthria, dysphagia, and muscle weakness are early clinical manifestations of ALS.
A nurse teaches a client with a lower motor neuron lesion who wants to achieve bladder control. Which statement should the nurse include in this client's teaching? a. "Stroke the inner aspect of your thigh to initiate voiding." b. "Use a clean technique for intermittent catheterization." c. "Implement digital anal stimulation when your bladder is full." d. "Tighten your abdominal muscles to stimulate urine flow."
ANS: D In clients with lower motor neuron problems such as spinal cord injury, performing a Valsalva maneuver or tightening the abdominal muscles are interventions that can initiate voiding. Stroking the inner aspect of the thigh may initiate voiding in a client who has an upper motor neuron problem. Intermittent catheterization and digital anal stimulation do not initiate voiding or bladder control.
A nurse prepares a client for prescribed magnetic resonance imaging (MRI). Which action should the nurse implement prior to the test? a. Implement nothing by mouth (NPO) status for 8 hours. b. Withhold all daily medications until after the examination. c. Administer morphine sulfate to prevent claustrophobia during the test. d. Place the client in a gown that has cloth ties instead of metal snaps.
ANS: D Metal objects are a hazard because of the magnetic field used in the MRI procedure. Morphine sulfate is not administered to prevent claustrophobia; lorazepam (Ativan) or diazepam (Valium) may be used instead. The client does not need to be NPO, and daily medications do not need to be withheld prior to MRI.
A nurse cares for a client who presents with an acute exacerbation of multiple sclerosis (MS). Which prescribed medication should the nurse prepare to administer? a. Baclofen (Lioresal) b. Interferon beta-1b (Betaseron) c. Dantrolene sodium (Dantrium) d. Methylprednisolone (Medrol)
ANS: D Methylprednisolone is the drug of choice for acute exacerbations of the disease. The other drugs are not used to treat acute exacerbations of MS. Interferon beta-1b is used to treat and control MS, decrease specific symptoms, and slow the progression of the disease. Baclofen and dantrolene sodium are prescribed to lessen muscle spasticity associated with MS.
A nurse assesses clients on the medical-surgical unit. Which client should the nurse identify as at high risk for pancreatic cancer? a. A 26-year-old with a body mass index of 21 b. A 33-year-old who frequently eats sushi c. A 48-year-old who often drinks wine d. A 66-year-old who smokes cigarettes
ANS: D Risk factors for pancreatic cancer include obesity, older age, high intake of red meat, and cigarette smoking. Sushi and wine intake are not risk factors for pancreatic cancer.
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.
A client has just had a central line catheter placed that is specific for hemodialysis. What is the most appropriate action by the nurse? a. Use the catheter for the next laboratory blood draw. b. Monitor the central venous pressure through this line. c. Access the line for the next intravenous medication. d. Place a heparin or heparin/saline dwell after hemodialysis.
ANS: D The central line should have a heparin or heparin/saline dwell after hemodialysis treatment. The central line catheter used for dialysis should not be used for blood sampling, monitoring central venous pressures, or giving drugs or fluids.
A client with end-stage heart failure is awaiting a transplant. The client appears depressed and states, "I know a transplant is my last chance, but I don't want to become a vegetable." What is the nurse's best response? a. "Would you like to speak with a priest or chaplain?" b. "I will consult a psychiatrist to speak with you." c. "Do you want to come off the transplant list?" d. "Would you like information about advance directives?"
ANS: D The client is verbalizing a real concern or fear about negative outcomes of the surgery. This anxiety itself can have a negative effect on the outcome of the surgery because of sympathetic stimulation. The best action is to allow the client to verbalize the concern and work toward a positive outcome without making the client feel as though he or she is crazy. The client needs to feel that he or she has some control over the future.
A client has been admitted to the intensive care unit with worsening pulmonary manifestations of heart failure. What is the nurse's best action? a. Place the client in a high Fowler's position. b. Begin cardiopulmonary resuscitation (CPR). c. Promote rest and minimize activities. d. Administer loop diuretics as prescribed.
ANS: D The client with worsening heart failure is most at risk for pulmonary edema as a consequence of fluid retention. Administering diuretics will decrease the fluid overload, thereby decreasing the incidence of pulmonary edema. High Fowler's position might help the client breathe easier but will not solve the problem. CPR is not warranted in this situation. Rest is important for clients with heart failure, but this is not the priority.
The nurse is obtaining the admission health history for a young adult who presents with fever, dyspnea, and a murmur. What priority data does the nurse inquire about? a. Family history of coronary artery disease b. Recent travel to Third World countries c. Pet ownership, especially cats with litter boxes d. History of a systemic infection within the past month
ANS: D The clinical manifestations suggest infective endocarditis, which can occur within 2 to 4 weeks after a systemic infection or bacteremia. Assessing for coronary artery disease, recent travel, or pet ownership is not related to endocarditis.
An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first? a. Assess level of consciousness. b. Obtain vital signs. c. Administer oxygen therapy. d. Evaluate respiratory status.
ANS: D The first priority for a client with a spinal cord injury is assessment of respiratory status and airway patency. Clients with cervical spine injuries are particularly prone to respiratory compromise and may even require intubation. The other assessments should be performed after airway and breathing are assessed.
After teaching a client newly diagnosed with epilepsy, the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching? a. "I will wear my medical alert bracelet at all times." b. "While taking my epilepsy medications, I will not drink any alcoholic beverages." c. "I will tell my doctor about my prescription and over-the-counter medications." d. "If I am nauseated, I will not take my epilepsy medication."
ANS: D The nurse must emphasize that antiepileptic drugs must be taken even if the client is nauseous. Discontinuing the medication can predispose the client to seizure activity and status epilepticus. The client should not drink alcohol while taking seizure medications. The client should wear a medical alert bracelet and should make the doctor aware of all medications to prevent complications of polypharmacy.
A client with chronic kidney disease states, "I feel chained to the hemodialysis machine." What is the nurse's best response to the client's statement? a. "That feeling will gradually go away as you get used to the treatment." b. "You probably need to see a psychiatrist to see if you are depressed." c. "Do you need help from social services to discuss financial aid?" d. "Tell me more about your feelings regarding hemodialysis treatment."
ANS: D The nurse needs to explore the client's feelings in order to help the client cope and enter a phase of acceptance or resignation. It is common for clients to be discouraged because of the dependency of the treatment, especially during the first year. Referrals to a mental health provider or social services are possibilities, but only after exploring the client's feelings first. Telling the client his or her feelings will go away is dismissive of the client's concerns.
A client with acute kidney injury has a blood pressure of 76/55 mm Hg. The health care provider ordered 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client is starting to develop shortness of breath. What is the nurse's priority action? a. Calculate the mean arterial pressure (MAP). b. Ask for insertion of a pulmonary artery catheter. c. Take the client's pulse. d. Slow down the normal saline infusion.
ANS: D The nurse should assess that the client could be developing fluid overload and respiratory distress and slow down the normal saline infusion. The calculation of the MAP also reflects perfusion. The insertion of a pulmonary artery catheter would evaluate the client's hemodynamic status, but this should not be the initial action by the nurse. Vital signs are also important after adjusting the intravenous infusion.
A nurse cares for a client who has been diagnosed with the Huntington gene but has no symptoms. The client asks for options related to family planning. What is the nurse's best response? a. "Most clients with the Huntington gene do not pass on Huntington disease to their children." b. "I understand that they can diagnose this disease in embryos. Therefore, you could select a healthy embryo from your fertilized eggs for implantation to avoid passing on Huntington disease." c. "The need for family planning is limited because one of the hallmarks of Huntington disease is infertility." d. "Tell me more specifically what information you need about family planning so that I can direct you to the right information or health care provider."
ANS: D The presence of the Huntington gene means that the trait will be passed on to all offspring of the affected person. Understanding options for contraception and conception (e.g., surrogacy options) and implications for children may require the expertise of a genetic counselor or a reproductive specialist. The other statements are not accurate.
A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain? a. Loss of bladder control b. Other medical conditions c. Progression of symptoms d. Time of symptom onset
ANS: D The time limit for initiating fibrinolytic therapy for a stroke is 3 to 4.5 hours, so the exact time of symptom onset is the most important information for this client. The other information is not as critical.
The client who just started taking isosorbide dinitrate (Isordil) reports a headache. What is the nurse's best action? a. Titrate oxygen to relieve headache. b. Hold the next dose of Isordil. c. Instruct the client to drink water. d. Administer PRN acetaminophen.
ANS: D The vasodilating effects of this drug frequently cause clients to have headaches during the initial period of therapy. Clients should be told about this side effect and encouraged to take the medication with food. Some clients obtain relief with mild analgesics, such as acetaminophen.
A client in the intensive care unit is scheduled for a lumbar puncture (LP) today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. What action by the nurse is best? a. Ensure that informed consent is on the chart. b. Document these findings in the client's record. c. Give the prescribed preprocedure sedation. d. Notify the provider of the findings immediately.
ANS: D This client is exhibiting signs of increased intracranial pressure. The nurse should notify the provider immediately because performing the LP now could lead to herniation. Informed consent is needed for an LP, but this is not the priority. Documentation should be thorough, but again this is not the priority. The preprocedure sedation (or other preprocedure medications) should not be given as the LP will most likely be canceled.
A new nurse has been assigned a client who is in the hospital to receive iodine-131 treatment. Which action by the nurse is best? a. Ensure the client is placed in protective isolation. b. Hand off a pregnant client to another nurse. c. No special action is necessary to care for this client. d. Read the policy on handling radioactive excreta.
ANS: D This type of radioisotope is excreted in body fluids and excreta (urine and feces) and should not be handled directly. The nurse should read the facility's policy for handling and disposing of this type of waste. The other actions are not warranted.
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.
A client is being taught about drug therapy for Helicobacter pylori infection. What assessment by the nurse is most important? a. Alcohol intake of 1 to 2 drinks per week b. Family history of H. pylori infection c. Former smoker still using nicotine patches d. Willingness to adhere to drug therapy
ANS: D Treatment for this infection involves either triple or quadruple drug therapy, which may make it difficult for clients to remain adherent. The nurse should assess the client's willingness and ability to follow the regimen. The other assessment findings are not as critical.
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 nurse prepares to provide perineal care to a client with meningococcal meningitis. Which personal protective equipment should the nurse wear? (Select all that apply.) a. Particulate respirator b. Isolation gown c. Shoe covers d. Surgical mask e. Gloves
ANS: D, E Meningeal meningitis is spread via saliva and droplets, and Droplet Precautions are necessary. Caregivers should wear a surgical mask when within 6 feet of the client and should continue to use Standard Precautions, including gloves. A particulate respirator, an isolation gown, and shoe covers are not necessary for Droplet Precautions.
The nurse teaches a client that intraperitoneal chemotherapy will be delivered to which part of the body? A.) Veins of the legs B.) Lung C.) Heart D.) Abdominal cavity
Abdominal cavity Intraperitoneal chemotherapy is placed in the peritoneal cavity or the abdominal cavity. Intravenous drugs are delivered through veins. Chemotherapy delivered into the lungs is typically placed in the pleural space (intrapleural). Chemotherapy is not typically delivered into the heart.
A client awaiting kidney transplantation states, "I can't stand this waiting for a kidney, I just want to give up." Which statement by the nurse is most therapeutic? "I'll talk to the health care provider and have your name removed from the waiting list." "You sound frustrated with the situation." "You're right, the wait is endless for some people." "I'm sure you'll get a phone call soon that a kidney is available."
Acknowledging the client's frustration reflects the feelings the client is having and offers assistance and support. Talking to the health care provider and removing the client from the waiting list does not allow the nurse to hear more and perhaps offer therapeutic listening or a solution to the problem. Telling the client that the wait is endless for some people cuts the client off from sharing his or her concerns and accentuates the negative aspects of the situation. The waiting time for kidney matches is increasing due to a shortage of organs; the nurse should not offer false hope by suggesting that the client will get a phone call soon.
All of these nursing actions are included in the plan of care for a client who has just been extubated. Which action should the RN delegate to unlicensed assistive personnel (UAP)? A. Keep the head of the bed elevated. B. Teach about incentive spirometer use. C. Monitor vital signs every 5 minutes. D. Adjust the nasal oxygen flow rate.
A
Which conditions are identified as specific causes of distributive shock? Select all that apply. 1 Sepsis 2 Cardiac tamponade 3 Anaphylaxis 4 Capillary leak 5 Pericarditis
1. Sepsis 3 . Anaphylaxis 4 . Capillary leak Rationale:
which lab resluts will the nurse expect to decrease (Select all that apply) a. cd4+ b. cd8+ c. WBC d. lymphocytes e. HIV antibodies
a, c, d
A nurse is caring for four clients receiving enteral tube feedings. Which client should the nurse see first? a. Client with a blood glucose level of 138 mg/dL b. Client with foul-smelling diarrhea c. Client with a potassium level of 2.6 mEq/L d. Client with a sodium level of 138 mEq/L
c. Client with a potassium level of 2.6 mEq/L
a patient with HIV is receiving meds to reduce viral load and improve cd4+ counts. which term accurately describes this HIV drug regimen a. interferon treatment b. antiviremia c. ELISA administration d. HAART
d
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.