Final Exam

While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. What action would the nurse take first? a. Contact the primary health care provider and prepare for intubation. b. Administer prescribed albuterol nebulizer therapy. c. Place the client in high-Fowler position. d. Ask the client to perform deep-breathing exercises (26)

.ANS: A Facial and neck tissue edema can occur in clients with facial trauma. Airway patency is the highest priority. Clients who experience stridor and hypoxia, manifested by anxiety and restlessness, would be immediately intubated to ensure airway patency. Albuterol decreases bronchi and bronchiole inflammation, not facial and neck edema. Although putting the client in high-Fowler position and asking the client to perform breathing exercises may temporarily improve the patient's comfort, these actions will not decrease the underlying problem or improve airway patency

A client had a myringotomy. What would the nurse include as part of discharge teaching? a. Buy dry shampoo to use for a week. b. Drink liquids through a straw. c. Flying is not allowed for 1 month. d. Hot water showers will help the pain. (43)

ANS: A The client cannot shower or get the head wet for 1 week after surgery, so using dry shampoo is a good suggestion. The other instructions are incorrect: straws are not allowed for 2 to 3 weeks, flying is not allowed for 2 to 3 weeks, and the client should not shower

A nurse is assessing clients with pressure injuries. Which wound description is correctly matched to its description? a. Suspected deep tissue injury: nonblanchable deep purple or maroon. b. Stage 2: may have visible adipose tissue and slough. c. Stage 3: may have a pink or red wound bed. d. Stage 4: wound bed is obscured with eschar or slough. (23)

ANS: A A suspected deep tissue injury is characterized by persistent, nonblanchable purple or maroon discoloration. A stage 2 wound may have a pink of red would bed with granulation tissue. The stage 3 wound may have visible adipose tissue and slough. A stage 4 wound is full-thickness skin loss with exposed or palpable fascia, muscle, tendon, ligament, cartilage, or bone. An unstageable wound is obscured by eschar or slough making assessment impossible.

The nurse is caring for a client diagnosed with probable gastroesophageal reflux disease (GERD). What assessment finding(s) would the nurse expect? (Select all that apply.) a. Dyspepsia b. Regurgitation c. Belching d. Coughing e. Chest discomfort f. Dysphagia (49)

ANS: A, B, C, D, E, F All of these signs and symptoms are commonly seen in clients who have GERD

A nurse reviews a client's laboratory results. Which results from the client's urinalysis would the nurse identify as normal? (Select all that apply.) a. pH: 6 b. Specific gravity: 1.015 c. Protein: 1.2 mg/dL d. Glucose: negative e. Nitrate: small f. Leukocyte esterase: positive (60)

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

A nurse is caring for a client whose Braden Scale score is 9. What intervention demonstrates a lack of evidence-based knowledge? a. Requests a referral to a registered dietitian nutritionist. b. Raises the head of the bed no more than 45 degrees. c. Performs perineal cleansing every 2 hours. d. Assesses the client's entire skin surface daily. (23)

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. The nurse needs to keep the head of the bed elevated to no more than 30 degrees to prevent shearing. An RDN consultation, frequent perineal cleaning, and assessing the client's entire skin surface are all appropriate actions.

A nurse prepares a client who is scheduled for a bronchoscopy with transbronchial biopsy procedure at 9:00 AM (0900). What actions would the nurse take? (Select all that apply.) a. Provide a clear liquid breakfast. b. Verify that the informed consent was obtained. c. Document the client's allergies. d. Review laboratory results. e. Hold the client's bronchodilator. f. Monitor the client for at least 24 hours afterwards. (24)

ANS: B, C, D, F Prior to a bronchoscopy, the nurse would verify that the informed consent was obtained, keep the client NPO for 4 to 8 hours prior to the procedure or per agency policy to prevent aspiration, document allergies, and review laboratory results including complete blood count and bleeding times. There is no reason to hold the client's bronchodilator prior to this procedure. The nurse will monitor the client at least every 4 hours for 24 hours.

An emergency department nurse assesses a female client. Which assessment findings would alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.) a. Hypertension b. Fatigue despite adequate rest c. Indigestion d. Abdominal pain e. Shortness of breath (30)

ANS: B, C, E Women may not have chest pain with myocardial infarction, but may feel discomfort or indigestion. They often present with a triad of symptoms—indigestion or feeling of abdominal fullness, feeling of chronic fatigue despite adequate rest, and feeling unable to catch their breath. Frequently, women are not diagnosed and therefore are not treated adequately. Hypertension and abdominal pain are not associated with acute coronary syndrome

The nurse is teaching a client with obstructive sleep apnea (OSA) about the prescribed CPAP. What information does the nurse include? (Select all that apply.) a. Insurance will cover the cost if you wear it at least 4 hours a day. b. Once the delivery mask is adjusted, do not loosen the straps. c. The CPAP provides pressure that holds your upper airways open. d. You need to clean the mask at least once a week to prevent infection. e. The humidification increases the risk of fungal infections. f. Be patient when first using the system, it can be frustrating at first (26)

ANS: B, C, E, F A CPAP for OSA provides pressure that keeps the upper airway open. A properly fitting mask or nasal pillows is necessary to provide the pressure. Humidification in the system leads to an increased risk for fungal infections. Patients may have anxiety about using the equipment and worry about it being disruptive; most clients have a period of adjustment when first starting to use a CPAP. Medicare will usually cover the cost if the client wears the CPAP at least 6 hours a day. The mask or pillows should be cleaned daily

A nurse assesses a young female client who is prescribed tazarotene. 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?" (23)

ANS: C Tazarotene has many side effects. It is a known teratogen and can cause severe birth defects. Strict birth control measures must be used during therapy. The other questions are not directly related to this medication.

The nurse assesses a client for factors that place the client at risk for cataracts. Which factor places the client at the highest risk for cataract development? a. Heart disease b. Glaucoma c. Diabetes mellitus d. Advanced age (42)

ANS: D Advanced age is the major risk factor for developing cataracts because the lens loses water and lens fibers become more compact.

cranial nerve functions

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A nurse auscultates a harsh hollow sound over a client's trachea and larynx. What action would the nurse take first? a. Document the findings. b. Administer oxygen therapy. c. Position the client in high-Fowler position. d. Administer prescribed albuterol. (24)

ANS: A Bronchial breath sounds, including harsh, hollow, tubular, and blowing sounds, are a normal finding over the trachea and larynx. The nurse would document this finding. There is no need to implement oxygen therapy, administer albuterol, or change the client's position because the finding is normal.

The nurse is performing an assessment of cranial nerve III. Which testing is appropriate? a. Pupil constriction b. Deep tendon reflexes c. Upper muscle strength d. Speech and language (38)

ANS: A CN III is the oculomotor nerve which controls eye movement, pupil constriction, and eyelid movement.

The nurse is teaching a client who has pernicious anemia about necessary dietary changes. Which statement by the client indicates understanding about those changes? a. "I'll increase animal proteins like fish and meat." b. "I'll work on increasing my fats and carbohydrates." c. "I'll avoid eating green leafy vegetables. d. "I'll limit my intake of citrus fruits." (37)

ANS: A Clients who have pernicious anemia have a Vitamin B12 deficiency and need to consume foods high in Vitamin B12, such as animal and plant proteins, citrus fruits, green leafy vegetables, and dairy products. While carbohydrates and fats can provide sources of energy, they do not supply the necessary nutrient to improve anemia.

A nurse teaches assistive personnel (AP) about how to care for a client with Parkinson disease. Which statement would the nurse include as part of this teaching? 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." (38)

ANS: A Clients with Parkinson disease do not move as quickly and can have functional problems. The client would 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 would assess the client's ability to eat and swallow; this would not be delegated. Appointments and activities would 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 client presents to the emergency department in sickle cell disease crisis. What intervention by the nurse takes priority? a. Administer oxygen. b. Initiate pulse oximetry. c. Give pain medication. d. Start an IV line. (37)

ANS: A All actions are appropriate, but remembering the ABCs, oxygen would come first. The main problem in a sickle cell crisis is tissue and organ hypoxia, so providing oxygen helps halt the process.

To promote comfort and the passage of flatus after a colonoscopy, in what position does the nurse place the client? a. Left lateral b. Prone c. Right lateral d. Supine (48)

ANS: A After colonoscopy, clients have less discomfort and quicker passage of flatus when placed in the left lateral position

A nurse caring for a client with sickle cell disease (SCD) reviews the client's laboratory test results. Which finding would the nurse report to the primary health care provider? a. Creatinine: 2.9 mg/dL (256 mcmol/L) b. Hematocrit: 30% c. Sodium: 146 mEq/L (146 mmol/L) d. White blood cell count: 12,000/mm3 (12 × 109/L) (37)

ANS: A An elevated creatinine indicates kidney damage, which occurs in SCD. A hematocrit level of 30% is an expected finding, as is a slightly elevated white blood cell count due to chronic inflammation. A sodium level of 146 mEq/L (146 mmol/L), although slightly high, is not concerning.

A client in sickle cell crisis is dehydrated and in the emergency department. The nurse plans to start an IV. Which fluid choice is best? a. 0.45% normal saline b. 0.9% normal saline c. Dextrose 50% (D50) d. Lactated Ringer's solution (37)

ANS: A Because clients in sickle cell crisis are often dehydrated, the fluid of choice is a hypotonic solution such as 0.45% normal saline. 0.9% normal saline and lactated Ringer's solution are isotonic. D50 is hypertonic and not used for hydration.

An older adult has had an instance of drug toxicity and asks why this happens, since the client has been on this medication for years at the same dose. What response by the nurse is best? a. "Changes in your liver cause drugs to be metabolized differently." b. "Perhaps you don't need as high a dose of the drug as before." c. "Stomach muscles atrophy with age and you digest more slowly." d. "Your body probably can't tolerate as much medication anymore." (48)

ANS: A Decreased liver enzyme activity depresses drug metabolism, which leads to accumulation of drugs—possibly to toxic levels. The other options do not accurately explain this age-related change.

The client's electronic health record indicates genu varum. What does the nurse understand this term to mean? a. Bow-legged b. Fluid accumulation c. Knock-kneed d. Spinal curvature (44)

ANS: A Genu varum is a bow-legged deformity. A fluid accumulation is an effusion. Genu valgum is knock-kneed. A spinal curvature could be kyphosis or lordosis.

A client has mastoiditis and is prescribed antibiotics. What health teaching by the nurse is most important for this client? a. "Immediately report headache or stiff neck." b. "Keep all follow-up appointments." c. "Take the antibiotics with a full glass of water." d. "Take the antibiotic on an empty stomach." (43)

ANS: A Meningitis is a complication of mastoiditis. The client should be taught to take all antibiotics as prescribed and to report manifestations of meningitis such as fever, headache, or stiff neck. Keeping follow-up appointments is important for all clients. Without knowing what antibiotic was prescribed, the nurse cannot instruct the client on how to take it.

The nurse notes that the primary health care provider documented the presence of mucosal erythroplasia in a client. What does the nurse understand that this most likely means for this client? a. Early sign of oral cancer b. Fungal mouth infection c. Inflammation of the gums d. Obvious oral tumor (49)

ANS: A Mucosal erythroplasia is the earliest sign of oral cancer. It is not a fungal infection, inflammation of the gums, or an obvious tumor.

A nurse contacts the primary health care provider after reviewing a client's laboratory results and noting a blood urea nitrogen (BUN) of 35 mg/dL (12.5 mmol/L) and a serum creatinine of 1.0 mg/dL (88.4 mcmol/L). What collaborative care measure would the nurse recommend? a. Intravenous fluids b. Hemodialysis c. Fluid restriction d. Urine culture and sensitivity (60)

ANS: A Normal BUN is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). Normal creatinine is 0.6 to 1.2 mg/dL (53.0 to 106.1 mcmol/L) (males) or 0.5 to 1.1 mg/dL (44.2 to 97.2 mcmol/L) (females). Creatinine is more specific for kidney function than BUN, because BUN can be affected by several factors (dehydration, high-protein diet, and catabolism). This client's creatinine is normal, which suggests a nonrenal cause for the elevated BUN. A common cause of increased BUN is dehydration, so the nurse would recommend giving the client more fluids, not placing the client on fluid restrictions. Hemodialysis is not an appropriate treatment for dehydration. The lab results do not indicate an infection; therefore, a urine culture and sensitivity are not appropriate

A clinic nurse is working with an older client. What action is most important for preventing infections in this client? a. Assessing vaccination records for booster shot needs b. Encouraging the client to eat a nutritious diet c. Instructing the client to wash minor wounds carefully d. Teaching hand hygiene to prevent the spread of microbes (16)

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

A nurse teaches a young female client who is prescribed cephalexin for a urinary tract infection. Which statement would the nurse include in this client's teaching? a. "Use a second form of birth control while on this medication." b. "You will experience increased menstrual bleeding while on this drug." c. "You may experience an irregular heartbeat while on this drug." d. "Watch for blood in your urine while taking this medication." (61)

ANS: A The client should use a second form of birth control because antibiotic therapy reduces the effectiveness of estrogen-containing contraceptives. She should not experience increased menstrual bleeding, an irregular heartbeat, or blood in her urine while taking the drug.

A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. What action would the nurse take next? a. Collect the nasal drainage on a piece of filter paper. b. Encourage the client to blow his or her nose. c. Perform a test focused on a neurologic examination. d. Palpate the nose, face, and neck. (26)

ANS: A The client with nasal drainage after facial trauma could have a skull fracture resulting in leakage of cerebrospinal fluid (CSF). CSF can be differentiated from regular drainage by the fact that it forms a halo when dripped on filter paper and tests positive for glucose. The other actions would be appropriate but are not as high a priority as assessing for CSF. A CSF leak would increase the patient's risk for infection

A nurse is assessing a dark-skinned client for pallor. What nursing assessment is best to assess for pallor in this client? a. Assess the conjunctiva of the eye. b. Have the patient open the hand widely. c. Look at the roof of the patient's mouth. d. Palpate for areas of mild swelling. (36)

ANS: A To assess pallor in dark-skinned people, assess the conjunctiva of the eye or the mucous membranes. Looking at the roof of the mouth can reveal jaundice. Opening the hand widely is not related to pallor, nor is palpating for mild swelling.

A client has a foreign body in one eye. What action by the nurse is appropriate for the client's care? a. Administering ordered antibiotics b. Assessing the patient's visual acuity c. Obtaining consent for enucleation d. Removing the object immediately (42)

ANS: A To prevent infection, antibiotics are provided. Visual acuity in the affected eye cannot be assessed. The client may or may not need enucleation. The object is only removed by the ophthalmologist.

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) infection cultured from the urine. What action by the nurse is most appropriate? a. Prepare to administer vancomycin. b. Strictly limit visitors to immediate family only. c. Wash hands only after taking off gloves after care. d. Wear a respirator when handling urine output. (21)

ANS: A Vancomycin is one of a few drugs approved to treat MRSA. The others include linezolid and ceftaroline fosamil. Delafloxacin is a new antibiotic approved to treat MRSA. Visitation does not need to be limited to immediate family only. Hand hygiene is performed before and after wearing gloves. A respirator is not needed, but if splashing is anticipated, a face shield can be used

A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization. What actions would the nurse take prior to the catheterization? (Select all that apply.) a. Assess for allergies to iodine. b. Administer intravenous fluids. c. Assess blood urea nitrogen (BUN) and creatinine results. d. Insert a Foley catheter. e. Administer a prophylactic antibiotic. f. Insert a central venous catheter. (30)

ANS: A, B, C If the client has kidney disease, fluids may be given 12 to 24 hours before the procedure for renal protection. Hydration would continue after the procedure. The client would be assessed for allergies to iodine, including shellfish; the contrast medium used during the catheterization contains iodine. Baseline renal labs would be assessed. A Foley catheter and central venous catheter are not required for the procedure and would only increase the client's risk for infection. Prophylactic antibiotics are not administered prior to a cardiac catheterization

A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? (Select all that apply.) a. The client does not allow smoking in the house. b. Electrical cords are in good working order. c. Flammable liquids are stored in the garage. d. Household light bulbs are the fluorescent type. e. The client does not have pets inside the home. f. No alcohol-based hand sanitizers are present (25)

ANS: A, B, C Oxygen it enhances combustion, so precautions are needed whenever using it. The nurse would assess if the client allows smoking in the house, whether electrical cords are in good shape or are frayed, and if flammable liquids are stored (and used) in the garage away from the oxygen. Light bulbs and pets are not related to oxygen safety. Alcohol-based hand sanitizers are permitted.

For a person to be immunocompetent, which processes need to be functional and interact appropriately with each other? (Select all that apply.) a. Antibody-mediated immunity b. Cell-mediated immunity c. Inflammation d. Red blood cells e. White blood cells (16)

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

******** A nurse assesses an older client. Which assessment findings would the nurse identify as normal changes in the nervous system related to aging? (Select all that apply.) a. Long-term memory loss b. Slower processing time c. Increased sensory perception d. Decreased risk for infection e. Change in sleep patterns (38)

ANS: B, E Normal changes in the nervous system related to aging include recent memory loss, slower processing time, decreased sensory perception, an increased risk for infection, changes in sleep patterns, changes in perception of pain, and altered balance and/or decreased coordination.

A nurse teaches a client who is being discharged after a jaw wiring for a mandibular fracture. Which statements would the nurse include in this patient's teaching? (Select all that apply.) a. "You will need to cut the wires if you start vomiting." b. "Eat six soft or liquid meals each day while recovering." c. "Use a Waterpik for dental hygiene until you can brush again. d. "Sleep in a semi-Fowler position after the surgery." e. "Gargle with mouthwash that contains hydrogen peroxide once a day." (26)

ANS: A, B, C, D The client needs to know how to cut the wires in case of emergency. If the client vomits, he or she may aspirate. The client would also be taught to eat soft or liquid meals multiple times a day, irrigate the mouth with a Waterpik to prevent infection, and sleep in a semi-Fowler position to assist in avoiding aspiration. Mouthwash with hydrogen peroxide is not a recommendation.

A female client is preparing to have open magnetic resonance imaging (MRI) of the spine. What action(s) by the nurse is (are) most important to assess before the test? (Select all that apply.) a. Ask if the client has a history of kidney disease. b. Ask the client if she could possibly be pregnant. c. Ensure that the patient has no metal or electronic implants. d. Assess the client for the ability to communicate. e. Assess the client for a history of claustrophobia (44)

ANS: A, B, C, D The contrast agent that is used for an MRI is gadolinium which can cause complications if the client is pregnant or has kidney disease. The client needs to be able to communicate and should not have any metal or electronic implants due to the magnetic nature of the machine. For an open MRI, claustrophobia is not an issue because the client is not encased in the device.

A nurse assesses a client who is 6 hours postsurgery for a nasal fracture and has nasal packing in place. What actions would the nurse take? (Select all that apply.) a. Observe for clear drainage. b. Assess for signs of bleeding. c. Watch the client for frequent swallowing. d. Ask the client to open his or her mouth. e. Administer a nasal steroid to decrease edema. f. Change the nasal packing. (26)

ANS: A, B, C, D The nurse would observe for clear drainage because of the risk for cerebrospinal fluid leakage. The nurse would assess for signs of bleeding by asking the client to open his or her mouth and observing the back of the throat for bleeding. The nurse would also note whether the client is swallowing frequently because this could indicate postnasal bleeding. A nasal steroid would increase the risk for infection. It is too soon to change the packing, which would be changed by the surgeon the first time.

The nurse is teaching a client about care after surgery to repair a retinal detachment. What health teaching would the nurse include? (Select all that apply.) a. "Report sudden pain in the surgical eye." b. "Report if the surgical eye remains dilated." c. "Avoid close vision activities in the first week." d. "Avoid activities that increase intraocular pressure." e. "Report sudden reduced visual acuity."

ANS: A, B, C, D, E All of these instructions are important for the client who has a retinal detachment repair.

The nurse is teaching a client about the risk of uncontrolled or untreated the client's gastroesophageal reflux disease (GERD). What complication(s) may occur if the GERD is not successfully managed? (Select all that apply.) a. Asthma b. Laryngitis c. Dental caries d. Cardiac disease e. Cancer (49)

ANS: A, B, C, D, E Any of these complications may occur in clients who have uncontrolled or untreated GERD

A nurse is teaching a community group about the long-term effects of untreated sleep apnea. What information does the nurse include? (Select all that apply.) a. Hypertension b. Stroke c. Weight gain d. Diabetes e. Cognitive deficits f. Pulmonary disease (26)

ANS: A, B, C, D, E, F The long-term effects of untreated sleep apnea include increased risk for hypertension, stroke, cognitive deficits, weight gain, diabetes, and pulmonary and cardiovascular disease.

The nurse is caring for a client after ear surgery. What health teaching instruction(s) would the nurse provide for this client to promote healing? (Select all that apply.) a. "Avoid straining when having a bowel movement." b. "Avoid drinking through a straw for 2 to 3 weeks." c. "Avoid air travel for 2 to 3 weeks after surgery." d. "Avoid crowds and people with infection, especially respiratory infection." e. "Avoid moving your head quickly, jumping, or bending over for 2 to 3 weeks." f. "Blow your nose very gently without blocking either nostril and keep your mouth open." (43)

ANS: A, B, C, D, E, F It is imperative that the patient having ear surgery is free from ear infection. The other precautions help to prevent increased intra-ear pressure which can affect the surgical procedure

A client had an endoscopic retrograde cholangiopancreatography (ERCP). The nurse teaches the client and family about the signs of potential complications which include what problems? (Select all that apply.) a. Cholangitis b. Pancreatitis c. Perforation d. Renal lithiasis e. Sepsis (48)

ANS: A, B, C, E Possible complications after an ERCP include cholangitis, pancreatitis, perforation, sepsis, and bleeding. Kidney stones are not a complication of ERCP.

A nurse is teaching a client about possible complications and hazards of home oxygen therapy. About which complications does the nurse plan to teach the client? (Select all that apply.) a. Absorptive atelectasis b. Combustion c. Dried mucous membranes d. Alveolar recruitment e. Toxicity (25)

ANS: A, B, C, E Complications of oxygen therapy include absorptive atelectasis, combustion, dried mucous membranes, and oxygen toxicity. Alveolar recruitment may be a benefit of high-flow nasal cannulas such as Vapotherm, which both humidifies and warms the oxygen.

The nurse working with older clients understands age-related changes in the gastrointestinal system. Which changes does this include? (Select all that apply.) a. Decreased hydrochloric acid production b. Diminished sensation that can lead to constipation c. Fat not digested as well in older adults d. Increased peristalsis in the large intestine e. Pancreatic vessels become calcified (48)

ANS: A, B, C, E Several age-related changes occur in the gastrointestinal system. These include decreased hydrochloric acid production, diminished nerve function that leads to decreased sensation of the need to pass stool, decreased fat digestion, decreased peristalsis in the large intestine, and calcification of pancreatic vessels

A nurse asks the supervisor why older adults are more prone to infection than other adults. What reasons does the supervisor give? (Select all that apply.) a. Age-related decrease in immune function b. Decreased cough and gag reflexes c. Diminished acidity of gastric secretions d. Increased lymphocytes and antibodies e. Thinning skin that is less protective f. Higher rates of chronic illness (21)

ANS: A, B, C, E, F Older adults have several age-related changes making them more susceptible to infection, including decreased immune function, decreased cough and gag reflex, decreased acidity of gastric secretions, thinning skin, fewer lymphocytes and antibodies, and higher rates of chronic illness.

A nurse assesses a client who has had two episodes of bacterial cystitis in the last 6 months. Which question(s) would the nurse ask? (Select all that apply.) a. "How much water do you drink every day?" b. "Do you take estrogen replacement therapy?" c. "Does anyone in your family have a history of cystitis?" d. "Are you on steroids or other immune-suppressing drugs?" e. "Do you drink grapefruit juice or orange juice daily?" (61)

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

A nurse cares for clients with urinary incontinence. Which types of incontinence are correctly paired with their description? (Select all that apply.) a. Stress incontinence—urine loss with physical exertion b. Urge incontinence—loss of urine upon feeling the need to void c. Functional incontinence—urine loss results from abnormal detrusor contractions d. Overflow incontinence—constant dribbling of urine e. Reflex incontinence—leakage of urine without lower urinary tract disorder (61)

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

The nurse is teaching an elderly client the risks of infection for older adults. Which of the following factors would the nurse include in the education? (Select all that apply.) a. Higher risk for respiratory tract and genitourinary infections. b. May not have a fever with severe infection. c. Show expected changes in white blood cell counts. d. Should receive influenza, pneumococcal, and shingles vaccinations. e. Skin tests for tuberculosis may be falsely negative. f. Booster vaccinations are not likely needed as one ages. (16)

ANS: A, B, D, E Immunity changes during an adult's life and older adults have decreased immune function. The number and function of neutrophils and macrophages are reduced leading to reduced response to infection and injury, such as temperature elevation. The usual response of an increased white blood cell count is delayed or absent. Older adults are less able to make new antibodies in response to the presence of new antigens requiring repeat vaccinations and immunizations. Skin tests for tuberculosis may be falsely negative and there is an increased risk for bacterial and fungal infections due to the decreased number of circulating T-lymphocytes.

A nurse assesses a client with an injury to the medulla. Which clinical manifestations would the nurse expect to find? (Select all that apply.) a. Decreased respiratory rate b. Impaired swallowing c. Visual changes d. Inability to shrug shoulders e. Loss of gag reflex (38)

ANS: A, B, D, E Cranial nerves IX (glossopharyngeal), X (vagus), XI (accessory), and XII (hypoglossal) emerge from the medulla, as do portions of cranial nerves VII (facial) and VIII (acoustic). Damage to these nerves causes decreased respirations, impaired swallowing, inability to shrug shoulders, and loss of the gag reflex. The other manifestations are not associated with damage to the medulla.

A nurse is assessing a community group for dietary factors that contribute to osteoporosis. In addition to inquiring about calcium, the nurse also assesses for which other dietary components? (Select all that apply.) a. Alcohol b. Caffeine c. Fat d. Carbonated beverages e. Vitamin D (45)

ANS: A, B, D, E Dietary components that affect the development of osteoporosis include alcohol, caffeine, high phosphorus intake, carbonated beverages, and vitamin D. Tobacco is also a contributing lifestyle factor. Fat intake does not contribute to osteoporosis.

The nurse teaches assistive personnel about age-related changes that affect the eyes and vision. Which changes would the nurse include? (Select all that apply.) a. Decreased eye muscle tone b. Development of arcus senilis c. Increase in far point of near vision d. Decrease in general color perception e. Increase in point of near vision (42)

ANS: A, B, D, E Normal age-related changes include decreased eye muscle tone, development of arcus senilis, decreased color perception, and increased point of near vision. The far point of near vision typically decreases.

A nurse cares for many clients with pressure injuries. What actions by the nurse are considered best practice? (Select all that apply.) a. Conduct ongoing assessments that include pain. b. Use normal saline to cleanse around the pressure injury. c. Soak eschar daily until it softens and can be removed. d. Consult with a registered dietitian nutritionist. e. Use antimicrobial agents to clean wounds that are infected. f. Consider the use of adjuvant therapies for nonhealing wounds. (23)

ANS: A, B, D, E, F Best practice for pressure injury wound management includes ongoing assessments that include pain, using normal saline to clean gently around the wound, ensuring optimal nutrition by involving a registered dietitian nutritionist, using an antimicrobial agent to clean wounds that are anticipated to become infected, and considering the use of adjuvant therapies such as stimulation, negative-pressure wound therapy, ultrasound, hyperbaric oxygen, and topical growth factors. The nurse would not disturb stable eschar

What statements about the complement system are correct? (Select all that apply.) a. Comprised of 20 types of inactive plasma proteins. b. Act as enzymes when activated to enhance innate immunity. c. Phagocytize foreign invaders quickly by destroying their membranes. d. Sticks to the antigen and forms a membrane attack complex. e. Maintain and prolong inflammation from non-self cells. f. Is part of the innate immune system. (16)

ANS: A, B, D, F The complement system is made up of 20 different types of inactive plasma proteins that, when activated, act as enzymes to enhance (or complement) cell actions in innate immunity. They join other proteins to surround antigens and "fix" or stick to the antigen quickly forming a membrane attack complex on the antigen surface. This action makes immune cell attachment to antigens and phagocytosis more efficient. They are part of innate immunity. They do not phagocytize invaders themselves nor do they maintain and prolong inflammation from allergens.

A nurse cares for a client who is recovering from a colonoscopy. Which actions would the nurse take? (Select all that apply.) a. Obtain vital signs every 15 to 30 minutes until alert. b. Assess the client for rectal bleeding and severe pain. c. Administer prescribed pain medications as needed. d. Monitor the client's serum and urine glucose levels. e. Confirm the client has a ride home and plans to rest (48)

ANS: A, B, E During the recovery phase after a colonoscopy, the nurse would obtain vital signs every 15 to 30 minutes until the client is alert, assess for rectal bleeding or severe pain, and confirm the client has arranged for another person to drive home to get rest. Pain medications are not necessary after the procedure, and neither is glucose monitoring.

The nurse assesses a client who is experiencing a common migraine without an aura. Which assessment finding(s) would the nurse expect? (Select all that apply.) a. Headache lasting up to 72 hours b. Unilateral and pulsating headache c. Abrupt loss of consciousness d. Acute confusion e. Pain worsens with physical activities f. Photophobia (39)

ANS: A, B, E, F A common migraine with an aura is usually accompanied by photophobia, phonophobia, unilateral and pulsating pain, and nausea and/or vomiting. These migraines usually last 4 to 72 hours and are aggravated by physical activity. Loss of consciousness and acute confusion are not associated with a common migraine without an aura.

A nurse plans care for an older adult patient. Which interventions should the nurse include in this client's plan of care to promote kidney health? (Select all that apply.) a. Ensure adequate fluid intake. b. Leave the bathroom light on at night. c. Encourage use of the toilet every 6 hours. d. Delegate bladder training instructions to the assistive personnel (AP). e. Provide thorough perineal care after each voiding. f. Assess for urinary retention and urinary tract infection. (60)

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

The nurse is caring for a client with sialadenitis. What comfort measures are appropriate for this client? (Select all that apply.) a. Applying warm compresses b. Applying ice to salivary glands c. Offering fluids every hour d. Providing lemon-glycerin swabs e. Reminding the patient to avoid speaking (49)

ANS: A, C Warm compresses and fluids can help promote comfort for this client. Application of ice or lemon-glycerin swabs would not be used. Speaking has no effect on this condition.

A client is being admitted with suspected tuberculosis (TB). What actions by the nurse are best? (Select all that apply.) a. Admit the client to a negative-airflow room. b. Maintain a distance of 3 feet (1 m) from the client at all times. c. Obtain specialized respirators for caregiving. d. Other than wearing gloves, no special actions are needed. e. Wash hands with chlorhexidine after providing care. f. Assure client has a respirator for moving between departments. (21)

ANS: A, C A client with suspected TB is admitted to Airborne Precautions, which includes a negative-airflow room and special N95 or PAPR masks to be worn when providing care. A 3-foot (1 m) distance without a mask is required for Droplet Precautions (a nurse providing direct care cannot ensure that he or she will never need to be within 3 feet of the client). Chlorhexidine is used for clients with a high risk of infection. When moving between departments, the client wears a surgical mask.

An older client asks the nurse why "people my age" have weaker immune systems than younger people. What responses by the nurse are best? (Select all that apply.) a. "Bone marrow produces fewer blood cells as you age." b. "You may have decreased levels of circulating platelets." c. "You have lower levels of plasma proteins in the blood." d. "Lymphocytes become more reactive to antigens." e. "Spleen function declines after age 60." (36)

ANS: A, C The aging adult has bone marrow that produces fewer cells and decreased blood volume with fewer plasma proteins. Platelet numbers remain unchanged, lymphocytes become less reactive, and spleen function stays the same.

The nurse assesses a client who has Parkinson disease. Which signs and symptoms would the nurse recognize as a key feature of this disease? (Select all that apply.) a. Flexed trunk b. Long, extended steps c. Slow movements d. Uncontrolled drooling e. Tachycardia (39)

ANS: A, C, D Key features of Parkinson disease include a flexed trunk, slow and hesitant steps, bradykinesia, and uncontrolled drooling. Tachycardia is not a key feature of this disease.

The nurse is learning about immunoglobulins. . Which principles does the nurse learn? (Select all that apply.) a. IgA is found in high concentrations in secretions from mucous membranes. b. IgD is present in the highest concentrations in mucous membranes. c. IgE is associated with antibody-mediated hypersensitivity reactions. d. IgG comprises the majority of the circulating antibody population. e. IgM is the first antibody formed by a newly sensitized B-cell. (16)

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

A nurse is studying the function of immunoglobulins. Which immunoglobulins are correctly matched to their function? (Select all that apply.) a. IgA: most responsible for preventing infection in the respiratory tracts, the GI tract, and the genitourinary tract. b. IgD: provides protection against parasite infestations, especially helminths. c. IgE: associated with antibody-mediated immediate hypersensitivity reactions. d. IgG: activates classic complement pathway and enhances neutrophil and macrophage actions. e. IgM: first antibody formed by a newly sensitized B-lymphocyte plasma cell (16)

ANS: A, C, D, E All options are true except IgD acts as a B-cell antigen receptor. IgE provides protection against parasite infestations, especially helminths.

A nurse working with clients diagnosed with sickle cell disease (SCD) teaches about self-management to prevent exacerbations and sickle cell crises. What factor(s) should clients be taught to avoid? (Select all that apply.) a. Dehydration b. Exercise c. Extreme stress d. High altitudes e. Pregnancy (37)

ANS: A, C, D, E Several factors cause red blood cells to sickle in SCD, including dehydration, extreme stress, high altitudes, and pregnancy. Strenuous exercise can also cause sickling, but not unless it is very vigorous.

A client asks the nurse why she has urinary incontinence. What risk factors would the nurse recall in preparing to respond to the client's question? (Select all that apply.) a. Diuretic therapy b. Anorexia nervosa c. Stroke d. Dementia e. Arthritis f. Parkinson disease (61)

ANS: A, C, D, E, F Drugs, such as diuretics, cause frequent voiding, often in large amounts. Diseases or disorders that limit mobility, such as stroke, arthritis, and Parkinson disease, can prevent an individual from getting to the bathroom in a timely manner. Mental/behavioral problems, such as dementia, impair cognition and the ability to recognize when he or she needs to void

A nurse is studying the functions of specific leukocytes. Which leukocytes are matched correctly with their function? (Select all that apply.) a. Monocyte: matures into a macrophage. b. Basophil: releases vasoactive amines during an allergic reaction. c. Plasma cell: secretes immunoglobulins in response to the presence of a specific antigen. d. Cytotoxic T-cells: attacks and destroys ingested poisons and toxins. e. Natural killer cell: nonselectively attacks non-self cells. f. Regulator T-cells: become sensitized for self-recognition in the bone marrow. (16)

ANS: A, C, E Monocytes mature into macrophages, plasma cells secrete immunoglobulin in the presence of specific antigens, and natural killer cells nonselectively attack non-self cells. Basophils release histamines, kinins, and heparin in areas of tissue damage. Cytotoxic T-cells selectively attack and destroy non-self cells, including virally infected cells, grafts, and transplanted organs. Regulator T-cells become sensitized for self-recognition in the thymus.

A nurse reviews a client's laboratory results. Which findings would alert the nurse to the possibility of atherosclerosis? (Select all that apply.) a. Total cholesterol: 280 mg/dL (7.3 mmol/L) b. High-density lipoprotein cholesterol: 50 mg/dL (1.3 mmol/L) c. Triglycerides: 200 mg/dL (2.3 mmol/L) d. Serum albumin: 4 g/dL (5.8 mcmol/L) e. Low-density lipoprotein cholesterol: 160 mg/dL (4.1 mmol/L) (30)

ANS: A, C, E A lipid panel is often used to screen for cardiovascular risk. Total cholesterol, triglycerides, and low-density lipoprotein cholesterol levels are all high, indicating higher risk for cardiovascular disease. High-density lipoprotein cholesterol is within the normal range for both males and females. Serum albumin is not assessed for atherosclerosis

A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure would the nurse assess? (Select all that apply.) a. Thrombophlebitis b. Stroke c. Pulmonary embolism d. Myocardial infarction e. Cardiac tamponade f. Dysrhythmias (30)

ANS: A, C, E Complications from a right-sided heart catheterization include thrombophlebitis, pulmonary embolism, and vagal response. Cardiac tamponade is a risk of both right- and left-sided heart catheterizations. Stroke, myocardial infarction, and dysrhythmias are complications of left-sided heart catheterizations.

The nurse is caring for a client who has Alzheimer disease. The client's wife states, "I am having trouble managing his behaviors at home." Which questions would the nurse ask to assess potential causes of the client's behavior problems? (Select all that apply.) a. "Does your husband bathe and dress himself independently?" b. "Do you weigh your husband each morning around the same time?" c. "Does his behavior become worse around large crowds?" d. "Does your husband eat healthy foods including fruits and vegetables?" e. "Do you have a clock and calendar in the bedroom and kitchen?" (39)

ANS: A, C, E To minimize behavior problems, the nurse would encourage the patient to be as independent as possible with ADLs, minimize excessive simulation, and assist the patient to remain orientated. The nurse would assess these activities by asking if the patient is independent with bathing and dressing, if behavior worsens around crowds, and if a clock and single-date calendar are readily available. Diet and weight are not related to the management of behavior problems for a patient who has Alzheimer disease.

The nurse is planning health teaching for a client starting mirabegron for urinary incontinence. What health teaching would the nurse include? (Select all that apply.) a. "Monitor blood tests carefully if you are prescribed warfarin." b. "Avoid crowds and individuals with infection." c. "Report any fever to your primary health care provider." d. "Take your blood pressure frequently at home." e. "Report palpitations or chest soreness that may occur." (61)

ANS: A, D This drug can cause increase blood pressure and, therefore, the client's blood pressure should be monitored. Mirabegron can increase the effect of warfarin causing bleeding or bruising. The client will need additional coagulation studies to ensure that the INR is within a therapeutic range.

A nurse assesses a client who is prescribed varenicline for smoking cessation. Which signs or symptoms would the nurse identify as adverse effects of this medication? (Select all that apply.) a. Visual hallucinations b. Tachycardia c. Decreased cravings d. Manic behavior e. Increased thirst f. Orangish urine (24)

ANS: A, D Varenicline has a black box warning stating that the drug can cause manic behavior and hallucinations. The nurse would assess for changes in behavior and thought processes, including manic behaviors and visual hallucinations. Tachycardia, increased thirst, and orange-colored urine are not adverse effects of this medication. Decreased cravings are a therapeutic response to this medication.

A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements would the nurse include in communications with the respiratory therapist prior to the tests? (Select all that apply.) a. "I held the client's morning bronchodilator medication." b. "The client is ready to go down to radiology for this examination." c. "Physical therapy states the client can run on a treadmill." d. "I advised the client not to smoke for 6 hours prior to the test." e. "The client is alert and can follow your commands." (24)

ANS: A, D, E To ensure that the PFTs are accurate, the therapist needs to know that no bronchodilators have been administered in the past 4 to 6 hours (depending on the suspected cause), the client did not smoke within 6 to 8 hours prior to the test, and the client can follow basic commands, including different breathing maneuvers. The respiratory therapist can perform PFTs at the bedside or the respiratory lab. A treadmill is not used for this test.

The nurse is caring for a client in late-stage Alzheimer disease. Which assessment finding(s) will the nurse anticipate? (Select all that apply.) a. Immobile b. Has difficulty driving c. Wandering d. ADL dependent e. Incontinent f. Possible seizures (39)

ANS: A, D, E, F The client in late-stage Alzheimer disease is totally bedridden and immobile, and therefore, cannot ambulate to wander or drive. The client is incontinent and ADL dependent.

A nurse assesses a client who presents with early koilonychias. Which assessments will the nurse complete next? (Select all that apply.) a. Review the client's health history for a diagnosis of iron deficiency anemia. b. Palpate the client's nail base for potential edemata and sponginess. c. Ask the client about prolonged contact with chemical irritants. d. Assess the client for signs of chronic obstructive pulmonary disease. e. Request a prescription to assess the client's hemoglobin A1C. (22)

ANS: A, E Early koilonychias manifests as flattening of the nail plate with an increased smoothness of the nail. This is caused by iron deficiency with or without anemia, poorly controlled diabetes, and local injury. Nails with visible edema and sponginess when palpated are associated with clubbing. Chronic obstructive pulmonary disease may cause clubbing of the nails and chemical irritants are associated with late koilonychias.

A client had a retinal detachment and has undergone surgical correction. What discharge health teaching is most important for the nurse to include? a. "Avoid reading, writing, or close work such as sewing." b. "Report immediate loss of vision of pain in the affected eye." c. "Keep the follow-up appointment with the ophthalmologist." d. "Remove your eye patch every hour for eyedrops." (42)

ANS: B After surgery for retinal detachment, the client is advised to avoid reading, writing, and close work because these activities cause rapid eye movements. However, more importantly is the need for the client or family to report loss of vision or pain in the surgical eye. Keeping a postoperative appointment is important for any surgical patient. The eye patch is not removed for eyedrops after retinal detachment repair

A nurse reviews the health history of a client with an oversecretion of renin. Which disorder would the nurse correlate with this assessment finding? a. Alzheimer disease b. Hypertension c. Diabetes mellitus d. Viral hepatitis (60)

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

The nurse knows that a client with prolonged prothrombin time (PT) values (not related to medication) probably has dysfunction in which organ? a. Kidneys b. Liver c. Spleen d. Stomach (48)

ANS: B Severe acute or chronic liver damage leads to a prolonged PT secondary to impaired synthesis of clotting proteins. The other organs are not related to this issue

A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention would the nurse be prepared to implement while this client waits for surgery? a. Administration of IV furosemide b. Initiation of an external pacemaker c. Assistance with endotracheal intubation d. Placement of central venous access (30)

ANS: B The RCA supplies the right atrium, right ventricle, inferior portion of the left ventricle, and atrioventricular (AV) node. It also supplies the sinoatrial node in 50% of people. If the client totally occludes the RCA, the AV node would not function and the client would go into heart block, so emergency pacing would be available for the client. Furosemide, intubation, and central venous access will not address the primary complication of RCA occlusion, which is AV node (and possibly SA node) malfunction.

A client has a bone density score of -2.8. What intervention would the nurse anticipate based on this assessment? a. Asking the client to complete a food diary b. Planning to teach about bisphosphonates c. Scheduling another scan in 2 years d. Scheduling another scan in 6 months (45)

ANS: B A T-score from a bone density scan at or lower than -2.5 indicates osteoporosis. The nurse would plan to teach about medications used to treat this disease, such as the bisphosphonates. A food diary is helpful to determine if the client gets adequate calcium and vitamin D, but at this point, dietary changes will not prevent the disease. Simply scheduling another scan will not help treat the disease either - need to be able to sit up for 30 to 60 minutes after taking bisphophonates

A nurse evaluates the following data in a client's chart: Admission Note A 78-year-old male with a past medical history of atrial fibrillation is admitted with a chronic leg wound Prescriptions Warfarin sodium (Coumadin) Sotalol (Betapace) Wound Care Negative-pressure wound therapy (NPWT) to leg wound Based on this information, which action would the nurse take first? a. Assess the client's vital signs and initiate continuous telemetry monitoring. b. Contact the primary health care provider to discuss the treatment c. Consult the wound care nurse to apply the VAC device. d. Obtain a prescription for a low-fat, high-protein diet with vitamin supplements (23)

ANS: B A client on anticoagulants is not a candidate for NPWT because of the incidence of bleeding complications. The health care primary health care provider needs this information quickly to plan other therapy for the client's wound. The nurse would contact the wound care nurse after alternative orders for wound care are prescribed. Vital signs and telemetry monitoring are appropriate for a client who has a history of atrial fibrillation and would be implemented as routine care for this client. A low-fat, high-protein diet with vitamin supplements will provide the client with necessary nutrients for wound healing but can be implemented after wound care, vital signs, and telemetry monitoring.

A client has been prescribed denosumab. What health teaching about this drug is most appropriate for the nurse to include? a. "Drink at least 8 ounces (240 mL) of water with it." b. "Make appointments to come get your injection." c. "Sit upright for 30 to 60 minutes after taking it." d. "Take the drug on an empty stomach." (45)

ANS: B Denosumab is given by subcutaneous injection twice a year. The client does not need to drink 8 ounces (240 mL) of water with this medication as it is not taken orally. The client does not need to remain upright for 30 to 60 minutes after taking this medication, nor does the client need to take the drug on an empty stomach.

A nurse assesses a client and identifies that the client has pale conjunctivae. Which focused assessment will the nurse complete next? a. Partial thromboplastin time b. Hemoglobin and hematocrit c. Liver enzymes d. Basic metabolic panel (22)

ANS: B Pale conjunctivae signify anemia. The nurse will assess the client's hemoglobin and hematocrit to confirm anemia. The other laboratory results do not relate to this client's potential anemia.

A nurse is teaching a client who experiences migraine headaches and is prescribed propranolol. Which statement would the nurse include in this client's teaching? a. "Take this drug only when you have symptoms indicating the onset of a migraine headache." b. "Take this drug as prescribed, 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 drug will have no effect on your heart rate or blood pressure because you are taking it for migraines." (39)

ANS: B Propranolol is a beta-adrenergic blocker which is 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 would monitor these side effects. The other responses do not discuss appropriate uses of this drug.

The nurse obtains a health history on a client prior to administering prescribed sumatriptan succinate for migraine headaches. Which condition would alert the nurse to withhold the medication and contact the primary health care provider? a. Bronchial asthma b. Heart disease c. Diabetes mellitus d. Rheumatoid arthritis (39)

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 heart disease, hypertension, or Prinzmetal angina. The other conditions would not affect the client's treatment. DIF: Appl

The nurse is teaching assistant personnel (AP) about care of an older ambulatory adult who has osteopenia. Which statement by the AP indicates understanding of the teaching? a. "I will tell the client to change positions frequently to prevent pressure injury." b. "I will remind the client to take frequent walks to strengthen bones." c. "I will assist the client with activities of daily living as needed." d. "I will apply warm compresses to the joints to relieve pain." (44)

ANS: B The ambulatory client who has osteopenia has experienced bone loss. Therefore, taking walks as a weight-bearing exercise helps to prevent further bone loss. The client does not have joint pain and does not need assistance or position changes because the client is ambulatory and probably independent.

When assessing a client who had a traumatic brain injury, the nurse notes that the client is drowsy but easily aroused. What level of consciousness will the nurse document to describe this client's current level of consciousness? a. Alert b. Lethargic c. Stuporous d. Comatose (38)

ANS: B The client is categorized as being lethargic because he or she can be easily aroused even though drowsy. The nurse would carefully monitor the client to determine any decrease in the level of consciousness (LOC).

The nursing is teaching a client diagnosed with gastroesophageal reflux disease (GERD) who is planning to have an endoscopic radiofrequency (Stretta) procedure. What preprocedure health teaching would the nurse include? (Select all that apply.) a. "You will need to be on a liquid diet for the first week after the procedure." b. "Avoid taking any NSAIDs like ibuprofen for 10 days before the procedure." c. "Contact the primary health care provider after the procedure if you have increased pain." d. "You will need a nasogastric tube for a few days after the procedure." e. "You will have a small incision in your stomach area that will have a wound closure. (49)

ANS: B, C The client having this procedure does not have an incision and will not require a nasogastric tube (NGT). The client should avoid an NGT placement for at least a month after the procedure. A liquid diet is required for only 24 hours after the procedure and then the client should progress to include soft floods like custard and applesauce.

An older client's serum calcium level is 8.7 mg/dL (2.18 mmol/L). What possible etiology(ies) does the nurse consider for this result? (Select all that apply.) a. Good dietary intake of calcium and vitamin D b. Normal age-related decrease in serum calcium c. Possible occurrence of osteoporosis or osteopenia d. Potential for metastatic cancer or Paget disease e. Recent bone fracture in a healing stage (44)

ANS: B, C This slightly low calcium level could be an age-related decrease in serum calcium or could indicate a metabolic bone disease, such as osteoporosis or osteopenia. A good dietary intake would be expected to produce normal values. Metastatic cancer, Paget disease, or healing bone fractures will elevate calcium.

A nurse works in a gerontology clinic. What age-related change(s) related to the hematologic system will the nurse expect during health assessment? (Select all that apply.) a. Dentition deteriorates with more cavities. b. Nail beds may be thickened or discolored. c. Progressive loss or thinning of hair occurs. d. Sclerae begin to turn yellow or pale. e. Skin becomes more oily. (36)

ANS: B, C Common findings in older adults include thickened or discolored nail beds, dry (not oily) skin, and thinning hair. The nurse adapts to these changes by altering assessment techniques. Having more dental caries and changes in the sclerae are not normal age-related changes.

A nurse is learning about the types of different cells involved in the inflammatory response. Which principles does the nurse learn? (Select all that apply.) a. Basophils are only involved in the general inflammatory process. b. Eosinophils increase during allergic reactions and parasitic invasion. c. Macrophages can participate in many episodes of phagocytosis. d. Monocytes turn into macrophages after they enter body tissues. e. Neutrophils can only take part in one episode of phagocytosis. (16)

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

A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply.) a. Blood pressure of 140/88 mm Hg b. Serum potassium of 2.9 mEq/L (2.9 mmol/L) c. Warmth and redness at the site d. Expanding groin hematoma e. Rhythm changes on the cardiac monitor f. Oxygen saturation 93% on room air (30)

ANS: B, D, E After a cardiac catheterization, the nurse monitors vital signs, entry site, cardiac function, and distal circulation. The potassium is very low which can lead to dysrhythmias. An expanding hematoma signifies bleeding. Rhythm changes on the monitor are a known complication. These findings would require prompt action. The client's blood pressure is slightly elevated but does not need immediate action. Warmth and redness at the site would indicate an infection, but this would not be present in the first few hours. The oxygen saturation is slightly low but not critical and there is no baseline to compare it to.

A nurse prepares a client for a pharmacologic stress echocardiogram. What actions would the nurse take when preparing this client for the procedure? (Select all that apply.) a. Assist the primary health care provider to place a central venous access device. b. Prepare for continuous blood pressure and pulse monitoring. c. Administer the client's prescribed beta blocker. d. Give the client nothing by mouth 3 to 6 hours before the procedure. e. Explain to the client that dobutamine will simulate exercise for this examination. (30)

ANS: B, D, E Clients receiving a pharmacologic stress echocardiogram will need peripheral venous access and continuous blood pressure and pulse monitoring. The client must be NPO 3 to 6 hours prior to the procedure. Education about dobutamine, which will be administered during the procedure, would be performed. Beta blockers are often held prior to the procedure as they lower the heart rate and may result in inaccurate results.

A nurse assesses a client who is recovering from a thoracentesis. Which assessment findings would alert the nurse to a potential pneumothorax? (Select all that apply.) a. Bradycardia b. New-onset cough c. Purulent sputum d. Tachypnea e. Pain with respirations f. Rapid, shallow respirations (24)

ANS: B, D, E Symptoms of a pneumothorax include tachycardia, tachypnea, new-onset "nagging" cough, and pain that is worse at the end of inhalation and the end of exhalation on the affected side. Additional symptoms include trachea slanted to the unaffected side, cyanosis, and the affected side of the chest that does not move in and out with respirations. Purulent sputum is a symptom of infection.

A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement would the nurse include in this client's teaching? a. "Make a list of reasons why smoking is a bad habit." b. "Rise slowly when getting out of bed in the morning." c. "Smoking while taking this medication will increase your risk of a stroke." d. "Stopping this medication suddenly increases your risk for a heart attack." (24)

ANS: C Clients who smoke while using drugs for nicotine replacement therapy increase the risk of stroke and heart attack. Nurses would teach clients not to smoke while taking these drugs. The nurse would encourage the client to make a list of reasons for stopping the habit but would not phrase it so judgmentally. Orthostatic hypotension is not a risk with nicotine replacement therapy. Stopping suddenly does not increase the risk of heart attack.

The nurse is teaching the daughter of a client who has middle-stage Alzheimer disease. The daughter asks, "Will the sertraline my mother is taking improve her dementia?" How would the nurse respond about the purpose of the drug? a. "It will allow your mother to live independently for several more years." b. "It is used to halt the advancement of Alzheimer 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." (39)

ANS: C Drug therapy is not effective for treating dementia or halting the advancement of Alzheimer disease. However, certain psychoactive drugs may help suppress emotional disturbances and manage depression, psychoses, or anxiety. Drug therapy will not allow the client with middle-stage dementia to safely live independently.

A nurse assesses female client who is experiencing a myocardial infarction. Which clinical manifestation would the nurse expect? a. Excruciating pain on inspiration b. Left lateral chest wall pain c. Fatigue and shortness of breath d. Numbness and tingling of the arm (30)

ANS: C In women, fatigue, shortness of breath, and indigestion may be the major symptoms of myocardial infarction caused by poor cardiac output. Chest pain is the classic symptom of myocardial infarction and can be present in women. Pain on inspiration may be related to a pleuropulmonary cause. Numbness and tingling of the arm could also be related to the myocardial infarction, but are not known to be specific symptoms for women having and MI.

A nurse reviews the urinalysis results of a client and notes a urine osmolality of 1200 mOsm/kg (1200 mmol/kg). Which action would the nurse take? a. Contact the primary health care provider to recommend a low-sodium diet. b. Prepare to administer an intravenous diuretic. c. Encourage the client to drink more fluids. d. Obtain a suction device and implement seizure precautions. (60)

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

The client's electronic health record indicates a sensorineural hearing loss. What assessment question does the nurse ask to determine the possible cause? a. "Do you feel like something is in your ear?" b. "Do you have frequent ear infections?" c. "Have you been exposed to loud noises?" d. "Have you been told your ear bones don't move?" (43)

ANS: C Sensorineural hearing loss can occur from damage to the cochlea, the eighth cranial nerve, or the brain. Exposure to loud music is one etiology. The other questions are related to conductive hearing loss.

A nurse is teaching a client and family about self-care at home for the client's wound infected with methicillin-resistant Staphylococcus aureus. What statement by the client indicates a need to review the information? a. "I will keep dry bandages on the wound and change them when drainage appears." b. "I will shower instead of taking a bath in the bathtub each day." c. "If the dressing is dry, I can sit or sleep anywhere in the house." d. "I will clean exposed household surfaces with a bleach and water mixture." (23)

ANS: C The client should not sit on upholstered furniture or sleep in the same bed as another person until the infection has cleared. The other statements show good understanding.

A nurse is caring for a client who had a modified uvulopalatopharyngoplasty (modUPPP) earlier in the day for obstructive sleep apnea. Which assessment finding indicates that a priority goal has been met? a. Client reports pain is controlled satisfactorily with analgesic regime. b. Client does not have foul odor to the breath or beefy red mucus membranes. c. Client is able to swallow own secretions without drooling. d. Client's vital signs are within normal parameters. (26)

ANS: C The priority after a modUPPP is maintaining a patent airway. The client who has a patent airway can swallow his or her own secretions without drooling. Controlled pain is important, but not the priority. Foul breath odor and beefy red mucus membranes indicate possible infection, which probably would not occur this soon after surgery, but preventing infection does not take priority over airway. Vital signs "within normal parameters" are vague.

A nurse is caring for four clients. After reviewing today's laboratory results, which client would the nurse assess first? a. Client with an international normalized ratio of 2.8 b. Client with a platelet count of 128,000/mm3 (128 × 109/L). c. Client with a prothrombin time (PT) of 28 seconds d. Client with a red blood cell count of 5.1 million/mcL (5.1 × 1012/L) (36)

ANS: C A normal PT is 11 to 12.5 seconds. This client is at high risk of bleeding with a PT of 28 seconds. The other values are within normal limits.

A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention? a. Client reports being dizzy—nurse calls the Rapid Response Team. b. Client's heart rate is 55 beats/min—nurse withholds pain medication. c. Client has reduced breath sounds—nurse calls primary health care provider immediately. d. Client's respiratory rate is 18 breaths/min—nurse decreases oxygen flow rate. (24)

ANS: C A potentially serious complication after biopsy is pneumothorax, which is indicated by decreased or absent breath sounds. The primary health care provider needs to be notified immediately. Dizziness without other data would not lead the nurse to call the RRT. If the client's heart rate is 55 beats/min, no reason is known to withhold pain medication. A respiratory rate of 18 breaths/min is a normal finding and would not warrant changing the oxygen flow rate.

A nurse is teaching a client with cerebellar function impairment. Which statement would the nurse include in this client's discharge teaching? a. "Connect a light to flash when your door bell rings." b. "Label your faucet knobs with hot and cold signs." c. "Ask a friend to drive you to your follow-up appointments." d. "Use a natural gas detector with an audible alarm." (38)

ANS: C Cerebellar function enables the client to predict distance or gauge the speed with which one is approaching an object, control voluntary movement, maintain equilibrium, and shift from one skilled movement to another in an orderly sequence. A client who has cerebellar function impairment should not be driving. The client would not have difficulty hearing, distinguishing between hot and cold, or smelling.

A client is having an esophagogastroduodenoscopy (EGD) and has been given midazolam hydrochloride. The client's respiratory rate is 8 breaths/min. What action by the nurse is appropriate? a. Administer naloxone. b. Call the Rapid Response Team. c. Provide physical stimulation. d. Ventilate with a bag-valve-mask (48)

ANS: C For an EGD, clients are given mild sedation but would still be able to follow commands. For shallow or slow respirations after the sedation is given, the nurse's most appropriate action is to provide a physical stimulation such as a sternal rub and directions to breathe deeply. Naloxone is not the antidote for midazolam HCl. The Rapid Response Team is not needed at this point. The client does not need manual ventilation.

The nurse assesses the client using the device pictured below to deliver 50% O2: The nurse finds that the mask fits snugly, the skin under the mask and straps is intact, and the flow rate of the oxygen is 3 L/min. What action by the nurse is best? a. Assess the client's oxygen saturation. b. Document these findings in the chart. c. Immediately increase the flow rate. d. Turn the flow rate down to 2 L/min (25)

ANS: C For the venturi mask to deliver high flow of oxygen, the flow rate must be set correctly, usually between 4 and 10 L/min. The client's flow rate is too low and the nurse would increase it. After increasing the flow rate, the nurse assesses the oxygen saturation and documents the findings.

A nurse asks a client to take deep breaths during an electroencephalography. The client asks, "Why are you asking me to do this?" How would the nurse respond? a. "Hyperventilation causes vascular dilation of cerebral arteries, which decreases electoral activity in the brain." b. "Deep breathing helps you to relax and allows the electroencephalograph to obtain a better waveform." c. "Hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity." d. "Deep breathing will help you to blow off carbon dioxide and decreases intracranial pressures." (38)

ANS: C Hyperventilation produces cerebral vasoconstriction and alkalosis, which increase the likelihood of seizure activity. The client is asked to breathe deeply 20 times for 3 minutes. The other responses are not accurate.

After teaching a client with bacterial cystitis who is prescribed phenazopyridine, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? a. "I will not take this drug with food or milk." b. "I will have my partners tested for STIs." c. "An orange color in my urine should not alarm me." d. "I will drink two glasses of cranberry juice daily." (61)

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

A client is scheduled for a tympanoplasty. What action(s) by the nurse are (is) most appropriate? (Select all that apply.) a. Administer preoperative opioids. b. Assess for allergies to local anesthetics. c. Ensure that informed consent is on the health record. d. Give prescribed antivertigo medications. e. Teach that hearing improves immediately (43)

ANS: C Preoperatively, the nurse ensures that informed consent is in the health record. Local anesthetics can be used, but general anesthesia is used more often. Antivertigo medications are not used. Hearing will be decreased immediately after the operation until the ear packing is removed.

A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure injury 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 hemiparesis and incontinence d. A 78 year old requiring assistance to ambulate with a walker (23)

ANS: C Risk factors for development of a pressure injury include lack of mobility, exposure of skin to excessive moisture (e.g., urinary or fecal incontinence), malnourishment, and aging skin. The client with hemiparesis and incontinence has two risk factors. The client with pneumonia has no identified risk factors. The other two are at lower risk if they are not very mobile, but having two risk factors is a higher risk.

A nurse assesses clients in an osteoporosis clinic. Which client would the nurse assess first? a. Client taking calcium with vitamin D who reports flank pain 2 weeks ago. b. Client taking ibandronate who cannot remember when the last dose was. c. Client taking raloxifene who reports unilateral calf swelling. d. Client taking risedronate who reports occasional dyspepsia. (45)

ANS: C The client on raloxifene needs to be assessed first because of the potential for deep vein thrombosis, which is an adverse effect of raloxifene. The client with flank pain may have had a kidney stone but is not acutely ill now. The client who cannot remember taking the last dose of ibandronate can be seen last. The client on risedronate may need to change medications.

A client has thrombocytopenia. What statement indicates that the client understands self-management of this condition? a. "I brush and use dental floss every day." b. "I chew hard candy for my dry mouth." c. "I usually put ice on bumps or bruises." d. "Nonslip socks are best when I walk." (37)

ANS: C The client should be taught to apply ice to areas of minor trauma. Flossing is not recommended. Hard foods should be avoided. The client should wear well-fitting shoes when ambulating.

A client has an open traditional hiatal hernia repair this morning. What is the nurse's priority for client care at this time? a. Managing surgical pain b. Ambulating the client early c. Preventing respiratory complications d. Managing the nasogastric tube (49)

ANS: C The client who has traditional surgery (rather than minimally invasive surgery) is at risk for respiratory complications such as atelectasis and pneumonia because he or she has an incision that may prevent the client from taking deep breaths or using an incentive spirometer. Therefore, the nurse's priority is to prevent these potentially life-threatening respiratory problems.

A hospitalized client's strength of the upper extremities is rated at a 4. What does the nurse understand about this client's ability to perform activities of daily living (ADLs)? a. The client is able to perform ADLs but not lift some items. b. The client is unable to perform ADLs alone. c. No difficulties are expected with ADLs. d. The client would need almost total assistance with ADLs (44)

ANS: C This rating indicates good muscle strength with full range of motion

A new nurse reads a client has a wound "healing by second intention" and asks what that means. Which description by the charge nurse is most accurate? a. "The wound edges have been approximated and stitched together." b. "The wound was stapled together after an infection was cleared up." c. "The wound is an open cavity that will fill in with granulation tissue." d. "The wound was contaminated by debris and can't be closed at all." (23)

ANS: C Wounds healing by second intention are deeper wounds that leave open cavities. These wounds heal as connective tissue fills in the dead space. A wound that has its edges brought together (approximated) and sutured or stapled together is said to be healing by first intention. A wound that was left open while an infection healed and then is closed is an example of healing by third intention. A wound that cannot be closed at all would be left to heal by second intention.

The nurse reviews a list of drugs that can cause secondary osteoporosis.Which drugs are most commonly associated with this health problem? (Select all that apply.) a. Antianxiety agents b. Antibiotics c. Barbiturates d. Corticosteroids e. Loop diuretics (45)

ANS: C, D, E Several classes of drugs can cause secondary osteoporosis, including barbiturates, corticosteroids, and loop diuretics. Antianxiety agents and antibiotics are not associated with the formation of osteoporosis.

The nurse is reviewing the laboratory profile for a client who has muscular dystrophy. Which laboratory value(s) would the nurse expect to be elevated? (Select all that apply.) a. Calcium (Ca) b. Phosphate (PO4) c. Creatine kinase (CK) d. Lactic dehydrogenase (LDH) e. Aspartate aminotransferase (AST) f. Aldolase (ALD) (44)

ANS: C, D, E, F Muscular dystrophy causes elevations in muscle enzymes and does not affect minerals like calcium and phosphorus.

The nurse assesses a client's oral cavity as seen in the photo below: What action by the nurse is most appropriate? a. Encourage the client to have genetic testing. b. Instruct the client on high-fiber foods. c. Place the client in protective precautions. d. Teach the client about cobalamin therapy (37)

ANS: D This condition is known as glossitis, and is characteristic of B12 anemia. If the anemia is a pernicious anemia, it is treated with cobalamin. Genetic testing is not a priority for this condition. The client does not need high-fiber foods or protective precautions.

A nurse manager is preparing an educational session for floor nurses on drug-resistant organisms. Which statement below indicates the need to review this information? a. "Methicillin-resistant Staphylococcus aureus can be hospital- or community-acquired." b. "Vancomycin-resistant Enterococcus can live on surfaces and be infectious for weeks." c. Carbapenem-resistant Enterobacteriaceae is hard to treat due to enzymes that break down antibiotics." d. "If you leave work wearing your scrubs, go directly home and wash them right away." (21)

ANS: D To help prevent the transmission of an MDRO, wear scrubs and change clothes before leaving work. Keep work clothes separate from personal clothes. The nursing manager would need to correct his or her knowledge if he or she is letting staff know that wearing scrubs home is alright. The other statements are correct about multi-drug resistant organisms.

A nurse is caring for a client who has a nonhealing pressure injury on the right ankle. Which action would the nurse take first? a. Draw blood for albumin, prealbumin, and total protein. b. Prepare for and assist with obtaining a wound culture. c. Instruct the client to elevate the foot. d. Assess the right leg for pulses, skin color, and temperature. (23)

ANS: D A client with an ulcer on the foot would 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.

An emergency department nurse triages clients who present with chest discomfort. Which client would the nurse plan to assess first? a. Client who describes pain as a dull ache. b. Client who reports moderate pain that is worse on inspiration. c. Client who reports cramping substernal pain. d. Client who describes intense squeezing pressure across the chest. (30)

ANS: D All clients who have chest pain would be assessed more thoroughly. To determine which client would be seen first, the nurse must understand common differences in pain descriptions. Intense stabbing and viselike (squeezing) substernal pain or pressure that spreads through the client 's chest, arms, jaw, back, or neck are indicatives of a myocardial infarction. The nurse would plan to see this client first to prevent cardiac cell death. A dull ache, pain that gets worse with inspiration, and cramping pain are not usually associated with myocardial infarction

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 that 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." (39)

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 would 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.

A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment would the nurse complete as the priority prior to this procedure? a. Client's level of anxiety b. Ability to turn self in bed c. Cardiac rhythm and heart rate d. Allergies to iodine-based agents (30)

ANS: D Before the procedure, the nurse would ascertain whether the client has an allergy to iodine-containing preparations, such as seafood or local anesthetics. The contrast medium used during the procedure is iodine based. This allergy can cause a life-threatening reaction, so it is a high priority. It is important for the nurse to assess anxiety, mobility, and baseline cardiac status, but allergies take priority for client safety.

The nurse is assessing a client diagnosed with trigeminal neuralgia affecting cranial nerve V. What assessment findings will the nurse expect for this client? a. Expressive aphasia b. Ptosis (eyelid drooping) c. Slurred speech d. Severe facial pain (38)

ANS: D Cranial nerve (CN) V is the Trigeminal Nerve which has both a motor and sensory function in the face. When affected by a health problem, the client experiences severely facial pain. Expressive aphasia results from damage to the Broca speech area in the frontal lobe of the brain. Ptosis can result from damage to CN III and slurred speech often occurs from either damage to several cranial nerves or from damage to the motor strip in the frontal lobe of the brain.

The primary health care provider prescribes donepezil for a client diagnosed with early-stage Alzheimer disease. What teaching about this drug will the nurse provide for the client's family caregiver? a. "Monitor the client's temperature because the drug can cause a low grade fever." b. "Observe the client for nausea and vomiting to determine drug tolerance." c. "Donepezil will prevent the client's dementia from progressing as usual." d. "Report any client dizziness or falls because the drug can cause bradycardia." (39)

ANS: D Donepezil is a cholinesterase inhibitor that may temporarily slow cognitive decline for some clients but does not alter the course of the disease. The family caregiver would want to monitor the client's heart rate and report any incidence of dizziness or falls because the drug can cause bradycardia. It does not typically cause fever or nausea/vomiting

A nurse cares for a client who has kidney stones from gout ricemia. Which medication does the nurse anticipate administering? a. Phenazopyridine b. Doxycyline c. Tolterodine d. Allopurinol (61)

ANS: D Stones caused by hyperuricmia caused by gout or other reason respond to allopurinol. Phenazopyridine is given to clients with urinary tract infections. Doxycycline is an antibiotic. Tolterodine is an anticholinergic with smooth muscle-relaxant properties.

A client is having a radioisotopic imaging scan. What action by the nurse is most important? a. Assess the client for shellfish allergies. b. Place the client on radiation precautions. c. Sedate the client before the scan. d. Teach the client about the procedure. (36)

ANS: D The nurse should ensure that teaching is done and the client understands the procedure. Contrast dye is not used, so shellfish/iodine allergies are not related. The client will not be radioactive and does not need radiation precautions. Sedation is not used in this procedure.

A hospitalized client has a platelet count of 58,000/mm3 (58 × 109/L). What action by the nurse is most appropriate? a. Encourage high-protein foods. b. Institute neutropenic precautions. c. Limit visitors to healthy adults. d. Place the client on safety precautions. (36)

ANS: D With a platelet count between 40,000 and 80,000/mm3 (40 and 80 × 109/L), clients are at risk of prolonged bleeding even after minor trauma. The nurse would place the client on safety or bleeding precautions as the most appropriate action. High-protein foods, while healthy, are not the priority. Neutropenic precautions are not needed as the patient's white blood cell count is not low. Limiting visitors would also be more likely related to a low white blood cell count.

Which statements are true regarding Standard Precautions? (Select all that apply.) a. Always wear a gown when performing hygiene on clients. b. Sneeze into your sleeve or into a tissue that you throw away. c. Remain 3 feet (1 m) away from any client who has an infection. d. Use personal protective equipment as needed for client care. e. Wear gloves when touching clients' excretions or secretions. f. Cohorting clients who have infections caused by the same organism (21)

ANS: D, E Standard Precautions implies that contact with bodily secretions, excretions, and moist mucous membranes and tissues (excluding perspiration) is potentially infectious. Always wear gloves when coming into contact with such material. Other personal protective equipment is used based on the care being given. For example, if face splashing is expected, you will also wear a mask. Wearing a gown for hygiene is not required. Sneezing into your sleeve or tissue is part of respiratory etiquette. Remaining 3 feet (1 m) away from client is also not part of Standard Precautions. Cohorting infectious clients can be used for deciding room/bed placement, but is not part of Standard Precautions.

Location of Heart Valves

Aortic valve - Usually best heard in the 2nd intercostal space of the right sternal border Pulmonary valve - Usually best heard in the 2nd and 3rd intercostal spaces of the left sternal border, but can extend even further. Tricuspid valve - Usually best heard in the 4th intercostal space of the left lower sternal border Mitral valve - Usually best heard at the apex (around the 5th intercostal space in the mid-clavicular line)

quick labs reference

Normal urine specific gravity : 1.005 - 1.030 Normal BUN : 10 - 20 mg/dL Normal creatinine : 0.6 - 1.2 mg/dL m 0.5 - 1.1 mg/dL f Normal urine osmoalality : 300 - 900 mOsm/kg ~ Renal threshold for glucose is roughly 220 mg/dL , once over, glucose will be present in the urine