Final Exam Review

A patient is admitted with chest pain and is diagnosed with coronary artery disease. Which of the following interventions should the nurse prioritize?

Administering oxygen Rationale: Administering oxygen. The priority intervention for a patient with chest pain and coronary artery disease is to administer oxygen to improve oxygenation and decrease the workload on the heart.

The nurse is assessing a client with a chest tube. Which of the following would require further investigation?

Continuous gentle bubbling in the water seal chamber

What is the most common location for atherosclerosis to occur?

Coronary arteries Rationale: Atherosclerosis commonly occurs in the coronary arteries that supply blood to the heart muscle. When these arteries become narrowed or blocked, it can lead to a heart attack.

A nurse is assessing a client with left-sided heart failure. Which assessment finding is consistent with this diagnosis?

Crackles in the lungs

The nurse is educating a client with heart failure about dietary modifications. Which dietary instructions would be most appropriate for this client?

Restrict sodium intake

A client with left-sided heart failure is prescribed digoxin. Which finding would indicate a potential digoxin toxicity?

Visual disturbances

The client is receiving UV light treatments for psoriasis along with methoxsalen, a photosensitising agent. What precaution should be the first day after treatment?

Wear ultraviolet B-protective sunglasses

What medications are used to treat HSV?

acyclovir, valacyclovir, and famciclovir—can suppress symptoms and shorten the course of the infection

What foods should be avoided with prostatitis?

alcohol, coffee, tea, chocolate, cola, and spices

What are the clinical manifestations of fibroids?

asymptomatic, abnormal vaginal bleeding, pain, backache, pressure, bloating, constipation, and urinary problems

What are the clinical manifestations of breast cancer?

lesions are nontender, fixed, and hard with irregular borders

The nurse is caring for the client with psoriasis taking methotrexate. Which laboratory tests are most important for the nurse to monitor? SATA

liver function tests white blood cells

What are common signs and symptoms of tuberculosis?

low-grade fever, cough, night sweats, fatigue, and weight loss

What are the clinical manifestations of PCOS?

obesity, insulin resistance, glucose intolerance, dyslipidemia, sleep apnea, and infertility

An adult has a left, above the knee amputation two weeks ago. The nurse places him in a prone position tree times a day because:

prevents flexion contractures

What medications of given for BPH?

relax smooth muscle: Alpha-adrenergic blockers decrease prostate size: 5-alpha-reductase inhibitors

What are the chemoprevention medications for high risk?

tamoxifen and raloxifene

What are the complications of a tracheostomy?

tube dislodgement, accidental decannulation, bleeding, pneumothorax, air embolism, aspiration

What are the clinical manifestations of PID?

vaginal discharge, dyspareunia, dysuria, pelvic or lower abdominal pain, tenderness that occurs after menses, and postcoital bleeding

What is the treatment for PCOS?

weight loss, oral contraceptives, metformin

The nurse is caring for a client with burns who weighs 143 lbs. and has sustained burns over 15% of their TBSA. According to the Parkland formula, how much fluid should be administered per hour during the second 16 hours of fluid resuscitation?

61

Larry's anterior trunk, both front upper extremities, both lower extremities sustained second and third degree burn. Estimate the total percentage of body surface area burned using the Rule of Nines.

63%

A female client seen in the ambulatory care clinic has a history of herpes syphilis infection. The nurse assessing the client for reinfection would expect to observe a lesion on the labia that has which characteristic?

Appears as 1 or more vesicles that then rupture Rationale: The characteristic lesion of syphilis is painless and indurated. The lesion is referred to as a chancre. Genital warts are characterized by cauliflowerlike growths or growths that are soft and fleshy. Scabies is characterized by erythematous, papular eruptions. Genital herpes is accompanied by the presence of 1 or more vesicles that then rupture and heal.

What are the clinical manifestations of cervical cancer?

Asymptomatic in early stages later in the disease: discharge, irregular bleeding, or pain or bleeding after penile-vaginal intercourse occur Advance disease: Leg pain, dysuria, rectal bleeding, and edema of the extremities

A client with active TB is prescribed a combination regimen of isoniazid (INH), rifampin (RIF), pyrazinamide (PZA), and ethambutol (EMB). The nurse should instruct the client to:

Report any visual disturbances while on ethambutol (EMB). Rationale: Ethambutol (EMB) can cause ocular toxicity, including visual disturbances and color blindness. The client should be educated to report any changes in vision promptly to the healthcare provider. Regular visual monitoring may also be necessary during treatment.

A patient with an enlarging, irregular mole that is 7 mm in diameter is scheduled for outpatient treatment. The nurse should plan to prepare the patient for which procedure?

Surgical incision

The nurse is caring for a client receiving mechanical ventilation in synchronized intermittent mandatory ventilation (SIMV) mode. Which statement accurately describes SIMV mode?

Delivers a preset tidal volume and rate, but the client can initiate additional breaths

The nurse is caring for a client with a chest tube. Which finding requires immediate intervention?

Sudden cessation of chest tube drainage

The nurse is caring for an adult client with burns who weighs 80 kg and has sustained burns over 30% of their TBSA. According to the Parkland formula, how much fluid should be administered per hour during the first 8 hours of fluid resuscitation?

300

The nurse is caring for a client with burns who weighs 70 kg and has sustained burns over 25% of their TBSA. According to the Parkland formula, what is the total volume of fluid that should be administered in the first 24 hours?

3500

The nurse is training a client over the phone who states having a contact dermatitis rash. Which option of over-the-counter preparations does the nurse suggest for the client? SATA

Topical antihistamines Moisturizing cream Lanolin based ointment

A nurse is teaching a patient with contact dermatitis of the arms and legs about ways to decrease pruritus. Which information should the nurse include in the teaching plan? SATA

Use an over the counter antihistamine to reduce itching Take cool or tepid baths several times daily to decrease itching Cool, wet clothes or compresses can be used to reduce itching

How is HPV prevented?

Vaccine given in two intramuscular doses, with the initial dose followed by a second dose 6 to 12 months after the first dose

The nurse is caring for a client with active pulmonary tuberculosis who is placed on airborne precautions. Which actions is most important for the nurse to take?

Wearing an N95 respirator mask when entering the client's room

The nurse is assessing a client with a history of asthma. Which finding requires intervention?

Wheezing heard upon auscultation

What are some ways to prevent atelectasis?

directed cough, suctioning, aerosol nebulizer treatments followed by chest physiotherapy

A day care worker comes to the clinic for mild itching and rash of both hands. The nurse suspects contact dermatitis. The diagnosis is confirmed if the rash appears

erythematous with raised papule

How often is cuff pressure measured for a ventilated patient?

every 6-8 hours

What are complications related to cuff pressure on ET tube?

high cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis low cuff pressure can increase the risk of aspiration pneumonia

How is PCOS diagnosed?

hyperandrogenism, chronic anovulation, and polycystic ovaries on ultrasound examination

What are the signs and symptoms of atelectasis?

increasing dyspnea (shortness of breath), cough, and sputum production, decreased breath sounds, crackles, typical after surgery

What are the signs and symptoms of chronic bronchitis?

inflammation and hyper-secretion of mucus for at least 3 months

What is the treatment for respiratory failure?

mechanical ventilation

What medication is used to treat bacterial vaginosis and trichomonas?

metronidazole

The nurse is assessing a client for possible tuberculosis infection. Which symptom is most indicative of active pulmonary tuberculosis?

Persistent cough lasting more than three weeks. Rationale: A persistent cough lasting more than three weeks is a hallmark symptom of active pulmonary tuberculosis. This cough may be accompanied by other symptoms such as fatigue, night sweats, fever, and weight loss. However, the persistent cough is the most indicative of active TB. Options B, C, and D are also commonly seen in tuberculosis, but the persistent cough is the most specific to active pulmonary TB.

Which of the following represents a significant risk immediately after surgery for repair of aortic aneurysm?

Potential alteration in renal perfusion Rationale: There is a potential alteration in renal perfusion manifested by decreased urine output. The altered renal perfusion may be related to renal artery embolism, prolonged hypotension, or prolonged aortic cross-clamping during the surgery.

The client in the gynecology clinic asks the nurse, "What are the risk factors for developing cancer of the cervix?" Which statement is the nurse's best response?

"A Chlamydia trachomatis infection can cause cancer of the cervix." Rationale: Risk factors for cancer of the cervix include sexual activity before the age of 20 years; multiple sexual partners; early childbearing; exposure to the human papillomavirus; HIV infection; smoking; and nutritional deficits of folates, beta carotene, and vitamin C.

A patient is diagnosed with peripheral artery disease caused by artheroclerosis. Which of the following symptoms is most commonly associated with this condition?

Intermittent claudication

The nurse is providing education to a client with osteoarthritis about non-pharmacological interventions for pain management. Which statement by the client indicates understanding of these interventions?

"Applying heat to the affected joints can help relieve pain and stiffness." Rationale: Applying heat to the affected joints can help relieve pain and stiffness associated with osteoarthritis. Heat therapy, such as warm packs or warm baths, promotes relaxation of the muscles, improves blood circulation, and reduces pain and joint stiffness. However, the client should be cautious about applying excessive heat or using heat for an extended duration to avoid burns.

The wife of a client with COPD is worried about caring for her husband at home. Which statement by the nurse provides the most valid information?

"Arrange a schedule so your husband does all necessary activities before noon; then he can rest during the afternoon and evening."

A 22-yr-old patient tells the nurse at the health clinic that he has recently had problems with erectile dysfunction. Which question should the nurse ask to assess for possible etiologic factors in this age group?

"Do you use recreational drugs or drink alcohol?" Rationale: A common cause of erectile dysfunction (ED) in younger men is use of recreational drugs or alcohol. Stress, priapism, and cardiovascular illness also contribute to ED, but they are not common etiologic factors in younger men.

A female client is suspected of having a vaginal infection caused by the organism Candida albicans. Which assessment question would elicit data associated with this infection?

"Have you had any vaginal discharge?" Rationale: Clinical manifestations of a Candida infection include vaginal pain, itching, and a thick white vaginal discharge. Hematuria, edema, flank pain, and headache are clinical manifestations associated with urinary tract infections.

The nurse is educating a client with asthma about trigger avoidance. Which statement indicates a need for further education?

"I can safely stop using my inhaler when symptoms improve."

The nurse is educating a client with a tuberculosis infection about medication therapy. Which statement by the client indicates a need for further teaching?

"I can stop taking my medications when I start to feel better."

The nurse is providing health education to a client recently diagnosed with tuberculosis. Which statement by the client indicates understanding of TB transmission?

"I will cover my mouth and nose when I sneeze or cough."

The nurse is providing education on tuberculosis prevention to a community group. Which statement by a participant indicates a need for further education?

"I will get the tuberculosis vaccine to prevent infection." Rationale: The tuberculosis vaccine (BCG) does not provide reliable protection against pulmonary tuberculosis, which is the most common form of the disease. It is primarily used in countries with a high prevalence of TB and is not routinely recommended in areas with low TB incidence. Options A, B, and C are all appropriate measures for TB prevention and treatment.

A nursing student is doing a presentation on human papillomavirus (HPV) for a young adult group aged 18 to 20 years old. What information should the nursing student include in this presentation? Select all that apply.

"Some forms of HPV can lead to cervical cancer." ."HPV is most commonly spread during vaginal or anal sexual contact." "In some types, HPV will go away on its own and does not cause health issues." Rationale: HPV has now become the most common sexually transmitted infection. Some types of HPV have been found to have a strong link to cervical cancer, while other types of HPV may resolve without any intervention. HPV may be contracted with any sexual partner. There is a vaccine for the known strains that may lead to cervical cancer, which can be administered to females from ages 9 to 26 years. HPV is spread through vaginal or anal sexual contact.

The nurse is teaching a group of women about modifiable risk factors for breast cancer. Which statement by a participant indicates understanding of the topic?

"Using hormone replacement therapy after menopause increases my risk." Rationale: Using hormone replacement therapy after menopause increases the risk of developing breast cancer. Option A is incorrect because having a family history of breast cancer is a non-modifiable risk factor. Option C is incorrect because being over the age of 70 is a non-modifiable risk factor. Option D is incorrect because certain ethnicities, such as Ashkenazi Jewish descent, have a higher risk of breast cancer.

A client with peripheral arterial disease presents with pain in their legs that worsens with activity and improves with rest. Which assessment finding would indicate a severe form of PAD?

Absent pulses in the feet

angiotensin-converting enzyme (ACE)-inhibitors

Administer on an empty stomach Adverse effects: •Hypotension •Cardiac arrhythmias •Renal dysfunction •Angioedema •Cough •Pancytopenia •Heart failure reflex tachycardia, chest pain, angina, heart failure, and cardiac arrhythmias; gastrointestinal (GI) irritation, ulcers, constipation, and liver injury; renal insufficiency, renal failure, and proteinuria; and rash, alopecia, dermatitis, and photosensitivity

When is the best time to perform BSE?

After menses (day 5 to day 7, counting the first day of menses as day 1.

What are the risk factors for endometrial cancer?

Age—usually >50 years; average age, 63 years •Obesity that results in increased estrone levels •Unopposed estrogen therapy (estrogen used without progesterone) •Other—nulliparity, truncal obesity, early menarche, late menopause (after 52 years of age) and the use of tamoxifen

The nurse is caring for a client on mechanical ventilation when a high-pressure alarm on the ventilator is activated. What is the priority action by the nurse?

Assess the client's airway and lung compliance. Rationale: When a high-pressure alarm on the ventilator is activated, the nurse should first assess the client's airway and lung compliance. High-pressure alarms are often triggered by factors such as a disconnected or kinked endotracheal tube, excessive secretions, or decreased lung compliance. Identifying and resolving the underlying cause is essential to ensure proper ventilation and prevent complications.

The nurse is caring for a client with a fractured arm. Which action is a priority in the care of the fracture?

Assessing neurovascular status distal to the fracture Rationale: Assessing neurovascular status distal to the fracture is a priority action. It helps determine the adequacy of circulation and nerve function, ensuring early detection of any complications such as compartment syndrome. Options A, B, and C are important interventions in fracture care but are not the priority when compared to neurovascular assessment.

The client with COPD is to be discharged home while receiving continuous oxygen at a rate of 2 L/min via cannula. What information does the nurse provide to the client and his wife regarding the use of oxygen at home?

Because of his need for oxygen, the client will have to limit activity at home Rationale: Because of his need for oxygen, the client will have to limit activity at home

While taking a health history on a 20-year-old female client, the nurse learns that the client is taking miconazole. The nurse is justified in presuming that this client has what medical condition?

Candidiasis Rationale: Candidiasis is a fungal or yeast infection caused by strains of Candida. Miconazole (Monistat) is an antifungal medication used in the treatment of candidiasis. This agent is inserted into the vagina with an applicator at bedtime and may be applied to the vulvar area for pruritus. HPV, bacterial vaginosis, and TSS are not treated by Monistat.

Which of the following complications is a potential risk for a client with untreated heart failure?

Cardiac tamponade

The nurse is assigned to teach health-seeking behaviors to young women. One topic the nurse plans to includes is the importance of the Pap test, which is used mainly to detect:

Cervical cancer

Which of the following assessment findings is most indicative of pericarditis?

Chest pain that worsens with inspiration

A nurse is caring for a client who had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires the nurse's immediate attention?

Client reports prickling sensation in the right hand Rationale: Prickling sensation is an indication of compartment syndrome and requires immediate action by the nurse. The other findings are normal for a client in this situation.

After inserting a speculum and visualizing the cervix and vaginal walls, the examiner applies acetic acid to the cervix. What is this procedure called?

Colposcopy

Calcium channel blockers

Common effects: Dizziness, drowsiness, light-headedness, nausea, vomiting, change in taste perception, skin rash, mouth sores Report any of the following to your healthcare provider: difficulty breathing; mouth sores; swelling of the feet, hands, or face; chest pain; palpitations; sore throat; and fever or chills. This drug should be taken on an empty stomach 1 hour before or 2 hours after meals. Do not stop taking this drug for any reason. Consult with your healthcare provider if you have problems taking this medication. You should avoid drinking grapefruit juice while you are taking this drug, because the combination of grapefruit juice and a calcium-channel blocker may cause toxic effects.

What are some complications of PCOS?

DM, increased blood lipids, cardiovascular disease, nonalcoholic fatty liver disease, endometrial cancer

What are some ways to reduce tissue irritation?

Daily bathing and adequate hygiene, a hair dryer on a cool setting will dry the area, and application of topical corticosteroids may decrease irritation.

A client is admitted to the hospital with benign prostatic hyperplasia, the nurse most relevant assessment would be:

Distention of the lower abdomen Rationale: This indicates that the bladder is distended with urine, therefore palpable.

Which of the following diagnostic tests is most commonly used to diagnose coronary artery disease?

Electrocardiogram (ECG) Rationale: An ECG is a common diagnostic test used to diagnose coronary artery disease. It can detect abnormalities in the heart's electrical activity, which can indicate the presence of the disease.

A client with pericarditis reports difficulty breathing and appears restless and anxious. What action should the nurse take first?

Elevate the head of the bed

What action will the nurse take when caring for a patient who has a radium implant for treatment of cervical cancer?

Encourage the patient to discuss any concerns by telephone. Rationale: The nurse should spend minimal time in the patient's room to avoid exposure to radiation. The patient and nurse can have longer conversations by telephone between the patient room and nursing station. To prevent displacement of the implant, absolute bed rest is required. Wearing of gloves and gown when changing linens and flushing the toilet several times are not necessary because the isotope is confined to the implant.

Which nursing intervention should be included in the plan of care for a client with COPD during and acute exacerbation?

Encourage the use of pursed-lip breathing during exhalation.

A nurse is caring for a client with right-sided heart failure. Which intervention would be the best for preventing venous stasis and deep vein thrombosis?

Encouraging frequent ambulation

The nurse is caring for a client receiving tadalafil (Cialis) for erectile dysfunction. The nurse should assess the client for potential adverse effects, including:

Flushing Rationale: Headache, flushing, nasal congestion and prolonged erection, known as priapism, is a potential adverse effect of medications used to treat erectile dysfunction, including tadalafil (Cialis). Priapism is a serious condition that requires immediate medical intervention to prevent permanent damage to the penis.

A client with valvular heart disease is prescribed digoxin. Which assessment finding is important for the nurse to monitor?

Heart rate

The nurse observes that the client's knee is swollen and painful. Consequently; which one of the following nursing measures should be carried out?

Help to change positions to achieve comfort

The following are lipid abnormalities. Which of the following is a risk factor for the development of atherosclerosis and PVD?

High levels of low density lipid (LDL) cholesterol Rationale: An increased in LDL cholesterol concentration has been documented at risk factor for the development of atherosclerosis. LDL cholesterol is not broken down into the liver but is deposited into the wall of the blood vessels.

The nurse is caring for a client in the emergent phase of burn injury. Which complication is commonly associated with this phase?

Hypovolemic shock Rationale: Hypovolemic shock is a common complication associated with the emergent phase of burn injury. Extensive fluid loss occurs as a result of the burn injury, leading to a decreased circulating blood volume and inadequate tissue perfusion. Prompt fluid resuscitation is essential during this phase to restore intravascular volume and stabilize the client's condition.

How is a breast self-exam performed?

In the shower: Use three or four fingers of the opposite hand to feel each breast firmly. Beginning at the outer edge, press the flat part of your fingers in small circles, moving the circles slowly around the breast. Gradually work toward the nipple.

A client with PAD is prescribed clopidogrel. Which finding would indicate potential adverse effect of the medication?

Increased bleeding tendency

When assessing a client with benign prostatic hyperplasia, which of the following would the nurse expect the client to report as the initial complaint?

Increased effort to void

What are the risk factors for pelvic inflammatory disease (PID)?

Infected with gonorrhea and chlamydia, polymicrobial early age at first sexual experience multiple sexual partners, frequent penile-vaginal intercourse, penile-vaginal intercourse without condoms, sex with a partner with an STI, and a history of STIs or previous pelvic infection

The nurse is conducting a community education program on basal cell carcinoma (BCC). Which statement should the nurse make?

It begins as a small, waxy nodule with rolled translucent, pearly borders

What should the nurse explain to a patient being prepared for colposcopy with a cervical biopsy?

It is similar to a speculum examination of the cervix and should cause little discomfort. Rationale: Colposcopy involves visualization of the cervix with a binocular microscope and is similar to a speculum examination. Anesthesia is not required and fasting is not necessary. A cervical biopsy may cause a minimal amount of pain.

A client with COPD is prescribed home oxygen therapy. Which safety precaution should the nurse emphasize to the client?

Keep the oxygen tank upright at all times

What is the most likely cause of low pressure alarm?

Leak in ventilator or tubing; cuff on tube/humidifier not tight

A client with mitral stenosis is at risk for developing which of the following complications?

Left-sided heart failure Rationale: Mitral stenosis is characterized by narrowing of the mitral valve, leading to impaired blood flow from the left atrium to the left ventricle. This can result in increased pressure and volume overload on the left side of the heart, eventually leading to left-sided heart failure. Options B, C, and D are not directly associated with mitral stenosis.

In reducing the risk of endocarditis, good dental care is an important measure. To promote good dental care in client with mitral stenosis in teaching plan should include proper use of...

Manual toothbrush Rationale: The use of electronic toothbrush, irrigation device or dental floss may cause bleeding of gums, allowing bacteria to enter and increasing the risk of endocarditis.

Which information should the nurse include in the teaching plan for a patient diagnosed with basal cell carcinoma (BCC)?

Minimising sun exposure reduces risk for future BCC.

The nurse is monitoring a client who has just returned from surgery after a transurethral resection of the prostate (TURP). The client has a 3-way Foley catheter in place for ongoing bladder irrigation. The nurse is observing the color of the client's urine and should expect which urine color during the immediate postoperative period?

Pale pink urine Rationale: If the bladder irrigation is infusing at a sufficient rate, the urinary drainage through the Foley tubing should be pale pink. Dark pink urine indicates that the rate of the irrigation solution should be increased. Tea-colored urine is not seen after TURP but may be noted in a client with other renal disorders such as renal failure. Bright red bleeding and clots could indicate a complication, and if this is noted, it should be reported to the primary health care provider.

Nurse Katrina would recognize that the demonstration of crutch walking with tripod gait was understood when the client places weight on the:

Palms of the hand Rationale: The palms should bear the client's weight to avoid damage to the nerves in the axilla.

How is cervical cancer diagnosed?

Pap smear, biopsy and colposcopy

As a result of fractured ribs, the client may develop:

Paradoxical respiration

The client who had a right modified radical mastectomy four (4) years before is being admitted for a cardiac work-up for chest pain. Which intervention is most important for the nurse to implement?

Post a message at the HOB for staff not to use the right arm for venipunctures or BPs. Rationale: The nurse should post a message at the head of the client's bed to not use the right arm for blood pressures or laboratory draws. This client is at risk for lymphedema, and this is a lymphedema precaution.

Photo-chemotherapy has been used as a treatment for which of the following skin disorders?

Psoriasis

Which topic will the nurse include in the preoperative teaching for a patient admitted for an abdominal hysterectomy?

Purpose of ambulation and leg exercises Rationale: Venous thromboembolism is a potential complication after the surgery, and the nurse will instruct the patient about ways to prevent it. Vaginal sensation is decreased after a vaginal hysterectomy but not after abdominal hysterectomy. Most hysterectomies are not done for treatment of cancer. Unless the patient has cancer, chemotherapy and radiation will not be prescribed. Because the patient will still have her ovaries, her estrogen level will not decrease.

What are the diagnostic tests for tuberculosis?

QuantiFERON-TB Gold TB Skin test Sputum culture Chest Xray

What is dilation and curettage (D&C)?

Removal of endometrial or endocervical tissue for cytologic examination or to control abnormal uterine bleeding

What is the first line medication therapy for tuberculosis?

Rifampin Isoniazid Pyrazinamide Ethambutol

What ventilator mode is used to wean a patient off a ventilator?

SIMV mode

Which of the following should the nurse teach the client about the signs of digitalis toxicity?

Seeing yellow spots Rationale: Seeing yellow spots and colored vision are common symptoms of digitalis toxicity

What are the risk factors fro ovarian cancer?

Sexual contact with men whose partners have had cervical cancer. Sex with uncircumcised men. Multiple sex partners. Early age (<20 years) at first coitus. Family history. Overweight status. Prolonged use of oral contraceptives, early child bearing age

Which of the following risk factors is the most modifiable for coronary artery disease?

Smoking Rationale: Smoking is the most modifiable risk factor for coronary artery disease. Smoking cessation significantly reduces the risk of developing the disease.

What are the risk factors of BPH?

Smoking, heavy alcohol consumption, obesity, reduced activity level, hypertension, heart disease, diabetes, and a Western diet

What are risk factors of fibroids?

Some genetic disposition Age 25-40

While you are mating your routine rounds you were told that there is a client in the ICU who is in respirator and who lip- reads. To establish relationship with him, communication is best accomplished by:

Speaking slowly but aloud

What is used to diagnose PID?

Symptoms and pelvic exam

Beta Blockers Contraindications

The beta-blockers are contraindicated in patients with bradycardia, heart block, and cardiogenic shock because blocking of the sympathetic response could exacerbate these diseases. Caution should be used in patients with diabetes, peripheral vascular disease, asthma, chronic obstructive pulmonary disease, or thyrotoxicosis because the blockade of the sympathetic response blocks normal reflexes that are necessary for maintaining homeostasis in patients with these diseases.

Which statement correctly describes suctioning through an endotracheal tube?

The catheter is inserted into the endotracheal tube until the client coughs, and intermittent suction is applied during withdrawal.

The occupational health nurse is preparing a class regarding sexually transmitted diseases (STDs) for employees at a manufacturing plant. Which high-risk behavior information should be included in the class information?

The more sexual partners, the greater the chance of developing an STD.

Which drug is a topical corticosteroid used to treat psoriasis?

Triamcinolone Rationale: Triamcinolone is a topical corticosteroid used to treat psoriasis. Coal tar is used for mild to moderate lesions of psoriasis. Neutrogena is a medicated shampoo. Methotrexate is a systemic therapy for psoriasis.

Which information should the nurse include when teaching patients about decreasing the risk for sun damage to the skin?

Try to stay out of the direct sun between the hours of 10 AM and 4 PM

The nurse is caring for a client receiving mechanical ventilation in SIMV (Synchronized Intermittent Mandatory Ventilation) mode. Which statement accurately describes the ventilator mode?

The ventilator provides a set number of breaths at a preset tidal volume, synchronized with the client's spontaneous breaths. Rationale: In SIMV mode, the ventilator provides a set number of breaths at a preset tidal volume, which are synchronized with the client's spontaneous breaths. The client can initiate additional breaths beyond the preset number, and the ventilator supports the client's effort by delivering the set tidal volume.

Measurement of the endometrium with endometrial cancer?

Thick

When continuous bladder irrigation is used following prostate surgery, the rate of flow is adjusted:

To keep the drainage to light pink

What medications are given for prostatitis?

bacterial: trimethoprim-sulfamethoxazole or a fluoroquinolone (e.g., ciprofloxacin) Normal urinalysis: NSAIDS Prostate relaxation: tamsulosin

What are the risk factors for HPV?

being young, being sexually active, having multiple sex partners, and having sex with a partner who has or has had multiple partners

What are side effects of Danazol?

fatigue, depression, weight gain, oily skin, decreased breast size, mild acne, hot flashes, and vaginal atrophy

What are some foods to avoid while taking isoniazid?

foods that contain tyramine and histamine (tuna, aged cheese, red wine, soy sauce, yeast extracts)

What medications are used to treat fibroids?

gonadotropin-releasing hormone (GnRH) progesterone antagonist

Nurse Hazel teaches the client with angina about common expected side effects of nitroglycerin including:

headache Rationale: Because of its widespread vasodilating effects, nitroglycerin often produces side effects such as headache, hypotension and dizziness.

What are the signs and symptoms of cor pulmonae?

dependent edema, distended neck veins, or pain in the region of the liver caused by pulmonary hypertension

What is one complication of having HSV?

Infection of baby during delivery

A patient with coronary artery disease is prescribed atorvastatin. Which of the following statements made by the patient indicates the need for further education?

"I can stop taking this medication once my cholesterol levels are normal." Rationale: Atorvastatin is a medication used to lower cholesterol levels and should be taken continuously as prescribed by the healthcare provider. Stopping the medication once cholesterol levels are normal can increase the risk of a heart attack.

A patient with coronary artery disease is prescribed nitroglycerin sublingually. Which of the following statements made by the patient indicates the need for further education?

"I can take up to four doses of nitroglycerin 5 minutes apart." Rationale: The correct dosing regimen for nitroglycerin is one tablet every 5 minutes, up to three doses. If chest pain persists after three doses, the patient should seek medical attention.

The nurse is discussing the HPV vaccine with a group of adolescents and their parents. Which statement by an adolescent indicates a need for further education about the vaccine?

"The HPV vaccine is most effective when given after becoming sexually active." Rationale: The statement "The HPV vaccine is most effective when given after becoming sexually active" indicates a need for further education. The HPV vaccine is most effective when administered before exposure to the virus through sexual activity. It is recommended to vaccinate adolescents before they become sexually active to provide optimal protection against HPV infections.

A patient with coronary artery disease is prescribed clopidogrel. Which of the following statements made by the patient indicates the need for further education?

"I should avoid taking this medication if I have a history of ischemic stroke." Rationale: Clopidogrel is an antiplatelet medication used to prevent blood clots in patients with coronary artery disease. However, it may increase the risk of bleeding and should not be used in patients with a history of hemorrhagic stroke.

The nurse is providing education to a client with asthma regarding trigger avoidance. Which statement by the client indicates a need for further teaching?

"I will limit my physical activity to prevent asthma attacks." Rationale: The statement "I will limit my physical activity to prevent asthma attacks" indicates a need for further teaching. Regular physical activity is generally encouraged for clients with asthma as it improves overall lung function and fitness. However, clients with exercise-induced asthma may benefit from pre-exercise bronchodilator use and appropriate warm-up techniques to prevent symptoms during exercise.

The nurse is teaching a family member about preventing ventilator- associated pneumonia in their loved one. Which statement by the family member indicated an understanding of VAP prevention?

"I will make sure to provide frequent oral care for my loved one."

Which of the following statements, if made by a patient who has had a basal cell carcinoma removed, would indicate to the nurse the need for further instruction?

"I will use tanning booths rather than sunbathing from now on."

The nurse is educating a client with left-sided heart failure about lifestyle modifications. Which statement by the client indicates a need for further teaching?

"I will weigh myself weekly and report sudden weight gain."

A couple is seen in the fertility clinic. After several tests it has been determined that the husband is not sterile and that the wife has nonpatent fallopian tubes. The nurse is preparing the woman and her husband for an in vitro fertilization. Which statement by the woman or her spouse indicates a need for further information about the procedure?

"The procedure is performed using artificial insemination of sperm instilled through the vagina." Rationale: In vitro fertilization is a method of medically assisted reproduction for women with nonpatent, diseased, or missing fallopian tubes or with infertility of unknown cause. Ova and sperm are obtained from the potential parent or donor, placed in a nutrient medium, and allowed to incubate; then the fertilized ovum is transferred into the woman's uterus. The woman houses the pregnancy throughout gestation and gives birth.

A new client has come to the dermatology clinic to be assessed for a reddened rash on the abdomen. For what diagnostic test should the nurse prepare the client to identify the causative allergen?

Skin biopsy

A client presents at an ambulatory clinic and reports pain and aching in the lower left leg. After examining the client, a health care provider determines the client has experienced a strain related to the client's exercise regimen. The treatment plan includes analgesics, rest, and cold and heat therapies. Which guideline should be included in the care plan?

1.After 48 hours, apply heat for periods of 15 to 30 minutes. Rationale: The injury should be managed with cold therapy for the first 48 hours, followed by heat therapy for periods of 15 to 30 minutes. Cold applications should be intermittent to avoid temperature-related injuries to the skin. Physical activities should be restricted for 2 to 5 days depending on the severity of the injury.

The nurse provides teaching to a client with osteoarthritis (OA). Which statement(s) indicate that teaching about pain management and functional ability were effective? Select all that apply.

1."I will need to lose some weight." 2."I will increase the amount of walking I do every day." Rationale: Pain management and optimal functional ability are the major goals of nursing interventions. With those goals in mind, nursing management of the client with OA includes pharmacologic and nonpharmacologic approaches as well as education. Weight loss is an important approach to lessen pain and disability caused by OA. Exercises such as walking should be begin in moderation and gradually increase. A sedentary lifestyle contributes to the development of OA so resting would not be encouraged. Canes or other assistive devices for ambulation should be considered, and any stigma about the use of these devices should be explored. Clients should plan daily exercise for a time when the pain is least severe or plan to use an analgesic agent before exercising.

To prepare a client who has a fractured femur for ambulation, the nurse teaches the client how to do quadriceps setting exercises. Which instruction is the most accurate?

1."Press the back of your knee against the bed." Rationale: Quadriceps setting exercises help the immobilized client keep the quadriceps muscles strong and ready for resuming ambulation. Pressing the back of the knee against the bed promotes tightening of the quadriceps muscle.

A client presents to the emergency department following a burn injury. The client has burns to the abdomen and front of the left leg. Using the rule of nines, the nurse documents the total body surface area percentage as

18 Rationale: The rule-of-nines system is based on dividing anatomic regions, each representing approximately 9% of the total body surface area (TBSA), quickly allowing clinicians to obtain an estimate. If a portion of an anatomic area is burned, the TBSA is calculated accordingly—for example, if approximately half of the anterior leg is burned, the TBSA burned would be 4.5%. More specifically, with an adult who has been burned, the percent of the body involved can be calculated as follows: head = 9%, chest (front) = 9%, abdomen (front) = 9%, upper/mid/low back and buttocks = 18%, each arm = 9% (front = 4.5%, back = 4.5%), groin = 1%, and each leg = 18% total (front = 9%, back = 9%). In this case the client's abdomen (9%) and front of the left leg (9%) add up to 18%.

A client arrives in the emergency department after being burned in a house fire. The client's burns cover the face and the left forearm. What extent of burns does the client most likely have, measured as a percentage?

18 Rationale: When estimating the percentage of body area or burn surface area that has been burned, the Rule of Nines is used: the face is 9%, and the forearm is 9% for a total of 18% in this client.

The nurse is providing instructions to a pregnant client with genital herpes about the measures that are needed to protect the fetus. Which instruction should the nurse provide to the client?

A cesarean section will be necessary if vaginal lesions are present and active at the time of labor. Rationale: For women with active lesions, either recurrent or primary at the time of labor, delivery should be by cesarean section to prevent the fetus from being in contact with the genital herpes. Clients should be advised to abstain from sexual contact while the lesions are present. If this is an initial infection, clients should continue to abstain until they become culture-negative because prolonged viral shedding may occur in such cases. The safety of antiviral medications has not been established during pregnancy, and it should be used only when a life-threatening infection is present.

The nurse is caring for a client with left-sided heart failure. Which nursing intervention would be the most effective in promoting gas exchange and reducing dyspnea?

Administering supplemental oxygen

Patients taking metronidazole and tinidazole should avoid what?

Alcohol

Who should be tested for chlamydia and gonorrhea?

All women aged 25 and younger who are sexually active should be screened annually.

Which of the following is a potential complication of cardiac catheterization?

Allergic reaction to contrast dye Rationale: Allergic reaction to contrast dye. One potential complication of cardiac catheterization is an allergic reaction to the contrast dye used during the procedure. Patients are typically screened for allergies and may be given medication to prevent an allergic reaction.

The nurse is planning health education for a client who has experienced a vaginal infection. What guidelines should the nurse include in this program regarding prevention?

Avoid commercial feminine hygiene products, such as sprays. Rationale: Instead of tight-fitting synthetic, nonabsorbent, heat-retaining underwear, cotton underwear is recommended to prevent vaginal infections. Douching is generally discouraged, as is the use of feminine hygiene products. Daily washing is not restricted. Some studies have found that submersion in particularly hot baths and/or adding salts or fragrances disrupts the vaginal PH (potential hydrogen) and may contribute to vaginal infections.

The nurse is caring for a client with repeated episodes of contact dermatitis is providing instruction to prevent future episodes. Which information should the nurse include?

Avoid cosmetics with fragrance

The nurse is caring for a client on mechanical ventilation when a low-pressure alarm on the ventilator is activated. What action should the nurse take first?

Check the ventilator circuit for leaks or disconnections. Rationale: When a low-pressure alarm on the ventilator is activated, the nurse should first check the ventilator circuit for leaks or disconnections. A low-pressure alarm may indicate an air leak or disconnection, compromising the delivery of ventilation to the client. Identifying and resolving the issue is crucial to maintain effective mechanical ventilation.

The nurse is caring for a client with left-sided heart failure. Which assessment finding would the nurse expect to find related to impaired tissue perfusion?

Cyanosis

What is used to diagnose HSV?

Direct visualization, swab of lesions, blood test

What is loop electrosurgical excision procedure (LEEP)?

Excision of a small amount of cervical tissue, and the pathologist examines the borders of the specimen to determine if disease is present

A nurse is assessing a client with suspected infective endocarditis. Which finding is a common symptom of the condition?

Fatigue

The nurse is providing education to a client about dietary choices for breast cancer prevention. Which food choice is recommended for reducing the risk of breast cancer?

Fruits and vegetables, such as berries and leafy greens Rationale: Fruits and vegetables, particularly berries and leafy greens, are recommended for reducing the risk of breast cancer. They contain phytochemicals, antioxidants, and fiber that help protect against cancer development. Options A, B, and D are not recommended choices for breast cancer prevention. Processed meats, red meat, and high-fat dairy products have been associated with an increased risk of breast cancer.

A nurse is caring for a client with left-sided heart failure. Which medication should the nurse anticipate administering to relieve shortness of breath?

Furosemide

What is the patient education for HSV?

Hand hygiene, avoid sexual contact, avoid exposure to the sun, transmission is possible even when no lesions present

What are the complications of a hysterectomy?

Infection, hemorrhage, DVT, PE, Bladder Dysfunction

What is a complication of endometriosis?

Infertility

The nurse is assisting with the removal of a client's chest tube. Which action is most important during the removal procedure?

Instructing the client to perform Valsalva maneuver during removal

When using a chest tube for pneumothorax, what signifies proper functioning of the chest tube?

Intermittent bubbling

What are the clinical manifestation of HSV?

Itching and pain occur as the infected area becomes red and edematous. Infection may begin with macules and papules and progress to vesicles and ulcers

What are the treatment options for fibroids?

Observation, myomectomy, hysterectomy

While performing an initial assessment of a client admitted with appendicitis, the nurse observes an elevated blue-black lesion on the client's ear. The nurse knows that this lesion is consistent with what type of skin cancer?

Malignant melanoma

What should the nurse instruct the patient to do after a PTCA procedure?

Monitor for signs of bleeding or hematoma Rationale: After a PTCA procedure, the nurse should instruct the patient to monitor for signs of bleeding or hematoma at the site of catheter insertion. The patient should also be instructed to avoid strenuous exercise and heavy lifting for several days.

Nurse hazel receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following?

Myocardial damage Rationale: Detection of myoglobin is a diagnostic tool to determine whether myocardial damage has occurred.

Which of the following medications is commonly prescribed for the treatment of angina?

Nitroglycerin Rationale: Nitroglycerin is a medication that is commonly prescribed for the treatment of angina. It works by dilating the blood vessels, increasing blood flow to the heart and reducing the workload on the heart.

The nurse is assessing a client with benign prostatic hyperplasia (BPH). Which urinary symptom is typically seen in clients with BPH?

Nocturia Rationale: Nocturia, the need to urinate frequently during the night, is a common urinary symptom seen in clients with BPH. As the prostate gland enlarges, it can obstruct the flow of urine, leading to incomplete bladder emptying and increased frequency of urination, particularly at night.

Dr. Marquez orders a continuous intravenous nitroglycerin infusion for the client suffering from myocardial infarction. Which of the following is the most essential nursing action?

Obtaining infusion pump for the medication Rationale: Administration of Intravenous Nitroglycerin infusion requires pump for accurate control of medication.

Patrick who is hospitalized following a myocardial infarction asks the nurse why he is taking morphine. The nurse explains that morphine:

Prevents shock and relieves pain Rationale: Morphine is a central nervous system depressant used to relieve the pain associated with myocardial infarction, it also decreases apprehension and prevents cardiogenic shock.

Nurse Trisha teaches a client with heart failure to take oral Furosemide in the morning. The reason for this is to help...

Prevents sleep disturbances during night Rationale: When diuretics are taken in the morning, client will void frequently during daytime and will not need to void frequently at night.

What are the signs and symptoms of tension pneumothorax?

the trachea is shifted away from the affected side, chest expansion may be decreased or fixed in a hyper-expansion state, breath sounds are diminished or absent,

A client is suspected to have tuberculosis. Which diagnostic test is most commonly used to confirm the diagnosis?

Sputum culture. Rationale: Sputum culture is the most commonly used diagnostic test to confirm tuberculosis infection. It involves collecting a sputum sample and culturing it to identify the presence of Mycobacterium tuberculosis, the bacterium that causes TB. While other tests like chest X-ray, Mantoux tuberculin skin test, and IGRA are used in the evaluation of TB, sputum culture is the gold standard for confirming the diagnosis.

Ventilator settings to know

tidal volume (6-10mL/kg), FIo2 (21%-100), rate (12-16)

A client has 15% blood loss. Which of the following nursing assessment findings indicates hypovolemic shock?

Systolic blood pressure less than 90mm Hg Rationale: Typical signs and symptoms of hypovolemic shock includes systolic blood pressure of less than 90 mm Hg.

What is the primary goal of treatment for atherosclerosis?

To prevent the progression of the disease Rationale: The primary goal of treatment for atherosclerosis is to prevent the progression of the disease by controlling risk factors such as high cholesterol, high blood pressure, and smoking. Medications such as statins may also be prescribed to lower cholesterol levels.

The nurse is caring for a client who has been diagnosed with genital herpes. When preparing a teaching plan for this client, what general guidelines should be taught?

Thorough hand washing is essential. Rationale: The risk of reinfection and spread of infection to others or to other structures of the body can be reduced by handwashing, use of barrier methods with sexual contact, and adherence to prescribed medication regimens. The lesions should be allowed to dry. Touching of lesions during an outbreak should be avoided; if touched, appropriate hygiene practices must be followed. Light does not eradicate the virus.

The nurse is caring for a client who is one (1) day postoperative hysterectomy for cancer of the ovary. Which nursing interventions should the nurse implement? Select all that apply.

a. Assess for calf enlargement and tenderness. c. Assess pain on a 1-to-10 pain scale. d. Apply sequential compression devices to legs. e. Assess bowel sounds every four (4) hours.

What medications are used to treat HPV?

topical application of trichloroacetic acid, podophyllin, cryotherapy, as well as surgical removal

An adult is supine. Which of the ff. can the nurse do to prevent external rotation of the legs?

use a trochanter roll alongside the client's upper thighs

What are some complications of HSV?

aseptic meningitis, neonatal transmission, and severe emotional stress

What type of pneumonia is common for patients receiving tube feedings?

aspiration pneumonia

What are the risk factors of candidiasis?

antibiotic therapy, nylon underwear, tight clothing, pregnancy, oral contraceptives

What are risk factors of endometrosis?

bearing children late, fewer children, shorter menstrual cycle (less than every 27 days), flow longer than 7 days, outflow obstruction, and younger age at menarche

How is endometriosis diagnosed?

bimanual pelvic examination and laparoscopic exam

What are the signs and symptoms of COPD?

chronic cough, sputum production, and dyspnea Barrel chest

What medication is used for ovulation for patients with PCOS?

clomiphene citrate

What are the risk factors of tuberculosis?

close contact with someone who has active TB. immunocompromised, Substance use disorder, any person without adequate health care, immigration from or recent travel to countries with a high prevalence of TB, institutionalization (e.g., long-term care facilities, psychiatric institutions, prisons), living in overcrowded, substandard housing, being a health care worker performing high-risk activities

What are the clinical manifestations of HPV?

condylomata (warty growths) that can appear on the vulva, vagina, cervix, and anus

What medications are used for erectile dysfunction?

oral medication (sildenafil, vardenafil, tadalafil) injection (alprostadil, papaverine, phentolamine) Suppositories (alprostadil) Penile implant/pump Vascular surgery

A client with COPD is receiving albuterol (short-acting beta-antagonist) via a metered- dose inhaler (MDI). Which instruction should the nurse provide to the client?

"Take a slow, deep breath and hold it for 10 seconds after each puff."

A client presents with an edematous and red left great toe and reports the same symptoms occurred 2 months ago. Which questions will the nurse ask to determine if the client is experiencing gout? Select all that apply.

1."Have you had any recent surgeries?" 3."What time of day does the pain occur?" 4."Do you consume alcoholic beverages?" 5."How long did the previous episode last?" Rationale: Acute arthritis is the most common early clinical manifestation of gout. The attack may be precipitated by stress from a recent surgery. The abrupt onset of an attack often occurs at night that awakens the client with severe pain, redness, swelling, and warmth of the affected joint. The attack may be precipitated by alcohol intake. Previous attacks tend to subside spontaneously over 3 to 10 days without treatment which is followed by a symptom-free period until the next attack, which may not come for months or years.

The side effect of bone marrow depression may occur with which medication used to treat gout?

1.Allopurinol Rationale: A client taking allopurinol needs to be monitored for the side effects of bone marrow depression, vomiting, and abdominal pain.

A nurse is caring for a client who is being assessed following reports of severe and persistent low back pain. The client is scheduled for diagnostic testing in the morning. Which of the following is not appropriate diagnostic tests for assessing low back pain?

1.Angiography Rationale: A variety of diagnostic tests can be used to address lower back pain, including CT, MRI, ultrasound, and x-rays. Angiography is not related to the etiology of back pain.

A client comes to the clinic 1 day after sustaining a sprain to the left ankle. What intervention can the nurse encourage the client to perform that will help improve circulation?

1.Applying cold compresses Rationale: Applying cold compresses in the first 24 to 48 hours after an injury to reduce swelling and relieve pain. After 2 days, when swelling is no longer likely to increase, applying heat reduces pain and relieves local edema by improving circulation. Full use of the injured joint is discouraged temporarily. Non-steroidal anti-inflammatory drugs will ease discomfort but not improve circulation.

A client with diabetes punctured the foot with a sharp object. Within a week, the client developed osteomyelitis of the foot. The client was admitted for IV antibiotic therapy. How long does the nurse anticipate the client will receive IV antibiotics?

1.At least 4 weeks Rationale: Identification of the causative organism to initiate appropriate and ongoing antibiotic therapy for infection control. IV antibiotic therapy is administered for at least 4 weeks, followed by another 2 weeks (or more) of IV antibiotics or oral antibiotics.

The nurse is caring for a client with osteoporosis. Which information will the nurse include when teaching actions to manage the condition? Select all that apply.

1.Avoid excessive alcohol intake 2.Plan for smoking cessation 3.Engage in regular weight-bearing exercise Rationale: Care of the client with osteoporosis focuses on actions to improve bone density. These actions include avoiding the excessive intake of alcohol. Clients who use tobacco products should be advised to quit. Regular weight-bearing exercise promotes bone formation. Recommendations include 20 to 30 minutes of aerobic, bone-stressing exercise daily. Current guidelines recommend that hormone therapy with estrogen not be used for primary prevention of bone loss in female clients who are postmenopausal. Swimming is not a weight-bearing exercise.

The nurse is monitoring for fluid and electrolyte changes in the emergent phase of burn injury for a patient. Which of the following will be an expected outcome? Select all that apply.

1.Base-bicarbonate deficit 2.Elevated hematocrit level 4.Sodium deficit Rationale: At the time of burn injury, some red blood cells may be destroyed and others damaged, resulting in anemia. Despite this, the hematocrit may be elevated due to plasma loss. Immediately after burn injury, hyperkalemia (excessive potassium) may result from massive cell destruction. Hyponatremia (serum sodium depletion) may be present as a result of plasma loss. There is a loss of bicarbonate ions accompanying sodium loss, which results in metabolic acidosis (base-bicarbonate deficit).

A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The client has been placed in traction until the femur can be rodded in surgery. For what early complication(s) should the nurse monitor this client? Select all that apply.

1.Deep vein thrombosis 2.Compartment syndrome 3.Fat embolism Rationale: Early complications include shock, fat embolism, compartment syndrome, and venous thromboemboli (deep vein thrombosis [DVT], pulmonary embolism [PE]). Infection and complex regional pain syndrome are later complications of fractures.

Which statements describe open reduction of a fracture? Select all that apply.

1.It is performed in the operating room. 2.The bone is surgically exposed and realigned. 3.The client usually receives general or spinal anesthetic. Rationale: Statements describing open reduction are the following: It is performed in the operating room, the bone is surgically exposed and realigned, and the client usually receives general or spinal anesthetic. The bone is restored to its normal position by external manipulation with closed reduction.

A nurse is caring for a client who has been diagnosed with psoriasis. The nurse is creating an education plan for the client. What information should be included in this plan?

1.Lifelong management is likely needed. Rationale: Psoriasis usually requires lifelong management. Psoriasis is not contagious. Many clients need reassurance that the condition is not infectious, not a reflection of poor personal hygiene, and not skin cancer. Excessive frequent washing of skin produces more soreness and scaling. Overuse of topical corticosteroids can result in skin atrophy, striae, and medication resistance.

A client is recovering from a below-the-knee traumatic amputation and is 72 hours post surgery. Which actions will the nurse take to promote healing of the wound? Select all that apply.

1.Measure the residual limb every 8 to 12 hours. 3.Assess neurovascular function of the residual limb. 4.Apply an elastic compression bandage over the wound site. Rationale: Amputation is the removal of a body part by a surgical procedure or trauma. Trauma is the second most common indication for an amputation. To promote wound healing, the residual limb should be measured every 8 to 12 hours. Neurovascular status of the residual limb should also be assessed every 8 to 12 hours. If the rigid or soft dressing inadvertently comes off, the residual limb should be wrapped with an elastic compression bandage. Application of consistent pressure to the residual limb reduces edema formation and helps to shape the residual limb so that it may fit a prosthetic. The limb should only be elevated for 24 hours after the amputation. After this period, elevation, abduction, external rotation, and flexion of the lower limb are to be avoided. The client is encouraged not to sit for long periods of time to prevent flexion contracture or with the affected extremity dangling or in a dependent position to prevent edema.

The nurse reviews information collected during a health history with a client. Which information will the nurse identify that increases the client's risk of developing gout? Select all that apply.

1.Older adulthood 2.Male gender 3.Body mass index 38 4.Ingests 4 cans of beer a day 5.Works as a computer programmer Rationale:Gout is the most common form of inflammatory arthritis. The incidence of gout increases with age and men are 3 to 4 times more likely to be diagnosed with gout than women. The incidence also increases with body mass index and alcohol consumption. Gout is not associated with any particular vocation.

A patient is diagnosed with osteomyelitis of the right leg. What signs and symptoms does the nurse recognize that are associated with this diagnosis? (Select all that apply.)

1.Pain 2.Erythema 3.Fever 5.Purulent drainage Rationale: When the infection is bloodborne, the onset is usually sudden, occurring often with the clinical and laboratory manifestations of sepsis (e.g., chills, high fever, rapid pulse, general malaise). The systemic symptoms at first may overshadow the local signs. As the infection extends through the cortex of the bone, it involves the periosteum and the soft tissues. The infected area becomes painful, swollen, and extremely tender. The patient may describe a constant, pulsating pain that intensifies with movement as a result of the pressure of the collecting purulent material (i.e., pus). When osteomyelitis occurs from spread of adjacent infection or from direct contamination, there are no manifestations of sepsis. The area is swollen, warm, painful, and tender to touch.

A group of students is reviewing information about cast composition in preparation for a discussion on the advantages and disadvantages of each. The students demonstrate understanding of the topic when they cite which of the following as an advantage of a plaster cast?

1.Quicker drying Rationale: Plaster casts require a longer time for drying but mold better to the client and are initially used until the swelling subsides. Fiberglass casts dry more quickly, are lighter in weight, longer lasting, and breathable.

The nurse is caring for a client 48 hours after their burn injury. Which treatment will the nurse anticipate to reduce the client's risk of mortality?

1.Remove burned tissue Rationale: The acute/intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of body functions. One of the most important medical interventions for clients with burns that positively affect mortality is early excision (surgical removal of tissue). The presence of open wounds or invasive organisms triggers the response to a large burn injury, a systemic cascade of events. Excising the necrotic tissue can ameliorate this response and preserve underlying viable tissue. Intravenous antibiotics and intravenous fluid therapy are not identified as interventions to reduce the risk of mortality. Regular bathing of unburned areas and changing linens can help prevent infection, but burned areas are not bathed.

Which nursing intervention is essential in caring for a client with compartment syndrome?

1.Removing all external sources of pressure, such as clothing and jewelry Rationale: Nursing measures should include removing all clothing, jewelry, and external forms of pressure (such as dressings or casts) to prevent constriction and additional tissue compromise. The extremity should be maintained at heart level (further elevation may increase circulatory compromise, whereas a dependent position may increase edema). A compression wrap, which increases tissue pressure, could further damage the affected extremity. There is no indication that diagnostic studies would require I.V. access in the affected extremity.

A client reports pain in the right knee, stating, "My knee got twisted when I was going down the stairs." The client was diagnosed with an injury to the ligaments and tendons of the right knee. Which terminology, documented by the nurse, best reflects the injury?

1.Sprain Rationale: A sprain is an injury to the ligaments and tendons surrounding a joint, usually caused by a wrenching or twisting motion. Dislocation refers to the separation of joint surfaces. Subluxation refers to partial separation or dislocation of joint surfaces. Strain refers to a muscle pull or tear.

A client with chronic osteomyelitis has undergone 6 weeks of antibiotic therapy. The wound appearance has not improved. What action would the nurse anticipate to promote healing?

1.Surgical debridement Rationale: In chronic osteomyelitis, surgical debridement is used when the wound fails to respond to antibiotic therapy. Wound packing, vitamin supplements, and wound irrigation are not the standard of care when treating chronic osteomyelitis.

A nurse is assessing a client for risk factors known to contribute to osteoarthritis. What assessment finding should the nurse interpret as a risk factor?

1.The client's body mass index is 34 (obese). Rationale: Risk factors for osteoarthritis include obesity and previous joint damage. Risk factors of OA do not include smoking or hypertension. Incidence increases with age, but a client who is 58 years old would not yet face a significantly heightened risk.

Lifestyle risk factors for osteoporosis include

1.lack of exposure to sunshine. Rationale: Lifestyle risk factors for osteoporosis include lack of exposure to sunshine, a diet low in calcium and vitamin D, cigarette smoking, consumption of alcohol and/or caffeine, and lack of weight-bearing exercise. Lack of weight-bearing exercise, not lack of aerobic exercise, is a lifestyle risk factor for osteoporosis. A diet low in calcium and vitamin D, not a low-protein, high-fat diet, is a lifestyle risk factor for osteoporosis. An estrogen deficiency or menopause is an individual risk factor for osteoporosis.

A 1-year-old client has a localized rash and is miserably itchy. The client's mother indicates having just started to use a new skin cream and that the rash developed within 12 hours of the first dose. What treatments would pediatrician prescribe? Select all that apply.

1.remove allergen Rationale: Treatment for both types of dermatitis is to remove the substances causing the reaction. This is done by flushing the skin with cool water.

A client with a right leg fracture is returning to the orthopedist to have the cast removed. During cast removal, it is important for the nurse to assure:

1.the client that he or she won't be cut. Rationale: Casts are removed with a mechanical cast cutter. Cast cutters are noisy and frightening but the blade does not penetrate deep enough to cut the client. The client needs reassurance that the machine will not cut into the skin. The other options are either irrelevant or not something the nurse knows for certain at this time.

The nurse is caring for a client with severe thermal burns who requires fluid resuscitation using the Parkland formula. The client has sustained burns over 40% of their total body surface area (TBSA). According to the Parkland formula, how would the nurse calculate the total volume of fluid required for the first 24 hours?

2 mL × TBSA × weight (kg) Rationale: The Parkland formula for fluid resuscitation in burn patients is calculated as 2 mL × TBSA × weight (kg). This formula is used to determine the total volume of fluid required for the first 24 hours after a burn injury. The calculated amount is then divided by 2 and administered over the first 8 hours, followed by the remaining half over the next 16 hours.

A nurse in a busy emergency department provides care for many clients who present with contusions, strains, or sprains. What are treatment modalities that are common to all of these musculoskeletal injuries? Select all that apply.

2.Applying ice 3.Compression dressings 4.Resting the affected extremity 6.Elevating the injured limb Rationale: Treatment of contusions, strains, and sprains consists of resting and elevating the affected part, applying cold, and using a compression bandage. Massage and corticosteroids are not used to treat these injuries.

The nurse is caring for a pediatric client with burns who weighs 15 kg and has sustained burns over 18% of their TBSA. According to the Parkland formula, how much fluid should be administered in the first 8 hours?

270

A client with asthma is experiencing an acute exacerbation. Which nursing intervention takes priority?

Administering a short-acting beta-antagonist inhaler

George who has undergone thoracic surgery has chest tube connected to a water-seal drainage system attached to suction. Presence of excessive bubbling is identified in water-seal chamber, the nurse should...

Check the system for air leaks Rationale: Excessive bubbling indicates an air leak which must be eliminated to permit lung expansion.

What are the causes of high-pressure alarms?

Coughing or plugged airway tube Patient-ventilator dyssynchrony Tubing kinked Pneumothorax Atelectasis Decreased lung compliance

A client is experiencing pruritus while having a dermatitis flare. Which of the client's action could aggravate the cause of pruritis?

Daily baths with fragrant soap Rationale: The use of fragrant soap is very drying to skin hence causing the pruritus.

A client is admitted to the hospital with a diagnosis of infective endocarditis. Which assessment finding should the nurse prioritize?

Decreased level of consciousness

A nurse is assessing a client with right-sided heart failure. Which assessment finding is consistent with the diagnosis?

Dependent edema

What are the clinical manifestations of bacterial vaginosis?

Gray-white to yellow-white discharge clinging to external vulva and vaginal walls

What are the types of inhalers used for asthma?

MDIs DPIs Nebulizer

The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a gynecology surgery floor. Which intervention cannot be delegated to the UAP?

Monitor the peri-pad count on a client diagnosed with fibroid tumors. Rationale: Monitoring a peri-pad count is done to determine if the client is bleeding excessively; the nurse should do this as part of the assessment.

The nurse should explain to the client with psoriasis that treatment usually involves:

Topical application of steroids

An x-ray demonstrates a fracture in which the fragments of bone are driven inward. This type of fracture is referred to as

depressed Rationale: Depressed skull fractures occur as a result of blunt trauma. A compound fracture is one in which damage also involves the skin or mucous membranes. A comminuted fracture is one in which the bone has splintered into several pieces. An impacted fracture is one in which a bone fragment is driven into another bone fragment.

What are the risk factors for bacterial vaginosis?

douching after menses, smoking, multiple sex partners, and other sexually transmitted infections (STIs)

When is the catheter removed after CBI?

when urine is clear

A client who has fractured the radial head asks the nurse about factors that will promote bone healing. Which statement should the nurse include when responding to the client? Select all that apply.

1."Immobilization of the fracture will promote healing by maximizing contact of bone fragments." 2."Fractured bones require a good blood supply and adequate nutrition for healing." 3."Weight bearing stimulates healing of the long bones of the leg, if the fracture is stabilized." Rationale: Factors that enhance fracture healing include immobilization of the fracture fragments, sufficient blood supply, proper nutrition, and weight bearing for stabilized long bones of the lower extremities. Older adults heal more slowly. Corticosteroids inhibit the repair rate and can cause osteoporosis.

A client with a burn over the lower leg asks why surgery is planned to remove the dead burned tissue. Which response will the nurse make?

1."It reduces the risk of complications from an infection." Rationale: Early surgical excision to remove devitalized tissue along with early burn wound closure has long been recognized as one of the most important factors contributing to survival in a client with a major burn injury. When conducted in a timely and efficient manner, surgical excision results in shorter lengths of hospital stay and decreased risk of complications from invasive burn wound sepsis. Surgical debridement is not done to reduce the amount of scarring or the amount of wound care that will be needed. Natural debridement is a bodily process that liquefies any damaged tissue and may take weeks to months to occur.

The nurse is providing instructions to the client following application of a fiberglass cast. Which statement by the client indicates further education is needed?

1."Under no circumstances should I get my cast wet." Rationale: Some fiberglass casts are waterproof, allowing the client to shower or swim. A wet fiberglass cast is susceptible to denting while it is wet. Fiberglass casting involves an exothermic reaction as the cast hardens. The cast should not come in contact with other plastics as the reaction occurs.

The current phase of a client's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the client is in what phase of burn care?

1.Acute Rationale: The acute or intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and gastrointestinal function. Infection prevention, burn wound care (i.e., wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound débridement, and wound grafting), pain management, and nutritional support are priorities at this stage. Priorities during the emergent or immediate resuscitative phase include first aid, prevention of shock and respiratory distress, detection and treatment of concomitant injuries, and initial wound assessment and care. The priorities during the rehabilitation phase include prevention of scars and contractures, rehabilitation, functional and cosmetic reconstruction, and psychosocial counseling.

A client is complaining of severe pain in the left great toe. What lab studies that the nurse reviews indicate that the client may have gout?

1.Elevated uric acid levels Rationale: Gout is characterized by hyperuricemia (accumulation of uric acid in the blood) caused by alterations in uric acid production, excretion, or both. An elevated white blood count may be indicative of any inflammatory response and is not specific to gout. A decreased hemoglobin and hematocrit may indicate bleeding from somewhere in the body. Increased AST and ALT would indicate liver dysfunction.

A nurse is caring for a client who had a right below-the-knee amputation (BKA). The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning. What nursing action will best achieve these goals?

1.Encouraging the client to turn from side to side and to assume a prone position Rationale: The nurse encourages the client to turn from side to side and to assume a prone position, if possible, to stretch the flexor muscles and to prevent flexion contracture of the hip. Postoperative ROM exercises are started early, because contracture deformities develop rapidly. ROM exercises include hip and knee exercises for clients with BKAs. The nurse also discourages sitting for prolonged periods of time.

A client with a right below-the-knee amputation is being transferred from the postanesthesia care unit to a medical-surgical unit. What is the highest priority nursing intervention by the receiving nurse?

1.Ensure that a large tourniquet is in the room. Rationale: The client with an amputation is at risk for hemorrhage. A tourniquet should be placed in plain sight for use if the client hemorrhages. Documenting the receiving report is important but is not the highest priority. The nurse may delegate to unlicensed assistive personnel (UAP) the job of gathering more pillows for positioning, but this is not the highest priority. The nurse will need to review the physician's orders for pain medication, but again, this is not the highest priority, because any hemorrhaging by the client needs to be addressed first.

A client has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this client's care?

1.Fluid status Rationale: During the early phase of burn care, the nurse is most concerned with fluid resuscitation, to correct large-volume fluid loss through the damaged skin. Infection control and early nutritional support are important, but fluid resuscitation is an immediate priority. Coping is a higher priority later in the recovery period.

A nurse should advise a client with gout to avoid which foods?

1.Organ meats Rationale: An excessive intake of foods that are high in purines (shellfish, organ meats) may result in symptoms of gout in susceptible persons. A diet low in purine is recommended.

A 75-year-old client had surgery for a left hip fracture yesterday. When completing the plan of care, the nurse should include assessment for which complications? Select all that apply.

1.Pneumonia 3.Skin breakdown 4.Atelectasis 5. Delirium Rationale: Complications in clients with hip fractures are often related to the client's age. During the first 24 to 48 hours following surgery for hip fracture, atelectasis or pneumonia can develop as a result of the anesthesia. Thromboemboli are possible, as is sepsis. Elderly clients are also at risk for delirium in hospital settings because of the stress of the trauma, unfamiliar surroundings, sleep deprivation, and medications. An elderly client with decreased mobility is at risk for skin breakdown. Necrosis is a potential complication of the surgery, but the complication would be with the femur, not the humerus

The client has just been diagnosed with osteomyelitis. What of the following is not a possible causes of osteomyelitis?

1.Progressive osteoporosis Rationale: The following are all causes of osteomyelitis: trauma, such as penetrating wounds or compound fractures; vascular insufficiency in clients with diabetes or peripheral vascular disease; and surgical contamination, such as pin sites of skeletal traction. Osteoporosis is not a cause of osteomyelitis.

A client is diagnosed with several fractured ribs after a motor vehicle crash. Which actions will the nurse take when caring for this client? Select all that apply.

1.Provide analgesics as prescribed. 3.Instruct on the use of an incentive spirometer. 4.Demonstrate the use of a pillow to splint the area. 5.Remind to take deep breaths and cough every hour. Rationale: Rib fractures are some of the most common thoracic injuries; they occur frequently in adults of all ages, typically from blunt trauma such as motor vehicle crashes or falls, and usually result in no impairment of function. The mainstay of treatment is pain control to decrease chest wall splinting and subsequent atelectasis. Therefore, analgesics should be provided as prescribed. An incentive spirometer should be used to prevent pooling of secretions. A pillow should be used to splint the area prior to deep breathing and coughing. Chest binders to immobilize the rib fracture are not used, because decreased chest expansion may result in atelectasis and pneumonia.

What laboratory value observed by the nurse is unexpected during the fluid remobilization phase of a major burn?

1.Serum sodium level of 140 mEq/L (normal) Rationale: In the acute/intermediate (fluid remobilization) phase of burn care, sodium is lost with water due to diuresis, and existing serum sodium is diluted with water influx, resulting in a decreased serum sodium level. Normal serum sodium level is 135 to 145 mEq/L, so 140 mEq/L is a normal finding, which is unexpected in the acute/intermediate phase of burn care. Normal hematocrit, metabolic acidosis, and hypokalemia are all expected findings during this phase.

A client seeks medical attention for a new skin condition. Which finding indicates to the nurse that the client is not experiencing contact dermatitis?

1.Silvery scales Rationale: Contact dermatitis is an inflammatory reaction of the skin to physical, chemical, or biological agents. The epidermis is damaged by repeated physical and chemical irritations. The eruptions begin when the causative agent contacts the skin. The first reactions include pruritis and burning. Later reactions include papules and vesicles. Silvery scales are associated with psoriasis.

A provider asks the nurse to teach a client with low back pain how to sit in order to minimize pressure on the spine. Which teaching points would the nurse include? Select all that apply.

1.Sit in a straight-backed chair with arm rests. 2.Use a firm pillow placed behind the thoracic vertebrae to straighten the small of the back. 3.Avoid hip extension. 4.Place feet flat on the floor. 5. Sit with the buttocks "tucked under." Rationale: All choices are correct, except that a soft pillow support is recommended to eradicate the hollow of the back.

The clinic nurse is caring for a client with an injured body part that does not require rigid immobilization. What method of immobilization would the nurse expect the health care provider to use on a short-term basis?

1.Splint Rationale: A splint immobilizes and supports an injured body part in a functional position and is used when the condition does not require rigid immobilization, causes a large degree of swelling, or requires special skin treatment. Casts and traction provide rigid immobilization. A brace provides support, controls movement, and prevents additional injury for more long-term use.

A client presents with silvery scales on the elbows and knees. The physician has made a diagnosis of plaque psoriasis. What is the probable cause of psoriasis? Select two that apply.

1.genetic predisposition 2.a triggering mechanism, such as systemic infection, injury to the skin, vaccination, or injection Rationale: Probable causes include genetic predisposition; or a triggering mechanism such as systemic infection, injury to the skin, vaccination, or injection. Furuncles and carbuncles are caused by injury, such as squeezing a lesion. They are also associated with diabetes mellitus because an elevated blood glucose level promotes microbial growth.

The nurse is preparing to initiate fluid resuscitation for a patient weighing 130 pounds (59 kg) who suffered a 58% total body surface area (TBSA) thermal burn. The health care provider ordered: 2 mL lactated Ringer's (LR) × patient's weight in kilograms × %TBSA to be administered over 24 hours. The nurse will administer ________________________ mL of fluid over the first 8 hours post-burn injury?

3422 Rationale: Convert pounds. to kilograms = 130/2.2 = 59 kg 2 mL x 59 kg x 58% TBSA = 6844 mL/24 hr. The infusion is regulated so that one-half of the calculated volume is administered in the first 8 hours after burn injury, so the nurse would infuse 3422 in the first eight hours and the second half of the calculated volume over the next 16 hours. Fluid resuscitation formulas are only a guideline. It is imperative that the rate of infusion be titrated hourly as indicated by physiologic monitoring of the patient's response.

Which information about continuous bladder irrigation will the nurse teach to a patient who is being admitted for a transurethral resection of the prostate (TURP)?

Bladder irrigation prevents obstruction of the catheter after surgery. Rationale: The purpose of bladder irrigation is to remove clots from the bladder and prevent obstruction of the catheter by clots. The irrigation does not decrease bleeding or improve hydration. Antibiotics are given by the IV route, not through the bladder irrigation

Mrs. Chua a 78 year old client is admitted with the diagnosis of mild chronic heart failure. The nurse expects to hear when listening to client's lungs indicative of chronic heart failure would be:

Crackles Rationale: Left sided heart failure causes fluid accumulation in the capillary network of the lung. Fluid eventually enters alveolar spaces and causes crackling sounds at the end of inspiration.

The nurse is caring for a client with pneumonia who is prescribed antibiotic therapy. Which assessment finding indicates a therapeutic response to the treatment?

Decreased temperature Rationale: A decreased temperature indicates a therapeutic response to antibiotic therapy in a client with pneumonia. Elevated temperature is a common symptom of pneumonia due to the inflammatory response caused by the infection. A decrease in temperature indicates a reduction in the infectious process.

A client suffered from a lower leg injury and seeks treatment in the emergency room. There is a prominent deformity to the lower aspect of the leg, and the injured leg appears shorter that the other leg. The affected leg is painful, swollen and beginning to become ecchymotic. The nurse interprets that the client is experiencing:

Fracture Rationale: Common signs and symptoms of fracture include pain, deformity, shortening of the extremity, crepitus and swelling.

A client presents with silvery scales on the elbows and knees. The physician has made a diagnosis of plaque psoriasis. What is the probable cause of psoriasis? SATA

Genetic predisposition A triggering mechanism, such as a systemic infection, injury to the skin, vaccination, or injection

What are the defining characteristics to diagnose respiratory failure?

Hypoxemia (PaO2 <60) Hypercapnia (CO2> 50) Acidosis (pH< 7.35)

What are some treatment alternatives for uterine bleeding?

Hysteroscopic resection of myomas Laparoscopic myomectomy Laparoscopic myolysis Uterine artery embolization (UAE)

Nitrates

Ideally, take the nitroglycerin before your chest pain begins. If you know that a certain activity usually causes chest pain (e.g., eating a big meal, attending a business meeting, engaging in sexual intercourse), take the tablet before undertaking that activity. Sublingual nitroglycerin is an unstable compound. Do not buy large quantities at a time because it does not store well. Keep the drug in a dark, dry place and in a dark-colored glass container, not a plastic bottle, with a tight lid. Leave it in its own bottle. Do not combine it with other drugs.

A nurse is caring for a client who has been diagnosed with psoriasis. The nurse is creating an education plan for the client. What information should be included in this plan?

Lifelong management is likely needed

What is the primary goal of treatment for unstable angina?

Reducing the risk of a heart attack Rationale: Unstable angina is a medical emergency that requires immediate treatment to reduce the risk of a heart attack. The primary goal of treatment is to prevent the formation of blood clots and restore blood flow to the heart muscle.

The client frequently finds lumps in her breasts, especially around her menstrual period. Which information should the nurse teach the client regarding breast self-care?

The client should practice breast self-examination monthly. Rationale: The American Cancer Society no longer recommends breast self-examination (BSE) for all women, but it is advisable for women with known breast conditions to perform BSE monthly to detect potential cancer.

What is the primary purpose of a cardiac catheterization procedure?

To diagnose the presence of heart disease Rationale: To diagnose the presence of heart disease. Cardiac catheterization is a diagnostic procedure used to visualize the heart and blood vessels to detect and evaluate the presence of heart disease.

An adult has chronic lower back pain and receives hot pack three times a week. The nurse knows that the treatment is given for which of the following reasons?

To relieve muscle spasm and promote muscle relaxation

Which of the following would indicate to the nurse that a patient has a DVT?

Unilateral leg pain

A patient is on the surgical unit after a total abdominal hysterectomy. Which finding requires contacting the health care provider?

Urine output of 125 mL in the first 8 hours after surgery Rationale: The decreased urine output indicates possible low blood volume and further assessment is needed to assess for possible internal bleeding. Decreased bowel sounds, minor drainage on the dressing, and abdominal pain with coughing are expected after this surgery.

What are the clinical manifestations of endometriosis?

dysmenorrhea, dyspareunia, and pelvic discomfort or pain. Dyschezia (pain with bowel movements) and radiation of pain to the back or leg

What care is provided after a mastectomy?

shoulder range of motion Avoid blood pressures, injections, and blood draws in affected extremity hand and arm care to prevent injury or trauma to the affected extremity compression sleeve or glove, exercises, manual lymph drainage Hematoma formation-warm compressions

What are the clinical manifestations of prostatitis?

sudden onset of fever, dysuria, perineal prostatic pain, and severe lower urinary tract symptoms including dysuria, frequency, urgency, hesitancy, and nocturia

What is the treatment for a pleural effusion?

thoracentesis

The nurse is providing discharge education to a client who underwent a vaginal hysterectomy. Which statement by the client indicates an understanding of potential complications following the procedure?

"I may experience shoulder pain due to the gas used during the surgery." Rationale: Shoulder pain due to the presence of residual carbon dioxide gas in the abdomen is a potential complication following a laparoscopic or robotic-assisted hysterectomy. The gas irritates the diaphragm, leading to referred pain in the shoulders. Educating the client about this potential complication promotes early recognition and alleviates anxiety.

Which of the following statements made by a patient with angina indicates a need for further education?

"I should take my nitroglycerin medication with grapefruit juice." Rationale: Grapefruit juice can increase the absorption of nitroglycerin, leading to an increased risk of side effects such as dizziness and headache. Patients with angina should avoid taking nitroglycerin with grapefruit juice.

A client who was injured while playing basketball reports an extremely painful elbow, which is very edematous. What type of injury has the client experienced?

1. sprain Rationale: Sprains are injuries to the ligaments surrounding a joint. A strain is an injury to a muscle when it is stretched or pulled beyond its capacity. A contusion is a soft tissue injury resulting from a blow or blunt trauma. Sprains are injuries to the ligaments surrounding a joint.

The nurse is caring for a patient with a pelvic fracture. What nursing assessment for a pelvic fracture should be included? (Select all that apply.)

1.Checking the urine for hematuria Palpating peripheral pulses in both lower extremities Rationale: In pelvic fracture, the nurse should palpate the peripheral pulses, especially the dorsalis pedis pulses of both lower extremities; absence of a pulse may indicate a tear in the iliac artery or one of its branches. To assess for urinary tract injury, the patient's urine is analyzed for blood.

The most important principle of psoriasis treatment is which of the following?

1.Gentle removal of scales Rationale: The most important principle of psoriasis treatment is gentle removal of scales. This can be accomplished with baths. After bathing, the application of emollient creams containing alpha-hydroxy acids or salicylic acid continues to soften thick scales. The patient and family should be encouraged to establish a regular skin care routine that can be maintained even when the psoriasis is not in an acute stage. Although dressing changes may be done in the treatment of psoriasis, it is not the most important principle of treatment.

The client with osteoarthritis is seen in the clinic. Which assessment finding indicates the client is having difficulty implementing self-care?

1.Has a weight gain of 5 pounds Rationale: Obesity is a risk factor for osteoarthritis. Excess weight is a stressor on the weight-bearing joints. Weight reduction is often a part of the therapeutic regimen.

A client is diagnosed with a first-degree strain of the left ankle related to running 5 miles daily. How would the nurse differentiate the first-degree strain from other strains and sprains?

1.The client has some edema of the left ankle with muscle spasms but is able to walk without assistive devices. Rationale: A first-degree strain involves mild stretching of the muscle or tendon, causing some edema and muscle spasm, but no real loss of function. The second-degree strain is partial tearing of muscle or tendon, leading to inability to bear weight and causing edema, muscle tenderness, muscle spasm, and ecchymosis. The third-degree tear is severe muscle and/or tendon tearing, causing severe pain, muscle spasm ecchymosis, edema, and loss of function. A first-degree sprain involves stretching of the ligament fibers characterized by mild edema, tenderness, and pain if the joint is moved.

A nurse is providing a class on osteoporosis at the local center for older adults. Which statement related to osteoporosis is most accurate?

1.The use of corticosteroids increases the risk of osteoporosis. Rationale: Corticosteroid therapy is a secondary cause of osteoporosis when taken for long-term use. Adequate levels of vitamin D are needed for absorption of calcium. A person's level of physical activity is a modifiable factor that influences peak bone mass. Lack of activity increases the risk for the development of osteoporosis. Primary osteoporosis occurs in women after menopause.

Which of the following are associated with compartment syndrome? Select all that apply.

1.Trauma from accidents 2.Surgery 3.Casts 4.Tight bandages 5. Crushing injuries Rationale: Risk factors for compartment syndrome include trauma from accidents, surgery, casts, tight bandages, and crushing injuries. In addition, it may be caused by any condition that increases the risk of bleeding or edema in a confined space including patients with soft tissue injury, without fractures, who are on anticoagulants or have bleeding disorders.

The nurse recognize what as an early sign of sepsis in a client with a burn injury?

1.Widened pulse pressure Rationale: In clients with burn injuries early sepsis can be hard to detect. Clients with burn injuries exhibit tachycardia, tachypnea, and elevated body temperature, all typical indications of sepsis. In the client with burn injury, indications of sepsis include elevated serum glucose values, increased heart rate, and narrowing mean arterial pressure. Both the typical elevated temperature and a temperature of less than 96.8 F (36 C) can indicate sepsis in a client with a burn injury.

A nurse is caring for a client with a warm and painful toe from gout. What medication will the nurse administer?

1.colchicine Rationale: A disease characterized by joint inflammation (especially in the great toe), gout is caused by urate crystal deposits in the joints. The health care provider orders colchicine to reduce these deposits and thus ease joint inflammation. Although aspirin reduces joint inflammation and pain in clients with osteoarthritis and rheumatoid arthritis, it isn't indicated for gout because it has no effect on urate crystal formation. Furosemide is a diuretic; it is not used to relieve gout. Calcium gluconate reverses a negative calcium balance and relieves muscle cramps; it is not used to treat gout.

The nurse is collaborating with the health care provider on a plan of care for a 54-year-old male client with osteomyelitis of the left femur secondary to uncontrolled type 1 diabetes. Click to highlight the prescriptions for care that the nurse should anticipate for this client.

2.Perform neurovascular checks of lower extremities every 8 hours. 3.Administer IV antibiotic based on culture and sensitivity report. 5.Administer ibuprofen 400 mg orally three times daily, as needed for pain. 6.Make referral to dietitian to discuss nutrition for healing and blood glucose control. 7.Provide education on self-blood glucose monitoring and insulin administration. Rationale: Osteomyelitis is a bone infection that produces pain, inflammation, swelling, and impaired mobility and requires prompt treatment to treat the infection and prevent loss of limb. The nurse should perform neurovascular checks of the affected leg every 8 hours to detect the development of nerve or vascular impairment. Osteomyelitis is treated with IV antibiotics determined by the identified pathogen on culture and sensitivity testing. Because there is reduced penetration of antibiotics in the bone tissue, IV antibiotic therapy may be needed for 6 to 12 weeks, followed by oral antibiotics. The pain of osteomyelitis can be controlled with oral analgesics, such as ibuprofen. The client should consume a healthy diet to promote bone healing and control blood glucose levels. Because uncontrolled blood glucose levels increase the risk for osteomyelitis and impair bone healing, the nurse should educate the client about self-blood glucose monitoring and insulin administration. The client's affected left leg should be elevated to reduce swelling and pain. The affected leg should not be placed in the dependent position. Because the bone is weakened by the infectious process, the client should avoid placing stress on the bone through weight-bearing activity.

A client with pneumonia is prescribed oxygen therapy. Which nursing intervention is essential when administering oxygen to this client?

Assessing oxygen saturation levels every 4 hours Rationale: Assessing oxygen saturation levels every 4 hours is essential when administering oxygen to a client with pneumonia. Oxygen saturation levels provide valuable information about the client's oxygenation status, helping the nurse determine the effectiveness of oxygen therapy and the need for adjustments in the delivery method or flow rate.

The nurse is caring for a client who has just had a radical mastectomy and axillary node dissection. When providing client education regarding rehabilitation, what should the nurse recommend?

Avoid lifting objects heavier than 10 pounds (d.5 kg). Rationale: Following an axillary dissection, the client should avoid lifting objects greater than 5 to 10 pounds, cutting the cuticles, and undergoing venipuncture on the affected side. Exercises of the hand and arm are encouraged and the use of a sling is not necessary.

Which of the following is true about verapamil?

It may cause a drop in blood pressure. Rationale: Verapamil usually decreases blood pressure, which is why it is sometimes used as an antihypertensive agent. Verapamil may be lethal if given to a patient with V-tach, therefore it should not be given to a tachycardic patient with a wide complex QRS. Verapamil is a calcium channel blocker and may actually cause PEA if given too fast intravenously or if given in excessive amounts. The specific antidote for overdose from verapamil, or any other calcium channel blocker, is calcium. Verapamil may cause hypotension.

Included in teaching the client with tuberculosis taking INH about follow-up home care, the nurse should emphasize that a laboratory appointment for which of the following lab tests is critical?

Liver function Rationale: INH can cause hepatocellular injury and hepatitis. This side effect is age-related and can be detected with regular assessment of liver enzymes, which are released into the blood from damaged liver cells.

The nurse is caring for a client with a fractured hip who is in traction. What intervention should the nurse prioritize to prevent complications?

Monitoring the client's skin integrity Rationale: Monitoring the client's skin integrity is a priority intervention in the care of a client in traction. Immobility and pressure from the traction device increase the risk of pressure ulcers. Regular skin assessments and appropriate interventions, such as repositioning and providing cushioning, are essential to prevent skin breakdown. Options A, B, and D are important aspects of care but are not the priority when compared to preventing complications related to skin integrity.

The nurse is conducting an interview of an older client and is concerned about the possibility of benign prostatic hyperplasia (BPH). Which are characteristics of this disorder? Select all that apply.

Nocturia Incontinence Enlarged Prostate Rationale: Nocturia, incontinence, and an enlarged prostate are characteristics of BPH and need to be assessed for in all male clients over 50 years of age. Nocturnal emissions are commonly associated with prepubescent males. Low testosterone levels (not BPH) may be associated with a decreased desire for sexual intercourse.

What precautions are there with Internal (Intracavitary) Irradiation?

Private room Lead shield placed at the doorway to the patient's room Vaginal packing to protect bladder and rectum

What is the gold standard surgical treatment for BPH?

Transurethral resection of the prostate (TURP)

What are the clinical manifestations of BPH?

Urinary frequency, urgency, nocturia, hesitancy in starting urination, a decrease in the volume and force of the urinary stream, dribbling

The clinic nurse has provided instructions regarding home care measures to a female client diagnosed with pelvic inflammatory disease (PID). Which statement, if made by the client, indicates an understanding of these measures?

"I need to avoid tight-fitting clothing." Rationale: The client who has been diagnosed with PID should avoid frequent douching because this decreases the normal flora that controls the growth of infectious organisms. The client should wear cotton undergarments, and clothes should not fit tightly. Tampons, if worn, should be changed frequently but should not be used during an acute infection. In fact, many primary health care providers recommend avoiding the use of tampons indefinitely. Intrauterine devices increase the client's susceptibility to PID.

The nurse is providing education on breast cancer prevention to a group of women. Which statement by a participant indicates a need for further education?

"I schedule yearly mammograms starting at the age of 40." Rationale: The ACS has changed the mammography recommendations to state that healthy women should have mammography every year beginning at age 45; women aged 40 to 44 have the option to begin yearly screening early (ACS, 2019). Women 55 and older may continue yearly screening or transition to every 2 years.

The nurse is providing education to a client with genital herpes regarding transmission to sexual partners. Which statement by the client indicates an understanding of the transmission risks?

"I should abstain from sexual activity during outbreaks to reduce the risk of transmission." Rationale: Abstaining from sexual activity during outbreaks of genital herpes can help reduce the risk of transmission. The virus can still be shed from the infected area, even in the absence of visible sores. Condom use and avoiding contact with the infected area during sexual activity can further decrease the risk of transmission but do not completely eliminate it. Oral sex can transmit the virus from the genital area to the oral area or vice versa.

The nurse is providing education to a client who will be receiving a cast for a fractured arm. Which statement by the client indicates understanding of cast care?

"I should avoid resting the cast on hard surfaces." Rationale: Resting the cast on hard surfaces can cause damage and lead to uneven pressure distribution. Clients should be advised to use pillows or soft surfaces for support. The client should not use a plastic, it could retain heat and prevent drying, scratching under the cast can cause skin damage and increase the risk of infection and the cast should not be completely covered, as it needs air circulation for proper drying and to prevent moisture buildup.

Which statement by the patient indicates that the nurse's teaching about treating vaginal candidiasis was effective?

"I should clean carefully after each urination and bowel movement." Rationale: Cleaning of the perineal area will decrease itching caused by contact of the irritated tissues with urine and reduce the chance of further infection of irritated tissues by bacteria in the stool. Sexual intercourse should be avoided for 1 week. Douching will disrupt normal protective mechanisms in the vagina. The cream should be used at night so that it will remain in the vagina for longer periods of time.

The nurse is teaching a client about the side effects of isoniazid (INH), a medication used to treat tuberculosis (TB). Which statement by the client indicates an understanding of the teaching?

"I should report any yellowing of the skin or eyes to my healthcare provider." Rationale: INH can cause hepatotoxicity, which may present as yellowing of the skin or eyes (jaundice). The client should be educated to report this side effect immediately to the healthcare provider for further evaluation and management.

There is one opening in the schedule at the dermatology clinic, and four patients are seeking appointments today. Which patient will the nurse schedule for the available opening?

-38-year-old with a 7 mm nevus on the face that has recently become darker

Which steps should the nurse provide clients who choose to perform breast self-examination (BSE) according to the American Cancer Society (ACS) guidelines? Rank in order of performance.

-Find a private place where the self-examination can be performed. -With the breasts exposed, stand in front of a mirror and examine the breasts from front and each side. -In the shower, soap the breasts, and perform palpation in a systematic manner on each breast. -Lie flat on the bed with a rolled towel placed under the scapula; perform palpation of each breast. -Pinch each nipple to see if fluid can be expressed.

A nurse's assessment of a client's knee reveals edema, tenderness, muscle spasms, and ecchymosis. The client states that 2 days ago the client ran in a long-distance race and now it "really hurts to stand up." The nurse should plan care based on the belief that the client has experienced what injury?

1. A second-degree burn Rationale: A second-degree strain involves tearing of muscle fibers and is manifested by notable loss of load-bearing strength with accompanying edema, tenderness, muscle spasm, and ecchymosis. A first-degree strain reflects tearing of a few muscle fibers and is accompanied by minor edema, tenderness, and mild muscle spasm, without noticeable loss of function. However, this client states a loss of function. A sprain normally involves twisting, which is inconsistent with the client's overuse injury.

A client aged 48 years comes to the clinic because they have discovered a lump in the breast. After diagnostic testing, the client receives a diagnosis of breast cancer. The client asks the nurse when the teenage daughters should begin mammography. What is the nurse's best advice?

Age 38 Rationale: A general guideline is to begin screening 5 to 10 years earlier than the age at which the youngest family member developed breast cancer, but not before age 25 years. In families with a history of breast cancer, a downward shift in age of diagnosis of about 10 years is seen. Because their mother developed breast cancer at age 48 years, the daughters should begin mammography at age 38 to 43 years.

The nurse is reviewing the medication regimen for a client with BPH. Which medication is commonly prescribed to help alleviate BPH symptoms?

Alpha-adrenergic blockers Rationale: Alpha-adrenergic blockers, such as tamsulosin (Flomax), are commonly prescribed to help alleviate BPH symptoms. These medications relax the smooth muscles of the prostate and bladder neck, improving urine flow and reducing urinary symptoms associated with BPH.

A client is admitted to the hospital with a diagnosis of benign prostatic hyperplasia, and a transurethral resection of the prostate is performed. Four hours after surgery, the nurse takes the client's vital signs and empties the urinary drainage bag. Which assessment finding indicates the need to notify the primary health care provider (PHCP)?

Blood pressure, 100/50 mm Hg; pulse, 130 beats per minute Rationale: Frank bleeding (arterial or venous) may occur during the first day after surgery. Some hematuria is usual for several days after surgery. A urinary output of 200 mL more than intake is adequate. A client pain rating of 2 on a 0 to 10 scale indicates adequate pain control. A rapid pulse with a low blood pressure is a potential sign of excessive blood loss. The PHCP should be notified.

Which of the following symptoms is the most common in patients with a myocardial infarction (MI)?

Chest pain or discomfort Rationale: Chest pain or discomfort is the most common symptom in patients with a myocardial infarction. Other symptoms may include shortness of breath, sweating, nausea, and vomiting.

A patient is admitted with suspected myocardial infarction. Which of the following diagnostic tests is the gold standard for diagnosing MI?

Electrocardiogram (ECG) Rationale: An ECG is the gold standard for diagnosing myocardial infarction. It can detect abnormalities in the heart's electrical activity and identify areas of ischemia or infarction.

What is the primary cause of atherosclerosis?

Elevated cholesterol levels Rationale: High levels of low-density lipoprotein (LDL) cholesterol are the primary cause of atherosclerosis. LDL cholesterol can build up in the walls of arteries, leading to the formation of plaques.

A client with PVD presents with skin discoloration and ulcers on their feet. Which nursing intervention is the highest priority?

Elevating the feet

The nurse is caring for a client on mechanical ventilation. Which intervention is most effective in preventing ventilator-associated pneumonia?

Elevating the head of the bed at least 30-45 degrees

The nurse is caring for a client with right-sided heart failure. Which intervention would be most appropriate for promoting venous return and reducing peripheral edema?

Elevating the legs

What are some ways to prevent VAP?

Elevation of the head of the bed (30° to 45°) Daily "sedation vacations" and assessment of readiness to extubate (see below) Peptic ulcer disease prophylaxis Deep venous thrombosis (DVT) prophylaxis (see below) Daily oral care with chlorhexidine (0.12% oral rinses)

A client with a fractured left tibia has a long leg cast and she is using crutches to ambulate. The nurse will assesses for which sign and symptom that indicates complication associated with crutch walking?

Forearm weakness Rationale: Forearm muscle weakness is a probable sign of radial nerve injury caused by crutch pressure on the axillae.

A male client's left tibia was fractured in an automobile accident, and a cast is applied. To assess for damage to major blood vessels from the fracture tibia, the nurse in charge should monitor the client for:

Prolonged reperfusion of the toes after blanching Rationale: . Damage to blood vessels may decrease the circulatory perfusion of the toes, this would indicate the lack of blood supply to the extremity.

A 49-year-old man who has type 2 diabetes, high blood pressure, hyperlipidemia, and gastroesophageal reflux tells the nurse that he has had recent difficulty in achieving an erection. Which of the following drugs from his current medications list may cause erectile dysfunction (ED)?

Propranolol (Inderal)

The nurse is reviewing the medical history of a client who has been diagnosed with osteomyelitis. Which risk factor should the nurse identify as a significant contributor to the development of osteomyelitis?

Recent surgical procedure Rationale: A recent surgical procedure is a significant risk factor for the development of osteomyelitis. Invasive procedures can introduce bacteria into the bloodstream, increasing the risk of infection reaching the bone and causing osteomyelitis.

Which of the following lifestyle modifications is recommended to prevent the development of atherosclerosis?

Regular exercise and a heart-healthy diet Rationale: Lifestyle modifications such as regular exercise and a heart-healthy diet can help prevent the development of atherosclerosis. It is important to avoid a sedentary lifestyle, consuming a diet high in saturated fat and cholesterol, and smoking cigarettes.

What is the role of a stent in a PTCA procedure?

To reduce the risk of restenosis Rationale: A stent is a small metal mesh tube that is inserted into the artery during a PTCA procedure to hold the artery open and reduce the risk of restenosis, which is the re-narrowing of the artery.

A client with a long history of cardiovascular problem including hypertension and angina is to be scheduled for cardiac catheterization. During pre cardiac catheterization teaching, the nurse should inform the client that the primary purpose of the procedure is.....

To visualize the disease process in the coronary arteries Rationale: The lumen of the arteries can be assessed by cardiac catheterization. Angina is usually caused by narrowing of the coronary arteries.

What is the treatment for erectile dysfunction?

Treat the cause (e.g., alcoholism, diabetes), adjustment of medications, endocrine therapy to treat erectile dysfunction secondary to hypothalamic-pituitary-gonadal dysfunction may reverse the condition.

What is the primary indication for a Percutaneous Transluminal Coronary Angioplasty (PTCA) procedure?

Unstable angina Rationale: The primary indication for a PTCA procedure is unstable angina, which is caused by a partial blockage in the coronary arteries that restricts blood flow to the heart muscle.

The client diagnosed with ovarian cancer has had eight (8) courses of chemotherapy. Which laboratory data warrant immediate intervention by the nurse?

Urinalysis report of 100 WBCs. Rationale: A normal urinalysis contains one (1) to two (2) WBCs. A report of 100 WBCs indicates the presence of an infection. A clean voided specimen should be obtained and a urine culture should be done. This client should be prescribed antibiotics immediately.

The nurse is caring for a client with prostatitis. Which symptom is commonly associated with this condition?

Urinary urgency Rationale: Urinary urgency is a common symptom associated with prostatitis. Inflammation of the prostate gland can cause irritation and compression of the urethra, leading to increased urgency and frequency of urination, hesitancy, dysuria, and a weak urine flow.