Fundamentals Physiological (eaq)Aspects

While receiving a preoperative enema, a client starts to cry and says, "I'm sorry you have to do this messy thing for me." What is the nurse's best response? 1 "I don't mind it." 2 "You seem upset." 3 "This is part of my job." 4 "Nurses get used to this."

2 "You seem upset."

A nurse is assigned to take care of a group of clients. Which client should the nurse see first? 1 A 2-yr-old male with diarrhea 2 A 35-yr-old male who is nauseated 3 A 40-yr-old female who has vomiting due to food poisoning 4 An 83-yr-old female whose last bowel movement was three days ago.

1 A 2-yr-old male with diarrhea The two-year-old child will be at higher risk for fluid and electrolyte imbalance due to higher fluid content of the body and decreased ability to regulate fluid balance, which put this client in life threatening situation.

A child is to receive 60 mg of phenytoin (Dilantin). The medication is available as an oral suspension that contains 125 mg/5 mL. How many milliliters should the nurse administer? Record the answer using one decimal place. ______ mL

2.4

A child is to receive 60 mg of phenytoin (Dilantin). The medication is available as an oral suspension that contains 125 mg/5 mL. How many milliliters should the nurse administer? Record the answer using one decimal place. ______ mL

2.4 mL

A physician orders guaifenesin (Humibid) 300 mg four times a day. The dosage strength is 200 milligrams/5 milliliters. To ensure the patient's safety, how many milliliters should the nurse administer for each dose? Record your answer using one decimal place. ____ mL

300mg/x = 200mg/5mL X = 7.5 mL

After abdominal surgery a client reports pain. What action should the nurse take first? 1 Reposition the client. 2 Obtain the client's vital signs. 3 Administer the prescribed analgesic. 4 Determine the characteristics of the pain.

4 Determine the characteristics of the pain. The exact nature of the pain must be determined to distinguish whether or not it is a result of the surgery. Repositioning the client, obtaining the client's vital signs, and administering the prescribed analgesic should be done later; the first action is to determine the cause of the pain.

A nurse reinforces teaching a client about Coumadin (warfarin) and concludes that the teaching is effective when the client states, "I must not drink: 1 apple juice. 2 grape juice. 3 orange juice. 4 cranberry juice.

4 cranberry juice. Antioxidants in cranberry juice may inhibit the mechanism that metabolizes Coumadin, causing elevations in the international normalized ratio (INR), resulting in hemorrhage. Apple juice, grape juice, and orange juice are fine to drink.

A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the nurse question? 1 Oral psyllium (Metamucil) 2 Oral potassium supplement 3 Parenteral half normal saline 4 Parenteral albumin (Albuminar)

4 Parenteral albumin (Albuminar) Albumin is hypertonic and will draw additional fluid from the tissues into the intravascular space. Oral psyllium will absorb the watery diarrhea, giving more bulk to the stool. An oral potassium supplement is appropriate because diarrhea causes potassium loss. Parenteral half normal saline is a hypotonic solution, which can correct dehydration.

The nurse assesses an edematous client and recalls that edema occurs in what extracellular fluid compartment? 1 Interstitial 2 Intercellular 3 Intravascular 4 Intracellular

1 Interstitial Edema is defined as the accumulation of fluid in the interstitial spaces. The incorrect answer options occur in other compartments: intercellular means between or among cells; intravascular means within a vascular space; and intracellular means within a cell.

An arterial blood gas report indicates the client's pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is 20 mEq/L. Which disturbance should the nurse identify based on these results? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

1 Metabolic acidosis

To prevent thrombophlebitis in the immediate postoperative period, which action is most important for a nurse to include in the client's plan of care? 1 Increase fluid intake. 2 Restrict fluids. 3 Encourage early mobility. 4 Elevate the knee gatch of the bed.

3 Encourage early mobility.

A nurse is evaluating the effectiveness of treatment for a client with excessive fluid volume. What clinical finding indicates that treatment has been successful? 1 Clear breath sounds 2 Positive pedal pulses 3 Normal potassium level 4 Increased urine specific gravity

1 Clear breath sounds

A nurse on the medical-surgical unit tells other staff members, "That client can just wait for the lorazepam (Ativan); I get so annoyed when people drink too much." What does this nurse's comment reflect? 1 Demonstration of a personal bias. 2 Problem solving based on assessment. 3 Determination of client acuity to set priorities. 4 Consideration of the complexity of client care.

1 Demonstration of a personal bias.

A nurse understands that the primary purpose for a client to undergo reconstructive surgery is to: 1 Restore function and/or appearance. 2 Replace an organ or tissue. 3 Relieve or reduce symptoms. 4 Remove or excise an organ or tissue.

1 Restore function and/or appearance.

A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L and a potassium level of 3.6 mEq/L. Based on the lab results and symptoms, what is the client experiencing? 1 Hypernatremia 2 Hyponatremia 3 Hyperkalemia 4 Hypokalemia

2 Hyponatremia The normal range for serum sodium is 135 to 145 mEq/L, and for serum potassium it is 3.5 to 5 mEq/L. Vomiting and use of diuretics, such as furosemide (Lasix), deplete the body of sodium. Without intervention, symptoms of hyponatremia may progress to include neurological symptoms such as confusion, lethargy, seizures, and coma. Hypernatremia results when serum sodium is greater than 145 mEq/L; hyperkalemia results when serum potassium is greater than 5.0 mEq/L; hypokalemia results when serum potassium is less than 3.5 mEq/L.

To minimize the side effects of the vincristine (Oncovin) that a client is receiving, what type of dietary plan does the nurse expect? 1 Low in fat 2 High in iron 3 High in fluids 4 Low in residue

3 High in fluids

The nurse is providing post-procedure care for a client that had a liver biopsy. To prevent hemorrhage, it is the nurse's highest priority to place the client in what position? 1 Prone 2 High-Fowler's 3 On the right side 4 Trendelenburg

3 On the right side Placing a client on the right side after a liver biopsy compresses the liver against the abdominal wall, thus holding pressure on the biopsy site and allowing clot formation.

What is the maximum length of time a nurse should allow an intravenous (IV) bag of solution to infuse? 1 6 hours 2 12 hours 3 18 hours 4 24 hours

4 24 hours After 24 hours there is increased risk for contamination of the solution and the bag should be changed. It is unnecessary to change the bag any less often.

A nurse assesses a client with dry and brittle hair, flaky skin, a beefy-red tongue and bleeding gums. The nurse recognizes that these clinical manifestations are most likely a result of: 1 A food allergy. 2 Noncompliance with medications. 3 Side effects from medications. 4 A nutritional deficiency.

4 A nutritional deficiency.

The client receives a prescription for tap water enemas until clear. The nurse is aware that no more than two enemas should be given at one time to prevent the occurrence of: 1 Hypercalcemia 2 Hypocalcemia 3 Hyperkalemia 4 Hypokalemia

4 Hypokalemia Repeated tap water enemas deplete cells and extracellular fluid of potassium and sodium resulting in hypokalemia, hyponatremia, and the potential for water intoxication.

A nurse assesses a client's serum electrolyte levels in the laboratory report. What electrolyte in intracellular fluid should the nurse consider most important? 1 Sodium 2 Calcium 3 Chloride 4 Potassium

4 Potassium

The intake and output of a client over an eight-hour period is: 0800: Intravenous (IV) infusing; 900 mL left in bag; 0830: 150 mL voided; From 0900-1500 time period: 200 mL gastric tube formula + 50 mL water; Repeated x 2.; 1300: 220 mL voided; 1515: 235 mL voided; 1600: IV has 550 mL left in bag. What is the difference between the client's intake and output? Record the answer using a whole number. _________ mL

495 mL

A client who weighs 176 pounds is receiving 8 mg/kg cyclosporine (Sandimmune) each day to prevent organ transplant rejection. How many milligrams should the nurse administer each day? Record your answer using a whole number. _________ mg

640 mg

An intravenous (IV) solution of 1000 mL 5% dextrose in water is to be infused at 125 mL/hr to correct a client's fluid imbalance. The infusion set delivers 15 drops/mL. To ensure that the solution will infuse over an eight-hour period, at how many drops per minute should the nurse set the rate of flow? Record the answer using a whole number. ______ gtts/min

Use the following formula to solve the problem. Drops per minute = total volume in drops (total mL x drop factor)/Total time in minutes (hours x 60) Drops per minute = 1000 mL x 15/8 x 60 = 15,000/480 = 31.25 = 31 gtts/min

A client is admitted to the hospital with a tentative diagnosis of infectious pulmonary tuberculosis. What infection control measures should the nurse take? 1 Don an N95 respirator mask before entering the room. 2 Put on a permeable gown each time before entering the room. 3 Implement contact precautions and post appropriate signage. 4 After finishing with patient care, remove the gown first and then remove the gloves.

1 Don an N95 respirator mask before entering the room.

A client has received instructions to take 650 mg aspirin (ASA) every 6 hours as needed for arthritic pain. What should the nurse include in the client's medication teaching? (Select all that apply.) 1 Take the aspirin with meals or a snack. 2 Make an appointment with a dentist if bleeding gums develop. 3 Do not chew enteric-coated tablets. 4 Switch to Tylenol (acetaminophen) if tinnitus occurs. 5 Report persistent abdominal pain

1 Take the aspirin with meals or a snack 3 Do not chew enteric-coated tablets. 5 Report persistent abdominal pain

A client is to receive 2000 mL of intravenous (IV) fluid in 12 hours. At what rate should the nurse set the electronic infusion control device? Record the answer using a whole number. ______ mL/hr

167 mL/hr

A prescription is written for famotidine (Pepcid) 20 mg intravenous piggyback (IVPB) every 12 hours. The vial is labeled 10 mg/1 mL. How many milliliters should the nurse administer? Record the answer using a whole number. _______ mL

2 mL

A client is to receive 125 mL of intravenous (IV) fluid every hour. The drop factor of the IV tubing is 10 gtt/mL. How many drops per minute should the nurse administer? Record your answer using a whole number. ______ gtts/min.

21 gtts/min

A client with Addison's disease is receiving cortisone therapy. The nurse expects what clinical indicators if the client abruptly stops the medication? (Select all that apply.) 1 Diplopia 2 Dysphagia 3 Tachypnea 4 Bradycardia 5 Hypotension

3 Tachypnea 5 Hypotension Tachypnea occurs with Addisonian crisis because of inadequate circulating glucocorticoids and mineralocorticoids. Inadequate circulating glucocorticoids and mineralocorticoids cause hypotension, pallor, weakness, tachycardia, and tachypnea. Double vision does not occur with Addisonian crisis. Difficulty swallowing does not occur with Addisonian crisis. Tachycardia, not bradycardia, occurs with Addisonian crisis.

A health care provider prescribes 250 mg of a medication. The vial reads 500 mg/mL. How much medication (mL) should the nurse administer? Include a leading zero if applicable. Record your answer using one decimal place. _____ mL

0.5 mL

A physician orders heparin 6,000 units subcutaneously daily. The pharmacy dispenses a vial containing 10,000 units per milliliter. To ensure the patient's safety, how many milliliters of heparin should the nurse administer? Include a leading zero if applicable. Record your answer using one decimal place. ______ mL

0.6 mL

Filgrastim (Neupogen) 5 mcg/kg/day by injection is prescribed for a client who weighs 132 lb. The vial label reads filgrastim 300 mcg/mL. How many milliliters should the nurse administer? Record the answer using a whole number. ______ mL

1 mL

A nurse provides teaching for a client who is scheduled for a cholecystectomy. In the initial postoperative period, the nurse explains that the most important part of the treatment plan is: 1 Early ambulation 2 Coughing and deep breathing 3 Wearing anti-embolic elastic stockings 4 Maintenance of a nasogastric tube

2 Coughing and deep breathing

A nurse assesses drainage on a surgical dressing and documents the findings. Which documentation is most informative? 1 "Moderate amount of drainage." 2 "No change in drainage since yesterday." 3 "A 10-mm-diameter area of drainage at 1900 hours." 4 "Drainage is doubled in size since last dressing change."

3 "A 10-mm-diameter area of drainage at 1900 hours."

An adolescent that had an inguinal hernia repair is being prepared for discharge home. The nurse provides instructions about resumption of physical activities. Which statement by the adolescent indicates that the client understands the instructions? 1 "I can ride my bike in about a week." 2 "I don't have to go to gym class for 3 months." 3 "I can't perform any weightlifting for at least 3 weeks." 4 "I can never participate in football again."

3 "I can't perform any weightlifting for at least 3 weeks."

The nurse is assessing a group of older adults. Which should the nurse consider to be least likely to be affected by aging? 1 Sense of taste or smell 2 Gastrointestinal motility 3 Muscle or motor strength 4 Strategies to handle stress

4 Strategies to handle stress

During history taking, a client reports experiencing black, tarry stools. The nurse recognizes that this may be an indication of: 1 Hemorrhoids, internal and external. 2 An overproduction of bile. 3 An iron deficiency. 4 Upper gastrointestinal bleeding.

4 Upper gastrointestinal bleeding.

A nurse is teaching a community group about the basics of nutrition. A participant questions why fluoride is added to drinking water. The nurse should respond that it is a necessary element added to drinking water to promote: 1 Dental health. 2 Growth and development. 3 Improved hearing. 4 Night vision.

1 Dental health.

After gastric surgery a client has a nasogastric tube in place. What should the nurse do when caring for this client? 1 Monitor for signs of electrolyte imbalance. 2 Change the tube at least once every 48 hours. 3 Connect the nasogastric tube to high continuous suction. 4 Assess placement by injecting 10 mL of water into the tube.

1 Monitor for signs of electrolyte imbalance. Gastric secretions, which are electrolyte rich, are lost through the nasogastric tube; the imbalances that result can be life threatening. Changing the nasogastric tube every 48 hours is unnecessary and can damage the suture line. High continuous suction can cause trauma to the suture line. Injecting 10 mL of water into the nasogastric tube to test for placement is unsafe; if respiratory intubation has occurred aspiration will result.

A client has a paracentesis, and the health care provider removes 1500 mL of fluid. To monitor for a serious postprocedure complication, the nurse should assess for: 1 Dry mouth 2 Tachycardia 3 Hypertensive crisis 4 Increased abdominal distention

2 Tachycardia

A client's chest tube has accidentally dislodged. What is the nursing action of highest priority? 1 Place the client in a left side-lying position. 2 Apply oxygen via non-rebreather mask. 3 Apply a petroleum gauze dressing over the site. 4 Prepare to reinsert a new chest tube.

3 Apply a petroleum gauze dressing over the site.

A nurse reviews a medical record of a client with ascites. What does the nurse identify that may be causing the ascites? 1 Portal hypotension 2 Kidney malfunction 3 Decreased liver function 4 Decreased production of potassium

3 Decreased liver function The liver manufactures albumin, the major plasma protein. A deficit of this protein lowers the osmotic (oncotic) pressure in the intravascular space, leading to a fluid shift. An enlarged liver compresses the portal system, causing increased, rather than decreased, pressure.

The nurse is caring for a client who is on a low carbohydrate diet. With this diet, there is decreased glucose available for energy, and fat is metabolized for energy resulting in an increased production of which substance in the urine? 1 Protein 2 Glucose 3 Ketones 4 Uric acid

3 Ketones As a result of fat metabolism, ketone bodies are formed and the kidneys attempt to decrease the excess by filtration and excretion. Excessive ketones in the blood can cause metabolic acidosis. A low carbohydrate diet does not cause increased protein, glucose, or uric acid in the urine.

The nurse should monitor for which involuntary physiological response in a client who is experiencing pain? 1 Crying 2 Splinting 3 Perspiring 4 Grimacing

3 Perspiring Perspiration is an involuntary physiological response. It is mediated by the autonomic nervous system under a variety of circumstances, such as rising ambient temperature, high humidity, stress, and pain

What factors are most important for the nurse to consider when delegating responsibilities? 1 Preferences of the clients and staff 2 Physical layout of the unit and client rooms 3 Staff member's level of education and expertise 4 Client's diagnosis and length of time in the hospital

3 Staff member's level of education and expertise

What response should a nurse be particularly alert for when assessing a client for side effects of long-term cortisone therapy? 1 Hypoglycemia 2 Severe anorexia 3 Anaphylactic shock 4 Behavioral changes

4 Behavioral changes Development of mood swings and psychosis is possible during long-term therapy with glucocorticoids because of fluid and electrolyte alterations.

A nurse is caring for an older adult who is taking acetaminophen (Tylenol) for the relief of chronic pain. Which substance is most important for the nurse to determine if the client is taking because it intensifies the most serious adverse effect of acetaminophen? 1 Alcohol 2 Caffeine 3 Saw palmetto 4 St. John's wort

1 Alcohol

When performing a postoperative assessment, which parameter would alert the nurse to a common side effect of epidural anesthesia? 1 Decreased blood pressure 2 Increased oral temperature 3 Diminished peripheral pulses 4 Unequal bilateral breath sounds

1 Decreased blood pressure The most important side effect to monitor in a client who has received epidural anesthesia is hypotension due to autonomic nervous system blockade. Therefore, in the immediate postoperative recovery period, the blood pressure should be assessed frequently. Other side effects include bradycardia, nausea, and vomiting. Increased oral temperature and unequal bilateral breath sounds are not effects associated with epidural anesthesia. Diminished peripheral pulses may result from hypotension, although they are not the most common side effects.

A client reports nausea, vomiting, and seeing a yellow light around objects. A diagnosis of hypokalemia is made. Upon a review of the client's prescribed medication list, the nurse determines that what is the likely cause of the clinical findings? 1 Digoxin (Lanoxin) 2 Furosemide (Lasix) 3 Propranolol (Inderal) 4 Spironolactone (Aldactone)

1 Digoxin (Lanoxin)

The nurse is preparing discharge instructions for a client who was prescribed enalapril maleate (Vasotec) for treatment of hypertension. Which is appropriate for the nurse to include in the client's teaching? 1 Do not change positions suddenly. 2 Light-headedness is a common adverse effect that need not be reported. 3 The medication may cause a sore throat for the first few days. 4 Schedule blood tests weekly for the first 2 months.

1 Do not change positions suddenly. Vasotec (enalapril) is classified as an ACE Inhibitor. ACE stands for angiotensin-converting enzyme. Vasotec is used to treat high blood pressure (hypertension) and congestive heart failure. It can also be used to treat a disorder of the ventricles. Angiotensin is a chemical that causes the arteries to become narrow. ACE inhibitors help the body produce less angiotensin, which helps the blood vessels relax and open up, which, in turn, lowers blood pressure. Clients should be advised to change position slowly to minimize orthostatic hypotension. A healthcare provider should be notified immediately if the client is experiencing light-headedness or feeling like he or she is about to faint, as this is a serious side effect.

The count of hydrocodone (Vicodin) is incorrect. After several minutes of searching the medication cart and Physiological Aspects of Care records, no explanation is found. Who should the primary nurse notify about the discrepancy? 1 Nursing unit manager 2 Hospital administrator 3 Quality control manager 4 Health care provider prescribing the medication

1 Nursing unit manager Controlled substance issues for a particular nursing unit are the responsibility of that unit's nurse manager. Responsibility flows directly from the staff of a nursing unit to the nurse manager; the nurse manager reports to a nurse administrator.

A client being treated for Influenza A (H1N1) is scheduled for a computed tomography (CT) scan. To ensure client and visitor safety during transport, the nurse should take which precaution? 1 Place a surgical mask on the client. 2 Other than Standard Precautions, no additional precautions are needed. 3 Minimize close physical contact. 4 Cover the client's legs with a blanket.

1 Place a surgical mask on the client. Nurses should provide influenza clients with face masks to wear for source control and tissues to contain secretions when outside of their room. Special precautions such as face masks should be taken to decrease the risk of further outbreak.

A health care provider prescribes an antibiotic intravenous piggyback (IVPB) twice a day for a client with an infection. The health care provider prescribes peak and trough levels 48 and 72 hours after initiation of the therapy. The client asks the nurse why there is a need for so many blood tests. The nurse's best response is, "These tests will: 1 determine adequate dosage levels of the drug." 2 detect if you are having an allergic reaction to the drug." 3 permit blood culture specimens to be obtained when the drug is at its lowest level." 4 allow comparison of your fever to when the blood level of the antibiotic is at its highest."

1 determine adequate dosage levels of the drug." Drug dosage and frequency are adjusted according to peak and trough levels to enhance efficacy by maintaining therapeutic levels. Peak and trough levels reveal nothing about allergic reactions. Blood cultures are obtained when the client spikes a temperature; they are not related to peak and trough levels of an antibiotic. A sustained decrease in fever is the desired outcome, not reduction just at peak serum levels of the medication.

When caring for a client with varicella and disseminated herpes zoster, the nurse should implement which types of precautions? (Select all that apply.) 1 Airborne 2 Contact 3 Droplet 4 Hazardous Wastes 5 Standard

1 Airborne 2 Contact 5 Standard Contact precautions are used for patients with known or suspected infections transmitted by direct contact or contact with items in the environment. Airborne precautions are used for clients known or suspected to have infections transmitted by the airborne transmission route. Varicella can be transmitted by airborne and contact.

What is a nurse's responsibility when administering prescribed opioid analgesics? (Select all that apply.) 1 Count the client's respirations. 2 Document the intensity of the client's pain. 3 Withhold the medication if the client reports pruritus. 4 Verify the number of doses in the locked cabinet before administering the prescribed dose. 5 Discard the medication in the client's toilet before leaving the room if the medication is refused.

1 Count the client's respirations. 2 Document the intensity of the client's pain. 4 Verify the number of doses in the locked cabinet before administering the prescribed dose.

A client with arthritis increases the dose of ibuprofen (Motrin, Advil) to abate joint discomfort. After several weeks the client becomes increasingly weak. The client is admitted to the hospital and is diagnosed with severe anemia. What clinical indicators does the nurse expect to identify when performing an admission assessment? (Select all that apply.) 1 Melena 2 Tachycardia 3 Constipation 4 Clay-colored stools 5 Painful bowel movements

1 Melena 2 Tachycardia Ibuprofen irritates the gastrointestinal (GI) mucosa and can cause mucosal erosion, resulting in bleeding; blood in the stool (melena) occurs as the digestive process acts on the blood in the upper GI tract.

A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment? (Select all that apply.) 1 Pain history including location, intensity and quality of pain 2 Client's purposeful body movement in arranging the papers on the bedside table 3 Pain pattern including precipitating and alleviating factors 4 Vital signs such as increased blood pressure and heart rate 5 The client's family statement about increases in pain with ambulation

1 Pain history including location, intensity and quality of pain 3 Pain pattern including precipitating and alleviating factors

The nurse manager is planning to assign unlicensed assistive personnel (UAP) to care for clients. What care can be delegated on a medical-surgical unit to UAP? (Select all that apply.) 1 Performing a bed bath for a client on bed rest. 2 Evaluating the effectiveness of acetaminophen and codeine (Tylenol #3). 3 Obtaining an apical pulse rate before oral digoxin (Lanoxin) is administered. 4 Assisting a client who has patient-controlled analgesia (PCA) to the bathroom. 5 Assessing the wound integrity of a client recovering from an abdominal laparotomy.

1 Performing a bed bath for a client on bed rest. 4 Assisting a client who has patient-controlled analgesia (PCA) to the bathroom. Performing a bed bath for a client on bed rest is within the scope of practice of UAP. Assisting a client who has PCA to the bathroom does not require professional nursing judgment and is within the job description of UAP. Evaluating human responses to medications requires the expertise of a licensed professional nurse. Obtaining an apical pulse rate requires a professional nursing judgment to determine whether or not the medication should be administered. Evaluating human responses to health care interventions requires the expertise of a licensed professional nurse.

A client has received instructions to take 650 mg aspirin (ASA) every 6 hours as needed for arthritic pain. What should the nurse include in the client's medication teaching? (Select all that apply.) 1 Take the aspirin with meals or a snack. 2 Make an appointment with a dentist if bleeding gums develop. 3 Do not chew enteric-coated tablets. 4 Switch to Tylenol (acetaminophen) if tinnitus occurs. 5 Report persistent abdominal pain.

1 Take the aspirin with meals or a snack. 3 Do not chew enteric-coated tablets. 5 Report persistent abdominal pain.

A nursing supervisor sends unlicensed assistive personnel (UAP) to help relieve the burden of care on a short-staffed medical-surgical unit. Which tasks can be delegated to UAP? (Select all that apply.) 1 Taking routine vital signs. 2 Applying a sterile dressing. 3 Answering clients' call lights. 4 Administering saline infusions. 5 Changing linens on an occupied bed. 6 Assessing client responses to ambulation.

1 Taking routine vital signs. 3 Answering clients' call lights. 5 Changing linens on an occupied bed.

A nurse is providing preoperative teaching for a client regarding use of an incentive spirometer and should include what instructions? 1 "Inhale completely and exhale in short, rapid breaths." 2 "Inhale deeply through the spirometer, hold it as long as possible, and slowly exhale." 3 "Exhale completely; take a slow, deep breath; hold it as long as possible, and slowly exhale." 4 "Exhale halfway, then inhale a rapid, small breath; repeat several times."

2 "Inhale deeply through the spirometer, hold it as long as possible, and slowly exhale." The correct procedure to maximize use of an incentive spirometer is to exhale completely, then take a slow, deep breath through the spirometer, and hold it as long as possible. This procedure will maximize inspiratory function by expanding the lungs. The client should practice using the incentive spirometer before surgery.

A client is scheduled to receive conscious sedation during a colonoscopy. The client asks the nurse, "How will they 'knock me out' for this procedure?" Which answer by the nurse correctly describes the route of administration for conscious sedation? 1 "You will receive the anesthesia through a face mask." 2 "You will receive medication through an intravenous catheter." 3 "We will give you an oral medication about one hour before the procedure." 4 "The nurse anesthetist will inject the medication into the epidural space of your spine."

2 "You will receive medication through an intravenous catheter."

A nurse manager is evaluating the performance of the LPN/LVN who is supervising Unlicensed Assistive Personnel (UAP). What action indicates to the nurse manager that the LPN/LVN needs further instruction? 1 Requests that the UAP take vital signs on the clients assigned to their team. 2 Asks the UAP to assess the client's response to a respiratory treatment 3 Instructs the UAP to communicate to a client that the meal trays will be delayed. 4 Collaborates with the UAP to determine the best time to ambulate a client.

2 Asks the UAP to assess the client's response to a respiratory treatment

A client is admitted to the hospital and benazepril hydrochloride (Lotensin) is prescribed for hypertension. Which is an appropriate nursing action for clients taking this medication? 1 Monitor the EEG. 2 Assess for dizziness. 3 Administer the drug after meals. 4 Assess for dark, tarry stools.

2 Assess for dizziness. Dizziness may occur during the first few weeks of therapy until the client adapts physiologically to the medication. An electroencephalogram is unnecessary. Cardiac monitoring may be instituted because of possible dysrhythmias. Administering the drug after meals is unnecessary; however, if nausea occurs, the medication may be taken with food or at bedtime. The blood pressure should be monitored before and after administration. Dark, tarry stools are not a side effect of Lotensin.

A client admitted to the hospital with a diagnosis of malabsorption syndrome exhibits signs of tetany. The nurse concludes that the tetany was precipitated by the inadequate absorption of which electrolyte? 1 Sodium 2 Calcium 3 Potassium 4 Phosphorus

2 Calcium The muscle contraction-relaxation cycle requires an adequate serum calcium-phosphorus ratio; the reduction of the ionized serum calcium level associated with malabsorption syndrome causes tetany (spastic muscle spasms).

An adult client presents to the Emergency Department with a nosebleed. After applying pressure, what is the next nursing action? 1 Obtain a medication history from the client 2 Check the blood pressure 3 Instruct the client to avoid picking the nose 4 Check the pulse

2 Check the blood pressure Nosebleeds can be indicative of high blood pressure in an adult. Of the choices provided, the first action of the nurse should be to check the client's blood pressure. If elevated, the nurse can initiate measures to decrease the blood pressure.

A client who is to have brain surgery has a signed advance directive in the medical record. In what situation should this document be used? 1 Discharge planning is not covered by insurance. 2 Client cannot consent to his or her own surgery. 3 Postoperative complications occur that require additional treatment. 4 Client death and which client's belongings are to be given to family members.

2 Client cannot consent to his or her own surgery. Advance directives allow clients to designate another person to consent to procedures if they are unable to do so.

A client with an abdominal wound infected with methicillin-resistant Staphylococcus aureus (MRSA) is scheduled for a computed tomography (CT) scan of the abdomen. To ensure client and visitor safety during transport, the nurse should implement which precaution? 1 No special precautions are required. 2 Cover the infected site with a dressing. 3 Drape the client with a covering labeled as biohazardous. 4 Place a surgical mask on the client.

2 Cover the infected site with a dressing.

The nurse understands that the action of an antidiuretic hormone (ADH) is to: 1 Reduce blood volume. 2 Decrease water loss in urine. 3 Increase urine output. 4 Initiate the thirst mechanism.

2 Decrease water loss in urine. ADH is released by the posterior pituitary gland. It is mainly released in response to a decrease in blood volume, or an increased concentration of sodium or other substances in plasma. It acts to decrease the production of urine by increasing the reabsorption of water by renal tubules. A decrease in ADH would cause reduced blood fluid volume, decreased ability of the kidneys to reabsorb water resulting in increased urine output, and an increase in the thirst mechanism

A client with Type I Diabetes complains of hunger, thirst, tiredness, and frequent urination. Based on these findings, the nurse should take what action? 1 Notify the physician immediately about the client's symptoms. 2 Determine the client's blood glucose level. 3 Administer the client's prescribed insulin. 4 Give the client a peanut butter and graham cracker snack.

2 Determine the client's blood glucose level.

A nurse is caring for a client who is receiving an intravenous (IV) infusion. What should the nurse do first if the IV infusion infiltrates? 1 Elevate the IV site. 2 Discontinue the infusion. 3 Attempt to flush the tubing. 4 Apply a warm, moist compress.

2 Discontinue the infusion. When an IV infusion infiltrates, it should be removed to prevent edema and pain. Elevation does not change the position of the IV cannula; the infusion must be discontinued. Flushing the tubing will add to the infiltration of fluid. Soaks may be applied, if prescribed, after the IV cannula is removed.

What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess? 1 Rapid, thready pulse 2 Distended jugular veins 3 Elevated hematocrit level 4 Increased serum sodium level

2 Distended jugular veins Because of fluid overload in the intravascular space, the neck veins become visibly distended. Rapid, thready pulse and elevated hematocrit level occur with a fluid deficit. If sodium causes fluid retention, its concentration is unchanged; if fluid is retained independently of sodium, its concentration is decreased.

A visitor in the waiting room of the emergency department has a syncopal episode and collapses on the floor. The event is witnessed by a nurse, who provides initial care. The nurse assessed the client, maintained safety of the environment, and gave a report to the emergency department nurse, who will provide ongoing care. What should the nurse who witnessed the event do next? 1 Contact the family 2 Document the incident 3 Report the incident to the nurse manager 4 Escort the client to the radiology department

2 Document the incident

A visitor in the waiting room of the emergency department has a syncopal episode and collapses on the floor. The event is witnessed by a nurse, who provides initial care. The nurse assessed the client, maintained safety of the environment, and gave a report to the emergency department nurse, who will provide ongoing care. What should the nurse who witnessed the event do next? 1 Contact the family 2 Document the incident 3 Report the incident to the nurse manager 4 Escort the client to the radiology department

2 Document the incident

A client becomes anxious after being scheduled for a colostomy. What is the most effective way for the nurse to help the client? 1 Administer the prescribed as needed (prn) sedative. 2 Encourage the client to express feelings. 3 Explain the postprocedure course of treatment. 4 Reassure the client that there are others with this problem.

2 Encourage the client to express feelings.

A client's intravenous (IV) infusion infiltrates. The nurse concludes that what is most likely the cause of the infiltration? 1 Excessive height of the IV bag 2 Failure to secure the catheter adequately 3 Contamination during the catheter insertion 4 Infusion of a chemically irritating medication

2 Failure to secure the catheter adequately Infiltration is caused by catheter displacement, allowing fluid to leak into the tissues. Excessive height of the IV bag will affect the flow rate, not cause infiltration. Contamination during the catheter insertion can lead to infection and phlebitis, not infiltration. Infusion of a chemically irritating medication can lead to phlebitis, not infiltration.

A nurse is caring for a client who is having diarrhea. To prevent an adverse outcome, the nurse should most closely monitor what patient data or assessment finding? 1 Skin condition 2 Fluid and electrolyte balance 3 Food intake 4 Fluid intake and output

2 Fluid and electrolyte balance

Based on the client's reported pain level, the nurse administers 8 mg of the prescribed morphine. The medication is available in a 10 mg syringe. Wasting of the remaining 2 mg of morphine should be done by the nurse and a witness. It is most appropriate for the nurse to ask which member of the health care team to be the witness? 1 Nursing supervisor 2 Licensed practical nurse (LPN) 3 Client's health care provider 4 Designated nursing assistant

2 Licensed practical nurse (LPN)

A client reports vomiting and diarrhea for three days. What clinical finding most accurately will indicate that the client has a fluid deficit? 1 Presence of dry skin 2 Loss of body weight 3 Decrease in blood pressure 4 Altered general appearance

2 Loss of body weight Dehydration is measured most readily and accurately by serial assessments of body weight; 1 L of fluid weighs 2.2 lb.

A nurse is preparing to administer an oil-retention enema and understands that it works primarily by: 1 Stimulating the urge to defecate. 2 Lubricating the sigmoid colon and rectum. 3 Dissolving the feces. 4 Softening the feces.

2 Lubricating the sigmoid colon and rectum. The primary purpose of an oil-retention enema is to lubricate the sigmoid colon and rectum. Secondary benefits of an oil-retention enema include stimulating the urge to defecate and softening feces. An oil-retention enema does not dissolve feces .

A health care provider prescribes transdermal fentanyl (Duragesic) 25 mcg/hr every 72 hours. During the first 24 hours after starting the fentanyl, what is the most important nursing intervention? 1 Change the dose until pain is tolerable. 2 Manage pain with oral pain medication. 3 Assess the client for anticholinergic side effects. 4 Instruct the client to take the medication with food.

2 Manage pain with oral pain medication.

A pain scale of 1 to 10 is used by a nurse to assess a client's degree of pain. The client rates the pain as an 8 before receiving an analgesic and a 7 after being medicated. What conclusion should the nurse make regarding the client's response to pain medication? 1 Client has a low pain tolerance. 2 Medication is not adequately effective. 3 Medication has sufficiently decreased the pain level. 4 Client needs more education about the use of the pain scale.

2 Medication is not adequately effective. The expected effect should be more than a 1-point decrease in the pain level.

When monitoring fluids and electrolytes, the nurse recalls that the major cation-regulating intracellular osmolarity is: 1 Sodium 2 Potassium 3 Calcium 4 Calcitonin

2 Potassium A decrease in serum potassium causes a decrease in the cell wall pressure gradient and results in water moving out of the cell. Besides intracellular osmolarity regulation, potassium also regulates metabolic activities, transmission and conduction of nerve impulses, cardiac conduction, and smooth and skeletal muscle contraction.

A client reports smoke coming from a utility room on the nursing unit. What is the initial action the nurse should take? 1 Pull the fire alarm on the unit. 2 Remove anyone that is in immediate danger. 3 Obtain a fire extinguisher and report to the fire area. 4 Close all windows and fire doors and await further instructions.

2 Remove anyone that is in immediate danger.

A client who sustained a large open wound as a result of an accident is receiving daily sterile dressing changes. To maintain sterility when changing the dressing, the nurse should: 1 Put the unopened sterile glove package carefully on the sterile field 2 Remove the sterile drape from its package by lifting it by the corners 3 Don sterile gloves before opening the package containing the field drape 4 Pour irrigation liquid from a height of at least three inches above the sterile container

2 Remove the sterile drape from its package by lifting it by the corners The outer one inch of the sterile field is considered contaminated and can be touched without wearing sterile gloves. The outside of an unopened sterile glove package is not sterile. The field will become contaminated if the unopened package is placed on the sterile field. The outer package, which contains a sterile field drape, is not sterile; if it is touched with sterile gloves, the sterile gloves will become contaminated. Liquids should be poured from a height of 4 to 6 inches; this ensures that the solution bottle does not contaminate the sterile container.

The nurse is caring for a client that is hyperventilating. The nurse recalls that the client is at risk for: 1 Respiratory acidosis 2 Respiratory alkalosis 3 Respiratory compensation 4 Respiratory decompensation

2 Respiratory alkalosis Hyperventilation causes excess amounts of carbon dioxide (CO2) to be eliminated, causing respiratory alkalosis.

A client's serum potassium level has increased to 5.8 mEq/L. What action should the nurse implement first? 1 Call the laboratory to repeat the test. 2 Take vital signs and notify the charge nurse or health care provider. 3 Inform the cardiac arrest team to place them on alert. 4 Take an electrocardiogram and have lidocaine available.

2 Take vital signs and notify the charge nurse or health care provider.

What are the desired outcomes that the nurse expects when administering a nonsteroidal antiinflammatory drug (NSAID)? (Select all that apply.) 1 Diuresis 2 Pain relief 3 Antipyresis 4 Bronchodilation 5 Anticoagulation 6 Reduced inflammation

2 Pain relief 3 Antipyresis 6 Reduced inflammation

What are the clinical indicators that a nurse expects when an intravenous (IV) line has infiltrated? (Select all that apply.) 1 Heat 2 Pallor 3 Edema 4 Decreased flow rate 5 Increased blood pressure

2 Pallor 3 Edema 4 Decreased flow rate The accumulation of fluid in the tissues between the surface of the skin and the blood vessels makes the skin appear pale. The accumulation of fluid in the interstitial compartment causes swelling. As the needle/catheter is dislodged from the vein, the drip rate of the IV slows or ceases. Heat is associated with phlebitis; the accumulation of room temperature IV fluid in the tissue makes the site feel cool. Increased blood pressure is a sign of circulatory overload; when an IV infusion has infiltrated, the intravascular fluid volume does not increase.

A client is being treated for Influenza A (H1N1). The nurse has provided instructions to the client about how to decrease the risk of transmission to others. Which patient statement indicates a need for further instruction/clarification? 1 "I should practice respiratory hygiene/cough etiquette." 2 "I should avoid contact with the elderly or children." 3 "I should obtain a pneumococcal vaccination each year." 4 "I should allow visitors for short periods of time only."

3 "I should obtain a pneumococcal vaccination each year."

A client is being treated for Influenza A (H1N1). The nurse has provided instructions to the client about how to decrease the risk of transmission to others. Which patient statement indicates a need for further instruction/clarification? 1 "I should practice respiratory hygiene/cough etiquette." 2 "I should avoid contact with the elderly or children." 3 "I should obtain a pneumococcal vaccination each year." 4 "I should allow visitors for short periods of time only."

3 "I should obtain a pneumococcal vaccination each year."

Neomycin, 1 gram, is prescribed preoperatively for a client with cancer of the colon. The client asks why this is necessary. How should the nurse respond? 1 "It is used to prevent you from getting a bladder infection before surgery." 2 "It will decrease your kidney function and lessen urine production during surgery." 3 "It will kill the bacteria in your bowel and decrease the risk for infection after surgery." 4 "It is used to alter the body flora, which reduces spread of the tumor to adjacent organs."

3 "It will kill the bacteria in your bowel and decrease the risk for infection after surgery." Neomycin provides preoperative intestinal antisepsis. It is not administered to prevent bladder infection. Nephrotoxicity is an adverse, not a therapeutic, effect. Neomycin will not prevent metastasis of the tumor to other areas.

A client asks the nurse, "Should I tell my partner that I just found out I'm human immunodeficiency virus (HIV) positive?" What is the nurse's most appropriate response? 1 "This is a decision you alone can make." 2 "Do not tell your partner unless asked." 3 "You are having difficulty deciding what to say." 4 "Tell your partner that you don't know how you became sick."

3 "You are having difficulty deciding what to say."

A client has a right above-the-knee amputation after trauma sustained in a work-related accident. Upon awakening from surgery, the client states, "What happened to me? I don't remember a thing." What is the nurse's best initial response? 1 "Tell me what you think happened." 2 "You will remember more as you get better." 3 "You were in a work-related accident this morning." 4 "It was necessary to amputate your leg after the accident."

3 "You were in a work-related accident this morning."

A client has undergone a subtotal thyroidectomy. The client is being transferred from the post anesthesia care unit/recovery area to the inpatient nursing unit. What emergency equipment is most important for the nurse to have available for this client? 1 A defibrillator 2 An IV infusion pump 3 A tracheostomy tray 4 An electrocardiogram (ECG) monitor

3 A tracheostomy tray The client who has undergone a subtotal thyroidectomy is at high risk for airway occlusion resulting from postoperative edema. With this in mind, emergency airway equipment such as a tracheostomy set and intubation supplies should be immediately available to the client. A defibrillator, an IV infusion pump, and an electrocardiogram (ECG) monitor are all equipment items that should be available to all postoperative clients.

The nurse instructs a client that, in addition to building bones and teeth, calcium is also important for: 1 Bile production. 2 Blood production. 3 Blood clotting. 4 Digestion of fats

3 Blood clotting. Calcium is important for blood coagulation. When tissue damage occurs, serum calcium is necessary to promote coagulation by activating certain clotting factors. Calcium acts as a catalyst in the clotting process in both the extrinsic and intrinsic pathways. Calcium is responsible for a number of body functions such as bone health, blood clotting, and muscle contraction and nerve impulses

A client is scheduled to receive phenytoin (Dilantin) 100 mg orally at 6 PM but is having difficulty swallowing capsules. What method should the nurse use to help the client take the medication? 1 Sprinkle the powder from the capsule into a cup of water. 2 Insert a rectal suppository containing 100 mg of phenytoin. 3 Contact the prescriber to determine if a change to a suspension form would be possible. 4 Obtain a change in the administration route to allow an intramuscular (IM) injection.

3 Contact the prescriber to determine if a change to a suspension form would be possible.

A client that is scheduled for a surgical resection of the colon and creation of a colostomy for a bowel malignancy asks why preoperative antibiotics have been prescribed. The nurse explains that the primary purpose is to: 1 Decrease peristalsis. 2 Minimize electrolyte imbalance. 3 Decrease bacteria in the intestines. 4 Treat inflammation caused by the malignancy.

3 Decrease bacteria in the intestines. To decrease the possibility of contamination, the bacteria count in the colon is lowered with antibiotics before surgery. Preoperative antibiotics do not have an effect on peristalsis, electrolyte balance, or treating inflammation.

The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia? 1 Crohn's 2 Cushing's 3 End-stage renal 4 Gastroesophageal reflux

3 End-stage renal One of the kidneys' functions is to eliminate potassium from the body; diseases of the kidneys often interfere with this function, and hyperkalemia may develop, necessitating dialysis.

A nurse is transcribing a practitioner's orders for a group of clients. Which order should the nurse clarify with the practitioner? 1 Discharge in am 2 Blood glucose monitoring ac and bedtime 3 Erythropoietin (Procrit) 6000 units subcutaneously TIW 4 Dalteparin (Fragmin) 5000 international units Sub-Q BID

3 Erythropoietin (Procrit) 6000 units subcutaneously TIW

A primary nurse receives prescriptions for a newly admitted client and has difficulty reading the health care provider's writing. Who should the nurse ask for clarification of this prescription? 1 Nurse practitioner 2 House health care provider that is on-call 3 Health care provider who wrote the prescription 4 Nurse manager familiar with the health care provider's writing

3 Health care provider who wrote the prescription

An assessment of the client on total parenteral nutrition (TPN) reveals a bounding pulse, distended jugular veins, dyspnea, and cough. What is the priority nursing intervention? 1 Ask the registered nurse start the client's infusion at a peripheral site 2 Slow the rate of the client's infusion of the TPN 3 Interrupt the client's infusion and notify the charge nurse or health care provider 4 Obtain the vital signs and continue monitoring the client's status

3 Interrupt the client's infusion and notify the charge nurse or health care provider The client is experiencing pulmonary edema because of a fluid volume excess. The high concentration of TPN precipitates a fluid shift from the interstitial compartment into the intravascular compartment. Fluid will continue to be infused, which will continue to increase the intravascular volume. TPN is not infused in a peripheral IV and the rate is not to be changed by the LPN, especially without a health care provider's order.

A client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity report that reveals the client has Vancomycin Resistant Enterococcus (VRE). After notifying the physician, which action should the nurse take to decrease the risk of transmission to others? 1 Insert a urinary catheter. 2 Initiate Droplet Precautions. 3 Move the client to a private room. 4 Use a high efficiency particulate air (HEPA) respirator during care.

3 Move the client to a private room.

A client with a diagnosis of uncontrolled diabetes began receiving Lasix (Furosemide) two days ago. The nurse reviews the morning lab results and discovers that the client's potassium level is 2.8 mEq/L. What is the most appropriate action for the nurse to take? 1 Hold the morning dose of the diuretic and have the lab repeat the test. 2 Continue to monitor the level to ensure that it stays within the normal limits. 3 Notify the primary healthcare provider of the result, which is critically low. 4 Anticipate a prescription for an increase in the dosage of the Lasix.

3 Notify the primary healthcare provider of the result, which is critically low. The physician should be notified because a potassium level of 2.8 mEq/L is low. Normal range for serum potassium is 3.5 to 5 mEq/L. Clients who are on diuretics require monitoring of serum electrolytes, especially potassium and sodium, because they also are excreted with water. The nurse should not hold the diuretic or repeat the lab test unless advised by the physician. The client's serum potassium level is critically below the normal limit and the physician should be notified. An increase in Lasix would cause an increased loss of potassium

A nurse assesses for hypocalcemia in a postoperative client. One of the initial signs that might be present is: 1 Headache. 2 Pallor. 3 Paresthesias. 4 Blurred vision.

3 Paresthesias. Normally, calcium ions block the movement of sodium into cells. When calcium is low, this allows sodium to move freely into cells, creating increased excitability of the nervous system. Initial symptoms are paresthesias. This can lead to tetany if untreated. Headache, pallor, and blurred vision are not signs of hypocalcemia.

A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes? 1 Skeletal and nervous 2 Circulatory and urinary 3 Respiratory and urinary 4 Muscular and endocrine

3 Respiratory and urinary Increased respirations blow off carbon dioxide (CO2 ), which decreases the hydrogen ion concentration and the pH increases (less acidity). Decreased respirations result in CO2 buildup, which increases hydrogen ion concentration and the pH falls (more acidity). The kidneys either conserve or excrete bicarbonate and hydrogen ions, which helps to adjust the body's pH . The buffering capacity of the renal system is greater than that of the pulmonary system, but the pulmonary system is quicker to respond.

A client receiving intravenous vancomycin (Vancocin) reports ringing in both ears. Which initial action should the nurse take? 1 Notify the primary healthcare provider. 2 Consult an audiologist. 3 Stop the infusion. 4 Document the finding and continue to monitor the client.

3 Stop the infusion.

A nurse is caring for a client with pulmonary tuberculosis who is to receive several antitubercular medications. Which of the first-line antitubercular medications is associated with damage to the eighth cranial nerve? 1 Isoniazid (INH) 2 Rifampin (Rifadin) 3 Streptomycin 4 Ethambutol (Myambutol)

3 Streptomycin Streptomycin is ototoxic and can cause damage to the eighth cranial nerve, resulting in deafness. Assessment for ringing or roaring in the ears, vertigo, and hearing acuity should be made before, during, and after treatment.

A nurse is providing care to a client eight hours after the client had surgery to correct an upper urinary tract obstruction. Which assessment finding should the nurse report to the charge nurse or surgeon? 1 Incisional pain 2 Absent bowel sounds 3 Urine output of 20 mL/hour 4 Serosanguineous drainage on the dressing

3 Urine output of 20 mL/hour A urinary output of 50 mL/hr or greater is necessary to prevent stasis and consequent infections after this type of surgery. The nurse should notify the surgeon of the assessment findings, as this may indicate a urinary tract obstruction.

A client with a history of ulcerative colitis is admitted to the hospital because of severe rectal bleeding. The client engages in angry outbursts and places excessive demands on the staff. One day an unlicensed assistive personnel (UAP) tells the nurse, "I've had it. I am not putting up with that behavior. I'm not going in there again." What is the best response by the nurse? 1 "You need to try to be patient. The client is going through a lot right now." 2 "I'll talk with the client. Maybe I can figure out the best way for us to handle this." 3 "Just ignore it and get on with your work. I'll assign someone else to take a turn." 4 "The client's frightened and taking it out on the staff. Let's think of approaches we can take."

4 "The client's frightened and taking it out on the staff. Let's think of approaches we can take."

A client has been diagnosed with type 1 Diabetes Mellitus. When providing instructions on sharps disposal, the nurse should instruct the client to place the syringes in: 1 Bubble wrap/packaging wrap 2 A garbage bag in the trash can 3 A cardboard box with a firmly secured lid 4 A plastic liquid detergent bottle with a screw-top lid

4 A plastic liquid detergent bottle with a screw-top lid

What clinical finding indicates to the nurse that a client may have hypokalemia? 1 Edema 2 Muscle spasms 3 Kussmaul breathing 4 Abdominal distention

4 Abdominal distention Hypokalemia diminishes the magnitude of the neuronal and muscle cell resting potentials. Abdominal distention results from flaccidity of intestinal and abdominal musculature. Edema is a sign of sodium excess. Muscle spasms are a sign of hypocalcemia. Kussmaul breathing is a sign of metabolic acidosis.

The nurse providing post-procedure care to a client who had a cardiac catheterization through the femoral artery discovers a large amount of blood under the client's buttocks. After donning gloves, which action should the nurse take first? 1 Apply pressure to the site. 2 Obtain vital signs. 3 Change the client's gown and bed linens. 4 Assess the catheterization site.

4 Assess the catheterization site. Observing standard precautions is the first priority when dealing with any body fluid, followed by assessment of the catheterization site as the second priority. This action establishes the source of the blood and determines how much blood has been lost. Once the source of the bleeding is determined the priority goal for this client is to stop the bleeding and ensure stability of the client by monitoring the vital signs.

A client is being discharged from the hospital with an indwelling urinary catheter. The client asks about the best way to prevent infection and keep the catheter clean. Which would be appropriate for the nurse to include in the client teaching? 1 Once a day, clean the tubing with a mild soap and water, starting at the drainage bag and moving toward the insertion site. 2 After cleaning the catheter site, it is important to keep the foreskin pushed back for 30 minutes to ensure adequate drying. 3 Clean the insertion site daily using a solution of one part vinegar to two parts water. 4 Change the drainage bag at least once a week as needed.

4 Change the drainage bag at least once a week as needed.

An adolescent is taken to the emergency department of the local hospital after stepping on a nail. The puncture wound is cleansed and a sterile dressing applied. The nurse asks about having had a tetanus immunization. The adolescent responds that all immunizations are up to date. Penicillin is administered, and the client is sent home with instructions to return if there is any change in the wound area. A few days later, the client is admitted to the hospital with a diagnosis of tetanus. Legally, what is the nurse's responsibility in this situation? 1 The nurse's judgment was adequate, and the client was treated accordingly. 2 The possibility of tetanus was not foreseen because the client was immunized. 3 Nurses should routinely administer immunization against tetanus after such an injury. 4 Data collection by the nurse was incomplete, and as a result the treatment was insufficient.

4 Data collection by the nurse was incomplete, and as a result the treatment was insufficient.

The nurse is caring for a client who is receiving therapy for vitamin B12 deficiency. Which finding indicates that the therapy is having the desired effect? 1 Normal serum electrolyte levels 2 Healthy skin integrity 3 Resolution of peripheral edema 4 Improved hemoglobin and hematocrit levels

4 Improved hemoglobin and hematocrit levels Vitamin B12 is essential for appropriate maturation of red blood cells; therefore relieving the deficiency is expected to improve hemoglobin and hematocrit (H&H) levels and decrease hypoxia-related problems. This disorder is known as pernicious anemia.

A health care provider prescribes famotidine (Pepcid) and magnesium hydroxide/aluminum hydroxide (Maalox) for a client with a peptic ulcer. The nurse should teach the client to take the Maalox at what time? 1 Only at bedtime, when famotidine is not taken. 2 Only if famotidine is ineffective. 3 At the same time as famotidine, with a full glass or water. 4 One hour before or two hours after famotidine

4 One hour before or two hours after famotidine Antacids interfere with complete absorption of famotidine; therefore, antacids should be administered at least one hour before or two hours after famotidine. Magnesium hydroxide/aluminum hydroxide usually is taken one hour after meals and at bedtime. Famotidine usually is prescribed once a day at bedtime. The client has received a prescription for both medications; the client should not be instructed to omit one of the medications without checking with the health care provider first.

A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the nurse question? 1 Oral psyllium (Metamucil) 2 Oral potassium supplement 3 Parenteral half normal 4 Parenteral albumin (Albuminar)

4 Parenteral albumin (Albuminar) Albumin is hypertonic and will draw additional fluid from the tissues into the intravascular space. Oral psyllium will absorb the watery diarrhea, giving more bulk to the stool. An oral potassium supplement is appropriate because diarrhea causes potassium loss. Parenteral half normal saline is a hypotonic solution, which can correct dehydration.

A nurse manager works on a unit where the nursing staff members are uncomfortable taking care of clients from cultures that are different from their own. How should the nurse manager address this situation? 1 Assign articles about various cultures so that they can become more knowledgeable. 2 Relocate the nurses to units where they will not have to care for clients from a variety of cultures. 3 Rotate the nurses' assignments so they have an equal opportunity to care for clients from other cultures. 4 Plan a workshop that offers opportunities to learn about the cultures they might encounter while at work.

4 Plan a workshop that offers opportunities to learn about the cultures they might encounter while at work.

When providing preoperative teaching, the nurse should focus primarily on: 1 Helping the client and family decide if surgery is necessary. 2 Providing emotional support to the client and family. 3 Giving minute-by-minute details of the surgery to the client and family. 4 Providing general information to reduce client and family anxiety.

4 Providing general information to reduce client and family anxiety.

A client undergoes a bowel resection. When assessing the client 4 hours postoperatively, the nurse identifies which finding as an early sign of shock? 1 Respirations of 10 2 Urine output of 30 ml/hour 3 Lethargy 4 Restlessness

4 Restlessness n the early stage shock, the client has increased epinephrine secretion. This, in turn, causes the client to become restless, anxious, nervous, and irritable. Decreased respiratory rate is a late sign of shock. A urine output of 30 ml/hour is within normal limits.

A client with a terminal illness reaches the stage of acceptance. How can the nurse best help the client during this stage? 1 Acknowledge the client's crying. 2 Encourage unrestricted family visits. 3 Explain details of the care being given. 4 Stay nearby without initiating conversation

4 Stay nearby without initiating conversation The nurse's presence communicates concern and provides an opportunity for the client to initiate communication; silence is an effective interpersonal technique that permits the client to direct the content and extent of verbalizations without the nurse imposing on the client's privacy.