FUNDS EAQ QUESTIONS

The nurse assesses a client who is receiving total parenteral nutrition for the specific complication of what condition? Infection Hepatitis Anorexia Dysrhythmias

Infection The concentration of glucose in the solution (20% to 25%) is a rich culture medium for bacterial and fungal growth. Hepatitis is not associated with total parenteral nutrition. Anorexia often is present before the medical decision to begin total parenteral nutrition; it is not a complication. Dysrhythmias are not related directly to total parenteral nutrition, but rather to concomitant hypokalemia, which can occur if potassium is not added to the solution.

Which of these is a one-on-one communication between a nurse and another person? Small-group communication Intrapersonal communication Interpersonal communication Transpersonal communication

Interpersonal communication

he nurse is using non-verbal active listening skills during a clinical therapeutic encounter with a client. Which non-verbal action best conveys engagement in this client interaction? Sitting with a relaxed posture Leaning toward the client Making eye contact Facing the client

Leaning toward the client

A nurse repositions a client who is diagnosed with emphysema to facilitate breathing. Which position facilitates maximum air exchange? Supine Orthopneic Low-Fowler Semi-Fowler

Orthopneic

After administering a loop diuretic, a nurse monitors the client for increased urine output. What principle explains the secondary water loss (diuresis) of a loop diuretic? Osmosis Filtration Diffusion Active transport

Osmosis Loop diuretics inhibit the reabsorption of sodium and water in the ascending loop of Henle. The increased sodium load in the distal tubule causes the passive transfer of water from the glomerular filtrate to urine through the process of osmosis. Filtration refers to solutes; solutes are not being passed into the urine. Diffusion is not specific to fluid; osmosis is. Active transport requires energy; water is passively moved from tubule cells to the urine.

A client asks about the purpose of a pulse oximeter. The nurse explains that it is used to measure what? Respiratory rate Amount of oxygen in the blood Percentage of oxygen-carrying hemoglobin Amount of carbon dioxide in the blood

Percentage of oxygen-carrying hemoglobin The pulse oximeter measures the oxygen saturation of blood by determining the percentage of oxygen-carrying hemoglobin. A pulse oximeter does not measure respiratory rate, nor does it interpret the amount of oxygen or carbon dioxide carried in the blood.

A client with a spinal cord injury tends to assume the low Fowler position excessively. In which area of the body will the nurse most likely discover a pressure ulcer? Elbows Occiput Ilium Sacrum

Sacrum

A client with acquired immunodeficiency syndrome (AIDS) and Cryptococcal pneumonia frequently is incontinent of feces and urine and produces copious sputum. When giving this client a bath, which protective equipment should the nurse make it a priority to use? Select all that apply. Goggles Surgical mask Shoe covers Gown Gloves N95 hepa mask

Surgical mask Gown Gloves

A healthcare provider prescribes a standard walker (pick-up walker with rubber tips on all four legs). The nurse identifies what clinical findings that indicate the client is capable of using a standard walker? Weak upper arm strength and impaired stamina Weight bearing as tolerated and unilateral paralysis Partial weight bearing on the affected extremity and kyphosis Strong upper arm strength and non-weight bearing on the affected extremity

Strong upper arm strength and non-weight bearing on the affected extremity

A healthcare team is delegated the task of assisting a client with bathing. Which member of the healthcare team is responsible and accountable for this aspect of client care? <p>A healthcare team is delegated the task of assisting a client with bathing. Which member of the healthcare team is responsible and accountable for this aspect of client care?</p> Nursing aide Registered nurse (RN) Patient care associate (PCA) Licensed vocational nurse (LVN)

Registered nurse (RN)

Oxygen given to clients during stage 4 of chronic obstructive pulmonary disease (COPD) should be administered in which manner? 1 to 2 L via nasal cannula to keep SaO 2 above 90%. 1 to 2 L via nasal cannula to maintain SaO 2 at or above 95%. 3 L via mask to maintain SaO 2 at 95%. Do not give oxygen because it may suppress hypoxic drive in client.

1 to 2 L via nasal cannula to keep SaO 2 above 90% Oxygen therapy usually is delayed until stage 4, which is very severe COPD. Usually it is administered at 1 to 2 L per minute to maintain SaO 2 at or above 90%. One to 2 L to maintain the SaO 2 above 95% is not necessary. Oxygen administration may not be necessary. Three liters of oxygen via a mask is unnecessary, and a level of 95% may suppress the hypoxic drive in clients who are chronic CO 2 retainers. Oxygen should not be given unless the chronic saturation level is less than 88%.

The client's serum sodium is 123 mEq/L (123 mmol/L). Which prescription should the nurse question? Provide pretzels as a snack daily. Restrict fluid intake to 1000 mL per day. Assess neurologic status every 2 hours. Administer intravenous fluid of one-half normal saline (NS) at 125 mL/hr.

Administer intravenous fluid of one-half normal saline (NS) at 125 mL/hr. Because one-half NS is a hypotonic solution, it is contraindicated. It would actually compound the issue instead of correcting the hyponatremia. Treatment for hyponatremia can include restricting fluid intake and increasing sodium intake either via oral intake or, in severe cases, intravenous fluids. The presence of hyponatremia, as well as correction of hyponatremia if done too quickly, can cause fluid shifts in the brain, resulting in altered mental status. Therefore it is important for the nurse to assess for neurologic changes.

A client is admitted to the hospital with a diagnosis of restrictive airway disease. The nurse expects the client to exhibit which early signs of respiratory acidosis? Select all that apply. Headache Irritability Restlessness Hypertension Lightheadedness

Headache Irritability Restlessness Headache is a symptom of cerebral hypoxia associated with early respiratory acidosis[1][2]. Irritability is a sign of cerebral hypoxia associated with early respiratory acidosis. Restlessness is a sign of cerebral hypoxia associated with early respiratory acidosis. Hypotension, not hypertension, is a key feature of acidosis. Lightheadedness is a symptom of respiratory alkalosis, not acidosis.

The nurse teaching a health awareness class identifies which situation as being the highest risk factor for the development of a deep vein thrombosis (DVT)? Pregnancy Inactivity Aerobic exercise Tight clothing

Inactivity

A client's laboratory report indicates hyperkalemia. Which responses should the nurse expect the client to exhibit? Select all that apply. Anorexia Vomiting Constipation Muscle weakness Irregular heart rate

Vomiting Muscle weakness Irregular heart rate Bouts of nausea and vomiting are common with hyperkalemia. Because of potassium's role in the sodium-potassium pump, an increase in potassium interferes with muscle contractions; it results in muscle weakness and areflexia. An increase in potassium can cause muscle twitching. The heart is a muscle, and hyperkalemia can cause palpitations and cardiac dysrhythmias. On an ECG tracing the T wave will be peaked with hyperkalemia. Anorexia occurs with hypokalemia, not hyperkalemia. Diarrhea, not constipation, occurs with hyperkalemia.

A client is to continue oxygen therapy at home when discharged. Which client statement indicates the need for further instruction by the nurse? "I will use only grounded electrical equipment." "I have a new woolen blanket to keep me warm." "I have told my family they cannot smoke in the house." "I will keep a pitcher of water near me so I drink enough.

"I have a new woolen blanket to keep me warm." An open flame or a spark from static electricity (generated by such items as leather-soled shoes; wool, silk, and nylon blankets; or ungrounded electrical appliances) can initiate an explosion and fire in the presence of higher-than-environmental oxygen levels. Grounded electrical equipment helps prevent sparks. When combined with oxygen, heat from lit cigarettes can ignite flammable material. Oxygen is drying; increased fluid intake is advisable.

The nurse is teaching a client self-management care in preventing and spreading methicillin-resistant Staphylococcus aureus (MRSA). Which statements made by the client indicate the need for further learning? Select all that apply. I can share athletic equipment." "I can participate in contact sports." "I should sit on upholstered furniture." "I should use antibacterial soaps for bathing." "I should wash all infected skin areas before covering those areas."

"I can share athletic equipment." "I can participate in contact sports." "I should sit on upholstered furniture."

A client with a thromboembolic disorder is receiving a continuous intravenous infusion of heparin at a rate of 1000 units per hour. There are 25,000 units of heparin in 500 mL of 5% dextrose solution. At how many milliliters per hour should the nurse set the rate on the electronic infusion control device? Record your answer using a whole number.

20mL/hr The ordered rate is 1000 u/hr. The available concentration is 25,000 u in 500 mL D5W. Make the necessary conversions and use dimensional analysis to determine the appropriate rate in mL/h. The ratio and proportion method is not appropriate for this situation.

Which intravenous fluid should the nurse classify as hypertonic? Ringer solution 5% dextrose in water Lactated Ringer solution 5% dextrose in normal saline

5% dextrose in normal saline An isotonic solution has the same osmolarity as body fluids. A hypertonic solution has a higher osmolarity than body fluids; it pulls fluid from cells, causing them to shrink and the extracellular space to expand. This hypertonic solution provides 586 mOsm/kg. This isotonic solution provides 309 mOsm/kg. The other isotonic solutions provide 278 mOsm/kg.

A client who had a right total hip replacement is progressing from the use of a walker to the use of a cane. In which hand should the nurse teach the client to hold the cane? Left hand Right hand Stronger hand Dominant hand

Left hand

An 85-year-old client has a serum potassium level of 6.7 mEq/L (6.7 mmol/L). Which nursing action is the priority at this time? Monitor for cardiovascular irregularities. Inquire about changes in bowel patterns. Assess for leg muscle twitching or weakness. Assess for signs and symptoms of dehydration.

Monitor for cardiovascular irregularities Cardiovascular changes are the most severe problems of hyperkalemia and are the most common cause of death from hyperkalemia. Changes in bowel patterns, leg muscle twitching, and weakness are signs of hyperkalemia but are not life threatening. Dehydration may be a cause of hyperkalemia.

To prepare a client for surgery, which explanation by a nurse would be accurate related to pneumatic compression devices? They help the venous blood return to the heart. They will not cause discomfort, but gently massage the legs. They are used instead of anticoagulant therapy. They must be worn until the first time the client gets out of bed.

They help the venous blood return to the heart.

When reestablishing a Jackson-Pratt drain after emptying its contents, the nurse squeezes the collection container and recaps the drain. What is the rationale for the nurse's action? To drain bile To restore suction To prevent infection To enhance gravity drainage

To restore suction Closed suction drains such as Hemovac and Jackson-Pratt suction by means of compression and reexpansion of the system. A T-tube drains bile. Compression does not prevent infection. A Penrose drain works by gravity.

A client has Clostridium difficile. The nurse is providing discharge instructions related to decreasing the risk of transmission to family members. What would be appropriate to include in the client's teaching? Increase fluids. Increase fiber in the diet. Wash hands with soap and water. Wash hands with an alcohol-based hand sanitizer

Wash hands with soap and water.

A nurse provides education to a client about how to prevent constipation. The nurse concludes that the teaching is understood when the client makes which statements? Select all that apply. "I may eat potatoes at dinner daily." "I should drink at least six glasses of water every day." "I must eat eggs for breakfast three times a week." "I can include bran muffins in my breakfast daily." "I will walk every day as part of my exercise regimen.

"I should drink at least six glasses of water every day." "I can include bran muffins in my breakfast daily." "I will walk every day as part of my exercise regimen." At least six glasses of water keeps the feces soft, which prevents constipation. Whole grains such as bran muffins are high in roughage, which prevents constipation. Walking increases intestinal motility, which helps prevent constipation. Potatoes and eggs do not contain roughage and will not prevent constipation.

A nursing student is listing the different aspects of obtaining informed consent from clients. Which point mentioned by the nursing student needs correction? "Informed consent is an important part of the nurse-client relationship; it is a vital part of the nursing duty." "Informed consent should be obtained in all situations except during extraordinary circumstances." "Informed consent is provided by clients based on the full disclosure of risks, benefits, alternatives, and consequences of refusal." "The primary healthcare provider legally has to disclose facts in terms that the client is able to understand to make an informed choice."

"Informed consent is an important part of the nurse-client relationship; it is a vital part of the nursing duty." Informed consent is a vital part of the relationship between the healthcare provider and the client. Nurses are responsible for making sure the healthcare provider explains any surgical procedure to the client including risks. Informed consent from clients should be obtained in all situations except emergencies, because failure to do so may lead to battery. Clients provide informed consent after they are made completely aware of the risks, benefits, alternatives, and consequences of refusing treatment. The person responsible for performing the procedure has the legal duty to disclose facts regarding the treatment in terms that the client is able to understand.

The nurse is instructing a female client how to collect a urine specimen. What should the nurse tell the client about obtaining the specimen? "Start urinating in the cup and then finish urinating in the toilet." "If you can't fill the cup then leave it on the toilet and use it again when you next void." "With the enclosed towelettes, wipe your labia from front to back before collecting the specimen." "When you finish, leave the cup on the back of the toilet and the aide will get it when making rounds."

"With the enclosed towelettes, wipe your labia from front to back before collecting the specimen." The client must use the packaged towelettes and wipe the labia from front to back before urinating. The client needs to urinate a small amount in the toilet first and then hold the cup under the perineal area and finish urinating in the cup. If the client cannot void enough for a specimen, the insufficient sample should be discarded and another specimen obtained when the client can void a sufficient amount. The client should notify the nurse immediately after the specimen is collected so it can be sent to the laboratory for analysis.

A client with a history of severe diarrhea for the past 3 days is admitted for dehydration. The nurse anticipates that which intravenous (IV) solution will be prescribed initially? 3% sodium chloride 0.9% sodium chloride 5% dextrose and 0.9% sodium chloride 5% dextrose and lactated Ringer solution

0.9% sodium chloride An IV solution of 0.9% sodium chloride is the most appropriate initial IV fluid for this client because it is an isotonic solution that will act as a volume expander to quickly replace volume losses and promote physiological stabilization. Three percent sodium chloride is a high-concentration (hypertonic) electrolyte solution; it would only be used in a client with hyponatremia and must be closely monitored during infusion. Five percent dextrose and 0.9% sodium chloride and 5% dextrose and lactated Ringer solution may be appropriate fluids to infuse after 0.9% sodium chloride.

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

A 2-year-old client with diarrhea The 2-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 a life-threatening situation. Care of the 35-year-old client with nausea is not a priority because the client's body has a higher ability to regulate fluid and electrolyte balance compared with the child. Care of the 83-year-old female having difficulty moving her bowels is not a nursing priority because it is not a life-threatening situation. Care of the 40-year-old female with vomiting is not a nursing priority because this client has a higher ability to regulate fluid and electrolyte balance compared with the child.

A nurse is caring for a client in respiratory distress. The healthcare provider prescribes oxygen therapy with a Venturi mask to be set at 35% oxygen. Which mask should the nurse use to implement the prescription?

A Venturi mask[1][2] can deliver a precise high-flow rate of oxygen. The concentration of oxygen and the liter flow are marked on the mask apparatus and can be adjusted to 24%, 28%, 31%, 35%, 40%, and 50% oxygen. Image A is a simple face mask. It delivers low to medium concentrations of oxygen by adjusting the oxygen flow rate to 6 to 10 L per minute. B is a partial rebreathing mask. It delivers a concentration of oxygen between 50% and 75% at a flow rate of 8 to 11 L per minute. C is a nonrebreathing mask. It delivers a high concentration (60% to 90%) of oxygen. It cannot be used with a high degree of humidity.

A client tells the nurse that the client's chest tube is scheduled to be removed soon. Before it is removed, what is the nurse aware of? The drainage system will be disconnected from the chest tube. A chest x-ray will be performed to determine lung re-expansion. An arterial blood gas will be obtained to determine oxygenation status. The client will be sedated 30 minutes before the procedure.

A chest x-ray will be performed to determine lung re-expansion. A chest x-ray should be performed to ensure and to document that the lung is reexpanded and has remained expanded. The drainage system should not be disconnected from the actual chest tube while still in the client because this may cause a pneumothorax to recur. An arterial blood gas may be performed before removal, but is not necessary. An oxygen saturation reading with a pulse oximeter is usually sufficient to determine oxygenation level. The client may be given pain medication before the procedure, but not sedation, as this may decrease the oxygen status.

A registered nurse is educating a nursing student about the importance of nursing documentation for performing risk management. What information should the nurse give? Select all that apply. "A nurse's documentation is the evidence of care that a client receives." "Nurses' notes should not be given to attorneys in the event of a lawsuit." "The nurse should note down assessments and significant changes in the client's health." "In case an occurrence report is filed, nurses should enter the information the client's charts." "Nurses should always document the primary healthcare providers' responses whenever they are contacted."

A nurse's documentation is the evidence of care that a client receives." "The nurse should note down assessments and significant changes in the client's health." "Nurses should always document the primary healthcare providers' responses whenever they are contacted." To perform risk management, nurses should always complete documentation in the appropriate manner. A nurse's documentation is considered to be an evidence of care received by a client. Documenting assessments and significant changes in the client's health are essential because this information helps to defend nurses in lawsuits. Nurses should document that the primary healthcare provider was contacted and document the provider's response to the situation at hand. Attorneys often review nurses' notes first if a lawsuit is filed. Nurses should never document that an occurrence report has been completed in a client's chart.

The nurse is preparing to perform endotracheal suctioning of a client with respiratory difficulties. Before beginning the procedure, what should the nurse do? Ask the client to take several deep breaths. Instruct the client to cough before suctioning. Administer 100% oxygen to the client. Change the suctioning equipment to ensure sterility.

Administer 100% oxygen to the client. Before suctioning, regardless of the means, oxygen should be administered, because the suctioning procedure depletes oxygen from the respiratory tract, causing a potential drop in oxygen saturation levels. In a client with an endotracheal tube, manually bagging with 100% oxygen will hyperoxygenate the lungs. The client who has an endotracheal tube may not be able to follow commands to take deep breaths or cough, or have the strength to do either, which is why manual bagging is preferred. A new sterile suction catheter should be used each time the client is suctioned, but the suction tubing and equipment need not be changed.

A healthcare provider prescribes enoxaparin 30 mg subcutaneously daily. Which measure would the nurse take when administering this medication? Push over 2 minutes. Administer in the abdomen. Rub site after administration. Remove air pocket from prepackaged syringe before administration.

Administer in the abdomen Enoxaparin specifically targets blood clots throughout the body and carries a lower risk of hemorrhage than that associated with the drugs heparin and warfarin. Enoxaparin is administered once a day through a subcutaneous injection site around the naval. Enoxaparin should be injected into the fatty tissue only, which is why the abdomen is the recommended injection site. Avoid administering in a muscle. Manufacturer recommendations indicate the air pocket from prepackaged syringes not be removed before administration. Rubbing the site is contraindicated, as it can cause bruising. There are no recommendations to push this subcutaneous medication over 2 minutes.

A healthcare provider prescribes ophthalmic drops for a client. What should a nurse include in the instructions for a client learning to self-administer eyedrops? Lie on the unaffected side for administration. Instill drops onto the pupil to promote absorption. Close eyes tightly after administering the eyedrops. Apply pressure to the nasolacrimal duct after instillation.

Apply pressure to the nasolacrimal duct after instillation Applying pressure prevents absorption into the duct, which may lead to systemic effects. Lying on the unaffected side is indicated for ear drops. Tilting the head back and looking up facilitate the instillation of eyedrops. Eyedrops should be instilled into the conjunctival sac, not onto the pupil. Closing the eyes tightly will force drops out of the eye.

When suctioning a client with a tracheostomy, an important safety measure for the nurse is to do what? Hyperventilate the client with room air before suctioning. Apply suction only as the catheter is being withdrawn. Insert the catheter until the cough reflex is stimulated. Remove the inner cannula before inserting the suction catheter.

Apply suction only as the catheter is being withdrawn. Use of suction upon withdrawal of a suction catheter reduces unnecessary removal of oxygen. In addition, suction should be applied intermittently during the withdrawal procedure to prevent hypoxia. A sterile catheter is used to prevent infection and the catheter should only be inserted approximately 1 to 2 cm past the end of the tracheostomy tube to prevent tissue trauma. Hyperventilating a client before suctioning should always be with oxygen, not room air. Inserting the catheter until the cough reflex is stimulated frequently occurs and does help to mobilize secretions, but is not a safety measure. Removal of the inner cannula before inserting the suction catheter is not necessary.

When providing care for a client who is receiving enteral feedings via a nasogastric (NG) tube, the nurse should take measures to prevent what serious complication? Skin breakdown Aspiration pneumonia Retention ileus Profuse diarrhea

Aspiration pneumonia Of the choices provided, the potential complication of highest risk for a client with an NG tube is aspiration pneumonia. Care should be taken to prevent dislodging of the tube or vomiting. Proper positioning of the client with an NG tube would include supine or side-lying, semi-Fowler or higher. Skin breakdown in a client with an NG tube may result from pressure of the tube against nasal structures. The tube should be periodically repositioned and taped to prevent this complication. A retention ileus is not related to an NG tube. A client who develops profuse diarrhea with an NG tube requires further investigation. It may be totally unrelated or a result of an enteral feeding incompatibility.

What action should the nurse manager take when it becomes apparent that communication between the nurse and the client is consistently superficial? Assessing the client's ability to understand the nurse's questions Evaluating how actively the nurse has been listening to the client Reinforcing to the client how important sharing is for successful recovery Reviewing how the questioning techniques are being used by the client

Assessing the client's ability to understand the nurse's questions Effective active listening is critical to the development of meaningful, therapeutic communication between the nurse and the client. A lack of effective listening on the part of the nurse commonly results in superficial, ineffective communication. Although there may be situations in which assessing the client's cognitive abilities, reinforcing the importance of effective communication, or reviewing communication skills is an appropriate intervention, there are other, more commonly observed barriers to effective therapeutic communication.

A nurse is explaining the nursing process to a nursing assistant. Which step of the nursing process should include interpretation of data collected about the client? Evaluation Assessment Nursing interventions Proposed nursing care

Assessment An actual or potential client health problem is based on the analysis and interpretation of the data previously collected during the assessment phase of the nursing process. Gathering data is included in the client's assessment. Nursing interventions are based on the earlier steps of the nursing process. The plan of care includes nursing actions to meet client needs. The needs first must be identified before nursing actions are planned.

To prevent excessive bruising when administering subcutaneous heparin, what technique will the nurse employ? Administer the injection via the Z-track technique Avoid massaging the injection site after the injection Use 2 mL of sterile normal saline to dilute the heparin Inject the drug into the vastus lateralis muscle in the thigh

Avoid massaging the injection site after the injection The site of the injection should not be massaged to avoid dispersion of the heparin around the site and subsequent bleeding into the area. The Z-track technique and the intramuscular route are not used with heparin; subcutaneous injection and intravenous administration are the routes appropriate for heparin administration. The drug should be injected into the subcutaneous tissue slowly, not quickly. Diluting heparin with normal saline is unnecessary. Generally heparin is provided by the pharmacy department in single-dose syringes.

A nurse provides discharge teaching to an older adult about care associated with activities of daily living. Which factor should the nurse mainly consider when counseling the client on how often to take a tub bath? Condition of the skin Ability of the client to provide self-care Degree of orientation to the environment Type of allergic reactions experienced by the client

Condition of the skin

Which nursing action helps reduce the development of healthcare-associated methicillin-resistant Staphylococcus aureus (HA-MRSA)? Applying triple antibiotic ointment to puncture sites Bathing clients every other day with soap and tepid water Bathing clients with chlorhexidine gluconate (CHG) solution Performing hand hygiene with soap and water after removing gloves

Bathing clients with chlorhexidine gluconate (CHG) solution

A client with type 1 diabetes of long duration takes NPH insulin 70% and regular insulin 30% every morning. At 11:30 am, before eating lunch, the client is admitted to the emergency department with an acute myocardial infarction. At 1:30 pm, the client's serum glucose level drops to 30 mg/dL (1.7 mmol/L), and insulin coma is diagnosed. To what factor does the nurse attribute the reason for the development of acute hypoglycemia? <p>A client with type 1 diabetes of long duration takes NPH insulin 70% and regular insulin 30% every morning. At 11:30 am, before eating lunch, the client is admitted to the emergency department with an acute myocardial infarction. At 1:30 pm, the client's serum glucose level drops to 30 mg/dL (1.7 mmol/L), and insulin coma is diagnosed. To what factor does the nurse attribute the reason for the development of acute hypoglycemia?</p> Because the client did not eat lunch, glycogenolysis increased after the client took the morning insulin. Because of the stress brought on by the chest pain, the use of serum glucose available to the client increased. Because the client is taking insulin shots rather than an oral antidiabetic, the client's glucose level dropped more quickly. Because of long-term use of insulin, the client's body became sensitive to the insulin dose, causing blood glucose levels to drop erratically.

Because the client is taking insulin shots rather than an oral antidiabetic, the client's glucose level dropped more quickly The dose of exogenous insulin causes a rapid drop in the blood glucose level, especially if food is not eaten. Lunch not being eaten after taking NPH insulin leads to hypoglycemia. Stress usually contributes to hyperglycemia because of glycogenolysis and gluconeogenesis. The use of insulin over long periods does not build tolerance to insulin or cause blood glucose levels to fluctuate dramatically.

Daily regular insulin has been prescribed for a client with type 1 diabetes. The nurse administers the insulin at 8 am. When should the nurse monitor the client for a potential hypoglycemic reaction? At breakfast Before lunch Before dinner In the early afternoon

Before lunch Regular insulin is short acting and peaks in 2 to 4 hours, which in this case will be at or before lunch. Breakfast is too soon; regular insulin peaks in 2 to 4 hours. Before dinner is too late; regular insulin peaks in 2 to 4 hours. The early afternoon is too late; regular insulin peaks in 2 to 4 hours.

The client is receiving high-flow intravenous (IV) fluid replacement therapy. Which nursing assessment findings are consistent with fluid volume overload? Select all that apply. Pulse quality Pulse pressure Bounding pulse Presence of dependent edema Neck vein distention in the upright position

Bounding pulse Presence of dependent edema Neck vein distention in the upright position Bounding pulse, presence of dependent edema, and neck vein distention in the upright position are all indicators of fluid overload, which should be reported by the nurse. Pulse quality and pulse pressure are indicators to monitor the client's response to fluid therapy.

A nurse administers a parenteral preparation of potassium slowly and cautiously to avoid which complication? Acidosis Cardiac arrest Psychoticlike reactions Edema of the extremities

Cardiac arrest Too rapid administration can cause hyperkalemia, which contributes to a long refractory period in the cardiac cycle, resulting in cardiac dysrhythmias and arrest. Although acidosis can cause hyperkalemia, hyperkalemia will not lead to acidosis. Psychoticlike reactions do not occur with hyperkalemia. Hyperkalemia usually causes nausea, vomiting, and diarrhea, which may result in dehydration; in this instance, fluid will shift from interstitial spaces to the intravascular compartment. With edema, the fluid shift occurs in the opposite direction.

The nurse is caring for a client before, during, and immediately after surgery. Which type of care is provided to the client? Care that supports physical functioning Care that supports homeostatic regulation Care that supports psychosocial functioning Care that provides immediate short-term help in physiological crises

Care that supports homeostatic regulation Providing perioperative care (care before, during, and immediately after surgery) involves care that supports homeostatic regulation. If interventions are provided to support the client in doing daily activities, they are considered a physiological basic domain that supports physical functioning. Providing behavioral and cognitive therapies helps to support psychosocial functioning and facilitates lifestyle changes. Providing immediate short-term help in physiological crises helps to support protection against harm.

Which represents appropriate nursing management of the client's nasogastric (NG) tube in the immediate postoperative period following gastroduodenostomy? Advancing the tube to the original insertion depth if the tube becomes dislodged. Obtaining a prescription to vigorously irrigate the nasogastric tube if clogging is noted. Carefully monitoring the nasogastric tube to ensure that the tube is patent and the suction is working. Reporting the presence of bright red gastric aspirant in the suction canister during the immediate postoperative period.

Carefully monitoring the nasogastric tube to ensure that the tube is patent and the suction is working. Ensuring that the nasogastric tube is patent and that the suction is working properly are priorities for the postoperative client to prevent retention of gastric secretions that may lead to abdominal distention, nausea, vomiting, and further serious complications. Advancing the tube to the original insertion depth if the tube becomes dislodged is not recommended. Improper reinsertion may result in the aspiration of gastric contents. Vigorous irrigation of the nasogastric tube, even if clogged, is not recommended because this can cause damage to the gastric mucosa. Finally, the presence of bright red gastric aspirant in the suction canister for the first 24 hours after surgery is a normal finding in the postoperative period.

A nurse applies a cold pack to treat an acute musculoskeletal injury. Cold therapy decreases pain by doing what? Promoting analgesia and circulation Numbing the nerves and dilating the blood vessels Promoting circulation and reducing muscle spasms Causing local vasoconstriction, preventing edema and muscle spasms

Causing local vasoconstriction, preventing edema and muscle spasms Cold causes the blood vessels to constrict, which reduces the leakage of fluid into the tissues and prevents swelling and therefore muscle spasms. Cold does promote analgesia but not circulation. It may numb nerves but does not dilate blood vessels. Cold therapy also may numb the nerves and surrounding tissues, thus reducing pain.

A nurse is preparing to administer an intravenous piggyback medication to a client who is receiving a continuous infusion of intravenous (IV) fluids. What is the priority nursing intervention? Get an additional IV infusion pump for the medication. Check the compatibility of the medication and the continuous IV solution. Disconnect the continuous IV solution while administering the piggyback medication. Flush the client's venous access device to ensure patency.

Check compatibility of the medication and the continuous IV solution Compatibility of the ordered IV medication and infusing IV solution needs to be verified to prevent harm to the client because incompatible solutions may increase, decrease, or neutralize effects of the medication. An additional IV infusion pump is not necessary because IV medication will be administered through a piggyback infusion. The nurse needs to stop IV fluids and disconnect the tubing only if the ordered IV medication is not compatible with IV fluids and there is an order to hold the continuous infusion. The client has a continuous infusion of IV; therefore patency of the IV access device is already determined

Which nursing interventions would be beneficial for providing safe oxygen therapy? Select all that apply. Check tubing for kinks Run wires under carpeting Post "no smoking" signs in the clients' rooms Place oxygen tanks flat in the carts when not in use Make sure that the client is familiar with the phrase "Stop, drop, and roll"

Check tubing for kinks Post "no smoking" signs in the clients' rooms Oxygen tubing should be checked for kinks during oxygen use. "No smoking" signs should be posted in the clients' rooms. Wires should not be kept under carpeting because heat buildup or friction can cause a fire. Oxygen tanks should be placed in an upright position in their carts or flat on floors. Being familiar with the phrase "Stop, drop, and roll" helps to describe when clothing or skin is burning.

A urine specimen is needed to test for the presence of ketones in a diabetic client. What should the nurse do when collecting this specimen from a urinary catheter? Disconnect the catheter, and drain the urine into a clean container. Clean the drainage valve, and remove the urine from the catheter bag. Wipe the catheter with alcohol, and drain the urine into a sterile test tube. Clamp the catheter, cleanse the port, and use a sterile syringe to remove urine.

Clamp the catheter, cleanse the port, and use a sterile syringe to remove urine. The urinary catheter and drainage bag should always remain a closed, sterile system; urine should be drawn only from the catheter port, not the collection bag. Cleaning the drainage valve and removing the urine from the catheter bag will not yield a fresh specimen indicating present acetone levels. The system should remain closed so that fewer microorganisms enter the urinary tract.

The nurse is instructing the student nurse how to administer percutaneous enterostomal gastrostomy (PEG) tube feeding to a client. What should the nurse tell the student? Select all that apply. Keep the client's head of bed elevated at least 10 degrees. Connect tube feeding bag to client and feeding pump. Flush with warm water before beginning feeding. Check prescription for correct client formula. Set correct rate and initiate pump. Check for diarrhea.

Connect tube feeding bag to client and feeding pump. Flush with warm water before beginning feeding. Check prescription for correct client formula. Set correct rate and initiate pump. Check for diarrhea. Connect the feeding bag to the client and pump and check for any residual feeding before initiating the feeding. Always check the most recent tube feeding prescription before initiating feeding. Flush the PEG tube with 30 mL of warm water and set correct rate on pump and begin feeding. Diarrhea is a complication of tube feedings and should be assessed. The client's head of bed needs to be elevated at least 30 degrees.

A nurse is providing immediate postoperative care to a client who had a lung resection for a malignancy. The client has a closed chest tube drainage system connected to suction. Which assessment finding requires additional evaluation by the nurse? A column of water 20 cm high in the suction control chamber 75 mL of bright red blood in the drainage collection chamber An intact occlusive dressing at the insertion site Constant bubbling in the water seal chamber

Constant bubbling in the water seal chamber Constant bubbling in the water seal chamber is indicative of an air leak. The nurse should assess the entire length of the system from the container to the client's chest wall tube insertion site to find the source of the air leak. If the source of the air leak is not found in the system and bubbling continues, the leak is most likely within the client's chest or at the insertion site. This could cause the lung to collapse because of a buildup of air pressure within the plural cavity, and therefore the healthcare provider should be notified. In this type of surgical procedure, 75 mL of blood in the chest tube collection chamber is an expected finding in the early postoperative period. A column of water 20 cm high in the suction control chamber and an intact occlusive dressing at the chest tube insertion site are also expected assessment findings.

A nurse assesses a client's intravenous site. What clinical finding, unique to infiltration, leads the nurse to conclude that the intravenous (IV) site has infiltrated, rather than become inflamed? Pain Coolness Localized swelling Cessation in flow of solution

Coolness When an IV infiltrates, the IV solution entering the interstitial space is at room temperature (approximately 75° F [23.9° C]), whereas body temperature is approximately 98.6° F (37° C); therefore, the client's skin will feel cool to the touch at the site of an IV infiltration. The site of an inflammation will feel warm to the touch because of vasodilation and hyperemia. Pain may occur with both an inflammation and an infiltration. The pain of an inflammation is related to the pressure of edema on nerve endings. The pain of an infiltration is related to the IV solution in the interstitial compartment pressing on nerve endings. An increase in interstitial fluid occurs with both an inflammation and an infiltration. With an inflammation there is increased vascular permeability at the site; fluid, proteins, and leukocytes then move from the intravascular compartment into the interstitial compartment. With an infiltration the IV solution enters the interstitial compartment rather than the intravascular compartment. A cessation in flow of solution occurs with both an inflammation and an infiltration. An inflammation in the vein at the insertion site may close the lumen of the vessel, interfering with the flow of solution. An infiltration will cause excess fluid in the interstitial compartment to the extent that it will not accommodate more solution, interfering with the flow of the solution.

The nurse assesses a client receiving intravenous (IV) fluids. Which assessment finding should warrant the nurse calling the primary healthcare provider? Crackles in lungs Supple skin turgor Urine output of 240 mL over 8 hours Increase in blood pressure from 110/76 to 124/68 mm Hg

Crackles in lungs Crackles in the lungs indicate the client is overloaded with fluids. The nurse should notify the primary healthcare provider to slow or discontinue the IV fluid. Supple skin turgor is a normal finding indicating that the IV fluid is working. A urine output of 240 mL in 8 hours is adequate. Therefore simply having a urine output of 30 mL/hr is not an indication that the IV fluid should be decreased or discontinued; it demonstrates that the kidneys are adequately perfused. An increase in blood pressure is to be expected with administration of fluid.

A client is admitted to the hospital for medical treatment of bronchopneumonia. Which test result should the nurse examine to help determine the effectiveness of the client's therapy? Bronchoscopy Pulse oximetry Pulmonary function studies Culture and sensitivity tests of sputum

Culture and sensitivity tests of sputum The aim of therapy is to eliminate the causative agent, which is determined from culture and sensitivity tests of sputum. Bronchoscopy shows the appearance of the bronchi but does not indicate the presence or absence of microorganisms. Pulse oximetry is used to assess for hypoxemia; it does not provide data on the condition of the lung tissue itself or on the presence or absence of microorganisms. Pulmonary function studies indicate air volume that may be within the expected range despite the presence of bronchopneumonia.

Which client response during the insertion of a nasogastric tube indicates to the nurse that the client is experiencing serious difficulty with the insertion? Choking Redness Gagging Cyanosis

Cyanosis If the nasogastric tube is passed accidentally into the trachea rather than the esophagus, it will obstruct the airway, causing cyanosis; this is a serious problem that must be corrected immediately. Choking may occur as the tube passes through the back of the throat; this commonly occurs with insertion of a nasogastric tube and is a temporary problem. Facial flushing (floridity) may result if the client attempts to fight the passage of the tube; this commonly occurs with insertion of a nasogastric tube and is a temporary problem. Gagging may occur as the tube passes from the nasal passage through the pharynx; this commonly occurs with insertion of a nasogastric tube and is a temporary problem.

Which intrinsic factors may contribute to falls in older adults? Select all that apply. Deconditioning Impaired vision Inappropriate foot wear Improper use of assistive devices Unfamiliar environment of hospital room

Deconditioning Impaired vision

On admission to the intensive care unit, a client is diagnosed with compensated metabolic acidosis. During the assessment, what is the nurse most likely to identify? Muscle twitching Mental instability Deep and rapid respirations Tachycardia and cardiac dysrhythmias

Deep and rapid respirations Deep, rapid respirations are an adaptation to a decreased serum pH. Carbonic acid dissociates in the lungs to hydrogen ions and carbon dioxide, which helps increase the serum pH. Muscle twitching results from low serum calcium (hypocalcemia), not compensated metabolic acidosis. Mental confusion does not occur in compensated acidosis; confusion can occur in uncompensated metabolic acidosis. Tachycardia and cardiac dysrhythmias are associated with hyperthyroidism, not compensated metabolic acidosis.

A nurse inspects a two-day-old intravenous (IV) site and identifies erythema, warmth, and mild edema. The client reports tenderness when the area is palpated. What should the nurse do first? Irrigate the IV tubing Discontinue the infusion Slow the rate of the infusion Obtain a prescription for an analgesic

Discontinue the infusion The clinical findings indicate the presence of inflammation. The IV catheter should be removed to prevent the development of thrombophlebitis. Irrigating the IV tubing and slowing the rate of the infusion do not address the underlying problem and may further irritate the vein and precipitate a thrombophlebitis. Although an analgesic may relieve the discomfort, it is not an intervention that will resolve the problem.

The nurse educates a client on decreasing the risk of developing antibiotic-resistant infections. Which statement made by the nurse will be most significant? "Wash your hands frequently." "Do not skip any dose of your antibiotics." "Save the unfinished antibiotics for later use." "Stop taking the antibiotics when you feel better."

Do not skip any dose of your antibiotics

The nurse is providing postoperative care 8 hours after a client had a total cystectomy and the formation of an ileal conduit. Which assessment finding should be reported immediately? Edematous stoma Dusky-colored stoma Absence of bowel sounds Pink-tinged urinary drainage

Dusky-colored stoma A dusky-colored stoma may denote a compromised blood supply to the stoma and impending necrosis. An edematous stoma and absence of bowel sounds are expected in the early postoperative period after this surgery. Pink-tinged urine may be present in the immediate postoperative period.

Following a major abdominal surgery, a client has a nasogastric tube attached to continuous low suction. The nurse caring for the client postoperatively monitors the client for what signs of hypokalemia? Select all that apply. Irritability Dysrhythmias Muscle weakness Abdominal cramps Acidosis

Dysrhythmias Muscle weakness Dysrhythmias are a sign of potassium depletion in cardiac muscles. Other cardiovascular effects include irregular, rapid, weak pulse; decreased blood pressure; flattened and inverted T waves; prominent U waves; depressed ST segments; peaked P waves; and prolonged QT intervals. Muscle weakness is a symptom of potassium depletion in skeletal muscles; potassium facilitates the conduction of nerve impulses and muscle activity. Irritability, as a result of heightened neuromuscular activity, is a sign of hyperkalemia. Abdominal cramps, as a result of heightened neuromuscular activity, is a symptom of hyperkalemia. In acidosis (metabolic), over half of the excess hydrogen ions are buffered in the cells. Electroneutrality is sustained partly by the passage of intracellular potassium into the extracellular fluid. Thus, metabolic acidosis results in a plasma potassium concentration that is elevated in relation to total body stores causing hyperkalemia.

The nurse is caring for a client who requires an intravenous infusion. The nurse explains the reason for the procedure while assembling the kit for the infusion. What is the role of the nurse in this situation? Educator Manager Advocate Caregiver

Educator

A nurse is caring for a postoperative client who has a nasogastric (NG) tube set to low intermittent suction. The nurse recalls that the primary reason that an intravenous infusion of 5% dextrose with 0.45% sodium chloride and 20 mEq of potassium has been prescribed is to prevent which complication? Constipation Dehydration Electrolyte imbalance Nausea and vomiting

Electrolyte imbalance When clients do not receive nutrients or fluids by mouth and have loss of electrolytes through the removal of gastric secretions via an NG tube, then electrolyte imbalance is a primary concern. Constipation is usually not a concern in this type of situation. Although dehydration is a possible effect of an NG tube removing gastric secretions and fluid, electrolyte balance is still the priority. An NG tube set to low intermittent suction usually relieves nausea and vomiting.

A client with the diagnosis of ulcerative colitis has surgery for the creation of an ileostomy. Postoperatively, for which potential life-threatening complication should the nurse assess the client? Wound infection Ischemia of the stoma Electrolyte imbalances Excoriation of skin around the stoma

Electrolyte imbalances An ileostomy directs liquid feces out of the body, bypassing the large intestine, where fluid and electrolytes normally are reabsorbed. The continuous excretion of liquid feces may deplete the body of fluid and electrolytes, resulting in a life-threatening fluid deficit and electrolyte imbalance. Although a wound infection is always a possibility after surgery, it is unlikely and not life threatening. Although the stoma should be assessed to ensure that it is not dark, but pink and moist, which indicates adequate circulation, this complication is unlikely and not life threatening. Although impaired skin integrity can occur when liquid feces remain on the skin surrounding the stoma, this should not occur if an appliance to collect the discharge is used correctly. Also, impaired skin integrity is not a life-threatening complication.

When caring for a client with pneumonia, which nursing intervention is the highest priority? Increase fluid intake. Employ breathing exercises and controlled coughing. Ambulate as much as possible. Maintain a nothing-by-mouth (NPO) status.

Employ breathing exercises and controlled coughing. For most clients, the most effective means of preventing fluid consolidation in the lungs with a diagnosis of pneumonia is to keep active by deep breathing and controlled coughing exercises. Increased fluid intake and ambulation are important aspects of care if not contraindicated, but they are secondary to deep breathing and coughing. Keeping the client NPO is not necessary; unless contraindicated, the client with pneumonia is usually offered the regular diet as tolerated.

A residual urine test is prescribed for a client with benign prostatic hyperplasia. What should the nurse instruct the client to do? Void after a urinary catheter is removed. Collect a specimen of urine during midstream. Attempt to void when a urinary catheter is in place. Empty the bladder before a urinary catheter is inserted.

Empty the bladder before a urinary catheter is inserted. Emptying the bladder before a urinary catheter is inserted measures how much urine remains in the bladder after voiding. Residual urine is the urine left in the bladder after urinating. After voiding, the client is catheterized, or a bladder scan can be used. The bladder will be empty of urine when the urinary catheter is removed. Collecting a specimen of urine during midstream is known as a clean-catch, or midstream, urine specimen, not a residual urine test. The urinary catheter will prevent urine accumulation.

A client is hospitalized with pressure ulcers. Which task could be delegated to an unlicensed nursing professional (UNP)? Select all that apply. Empty wound drainage containers. Report changes in wound appearance. Apply prescribed dressings and medications. Assess and record data about wound appearance. Choose dressings and therapies for wound treatment.

Empty wound drainage containers. Report changes in wound appearance. The UAP is eligible to empty wound drainage and report changes in wound appearance. The licensed practical nurse is eligible to apply prescribed dressings and medications to the client. A licensed practical nurse can collect and record data about the appearance of a wound. The registered nurse is eligible to choose dressings and therapies for wound treatment.

Which intervention should the nurse implement to help prevent atelectasis in a client with fractured ribs as a result of chest trauma? Apply a thoracic binder for support. Encourage coughing and deep breathing. Defer pain medication the first day after injury. Position the client face-down on a soft mattress.

Encourage coughing and deep breathing. Atelectasis with impaired gas exchange is a major complication when clients use shallow breathing to avoid pain; coughing and deep breathing help mobilize secretions. Applying a thoracic binder for support may impede deep breathing and coughing, which help prevent atelectasis. Analgesics are essential to diminish pain caused by breathing and to help motivate the client to cough and deep breathe. The prone position may diminish breathing for both lungs and is contraindicated.

Health promotion efforts within the healthcare system should include efforts related to secondary prevention. Which activities reflect secondary prevention interventions in relation to health promotion? Select all that apply. Encouraging regular dental checkups Facilitating smoking cessation programs Administering influenza vaccines to older adults Teaching the procedure for breast self-examination Referring clients with a chronic illness to a support group

Encouraging regular dental checkups Teaching the procedure for breast self-examination Encouraging regular dental checkups is a secondary prevention activity because it emphasizes early detection of health problems, such as dental caries and gingivitis. Teaching the procedure for breast self-examination is a secondary prevention activity because it emphasizes early detection of problems of the breast, such as cancer. Facilitating smoking cessation programs is a primary prevention activity because it emphasizes health protection against heart and respiratory diseases. Administering influenza vaccines to older adults is a primary prevention activity because it emphasizes health protection against influenza. Referring clients with a chronic illness to a support group is a tertiary prevention activity because it emphasizes care that is provided after illness already exists.

A client is scheduled for gastrointestinal surgery. What is the most important nursing action that should be implemented the evening before surgery? Describing the specific surgical procedure Ensuring the bowel preparation is initiated Encouraging the client to socialize with other clients Providing the client's food preferences for the evening meal

Ensuring the bowel preparation is initiated It is essential that the gastrointestinal tract be cleansed for surgery; proper visualization and prevention of peritonitis depend on the intestine being as clean of feces as possible. A specific and detailed description may cause anxiety and is unnecessary unless the client asks for this information. Encouraging the client to socialize with others is not the priority; however, therapeutic communication between the nurse and the client should be encouraged. Generally with gastrointestinal surgery, clear liquids are prescribed at least 24 to 48 hours before surgery and then nothing by mouth after midnight the night before surgery.

In a clinical study, subjects were given chlorhexidine and betadine as antiseptics. How will a nurse researcher categorize this research? Evaluation research Descriptive research Correlational research Experimental research

Experimental research

A nurse prepares to administer extended-release metformin to an older adult who has asked that it be crushed because it is difficult to swallow. What will prompt the nurse to ask the provider for a different form of metformin? This drug has a wax matrix frame that is difficult to crush. The drug has an unpleasant taste, which most clients find intolerable if crushed. If crushed, this drug irritates mucosal tissue and can cause oral and esophageal ulcer formation. Extended-release formulations are designed to be released slowly, and crushing the tablet will prevent this from occurring.

Extended-release formulations are designed to be released slowly, and crushing the tablet will prevent this from occurring. The slow-release formulary will be compromised and the client will not receive the entire dose if it is chewed or crushed. The capsules are not difficult to crush. Irritation of the mucosal tissue is not the reason the medication should not be crushed; however, this drug should be given with meals to prevent gastrointestinal irritation. Although taste could be a factor, it is not the priority issue.

The primary healthcare provider treats a client with a pressure ulcer. While assessing the client, the nurse identifies exposed bone and tendons. Which stage does the nurse document for this pressure ulcer? Stage I Stage II Stage III Stage IV

Stage IV A stage IV pressure ulcer involves full-thickness tissue loss and the tendons, bones, or muscles are exposed. In stage I, the skin is intact and there is a non-blanchable redness at a localized area, usually over a bony prominence. In stage II, there is a partial thickness loss of the dermis manifesting as a shallow open ulcer with a red-pink wound bed, without slough. In stage III, full-thickness tissue is lost.

A nurse receives a shift report on four adult clients who are between the ages of 25 and 55. Which client should the nurse assess first? Male client with a hemoglobin of 15.9 (160 mmol/L) Female client on warfarin (Coumadin) with an international normalized ratio (INR) of 7.5 Female client taking daily calcium supplements with a serum calcium level of 9.4 (2.35 mmol/L) Male client with a blood urea nitrogen (BUN) of 20 (7.1 mmol/L) and a creatinine of 1 (96 mcmol/L)

Female client on warfarin (Coumadin) with an international normalized ratio (INR) of 7.5 The client on warfarin (Coumadin) with an INR of 7.5 should be assessed first by the nurse because this is an elevated result. Normal is considered between 2 and 3. This result is not therapeutic, and the nurse should assess for bleeding and hemodynamic stability. The nurse should report the result to the physician and implement bleeding precautions. The other results are within normal ranges: hemoglobin for a male is 14 to 18 g/dL (140 to 180 mmol/L); serum calcium is 9.0 to 10.5 mg/dL (2.25 to 2.75 mmol/L); BUN is 5 to 20 mg/dL (3.6 to 7.1 mmol/L); and creatinine is 0.7 to 1.5 mg/dL (53 to 106 mcmol/L).

A nurse confers with the nutritionist about the diet of a 4-year-old child with spina bifida who spends many hours in a wheelchair. What should the nurse encourage the mother to increase in her child's diet? Select all that apply. Fat Fiber Protein Calories Carbohydrates

Fiber - combat constipation resulting from immobility Protein - maintain muscle mass and to help prevent pressure ulcers

A client is receiving furosemide. For which sign of hypokalemia should the nurse monitor the client? Chvostek sign Flabby muscles Anxious behavior Abdominal cramping

Flabby muscles With hypokalemia, failure occurs in myoneural conduction and smooth muscle functioning, resulting in fatigue; muscle weakness; and soft, flabby muscles. Chvostek sign, the contraction of the facial muscles in response to a light tap over the facial nerve in front of the ear, is associated with hypocalcemia; low calcium levels allow sodium to move into excitable cells, increasing depolarization and nerve excitability. Anxiety and irritability are associated with hyperkalemia. Hyperkalemia affects the nervous and muscular systems; fatigue, weakness, and lethargy are associated with hypokalemia. Decreased gastrointestinal motility occurs with hypokalemia; abdominal cramping is associated with hyperkalemia and is caused by hyperactivity of smooth muscles.

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

Fluid and electrolyte balance Monitoring fluid and electrolyte balance is the most important nursing intervention because excess loss of fluid through the multiple loose bowel movements associated with diarrhea lead to alteration in fluid and electrolyte imbalance. Although skin may become excoriated with diarrhea, this is not a life-threatening condition and therefore not the nursing priority. Even though absorption of nutrients is decreased with diarrhea malnutrition, it is not a life-threatening condition and therefore not the priority nursing intervention. Fluid intake and output provides information about fluid balance only, without taking into consideration the loss of electrolytes that accompanies diarrhea and therefore is not the best choice.

Which therapeutic communication technique is most useful for the nurse to use when the client begins to repeat previously mentioned issues in the same therapeutic conversation? Focusing Clarifying Paraphrasing Summarizing

Focusing

The nurse observes that an older client seldom eats the meat on the meal trays. The nurse discusses this observation with the client, and the client states, "I only eat meat once a week because old people don't need protein every day." What does the nurse determine that the client needs to be taught about? Need for home-delivered meals Foods that meet basic nutritional needs Effect of aging on the need for some foods Need for meat at least once per day throughout life

Foods that meet basic nutritional needs The need for nutrients, including protein, that meet basic nutritional needs continues throughout life. The priority is to educate the client, although home-delivered meals may be one way to provide adequate nutrition. Aging has no effect on the specific nutrients needed; however, it may influence digestion or absorption of food. Protein is needed every day, but it does not have to be in the form of meat.

A client is admitted to the hospital with a diagnosis of an exacerbation of asthma. What should the nurse plan to do to best help this client? Determine the client's emotional state. Give prescribed drugs to promote bronchiolar dilation. Provide education about the impact of a family history. Encourage the client to use an incentive spirometer routinely.

Give prescribed drugs to promote bronchiolar dilation. Asthma involves spasms of the bronchi and bronchioles as well as increased production of mucus; this decreases the size of the lumina, interfering with inhalation and exhalation. Bronchiolar dilation will reduce airway resistance and improve the client's breathing. Although identifying and addressing a client's emotional state is important, maintaining airway and breathing are the priority. In addition, emotional stress is only one of many precipitating factors, such as allergens, temperature changes, odors, and chemicals. Although recent studies indicate a genetic correlation along with other factors that may predispose a person to develop asthma, exploring this issue is not the priority. Use of an incentive spirometer is not helpful because of mucosal edema, bronchoconstriction, and secretions, all of which cause airway obstruction.

A nurse administers an intravenous solution of 0.45% sodium chloride. In what category of fluids does this solution belong? Isotonic Isomeric Hypotonic Hypertonic

Hypotonic Hypotonic solutions are less concentrated (contain less than 0.85 g of sodium chloride in each 100 mL) than body fluids. Isotonic solutions are those that cause no change in the cellular volume or pressure because their concentration is equivalent to that of body fluid. This relates to two compounds that possess the same molecular formula but that differ in their properties or in the position of atoms in the molecules (isomers). Hypertonic solutions contain more than 0.85 g of solute in each 100 mL.

A client with dementia and a percutaneous endoscopic gastrostomy (PEG) tube is being cared for at home. Which action provides evidence that a family member is effectively managing the client's care? Empty feeding bag stays attached to the tubing. Tube is flushed with air after medication is given. Replacement of the tube is done on a weekly basis. Head of the bed remains elevated after the feeding.

Head of the bed remains elevated after the feeding. The client's upper body must be elevated to prevent aspiration and promote digestion. Attaching the empty feeding bag to the tubing is not necessary. The end of the gastrostomy tube just needs to be covered. The tube is flushed with water, not air, before and after food or medication is given; excess air in the gastrointestinal tract can cause abdominal distention and cramping. Because the tube was inserted by a surgical procedure, it is replaced only when a problem is identified, and usually only by the healthcare provider.

A client is admitted with multiple injuries as a result of an accident. A tracheostomy was performed. While the nurse is caring for this client, the client coughs, expelling the tracheostomy tube onto the bed. What should the nurse's first action be? Hold the tracheostomy open with a tracheal dilator and call for assistance Insert an obturator into the tracheostomy and gently reinsert the tracheostomy tube Pick up the tracheostomy tube from the bed and replace it until a new tube is available Obtain a new tracheostomy tube, prepare the new holder, and insert the tube using the obturator

Hold the tracheostomy open with a tracheal dilator and call for assistance By holding the tracheostomy open with a tracheal dilator and calling for assistance, an immediate airway is provided without causing trauma; with assistance, a new tracheostomy tube can be inserted. The obturator will obstruct the airway. Replacing the tube that fell on the bed linen is contraindicated because it is contaminated; a sterile tube should be inserted. If the airway is not held open, the client will experience hypoxia.

After cataract surgery the nurse teaches a client how to self-administer eyedrops. The nurse reinforces the use of what technique? Placing the drops on the cornea of the eye Raising the upper eyelid with gentle traction Holding the dropper tip above the conjunctival sac Squeezing the eye shut after instilling the medication

Holding the dropper tip above the conjunctival sac Drops are placed within the lower lid (conjunctival sac). To protect against physical injury and infection, the dropper tip should not touch the eye. The lower lid is retracted for placement of eyedrops. Squeezing the eyes shut after administration of the medication should be avoided; this will squeeze medication out of the eye.

A primary healthcare provider is treating the red-color wound of a client caused by pressure ulcers. Which dressings are beneficial for wound recovery? Select all that apply. Absorptive dressings Hydrocolloid dressings Transparent film dressings Moist gauze dressings with antibiotics Telfa dressings with antibiotic ointment

Hydrocolloid dressings Transparent film dressings Telfa dressings with antibiotic ointment Hydrocolloid dressings, transparent film dressings, and telfa dressings with antibiotic ointment are beneficial for the healing of a red wound caused by pressure ulcers. Absorptive dressings and moist gauze dressings with antibiotics are used to treat yellow wounds, such as wounds with nonviable necrotic tissue.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The nurse would monitor the client for which complications? Select all that apply. Hyperglycemia Infection Hepatitis Anorexia Dysrhythmias

Hyperglycemia Infection Hyperglycemia related to the high concentration of dextrose in TPN is a common complication of this therapy and must be monitored for by the nurse. Another common complication is related to the central venous access that is needed for infusion of TPN. Catheter-related infection is frequently seen and must be monitored for by the nurse. Hepatitis is usually not associated with total parenteral nutrition. Anorexia often is present before the medical decision is made to begin total parenteral nutrition. Dysrhythmias are not related to total parenteral nutrition, but may be a sign of hyperkalemia or hypokalemia.

A nurse is teaching a client about the use of a metered-dose inhaler with a spacer. Which statement made by the client indicates the need for further teaching? "I will wait for at least 1 minute between puffs." "I will shake the whole unit vigorously one or two times." "I will hold my breath for at least 10 seconds after removing the mouthpiece." "I will insert the mouthpiece of the inhaler into the nonmouthpiece end of the spacer."

I will shake the whole unit vigorously one or two times The metered-dose inhaler should be shaken vigorously for a minimum of three or four times for proper mixing of the content inside the inhaler. A minimum of a 1-minute gap should be given in between the puffs to ensure proper movement of the medications into the lungs. After removing the mouthpiece, the client should hold his/her breath for at least 10 seconds so that the drug does not escape with exhalation. Inserting the mouthpiece of the inhaler into the nonmouthpiece end of the spacer is the correct way of closing the inhaler.

A client who is in the advanced stages of illness asks the nurse to contact pastoral services for support. According to the Macmillan model, what is the best nursing intervention in this situation? Immediately involve pastoral services while caring for the client. Involve the family member in the client's care instead of pastoral support. Listen to the client's request for support then carry on with the clinical work. Falsely promise that pastoral services has been contacted and plan to see the client.

Immediately involve pastoral services while caring for the client. The Macmillan nurse usually has the knowledge of advanced practice and possesses specialty training. This practice enhances the nurse to gain an in-depth knowledge about spiritual, social, and psychologic needs and the pathophysiology of clients living with advanced diseases. Therefore the nurse involves pastoral services while caring for the client. Involving a family member may decrease anxiety in the client but may not fulfill the wishes of the client. Just listening to the client's request without implementation or giving false promises can cause loss of trust in the client.

The nurse is performing nursing care therapies and including the client as an active participant in the care. Which basic step is involved in this situation? Planning Evaluation Assessment Implementation

Implementation The basic step implementation involves performing nursing care therapies and including the client as an active participant in the care. Planning involves nursing processes such as developing an individualized care plan. Evaluation involves nursing processes such as identifying the success in meeting desired outcomes. Assessment involves nursing processes such as collecting data about a client's physical, psychological, social culture.

Which step in the nursing process would involve promoting a safe environment for the client? Planning Diagnosis Assessment Implementation

Implementation The nurse promotes a safe environment during the implementation stage of the nursing process. During the planning stage, the nurse develops an individualized care plan for the client. The plan contains strategies and alternatives to achieve specific outcomes. During the diagnosis stage, the nurse analyzes the assessment data to determine the health care issues. The nurse collects comprehensive data pertinent to the client's health and situation during the assessment stage.

An injured client with an open wound is brought to the hospital. The doctor asks the nurse to administer a tetanus toxoid injection. Which step of the nursing process does the nurse follow next? Diagnosis Evaluation Assessment Implementation

Implementation The nurse will administer the tetanus as per the doctor's regime. The American Nurses Association identifies this standard of nursing practice as implementation. Diagnosis refers to analysis of the client's biological and psychosocial data to find out the relevant issues and problems. Evaluation is the procedure of assessing the desired outcomes of treatment. Assessment is done at the very beginning when the nurse collects the data about the client to make an accurate diagnosis.

Which client responses does the nurse determine represent the highest risk for the development of pressure ulcers? Incontinence and inability to move independently Periodic diaphoresis and occasional sliding down in bed Reaction to just painful stimuli and receiving tube feedings Adequate nutritional intake and spending extensive time in a wheelchair

Incontinence and inability to move independently

When obtaining a health history, the nurse is informed that a client has been taking digoxin. What therapeutic effect of digoxin does the nurse expect? Decreased cardiac output Decreased stroke volume of the heart Increased contractile force of the myocardium Increased electrical conduction through the atrioventricular (AV) node

Increased contractile force of the myocardium Digoxin produces a positive inotropic effect that increases the strength of myocardial contractions and thus cardiac output. The positive inotropic effect of digoxin increases, not decreases, cardiac output. Digoxin increases the strength of myocardial contractions (positive inotropic effect) and slows the heart rate (negative chronotropic effect); these effects increase the stroke volume of the heart. Digoxin decreases the refractory period of the AV node and decreases conduction through the sinoatrial (SA) and AV nodes.

After emergency surgery, the nurse teaches a client how to use an incentive spirometer. What client behavior indicates to the nurse that the spirometer is being used correctly? Inhales deeply through the mouthpiece, relaxes, and then exhales. Inhales deeply, seals the lips around the mouthpiece, and exhales. Uses the incentive spirometer for 10 consecutive breaths per hour. Coughs several times before inhaling deeply through the mouthpiece.

Inhales deeply through the mouthpiece, relaxes, and then exhales. Inhaling deeply through the mouthpiece, relaxing, and then exhaling are correct techniques; deep inhalation promotes alveolar expansion, and exhalation promotes lung recoil. Inhaling deeply, sealing the lips around the mouthpiece, and exhaling are incorrect techniques; inhalation should occur through the mouthpiece. The breaths should not be taken in succession; they should be spaced by several normal breaths to avoid fatigue. Coughing is done after deep breathing.

While visiting the hospital, the spouse of a client slips and falls on a recently washed floor in the hallway leading to the client's room. To meet the criteria of ethical practice, what action should the nurse who witnessed the occurrence take? Initiate an agency incident report. Report the fall to the state (provincial) health department. Write a brief description of the incident to be kept by the nurse manager. Determine that no documentation is needed because the visitor is not a client in the hospital.

Initiate an an agency incident report Health care agencies document the occurrence of any event out of the ordinary that results in or has the potential to harm a client, employee, or visitor. Falls by visitors are not required to be reported to state (provincial) health departments. However, incident reports are required to be presented to accrediting agencies for review when an agency is in the process of being accredited. Writing a brief description of the incident to be kept by the nurse manager is not a requirement of ethical practice. However, a nurse who is involved in an incident or is a witness to an incident should write an accurate description of the event, along with the names of individuals involved. This documentation should be kept by the nurse at home. Lawsuits may take several years before they come to trial, and personal notes may help the nurse recall the event. The documentation must accurately contain the same elements included in the formal incident report. Taking no action is irresponsible. All events out of the ordinary that result in or have the potential to harm a visitor should be documented in an agency incident report.

A registered nurse is evaluating the actions of a nursing student who is injecting an allergen in a client having a severe anaphylactic reaction to insect venom. Which action of the nursing student requires correction? Rotating the sites for each injection Aspirating for blood before giving the injection Injecting in an extremity close to a joint Observing the client for 20 minutes after an injection

Injecting in an extremity close to a joint The allergen extract should always be administered in an extremity away from a joint so that a tourniquet can be applied for a severe reaction. The injection sites should be rotated for each injection to prevent skin damage. Aspirating for blood before giving an injection should always be done to ensure that the allergen extract is not injected into a blood vessel. Systemic reactions are likely to occur immediately. Therefore the client should be observed for 20 minutes after the injection.

The nurse is transferring a client from the bed to the chair. Which action should the nurse take during the transfer? lace the client in a semi-Fowler position. Stand behind the client during the transfer. Turn the chair so it faces away from the bed. Instruct the client to dangle the legs.

Instruct the client to dangle the legs

A client with a history of hypertension has a blood pressure of 180/102 mm Hg. When the nurse asks whether the client has been taking any medications, the client replies, "I took the blood pressure pills the healthcare provider prescribed for a few weeks, but I didn't feel any different, so I decided I'd only take them when I feel sick." What is the best initial response by the nurse? "You must be quite frightened about having high blood pressure." "I'm glad to hear you have felt well enough to stop the medication." "It is important to take your medications daily to achieve optimal results." "You will need to document daily whether you took your medication or not."

It is important to take your medications daily to achieve optimal results "It is important to take your medications daily to achieve optimal results" is a nonjudgmental response that does not pressure the client but does indicate clearly that treatment is necessary. The response "I'm glad to hear you felt well enough to stop the medication" is not supported by the client's statement. The response "You must be quite frightened about having high blood pressure" does not address the correlation between blood pressure medication and controlling hypertension. Although it is important to document medication taking, the initial response should address the importance of medication to control the client's hypertension.

The nurse is caring for a client who is receiving intermittent intravenous piggyback doses of vancomycin every 12 hours. The primary healthcare provider prescribes trough levels of the antibiotic. The nurse schedules the blood sample to be obtained at what time? Just before the medication is administered Between 30 and 60 minutes after the infusion is completed Six hours after the dose is completely infused In the morning before the client eats breakfast

Just before the medication is administered Trough levels are measured in relation to the time a drug is administered. The trough level for a drug is drawn just before a drug is given, when the drug's level is at its lowest. Any other time would be inaccurate for a drug's trough level. The drug's peak level is drawn 30 to 60 minutes after the infusion is completed. Whether the client eats breakfast does not affect this drug's trough levels, as it is an intravenous infusion.

A client with a chest tube is to be transported via a stretcher. When transporting the client, what should the nurse do? Keep collection device attached to mechanical suction Keep chest tube clamped distal to the water-seal chamber Keep collection device below the level of the client's chest Keep chest tube end covered with sterile gauze pads taped to the client

Keep collection device below the level of the client's chest The collection device must be kept below the level of the chest to prevent backflow of fluid into the pleural space. A chest tube clamped distal to the water-seal chamber is contraindicated. The chest tube should not be clamped because it may precipitate a tension pneumothorax. A chest tube end covered with sterile gauze pads taped to the client is contraindicated. There is no reason to disconnect the chest tube from the water-seal system; this will allow atmospheric air to enter the pleural space, causing a pneumothorax.

A client who recently experienced a brain attack (cerebrovascular accident, CVA) and who has limited mobility reports constipation. What is most important for the nurse to determine when collecting information about the constipation? Presence of distention Extent of weight gained Amount of high-fiber food consumed Length of time this problem has existed

Length of time this problem has existed First, the nurse should establish when the client last defecated because the client may have perceived constipation. Abdominal distention may or may not be observed with constipation. Weight gain has no relationship to constipation. Although lack of bulk in the diet can lead to constipation, particularly in clients with limited activity or an inadequate fluid intake, the lack of bulk in the diet is not the most significant information to obtain at this time.

A nurse is providing tracheostomy care. Which action is priority? Place the client in the semi-Fowler position Maintain sterile technique during the procedure Monitor body temperature after the procedure is completed Clean the inner cannula with sterile water when it is removed

Maintain sterile technique during the procedure The tracheostomy site is a portal of entry for microorganisms. Sterile technique must be used. The high-Fowler position promotes maximum aeration of lungs. Body temperature is not related to the suctioning procedure. The cannula, if it is not disposable, generally is cleaned with peroxide and saline.

A client is admitted to the hospital with urinary retention, and an indwelling urinary catheter is prescribed by the primary healthcare provider. What should the nurse do to help prevent the client from developing a urinary tract infection? Assess urine specific gravity. Collect a weekly urine specimen. Maintain the prescribed hydration. Empty the drainage bag once a day.

Maintain the prescribed hydration. Promoting hydration maintains urine production that flushes the bladder, thereby preventing urinary stasis and possible infection. Although assessing urine specific gravity may help identify a urinary tract infection, it will not prevent it. Although collecting a weekly urine specimen for culture and sensitivity may help identify a urinary tract infection, it will not prevent it. The collection bag is emptied once every shift unless the bag is full and needs to be emptied sooner.

A client with pneumonia now requires use of a nonrebreathing mask to maintain adequate oxygen saturation levels. How does the nurse interpret this information? The client's pneumonia is continually improving. Oxygen concentrations up to 44% can be obtained. Mechanical ventilation may be required next. Nasal cannula may be used while the client is eating.

Mechanical ventilation may be required next. A nonrebreathing mask is used when the client requires higher oxygen concentrations and the condition is worsening. If the nonrebreathing mask does not improve oxygen saturation, the next steps to improving gas exchange and oxygenation are intubation and mechanical ventilation. Oxygen concentrations up to 90% can be achieved. Nasal cannula would not be advised, as the client requires more oxygen than can be delivered through this method.

When reviewing a drug to be administered, the nurse identifies that the package insert indicates that the Z-track injection technique should be used. Under what circumstance does the nurse expect that this technique will be necessary? Volume of medication to be administered is large. Medication is irritating to subcutaneous tissue and skin. Injection site must be massaged after it is administered. Procedure requires an air bubble to be drawn into the syringe.

Medication is irritating to subcutaneous tissue and skin. The Z-track method seals the puncture at the intramuscular level, preventing seepage of injected medication up the needle track and thereby avoiding injury to subcutaneous tissue and skin. The Z-track technique is unrelated to the volume of medication to be administered. When the volume of medication is large, it should be administered into a large muscle or divided into two syringes. Massage is avoided with the Z-track technique to help prevent the injected medication from flowing back up the needle track. Administration of a small air bubble at the completion of injection of medication into a muscle (air-lock technique) is no longer recommended because it does not increase the likelihood that medication will remain in the muscle without flowing back up the needle track.

On the second day after an abdominoperineal resection, the nurse anticipates that the colostomy stoma will have what appearance? Dry, pale pink, and flush with the skin Moist, red, and raised above the skin surface Dry, purple, and depressed below the skin surface Moist, pink, flush with the skin, and painful when touched

Moist, red, and raised above the skin surface The surface of a stoma is mucous membrane and should be dark pink to red, moist, and shiny; the stoma usually is raised beyond the skin surface. The stoma should be moist, not dry; pale pink indicates a low hemoglobin level. Although some stomas can be flush with the skin, a raised stoma is more common. The stoma should be moist, not dry; purple indicates compromised circulation. A depressed stoma is retracted and unexpected. Although the stoma should be moist and dark pink to red, it should not be painful; although some stomas can be flush with the skin, a raised stoma is more common.

A client is admitted with extensive bone and soft-tissue injuries to the leg. Sterile dressings are applied. Two days later, when removing the dressings, the nurse finds that one of the dressings has adhered to tissue in several places. Which action should the nurse take to loosen the dressing? Apply diluted hydrogen peroxide. Pull with gentle but steady traction. Soak the area in a solution of Betadine. Moisten the dressing with sterile saline.

Moisten the dressing with sterile saline Sterile saline will soften the dried exudates adhered to the dressing, limiting tissue damage when the dressing is removed. The use of hydrogen peroxide can be irritating to the tissues. Pulling off the dressing with steady traction may be painful and cause unnecessary tissue damage. The use of Betadine to remove a dressing is not recommended.

The fire alarm is sounding in a skilled nursing facility and smoke is pouring from the kitchen. What should the nurse do to ensure the safety of the clients, staff, and family members? Select all that apply. Move bedridden clients via stretcher Place ambulatory clients in wheelchairs Turn off all sources of supplemental oxygen Provide manual respiratory support to critically ill clients Close all windows and doors and use an ABC fire extinguisher

Move bedridden clients via stretcher Turn off all sources of supplemental oxygen Provide manual respiratory support to critically ill clients Close all windows and doors and use an ABC fire extinguisher

A client's parathyroid glands are removed. What clinical manifestation is indicative of the fluid and electrolyte imbalance associated with this surgery? Constipation Muscle spasms Hypoactive reflexes Increased specific gravity

Muscle spasms Removal of the parathyroids causes hypocalcemia and associated neuromuscular irritability. Constipation is a sign of hypercalcemia. Hypoactive reflexes are signs of hypercalcemia. Increased specific gravity is a sign of fluid volume deficit.

Which method of oxygen delivery should a nurse anticipate will be prescribed for a client with a pulse oximetry reading of 65%? Face tent Venturi mask Nasal cannula Nonrebreather mask

Nonrebreather mask The expected value of a pulse oximetry reading is 95% to 100%. Nonrebreather mask will deliver high oxygen concentrations (95% to 100%) at a liter flow of 10 to 15 L/min. When using a nonrebreather mask, the client breathes only the oxygen source from the bag. A face tent delivers 30% to 50% oxygen when set at a flow rate of 4 to 8 L/min. A Venturi mask delivers 24% to 50% oxygen when set at a flow rate of 4 to 10 L/min. A nasal cannula delivers 24% to 45% oxygen when set at a flow rate of 2 to 6 L/min.

During follow-up visits, the client's child reports to the nurse, "I tell my parent every day about what may happen if medications aren't taken as prescribed. Despite that, my parent does not take the medication regularly and is depressed." What can be inferred about the client's motivational level? Not motivated Intrinsically motivated Extrinsically motivated with self-determination Extrinsically motivated without self-determination

Not motivated

A client is admitted to the hospital for a surgical resection of the lower left lobe of the lung. After surgery the client has a chest tube to a closed chest drainage system. What should the nurse do to determine if the chest tube is patent? Milk the chest tube toward the drainage unit Check the amount of bubbling in the suction control chamber Observe for fluctuations of the fluid in the water-seal chamber Assess for extent of chest expansion in relation to breath sounds

Observe for fluctuations of the fluid in the water-seal chamber Fluctuations of the fluid in the water-seal chamber indicate effective communication between the pleural cavity and the drainage system. Milking the chest tube toward the drainage unit should be avoided because it raises pressure in the pleural space, which can result in a tension pneumothorax. Bubbling in the suction control chamber is expected and should be continuous. Extent of chest expansion in relation to breath sounds does not directly reflect the patency of the chest tube.

A healthcare provider prescribes two units of blood for a client who is bleeding. Which nursing interventions are necessary before the blood transfusion is administered? Select all that apply. Obtain the client's vital signs. Monitor hemoglobin and hematocrit levels. Allow the blood to reach room temperature. Determine typing and crossmatching of blood. Use a Y-type infusion set to initiate 0.9% normal saline.

Obtain the client's vital signs. Determine typing and crossmatching of blood. Use a Y-type infusion set to initiate 0.9% normal saline. Obtaining the client's vital signs provides a baseline and should be done before the transfusion is initiated. Prior to beginning the transfusion, the nurse and another hospital-approved personnel should double-check client identification and blood product identification (blood unit number, blood type and crossmatch data like Rh factor along with expiration date) with another licensed nurse. Using a Y-type infusion set with 0.9% saline on one side of the Y is necessary to prevent an acute immunologic reaction if the donated blood is not compatible with the client's blood. A Y-type infusion set is specific for blood administration. It has a special blood filter, the drop factor is different, and it allows for quick shutoff and the administration of normal saline in the event of a transfusion reaction. The laboratory results for hemoglobin and hematocrit levels were part of the data used to determine the need for blood initially and do not need to be performed again until after the transfusion is completed. Blood must be kept cold until ready for use; if blood is kept at room temperature for 30 minutes before administration, it should be returned to the blood bank; after it is started, blood must be administered within four hours.

A nurse is caring for an older bedridden male client who is incontinent of urine. Which action should the nurse take first? Restrict fluid intake. Offer the urinal regularly. Apply incontinence pants. Insert an indwelling urinary catheter.

Offer the urinal regularly. Offering the urinal is the first step. Retraining the bladder includes a routine pattern of attempts to void, which may increase bladder muscle tone and produce a conditioned response. Restricting fluid intake can result in dehydration and a urinary tract infection in an older client. Applying incontinence pants does not address the cause of the incontinence; also it promotes skin breakdown and can lower self-esteem. Inserting an indwelling urinary catheter increases the risk of a urinary tract infection. Also, it requires a primary healthcare provider's prescription.

A primary healthcare provider prescribed an indwelling urinary catheter for a client. Which catheter should the nurse use to implement this prescription?

Option C is an indwelling urinary catheter[1][2]; it has two lumens. One lumen is used to inflate the balloon at the tip of the catheter; this holds the catheter in place. The other lumen allows the continuous drainage of urine from the bladder via gravity into a collection bag. Option A is a simple one-lumen urethral catheter. It is used to empty the bladder of urine or to obtain a sterile urine specimen. It is inserted once, removed, and discarded. Option B is a mushroom-tipped Pezzar catheter that is used for suprapubic catheterization. Option D is a triple-lumen urinary catheter; it is used for continuous bladder irrigations. One lumen is used to inflate the balloon at the tip of the catheter. The second lumen is used to continuously instill a solution into the bladder. The third lumen allows the continuous drainage of fluid from the bladder via gravity into a collection bag.

An older client with shortness of breath is admitted to the hospital. The medical history reveals hypertension in the last year and a diagnosis of pneumonia three days ago. Which vital sign assessment would be seen as a sign that the client needs immediate medical attention? Oxygen Saturation: 89% Body temperature: 101°F Blood Pressure: 130/80 mmHg Respiratory rate: 26 beats/minute

Oxygen Saturation: 89% An oxygen saturation less than 90% observed in a client with pneumonia indicates that the client is at risk of respiratory depression. Oxygen saturation would take priority in initiating the care. The client's body temperature indicates fever due to pneumonia, which should be considered secondary to the oxygen saturation problem. The blood pressure reading is normal. The increased respiratory rate may be due to fever, which would be considered secondary to the oxygen saturation problem.

A nurse instructs a client to breathe deeply to open collapsed alveoli. What is the best explanation the nurse could offer to explain the relationship between alveoli and improved oxygenation? The alveoli need oxygen to live. The alveoli have no direct effect on oxygenation. Collapsed alveoli increase oxygen demand. Oxygen is exchanged for carbon dioxide in the alveolar membrane.

Oxygen is exchanged for carbon dioxide in the alveolar membrane The exchange of oxygen and carbon dioxide occurs in the alveolar membrane. Therefore, if the alveoli collapse, this exchange cannot occur because pulmonary ventilation is reduced. Explaining this process in simple terms to a client may increase compliance with recommended breathing exercises aimed at improving oxygenation. Alveoli do have a direct effect on oxygenation. The statements that alveoli need oxygen to live and that collapsed alveoli increase oxygen demand are nonspecific regarding the pathophysiology of the alveolar membrane.

A nurse is administering high concentrations of oxygen to a 7-year-old child. What is the nurse's most important consideration concerning the oxygen? A nonrebreather mask should be used. The tank should be labeled flammable. Oxygen must be warmed before administration. Oxygen must be humidified before administration.

Oxygen must be humidified before administration. Because of the drying nature of oxygen, it should be humidified before it is administered. The method of oxygen delivery and the amount are included in the healthcare provider's prescription. Oxygen is not combustible, but it supports fire. Oxygen is not warmed before administration; it is cool on administration.

A client has chest tubes attached to a chest tube drainage system. What should the nurse do when caring for this client? Clamp the chest tubes when suctioning. Palpate the surrounding area for crepitus. Change the dressing daily using aseptic technique. Empty the drainage chamber at the end of the shift.

Palpate the surrounding area for crepitus. Leakage of air into the subcutaneous tissue is evidenced by a crackling sound when the area is gently palpated; this is referred to as crepitus. Although hemostats should be readily available for any client with chest tubes in the event of a break in the drainage system, clamping the tube is not otherwise necessary and could cause backpressure. The dressing is not routinely changed to minimize the risk for pneumothorax. The system is kept closed to prevent the pressure of the atmosphere from causing a pneumothorax; drainage levels are marked on the drainage chamber to measure output. The chambers are not emptied; if they are filled, a new system will be attached.

The nurse understands that the best way to reduce catheter-associated urinary tract infections (CAUTIs) in long-term indwelling catheters is to do what? Perform catheter care twice a day. Replace the catheter on a routine basis. Administer cranberry tablets three times each day. Give antibiotics for the duration of catheter placement.

Perform catheter care twice a day. A bacterial biofilm develops in long-term indwelling catheters increasing the risk of catheter-associated urinary tract infection (CAUTI). The best way to eliminate this risk is to perform routine perineal hygiene and catheter care every day. Routine replacement of indwelling urinary catheters increases CAUTI risk. The efficacy of cranberry tablets in decreasing the frequency of urinary tract infections has not been established. Antibiotic therapy may increase the growth of microbes within the biofilm.

Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis? Planning Evaluation Assessment Implementation

Planning The planning phase of the nursing process is directly affected if the nurse does not make a nursing diagnosis. The nurse cannot plan or interpret correctly if the client's problems are not clear. The evaluation phase of the nursing process is not directly affected by the nursing diagnosis. A nursing diagnosis is based on an accurate assessment. The nurse must obtain and document a comprehensive assessment. In the absence of nursing diagnosis, the nurse cannot implement appropriate nursing interventions. The implementation phase is directly affected if there is no plan of care.

A nurse is caring for a client with a tracheostomy. Which action should the nurse implement when performing tracheal suctioning? Preoxygenate the client before suctioning. Employ gentle suctioning as the catheter is being inserted. Be sure the cuff of the tracheostomy is inflated during suctioning. Loosen the client's secretions before suctioning by instilling saline.

Preoxygenate the client before suctioning. Administration of 100% oxygen for a few minutes before suctioning reduces the risk of hypoxia, the major complication of suctioning. Suction is applied as the catheter is withdrawn, not during insertion, to prevent hypoxia. Tracheostomy cuffs are indicated when the client is on mechanical ventilation. Although a saline solution may be instilled into a tracheostomy, this practice is not recommended.

The nurse observes a client with chronic obstructive pulmonary disease (COPD) breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs and hears crackles and wheezes. What action should the nurse take? Encourage the client to take slow, deep breaths and administer 5 L/min oxygen per nasal cannula. Place the client in a side-lying position and perform chest physiotherapy using clapping and vibration. Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula. Assist the client in assuming a position of comfort and perform postural drainage.

Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula. Sitting facilitates breathing by increasing lung expansion; 2 L of oxygen promotes respirations while preventing carbon dioxide narcosis. However, the results of one recent study of clients with stable COPD indicate that the hypercarbic drive is preserved with oxygen higher than 2 L. More research is needed before this theory is applied clinically. Five liters of oxygen may cause respiratory depression and carbon dioxide narcosis in a client with COPD. Chest physiotherapy may be done later after the client's condition improves. Delaying intervention likely will worsen the respiratory distress.

A registered nurse is educating a nursing student about the primary level of prevention. What information should the nurse provide? Select all that apply. Primary prevention is also known as true prevention. Primary prevention is applied to clients who are considered physically and emotionally healthy. Primary prevention is directed towards rehabilitative care rather than diagnosis and treatment. Primary prevention activities enable clients to return to a normal level of health as early as possible. Primary prevention includes health education programs, immunizations, and physical and nutritional fitness activities.

Primary prevention is also known as true prevention. Primary prevention is applied to clients who are considered physically and emotionally healthy. Primary prevention includes health education programs, immunizations, and physical and nutritional fitness activities. Primary prevention is also known as true prevention as it precedes disease and dysfunction. Primary prevention is applied on those clients who are considered to be physically and emotionally healthy. Primary prevention focuses on health promotion. This includes health education programs, immunizations, and physical and nutritional fitness activities. Tertiary prevention is directed towards providing rehabilitative care to clients rather than diagnosis and treatment. Secondary prevention activities enable clients to return to a normal level of health as early as possible.

A nurse is caring for a client whose laboratory values indicate the presence of hyponatremia. Which factors does the nurse determine were the most likely cause of the hyponatremia? Select all that apply. Diabetes insipidus Profuse diaphoresis Excess sodium intake Removal of the parathyroid glands Rapid intravenous (IV) infusion of 5% dextrose in water

Profuse diaphoresis Rapid intravenous (IV) infusion of 5% dextrose in water Common causes of hyponatremia from loss of sodium-rich body fluids include draining wounds, diarrhea, vomiting, and primary adrenal insufficiency. Inappropriate use of sodium-free or hypotonic IV fluids (like D 5W) causes hyponatremia from water excess. Since perspiration contains high levels of sodium, this is a cause of hyponatremia. Diabetes insipidus results in inadequate antidiuretic hormone (ADH), causing water loss and hypernatremia. Excess sodium intake can lead to hypernatremia. Removal of the parathyroid glands can lead to hypocalcemia.

During chemotherapy, altered nutrition is a common side effect. Knowing that compromised nutrition can contribute to an increased risk of infection and other problems, what can the nurse do to offset nutritional deficiencies?

Provide oral supplements. The client with cancer may experience protein and calorie malnutrition characterized by fat and muscle depletion. Soft, nonirritating high-protein and high-calorie foods should be eaten throughout the day. Foods suggested for increasing the protein intake and high-calorie foods that provide energy and minimize weight loss are recommended. Teach the client to avoid extremes of temperature of food, spicy or rough foods, and other irritants. Encourage nutritional supplements like Ensure as an adjunct to meals and fluid intake. Teach the client to use nutritional supplements in place of milk when cooking or baking. Foods to which nutritional supplements can be easily added include scrambled eggs, pudding, custard, mashed potatoes, cereal, and cream sauces. Packages of instant breakfast can be used as indicated or sprinkled on cereals, desserts, and casseroles. Families are an integral part of the healthcare team. As symptom severity increases, the family's role in helping the client eat becomes increasingly critical. If the malnutrition cannot be treated with dietary intake, it may be necessary to use enteral or parenteral nutrition. Favorite foods are not offered during chemotherapy because the client's sense of taste has changed. Dairy products are a necessary part of a balanced diet and do not affect chemotherapy. High-protein shakes are used to encourage healing and protein intake.

A nurse uses therapeutic communication techniques in order to achieve desired client outcomes. Which communication technique is a part of therapeutic communication? Asking for explanations Showing sympathy to the client Asking personal questions of the client Providing relevant information to the client

Providing relevant information to the client Because clients have the right to know about their health status, the nurse should provide them with all relevant information. This is a therapeutic communication technique that enables clients to understand what is happening and what to expect. Asking for explanations, showing sympathy and asking personal questions of the client are nontherapeutic communication techniques.

A nurse assists a client who had bariatric surgery to be more mobile. What complication is the nurse attempting to prevent? Incisional pain Wound dehiscence Anastomosis leakage Pulmonary embolism

Pulmonary Embolism

A client with a history of heart failure is experiencing dyspnea with a respiratory rate of 32. Crackles are noted bilaterally. The client is in Sims position, receiving oxygen at 2 L/min via nasal cannula. Which action should the nurse take first? Raise the client to high-Fowler position Obtain the apical pulse and blood pressure Call the primary healthcare provider immediately Monitor the pulse oximeter to ascertain the oxygen level

Raise the client to high-Fowler position Raising the client to high-Fowler position will decrease orthopnea by using gravity to keep fluid in lower extremities, putting less stress on the heart. Obtaining a full set of vital signs would be the next priority after changing the client position. Calling the primary healthcare provider immediately would not be useful without having a full set of vital signs. The vital signs should include the oxygen saturation, which the healthcare provider would expect the nurse to provide.

A nurse in the postanesthesia care unit (PACU) is providing care to a client who had an abdominal cholecystectomy and observes serosanguineous drainage on the abdominal dressing. What is the next nursing action? Change the dressing. Reinforce the dressing. Replace the tape with Montgomery ties. Support the incision with an abdominal binder

Reinforce the dressing. The nurse should anticipate drainage and reinforce the surgical dressing as needed. Changing a dressing at this time is unnecessary and increases the risk for infection. Montgomery ties are used when frequent dressing changes are anticipated; they are not appropriate at this time. An abdominal binder rarely is prescribed, and it will interfere with assessment of the dressing at this time.

What is the most important intervention to prevent hospital-acquired catheter-associated urinary tract infections (CAUTIs)? Removing the catheter Keeping the drainage bag off of the floor Washing hands before and after assessing the catheter Cleansing the urinary meatus with soap and water daily

Removing the catheter Research demonstrates that decreasing the use of indwelling urinary catheters is the most important intervention to prevent hospital-acquired catheter-associated urinary tract infections (CAUTIs). Keeping the drainage bag off the floor, washing hands before and after assessing the catheter, and cleansing the urinary meatus daily with soap and water will help reduce infections; however, these are not the most important interventions to prevent CAUTIs.

A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who develops a pneumothorax and has a chest tube inserted. Which primary purpose of the chest tube will the nurse consider when planning care? Lessens the client's chest discomfort Restores negative pressure in the pleural space Drains accumulated fluid from the pleural cavity Prevents subcutaneous emphysema in the chest wall

Restores negative pressure in the pleural space Negative pressure is exerted by gravity drainage or by suction through the closed system. Though the discomfort may be lessened as a result of the insertion of the chest tube, this is not the primary purpose. There is an accumulation of air, not fluid, when a pneumothorax occurs in a client with COPD. Subcutaneous emphysema in the chest wall is associated most commonly with clients receiving air under pressure, such as that received from a ventilator; subcutaneous emphysema can also occur with a chest tube.

A client with a history of cardiac dysrhythmias is admitted to the hospital with dehydration. What does the nurse add to the client's plan of care? A glass of water every hour until hydrated Small, frequent intake of juices, broth, or milk Short-term nasogastric (NG) replacement of fluids and nutrients A rapid intravenous (IV) infusion of an electrolyte and glucose solution

Small, frequent intake of juices, broth, or milk Small, frequent intake of juices, broth, or milk will provide gradual replacement of both fluid and electrolytes without overloading the intravascular compartment. Water does not supply the necessary electrolytes, and hyponatremia may result. No data are presented to indicate that the client cannot take fluids orally; an NG tube is not necessary when the client can take fluids by mouth. A rapid IV infusion of an electrolyte and glucose solution is unsafe; rapid correction of a fluid and electrolyte imbalance is dangerous. Therapy should promote a gradual correction.

A client appears depressed since the surgical creation of a colostomy five days ago. The nurse determines that there is some movement toward adaptation to the change in body image when the client exhibits which behavior? Discusses the necessity of the colostomy Requests the nurse to change the dressing Looks at the face of the nurse during care Stares at the stoma during dressing changes

Stares at the stoma during dressing changes A willingness to view the stoma indicates the beginning of acceptance and integration of the colostomy into the body image. Discussing the necessity of the colostomy is evidence of intellectualization rather than acceptance of the change in body image. Requesting the nurse to change the dressing indicates lack of readiness to participate in the care of the stoma. Watching the face of the nurse during the care indicates that the client is observing the staff's response to and acceptance of the stoma and, by extension, the client as an individual.

A 24-hour urine test is prescribed for a client who has a tentative diagnosis of pheochromocytoma. What should the nurse do first? Start the time of the test after discarding the first voiding. Discard the last voiding in the 24-hour time period for the test. Insert a urinary retention catheter to promote the collection of urine. Strain the urine following each voiding before adding the urine to the container.

Start the time of the test after discarding the first voiding. The first voiding is discarded because that urine was in the bladder before the test began and should not be included. The last voiding should be placed in the specimen container because the urine was produced during the 24-hour time frame of the test. Discarding the last void in the 24-hour time period for the test is not necessary; voided specimens are acceptable. Straining the urine following each voiding before adding the urine to the container is not necessary; this is done for clients with renal calculi.

Ten minutes after the initiation of a blood transfusion, a client reports lumbar pain. What is the next nursing action? Stop the transfusion. Obtain the vital signs. Assess the pain further. Increase the flow of normal saline.

Stop the transfusion This is a sign of an acute hemolytic transfusion reaction, indicating that the recipient's blood is incompatible with the transfused blood; pain is caused by hemolysis, agglutination, and capillary plugging in the kidneys. Obtaining the vital signs and assessing the pain further are unsafe actions; more incompatible blood will be infused, increasing the severity of the transfusion reaction. Increasing the flow of normal saline is unsafe; the transfusion must be stopped first, and then normal saline should be infused to keep the line patent and to maintain blood volume.

While preforming nasotracheal suctioning, the nurse notices that the client has blood pressure of 90/70 and a heart rate of 50 beats per minute. What is the priority nursing intervention in this situation? Administering intravenous fluids to the client Reporting to the primary healthcare provider Stopping the suctioning procedure immediately Administering 100% oxygen manually to the client

Stopping the suctioning procedure immediately Nasotracheal suctioning can result in vagal stimulation and bronchospasm. Vagal stimulation can result in hypotension, bradycardia, heart block, ventricular tachycardia, or other dysrhythmias and require immediate intervention. Blood pressure of 90/70 and heart rate of 50 breaths per minute indicate hypotension and bradycardia so the nurse should immediately stop the suctioning procedure. The nurse can report to the primary healthcare provider, but only after stopping the suctioning. The nurse can administer intravenous fluids to the client, but only after ensuring the safety of the client. The nurse can administer 100% oxygen to the client, but only after stopping suctioning.

A nurse is providing immediate postoperative care to a client with a tracheostomy tube in place. The client suddenly develops noisy, increased respirations and an elevated heart rate. What action should the nurse take immediately? Suction the tracheostomy. Change the tracheostomy tube. Readjust the tracheostomy tube and tighten the ties. Perform a complete respiratory assessment.

Suction the tracheostomy. Noisy, increased respirations and increased pulse are signs that the client needs immediate suctioning to clear the airway of secretions. After suctioning, a complete respiratory assessment should be performed. After suctioning, then performing a respiratory assessment, further problem solving may require readjustment of the tracheostomy tube and ties or a healthcare provider changing the tracheostomy tube.

A nurse is caring for a client with the diagnosis of emphysema, a chronic obstructive pulmonary disease (COPD). The client is hypoxemic and also has chronic hypercarbia. Which statement reflects the oxygen needs of this client? The client may need up to 60% oxygen flow via Venturi mask. The client requires lower levels of oxygen delivery, usually 1 to 3 L/min via nasal cannula. The client should receive humidified oxygen delivered by a face mask. The client's respiratory treatment plan should have oxygen eliminated from it.

The client requires lower levels of oxygen delivery, usually 1 to 3 L/min via nasal cannula. Exogenous oxygen is necessary, but it must be delivered in low concentrations. It is not the method of oxygen delivery that is a concern, but rather the concentration of the oxygen. High oxygen concentrations will increase serum oxygen levels and interfere with the stimulus to breathe, which is a lowered oxygen level. The client will develop carbon dioxide narcosis when high levels of exogenous oxygen are administered. However, the results of one recent study of clients with stable COPD indicate that the hypercarbic drive is preserved with oxygen concentrations higher than 2 L/min. More research is needed before this theory is applied clinically. Usually, the body's stimulus to breathe is an elevated carbon dioxide level. In a client with COPD, breathing instead responds to lowered oxygen levels because of the body's exposure to continuously elevated levels of carbon dioxide.

A nurse is following the guidelines for high-quality documentation and reporting. Which guideline followed by the nurse while documenting factual records indicates a need for additional training? "The client seems restless." "The client states, 'I am worried.'" "The client's pulse rate is 90 beats/min." "The client has a body temperature of 39° C (102.2° F)."

The client seems restless. For high-quality documentation and reporting, the nurse should refrain from using vague terms such as "seems" or "appears" because these are not actual facts. Subjective data can be recorded by documenting the client's exact statements within quotation marks (for example, the nurse should write down that the client stated "I am worried"). Objective documentation includes direct observations and measurements such as the pulse rate and body temperature.

Which feature is characteristic of a risk nursing diagnosis? The diagnosis does not have related factors. The diagnosis can be used in any health state. The defining characteristics support the diagnostic judgment. The defining characteristics are supported by a client's readiness.

The diagnosis does not have related factors.

The nurse manager working at a rehabilitation center for older adults notices an increase in the incidence of client falls. The nurse manager reprimands the nurses and staff responsible for the falls and places them on probation. Which statement best describes the nurse manger's leadership style? The nurse manager exhibits autocratic leadership. The nurse manager demonstrates shared leadership. The nurse manger exhibits good clinical leadership skills. The nurse manger demonstrates effective interprofessional leadership.

The nurse manager exhibits autocratic leadership.

While assessing a client for the dorsalis pedis pulse, a nurse documents the reading as 1+. What can be inferred from this finding? There is absence of a pulse. The pulse strength is normal. The pulse strength is bounding. The pulse strength is barely palpable.

The pulse strength is barely palpable. A pulse strength of 1+ indicates a diminished or barely palpable pulse and requires immediate intervention. Absence of pulse is documented as 0. Normal pulse strength is documented as 2+. If the pulse strength is bounding, then it is documented as 4+.

What is the most important tool a nurse brings to the therapeutic nurse-client relationship? The self and a desire to help Knowledge of psychopathology Advanced communication skills Years of experience in psychiatric nursing

The self and a desire to help The nurse brings to a therapeutic relationship the understanding of self and basic principles of therapeutic communication; this is the unique aspect of the helping relationship. Knowledge of psychopathology, advanced communication skills, and years of experience in the field all support the psychotherapeutic management model, but none is the most important tool used by the nurse in a therapeutic relationship

A nurse is evaluating a client's response to fluid replacement therapy. Which clinical finding indicates successful replacement? Urinary output of 30 mL in an hour Central venous pressure reading of 1.5 mm Hg Baseline pulse rate of 120 beats/min that decreases to 110 beats/min within a 15-minute period Baseline blood pressure of 50/30 mm Hg that increases to 70/40 mm Hg within a 30-minute period

Urinary output of 30mL in an hour A urinary output rate of 30 mL/hour is considered adequate for perfusion of the kidneys, heart, and brain. A central venous pressure reading of 1.5 mm Hg indicates hypovolemia. A baseline pulse rate of 120 beats/min that decreases to 110 beats/min within a 15-minute period and a baseline blood pressure of 50/30 mm Hg that increases to 70/40 mm Hg within a 30-minute period indicate improvement but not necessarily adequate tissue perfusion.

What instruction regarding sample collection should the nurse give a client who is ordered a clean-catch urine specimen? Urinate small amount, stop flow, fill half of cup Collect the last urine sample voided in the night Keep the urine sample in dry warm area if delay is anticipated Send the urine sample to the laboratory within 6 hours of collection

Urinate small amount, stop flow, fill half of cup The nurse instructs the client to always collect the midstream urine to send as a test specimen. The client should be instructed to cleanse the perineum with the wipe provided, urinate a small amount, and then stop the flow. The client should then position the specimen cup a few inches from the urethra and resume urination, filling the cup at least half way. The client is asked to collect the first sample voided in the morning because the urine is highly concentrated in the morning. Keeping the urine sample in the refrigerator helps reduce bacterial growth due to alkaline environment. The cells in the urine sample begin to break down in alkalinity, and therefore the client is instructed to send the sample to the laboratory as soon as collected.

The nurse is providing instructions about foot care for a client with diabetes mellitus. What should the nurse include in the instructions? Select all that apply. Wear shoes when out of bed. Soak the feet in warm water daily. Dry between the toes after bathing. Remove corns as soon as they appear. Use a heating pad when the feet feel cold.

Wear shoes when out of bed. Dry between the toes after bathing.

A client attending a prenatal class about nutrition tells the nurse that she is a strict vegetarian (vegan). What should the nurse encourage the client to eat that includes all of the essential amino acids? Macaroni and cheese Whole-grain cereals and nuts Scrambled eggs and buttermilk Brown rice and whole-wheat bread

Whole-grain cereals and nuts This combination provides a complete protein for vegans because they do not eat foods from animal sources, which contain all of the essential amino acids. Macaroni and cheese provides a complete protein and is acceptable to ovo-lacto-vegetarians, who eat milk, eggs, and cheese, but is not acceptable to vegans. Eggs are a complete protein, but are not acceptable to vegans, only to ovo-lacto-vegetarians, who eat milk, eggs, and cheese. Brown rice and whole-wheat bread are both unrefined grains, but together they do not provide a complete protein.

A client is prone to hyponatremia. Which factors should the nurse identify that can precipitate hyponatremia? Select all that apply. Wound drainage Diuretic therapy Gastrointestinal (GI) suction Parenteral infusion of 0.9% sodium chloride Inappropriate anti-diuretic hormone (ADH) secretion

Wound drainage Diuretic therapy Gastrointestinal (GI) suction Inappropriate anti-diuretic hormone (ADH) secretion Wound drainage can result in hyponatremia from loss of sodium ions. Most diuretics interfere with sodium reabsorption in the nephrons and have the side effect of hyponatremia. Gastrointestinal fluids are rich in sodium ions, which are lost by GI suction. With the syndrome of inappropriate anti-diuretic hormone (SIADH), high levels of the anti-diuretic hormone (ADH) are produced, causing the body to retain water instead of excreting it normally in the urine. Parenteral infusion of 0.9% sodium chloride, an isotonic solution, should be compatible with body fluids; if given in excess, it may lead to hypernatremia.

A nurse is educating a client about the tertiary level of prevention. What information should the nurse provide? Select all that apply. Tertiary prevention focuses on preventing complications of illness. Tertiary prevention helps clients achieve as high a level of functioning as possible. Tertiary prevention aims at minimizing the effects of long-term disease or disability. Tertiary prevention is applied when the client is physically and emotionally healthy. Tertiary prevention activities are aimed at diagnosis and treatment instead of rehabilitation.

ertiary prevention focuses on preventing complications of illness. Tertiary prevention helps clients achieve as high a level of functioning as possible. Tertiary prevention aims at minimizing the effects of long-term disease or disability. Tertiary prevention is also known as preventive care since it aims at preventing further disability or reduced functioning in the clients. Even though clients may have developed limitations due to illness or impairment, tertiary prevention helps in achieving as high a level of functioning as possible. Tertiary prevention makes use of interventions that prevent complications and deteriorations in order to minimize the effects of long-term disease or disability. Tertiary prevention is applied when the client has a defect or disability that is permanent and irreversible. Tertiary prevention activities focus on rehabilitative care instead of diagnosis and treatment.