GERIATRIC ATI TEST 2ND WEEK ASSESS A RACIEL

A nurse is planning nutritional teaching for a client who is experiencing fatigue due to iron deficiency anemia. Which of the following foods should the nurse recommend to the client? 1.5 oz raisins 8 oz black tea 1 cup canned black beans 8 oz whole milk.

1 cup canned black beans The nurse should recommend canned black beans as they contain the greatest amount of iron at 4.56 mg per serving.

A nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements by the client should the nurse report to the provider? "I drink at least 2 quarts of fluid every day." "The last time I voided it was painful and red-tinged." "My period ended 2 days ago." "I don't eat shellfish because it gives me hives."

"I don't eat shellfish because it gives me hives." The client says she experiences hives after eating shellfish, which indicates a sensitivity. The contrast dye typically used for an IVP is an iodine derivative, and the client with a shellfish sensitivity may have cross-sensitivity to iodine and a serious iodine allergy. This nurse should report these finding to the client's provider.

A nurse is caring for a client who has named a person to serve as his health care proxy. The client states he needs clarification about this type of advance directives. Which of the following statements by the client indicates a need for clarification? "I can change who I designate as my health care proxy at any time." "If I become incapacitated, end-of-life choices will be made by my proxy." "I have to choose a family member as my health proxy." "The health care proxy does not go into effect until I am incapable of making decisions."

"I have to choose a family member as my health proxy." The client should choose someone he trusts and knows about his wishes for day-to-day and end-of-life care. It can be a family member, but it does not have to be a family member.

A nurse is providing dietary teaching for a client who has chronic obstructive pulmonary disease. Which of the following instructions should the nurse include? "Eat 3 large meals each day." "Limit water intake with meals." "Reduce protein intake." "Use a bronchodilator 1 hour before eating."

"Limit water intake with meals." The nurse should instruct the client to limit low nutrient liquids during meals to prevent early satiety and increase intake of nutrient dense foods.

A nurse at a family practice clinic receives a call from a client who is prescribed oral contraceptives but forgot to take one dose. The client reports she is in the first week of a 28-day cycle pack. Which of the following instructions should the nurse provide? "Do not have vaginal intercourse until after your next period." "Stop taking the pills and switch to a different contraceptive method." "Take the missed dose now, then continue the medication as ordered." "Take a home pregnancy test."

"Take the missed dose now, then continue the medication as ordered. "The nurse should tell the client to take the missed dose immediately, then continue with the pack as ordered. The nurse should also tell the client to use an additional form of contraception for 7 days.

A nurse is teaching a client who has a new prescription for topical betamethasone to treat contact dermatitis. Which of the following instructions should the nurse include? "Cover areas of excoriated skin with cream." "Use hot water to soothe the lesions." "Cover area with an occlusive dressing after application." "Use the cream for a few days after the area has healed."

"Use the cream for a few days after the area has healed." The client should continue to apply steroid cream to affected area for a few days after the area has healed to reduce the risk for reoccurrence.

A nurse is caring for a client who has a pulmonary embolism and has a new prescription for enoxaparin 1.5mg/kg/dose subcutaneous every 12 hr. The client weighs 245 lbs. How many mg should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) mg

1.5 mg1 kg245 lbX mg = × × 1 kg2.2 lb1 Step 4: Solve for X. X mg = 167.0454 mg Step 5: Round if necessary. 167.0454 = 167 mg Step 6: Determine whether the amount to administer makes sense. If the provider prescribed 1.5 mg/kg/dose and the client weighs 111.36 kg, it makes sense to administer 167 mg per dose. The nurse should administer enoxaparin subcutaneous 167 mg every 12 hr.

FLAG A nurse is preparing to administer Ringer's lactate 500 mL IV bolus to infuse over 3 hr. The drop factor of the manual IV tubing is 20 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) gtt/min

20 gttX gtt/min = 1 mL Step 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 20 gtt500 mL1 hrX gtt/min = × × 1 mL3 hr60 min Step 4: Solve for X. X gtt/min = 55.5555 gtt/min Step 5: Round if necessary. 55.5555 = 56 gtt/min Step 6: Determine whether the amount to administer makes sense. If the prescription reads 500 mL to infuse over 3 hours, it makes sense to administer 56 gtt/min. The nurse should set the manual IV infusion to deliver Ringers Lactate at 56 gtt/min.

A nurse is providing teaching about the Mediterranean diet to a client newly who has a new diagnosis of hypertension. Which of the following statements by the client indicates a need for further teaching? ?"I will limit my intake of red meat to twice weekly." "I can have dairy in moderate portions daily." "I can have fish two times a week." "I can drink wine in moderation."

?"I will limit my intake of red meat to twice weekly." This statement by the client indicates a need for further teaching. Following the Mediterranean diet, red meat should be limited to two times monthly.

A nurse at a health fair is assessing the weight status of four clients. Which of the following clients are classified as overweight? A female client who has a body mass index of 24 A male client who has a body mass index of 29 A female client who has a waist circumference of 101.6 cm (40 in) A male client who has a waist circumference of 96.52 cm (38 in)

A male client who has a body mass index of 29 A client who has a BMI of 25 to 29.9 is classified as overweight.

A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take? Raise the foot of the bed to a 90° angle. Remove the dressing to inspect the wound. Prepare to insert a central line. Administer oxygen via nasal cannula

Administer oxygen via nasal cannula The client has an increased respiratory rate and heart rate, indicating that she is having respiratory difficulty. The sucking chest wound indicates the client has a pneumothorax and/or a hemothorax. Administering oxygen will increase the oxygen exchange in the lungs and the oxygen available to the tissues

A nurse is caring for a client who has developed gout. Which of the following medications should the nurse prepare to administer? Zolpidem Alprazolam Spironolactone Allopurinol

Allopurinol Allopurinol is a xanthene oxidase inhibitor that reduces uric acid synthesis. The medication is prescribed to treat gout.

A nurse is developing a plan of care for a client who has a new ileal conduit. The nurse should include that the client is at risk for which of the following? (Select all that apply.) Anxiety Disturbed body image Impaired skin integrity Infection Fluid volume deficit

Anxiety is correct. Due to the effects an ileal conduit has on lifestyle and relationships, anxiety is appropriate for the nurse to include as a risk.\ Disturbed body image is correct. Due to the effects an ileal conduit has on body function, lifestyle, and relationships, disturbed body image is appropriate for the nurse to include as a risk. Impaired skin integrity is correct. Due to the external appliance, impaired skin integrity is appropriate for the nurse to include as a risk. Infection is correct. Due to the surgical procedure and the potential for obstruction, infection is appropriate for the nurse to include as a risk.

A nurse is caring for a client who has gastrointestinal bleeding. Which of the following actions should the nurse take first? Assess orthostatic blood pressure. Explain the procedure for an upper gastrointestinal series. Administer pain medication. Test the client's emesis for blood.

Assess orthostatic blood pressure. Using the nursing process, the first action the nurse should take is to assess the client by measuring the client's orthostatic blood pressure. This action determines if the client is hypovolemic and establishes a baseline for further measurements.

A nurse is instructing the parents of a client who has a new prescription for methylphenidate. Which of the following instructions should the nurse include? Avoid activities that require alertness such as driving. Increase caffeine intake. Take this medication before bedtime. Reduce calorie intake.

Avoid activities that require alertness such as driving. MY ANSWER The client should avoid driving and other activities that require alertness until the effects of this medication are known.

FLAG A nurse is developing a program about strategies to prevent foodborne illnesses for a community group. The nurse should plan to include which of the following recommendations? (Select all that apply). Avoid unpasteurized dairy products. Keep cold food temperatures below 4.4° C (40° F). Reheat leftovers before eating. Wash raw vegetables thoroughly in clean water. Keep cooked foods at 48.9° C (120° F).

Avoid unpasteurized dairy products is correct. Avoiding unpasteurized dairy products is a recommendation the nurse should plan to include in the program. Keep cold food temperatures below 4.4° C (40° F) is correct. Keeping cold food temperatures below 4.4° C (40° F) is a recommendation the nurse should plan to include in the program. Reheat leftovers before eating is correct. Reheating leftover before eating is a recommendation the nurse should plan to include in the program. Wash raw vegetables thoroughly in clean water is correct. Washing raw vegetables in clean water is a recommendation the nurse should plan to include in the program.

A nurse is speaking with a 35-year-old client who has fibrocystic disease of the breasts. At which of the following times should the nurse inform the client that manifestations are most evident? Before menstruation begins After menstruation ends During cold weather During hot weather

Before menstruation begins Manifestations of benign fibrocystic breast changes include painful breasts, smooth moveable lumps, and possible swelling of the breasts, which tends to worsen premenstrually. Reducing salt and caffeine intake sometimes helps.

A nurse is admitting a client who has type 1 diabetes mellitus. Diagnostic Results Casual blood glucose 580 mg/dL (less than 200 mg/dL) Sodium 152 mEq/L (136 to 145 mEq/L) Potassium 5.3 mEq/L (3.5 to 5 mEq/L) BUN 32 mg/dL (10 to 20 mEq/L) Creatinine 1.8 mg/dL (0.5 to 1.3 mg/dL) Serum pH 7.2 (7.35 to 7.45) HCO3- 13 mEq/L (21 to 28 mEq/L) Glycosylated hemoglobin 9.6% (less than 7% indicates good diabetic control) Urine reagent strip testing: pH 4.4 (4.6 to 8.0) Specific gravity 1.036 (1.005 to 1.030) Ketones positive (negative) Glucose present (none) ECG indicates tachycardia with prolonged PR interval with widened QRS and peaked T waves Medical History Type 1 diabetes mellitus (16 years) which is managed with insulin at bedtime and before each meal; measures capillary blood glucose twice daily. Motor-vehicle crash 3 years prior. Vital Signs Supine blood pressure 100/70 mm Hg Sitting blood pressure 85/50 mm Hg Heart rate 120/min Respiratory rate 24/min Temperature 37.9° C (100.2° F) Oxygen saturation 95% on room air Nurses Notes Admitted to unit from emergency department. Client's partner reports lethargy, vomiting, diarrhea, and fever lasting 2 days. Lethargic and rouses with physical stimuli. Glasgow coma scale score decreased from 14 to12. Auscultation of lungs reveals rales to the right lower lobe. Right upper lobe diminished but clear. Kussmaul respirations noted. 18-gauge IV in right forearm edematous and cool to touch.. Capillary refill 3 seconds. Dry mucous membranes, decreased skin turgor. Select the 7 findings that require immediate attention. IV access Oxygen saturation Sodium level Blood pressure results Bicarbonate level Glasgow Coma Scale score ECG findings Client's self-monitoring of blood glucose

Bicarbonate level is correct. The client's bicarbonate level (HCO3-) is above the expected reference range. Although this is an expected finding of diabetic ketoacidosis, the provider should be aware of this finding. Sodium level is correct. The client has manifestations of diabetic ketoacidosis, which can alter electrolyte levels. The sodium might be below, within, or above the expected reference range. Blood pressure results is correct. The nurse should identify that the client is experiencing orthostatic hypotension and should implement measures to ensure client safety by implementing fall precautions. The nurse should continue to monitor the client's blood pressure and notify the provider if hypotension does not resolve with the administration of IV fluid therapy. Client self-monitoring of blood glucose is correct. The nurse should plan to further assess the client's self-management of diabetes, including the client and care partner's ability to monitor blood glucose levels. Measuring glucose twice daily when taking insulin is likely not effective for the client since their glycosylated hemoglobin indicates poor diabetic control. IV access is correct. The presence of edema at the IV insertion site and cool temperature indicate that the client's IV access has infiltrated and should be discontinued and replaced. Glasgow coma scale score is correct. The nurse should recognize that a change from 14 to 12 in the Glasgow coma scale indicates a decline in the client's neurologic function and report this finding to the provider. ECG findings is correct. The client's potassium level is above the expected reference range of 3.5 to 5 mEq/L, indicating hyperkalemia. Hyperkalemia can cause cardiac arrythmias as well as a prolonged PR interval, widened QRS, and peaked T wave.

A nurse is teaching an older adult client who has an intracapsular fracture of the right hip following a fall about the purpose of Buck's extension traction. The nurse should include which of the following information in the teaching? Buck's extension traction will reduce the fracture. Buck's extension traction will relieve muscle spasms. Buck's extension traction will maintain alignment of the pins. Buck's extension traction will allow supported movement of the extremity.

Buck's extension traction will relieve muscle spasms. Buck's extension traction immobilizes the fractured bone to relieve associated muscle spasms and thereby relieve pain. Any movement of the fractured extremity will aggravate severe muscle spasm and trigger pain.

A nurse enters a client's room and finds the client pulseless. The family has requested a do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions should the nurse take? Call the emergency response team. Seek immediate help from the risk manager. Call the provider for a stat DNR order. Respect the family's wishes and do nothing.

Call the emergency response team. Unless the provider writes a DNR order, the nurse should make every effort to revive the client. The nurse should follow the facility's protocol for enacting the emergency response procedure.

A nurse is assessing a client who has hypoparathyroidism. Which of the following findings should the nurse expect? Flaccid muscles Client report of numbness in his hands Negative Chvostek's sign Client report of anorexia

Client report of numbness in his hands Numbness and tingling in the client's hands and feet are manifestations of hypoparathyroidism due to hypocalcemia.

A nurse is caring for a client who has an active upper gastrointestinal bleed. After inserting a NG tube into the client, which of the following findings should the nurse anticipate? Frothy pink drainage Dark amber drainage Coffee-ground drainage Greenish-yellow drainage

Coffee-ground drainage "Coffee-ground" drainage or emesis indicates the presence of blood. The coffee ground appearance is the result of the effects of methemoglobin on the hemoglobin.

A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency? A raised red rash around the fistula site Pain in the right arm proximal to the fistula site Cold and numb numbness distal to the fistula site Foul-smelling drainage from the fistula site

Cold and numb numbness distal to the fistula site Pallor and numbness distal to the fistula site are possible indicators of venous insufficiency and should be immediately reported to the provider.

A nurse is caring for a client who is postoperative following an open reduction internal fixation (ORIF) of a femur fracture. Which of the following parameters should the nurse include in the evaluation of the neurovascular status of the client's affected extremity? (Select all that apply.) Color Temperature Ecchymosis Skin integrity Sensation

Color is correct. Clients who have sustained trauma to an extremity, such as a fracture, are at increased risk for neurovascular compromise. The nurse should check the color of the client's affected extremity as part of this assessment. The nurse should identify pallor or cyanosis of the extremity as an indication of peripheral neurovascular dysfunction and should notify the provider. Temperature is correct. Clients who have sustained trauma to an extremity, such as a fracture, are at increased risk for neurovascular compromise. The nurse should monitor the temperature of the extremity as a part of this assessment and identify skin that is cool or cold to the touch as having decreased perfusion to the tissues of the extremity, which is an indication of peripheral neurovascular dysfunction. The nurse should report skin that is cool to the touch to the provider. Sensation is correct. Clients who have sustained trauma to an extremity, such as a fracture, are at increased risk for neurovascular compromise. The nurse should assess the client's extremity for numbness or tingling. The nurse should recognize diminished pain or paresthesia as an indication of damage to the nerves or peripheral neurovascular dysfunction and should report it to the provider.

A nurse is caring for an older adult client who has a urinary tract infection (UTI). Which of the following manifestations should the nurse identify as a finding specifically associated with this client? Urinary retention Low back pain Incontinence Confusion

Confusion Confusion is a clinical finding of UTIs specifically associated with older adult clients.

A nurse is caring for a client who has Cushing's syndrome. Which of the following interventions should the nurse expect to perform? (Select all that apply.) Assess blood glucose level Assess for neck vein distention Monitor for an irregular heart rate Monitor for postural hypotension Weigh the client daily

Cushing's syndrome affects blood glucose levels by causing increased release of glucose from the liver and decreased sensitivity of insulin receptors. Assess elevated blood glucose levels.

A nurse is caring for a client who has suspected cholecystitis. The nurse should expect the client's urine to appear which of the following colors? Pale yellow Greenish-brown Red Dark and foamy

Dark and foamy The nurse should expect the client to have dark and foamy urine, which indicates the kidneys are filtering excess bilirubin from the blood.

FLAG A nurse manager is preparing an inservice program for the nurses on the unit about the use of a new infusion pump. Which of the following teaching strategies is the most effective way to ensure that the staff can use the device correctly? Provide a written procedure for the use of the device for the staff to review. Demonstrate using the device and observe the staff returning the demonstration. Remind the staff to review the procedure manual prior to using the new pump. Identify the differences and new features of the device in a written brochure.

Demonstrate using the device and observe the staff returning the demonstration. The most effective strategy to ensure the staff nurses can perform a psychomotor skill, such as using an infusion pump, is to show them how to use the device and provide the opportunity for a return demonstration.

A nurse is teaching a client who has rheumatoid arthritis about taking methotrexate. Which of the following information should the nurse include? Take an antiemetic 1 hr following administration. Drink 2 to 3 L of water per day. Take the medication with an NSAID. Rinse mouth 2 times per day with an alcohol based mouthwash.

Drink 2 to 3 L of water per day. Methotrexate can cause renal toxicity. The client should drink 2 to 3 L of water per day to promote excretion of the medication.

A nurse working in an emergency room is caring for a client who has third degree frostbite to both lower extremities. The nurse should plan to take which of the following actions? Immerse the legs in cool water. Elevate the legs. Massage the legs. Apply dry heat to the legs.

Elevate the legs. When the extremities are rewarmed, it is necessary to handle the injured area carefully because the skin and tissues are fragile. Elevating the client's legs above the level of the heart is done to help prevent an increase in edema.

A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program? Establish the ability to communicate effectively. Compensate for loss of depth perception. Learn to control impulsive behavior. Improve left-side motor function.

Establish the ability to communicate effectively. A CVA is an interruption of the blood supply to any part of the brain, resulting in damaged brain tissue. The left hemisphere is usually dominant for language. Because this client had a left-side CVA, the nurse should anticipate the client will have some degree of aphasia and will require speech therapy to establish communication.

A nurse is caring for a client who has heart failure and a potassium level of 2.4 mEq/L. The nurse should identify which of the following medications as the cause of the client's low potassium level? Furosemide Nitroglycerin Metoprolol Spironolactone

Furosemide Furosemide is a loop (high-ceiling) diuretic that inhibits the reabsorption of sodium and chloride and results in diuresis, which decreases potassium through excretion in the distal nephrons. Hypokalemia is an adverse effect of furosemide.

A nurse is caring for a client who is 2 days postoperative following an above-the knee-amputation. Which of the following is an appropriate nursing intervention for this client at this time? Elevate the foot of the bed. Encourage the client to sit up as much as possible. Elevate the client's residual limb on a pillow. Have the client lie prone every 3 hr for 20 min at a time.

Have the client lie prone every 3 hr for 20 min at a time. The nurse should encourage the client to lie prone for 20 to 30 min every 3 to 4 hr to help prevent hip flexion contractures.

A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse the client is experiencing an increase in intracranial pressure (ICP)? (Select all that apply.) Headache Neck pain and stiffness Slurred speech Pupillary changes Disorientation

Headache is correct. A client who has increasing ICP might manifest a headache. Neck pain and stiffness is incorrect. Neck pain and stiffness are not manifestations of increasing ICP. Slurred speech is correct. A client who has increasing ICP might manifest slurred speech. Pupillary changes is correct. A client who has increasing ICP might manifest pupillary changes. Disorientation is correct. A client who has increasing ICP might display disorientation or confusion.

A nurse is caring for a client who is diabetic and reports a headache, restlessness, fatigue, and hunger. Then nurse should identify that the client is likely experiencing which of the following conditions? Hypoglycemia Hyperglycemia Neuropathy Hypokalemia

Hypoglycemia Hypoglycemia is a complication of diabetes indicating a blood glucose level less than 70 mg/dL. It can occur when excessive insulin or oral hypoglycemic are administered, with excessive physical activity, or when too little food is consumed. The manifestations of hypoglycemia include sweating, tremor, tachycardia, palpitations, headache, fatigue, nervousness, and hunger.

A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make? Fluid overload Left ventricular failure Intracardiac shunt Hypovolemia

Hypovolemia A low CVP indicates reduced right ventricular preload, which can be seen in clients who are experiencing hypovolemia, excessive blood loss, or overdiuresis.

A nurse is supervising a licensed practical nurse (PN) who is providing care to a client who is postoperative. Which of the following statements by the client requires the nurse to follow up with the PN? "I do not know how to make the remote control work." "Do you know when I will be going home?" "My dressing was changed earlier this morning." "I have not received any of my medications today."

I have not received any of my medications today." Failure to receive prescribed medications in a timely manner can have a negative effect on client outcomes. The nurse should immediately follow up with the PN to determine if medications have been administered and, if not, to learn why. It is possible that the client does not remember receiving medications or that no medications were been prescribed as of this time. Effective supervision requires that any issue that can negatively impact client care is followed up on immediately.

A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock? Increased heart rate Widening pulse pressure Increased deep tendon reflexes Pulse oximetry 96%

Increased heart rate The nurse should anticipate an increased heart rate as an early indication of shock because the body attempts to compensate for decreased circulatory volume.

Vital Signs Oral temperature 37.2° C (99° F) Heart rate 126/min Respiratory rate 22/min Blood pressure 118/70 mm Hg Oxygen saturation 96% Nurses' Notes Client reports abdominal pain, syncope, nausea, vomiting, and diarrhea following meal 30 min prior. Client is diaphoretic, flushed, and weak; abdominal distention present. Assisted to bed, positioned for comfort, medicated for incisional pain of 5 on a scale of 0 to 10. Medical History Obesity since childhood, BMI 39 Metabolic Syndrome Osteoarthritis Diagnostic Results Fasting blood glucose 280 mg/dL (74 to 106 mg/dL) Which of the following actions should the nurse plan to take? Select all that apply. Instruct the client to remain in low-Fowler's position for 20 min following meals. Instruct the client to consume fluids between, rather than with, meals. Encourage the client to eat 1 tsp honey with each meal. Provide food at moderate temperatures. Provide the client protein with each meal. Insert a nasogastric (NG) tube.

Instruct the client to consume fluids between, rather than with, meals is correct. Clients should drink fluids up to 30 min prior to a meal, and at least 30 to 60 min following a meal to prevent feeling full and not having an appetite for nutrient-dense foods. Provide the client protein with each meal is correct. Following bariatric surgery, clients should consume meals of high protein, fiber, fat, and low carbohydrates to promote optimal nutrition. Instruct the client to remain in low-Fowler's position for 20 min following meals is correct. To help manage dumping syndrome, clients should lie flat or in low-Fowler's position for 20 to 30 min following meals to delay stomach emptying. Provide food at moderate temperatures is correct. To manage dumping syndrome, the client should consume foods at a temperature that is not too hot or cold.

A nurse in a provider's office is assessing a client who has AIDS. The nurse notes that the client has multiple and widespread raised, purplish-brown skin lesions. The nurse should recognize that these findings indicate which of the following conditions? Actinic keratosis Kaposi's sarcoma Toxic epidermal necrosis Basal cell carcinoma

Kaposi's sarcoma Kaposi's sarcoma are AIDS-related malignant skin and mucous membrane lesions that are usually purplish-brown, raised, and edematous.

A nurse is caring for a 78-year-old client who was recently admitted from the emergency room and is reporting weakness. Medical History 78-year-old female admitted with watery diarrhea x 4 days Denies vomiting Reports having an upper respiratory infection 1 week ago and was treated with ampicillin Reports anorexia, unaware of any weight loss Lives alone Past medical history includes hypertension, COPD, and diabetes mellitus Walks for 30 min 5 out of 7 days/week Drinks an occasional glass of wine Smokes one-two cigarettes/day Nurses' Notes 0800: Alert and oriented x 3 Reports weakness and dizziness Skin pale and cool, poor skin turgor Mucous membranes dry with a white coating Denies nausea Lungs clear to auscultation Abdomen soft with hyperactive bowel sounds x 4 Reports diffuse abdominal tenderness on palpation Reports 3 watery bowel movements in the last 8 hr Urine dark yellow in color Output 30 mL/hr 1000: Up to bathroom with assistance of assistive personnel. Has syncopal episode. Assisted back to bed. No injuries noted. Instructed to not get out of bed without assistance. Vital Signs Temperature 37.2° C (99.0° F) oral Apical pulse 102/min regular Radial pulse 102/min regular and weak Respiratory rate 28/min Blood pressure 96/68 mm Hg Diagnostic Results 0800: Basic Metabolic Profile Sodium 149 mEq/L (136 to 145 mEq/L) Potassium 5.0 mEq/L (3.5 to 5 mEq/L) Chloride 102 mEq/L (98 to 106 mEq/L) Magnesium 1.8 mEq/L (1.3 to 2.1 mEq/L) Total calcium 9.5 mg/dL (9.0 to 10.5 mg/dL) Osmolality 301 mOsm/L (285 to 295 mOsm/L) ABGs pH 7.33 (7.35 to 7.45) PCO2 35 mm Hg (35 to 45 mm Hg) HCO3- 19 mEq/L (21 to 28 mEq/L) PO2 92 mm Hg (80 to 100 mm Hg) Drag words from the choices below to fill in each blank in the following sentence. The nurse has reviewed the client's medical record.The client is at risk for developing

Metabolic acidosis is correct. Metabolic acidosis is caused by either an overproduction of hydrogen ions, under elimination of hydrogen ions, underproduction of bicarbonate, or an over-elimination of bicarbonate. Diarrhea causes a base deficit due to over-elimination of bicarbonate (HCO3-) ions. Hypernatremia is correct. Hypernatremia is a serum sodium level greater than 145 mEq/L. It is caused by either actual sodium excesses or relative sodium excesses as seen with watery diarrhea.

A nurse is assessing a client who has Bell's palsy. Which of the following findings should the nurse expect? (Select all that apply.) Muscle distortion Pain behind the ear Hearing loss Facial twitching Impaired taste

Muscle distortion is correct. Bell's palsy, which is facial paralysis that stems from one-sided inflammation of cranial nerve VII, causes muscle distortion that gives the affected side a drooping appearance. Pain behind the ear is correct. Bell's palsy, which is facial paralysis that stems from one-sided inflammation of cranial nerve VII, causes pain behind the ear, in the face, and in the eye on the affected side. mpaired taste is correct. Bell's palsy, which is facial paralysis that stems from one-sided inflammation of cranial nerve VII, causes impaired taste, as well as difficulties with speech and eating.

A nurse is providing dietary teaching for a client who has a burn injury and adheres to a vegan diet. The nurse should recommend which of the following foods as the best source of protein to promote wound healing? One cup of brown rice One cup of orange juice One cup of pureed avocado One cup of lentils

One cup of lentils The nurse should determine that nuts and legumes, such as lentils, are the best foods to recommend for protein intake for this client. One cup of lentils contains 17.86 g of protein. A diet high in protein and calories is required to promote wound healing. Nuts and legumes are good sources of protein to include in a plant based diet such as a vegan diet.

A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate? Initiate a low-residue diet. Pantoprazole 80 mg IV bolus twice daily Ambulate twice daily. Pancrelipase 500 units/kg PO three times daily with meals

Pantoprazole 80 mg IV bolus twice daily The nurse should anticipate a provider's prescription for a proton pump inhibitor to decrease gastric acid production, which ultimately decrease pancreatic secretions.

A nurse is assessing a client who is 3 days postoperative following abdominal surgery and notes the absence of bowel sounds, abdominal distention, and the client passing no flatus. Which of the following conditions should the nurse suspect? Ulcerative colitis Cholecystitis Paralytic ileus Wound dehiscence

Paralytic ileus A paralytic ileus in a postoperative client is indicated by the absence of bowel sounds, abdominal distention, and the client passing no stool or flatus. It is often caused by bowel handling during surgery and opioid analgesic use.

A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take? Perform a neurovascular assessment. Explain the discharge instructions to the client and parents. Provide reassurance to the client and parents. Apply an ice pack to the casted leg.

Perform a neurovascular assessment. The greatest risk to the client is neurovascular injury. Therefore, the priority action is to perform a neurovascular assessment. This consists of assessing the involved extremity (the lower leg) at the most distal point (the foot) for circulation (color), motion (movement), and sensation, and can be remembered by the acronym "C-M-S check."

A nurse is caring for a client who has a new prescription for a low-sodium diet. The client's family has requested to bring in some of the client's favorite foods. Which of the following food items should the nurse tell the family members to omit? Boiled rice Flat bread Broiled fish fillet Pickled vegetables

Pickled vegetables Due to the pickling brine, pickled vegetables are high in sodium. The family should not bring this food item to the client.

A nurse is admitting an older adult client who has diabetic neuropathy with painful, burning feet. Which of the following interventions should the nurse anticipate the health care provider to prescribe? Place a bed cradle on the client's bed. Inspect the client's feet once weekly. Apply graduated compression stockings to the client's lower extremities. Put a heating pad on the client's feet.

Place a bed cradle on the client's bed. A bed cradle can reduce pain for a client who has diabetic neuropathy by preventing sheets from touching hypersensitive skin.

Vital Signs 1200: Temperature 38.6° C (101.5° F) Heart rate 109/min Respiratory rate 28/min Blood pressure 106/54 mm Hg Oxygen saturation 94% on room air Nurses Notes 1200: Client presents to ED with report of shortness of breath for 2 days, with headache, chills, fever, sore throat, and cough. States they went to a music concert recently "and probably picked up some kind of virus." Oriented to person, place, and time. Appears lethargic, difficulty answering questioning due to shortness of breath. Follows simple commands, moves all extremities with weakness. Client's face is flushed, sinus tachycardia, rate of 109/min, S1S2 heart sounds heard on auscultation. Pulses palpable. Breath sounds with crackles to right lower lobe, tachypnea, rate of 28/min. Frequent productive cough with thick yellow sputum. Client denies hemoptysis. Unable to lie down, states they are "more comfortable sitting up." Bowel sounds active x 4 quadrants. Denies diarrhea, last bowel movement yesterday. States "no appetite since I've been sick." Reports decreased urination over past 24 hr. "Haven't been drinking as much water as I should because my throat hurts." Client reports they have not had a pneumococcal vaccine and does not get annual influenza vaccinations. States, "I just hate needles. Medical History 1215: 70 years of age No significant medical history other than primary concern Well nourished Home Medications: Daily multi-vitamin Vitamin D Social History: Lives alone, partner died 5 years ago Drinks 1 to 2 glasses of red wine daily Has never smoked Walks 2 to 3 miles 6 days/week Diagnostic Results 1230: Chest x-ray: Areas of increased density and white infiltrates to lower right lobe indicative of pneumonia Select 4 findings in the client's medical record that place them at risk for pneumonia. Pneumococcal vaccine Level of consciousness Influenza vaccine Health history Fluid intake Age Smoking history

Pneumococcal vaccine is correct. The pneumococcal vaccine is recommended for adults over the age of 65 years. The client's avoidance of the vaccine places them at risk for contracting community-acquired pneumonia. Influenza vaccine is correct. The annual influenza vaccine is recommended for everyone over the age of 6 months. The client's avoidance of the vaccine places them at risk for contracting community-acquired pneumonia. Fluid intake is correct. Adequate fluid intake decreases a client's risk of contracting community-acquired pneumonia. The client reports decreased fluid intake and urinary output which places them at risk for additional complications from pneumonia. Age is correct. Being an older adult client increases the risk of contracting community-acquired pneumonia.

A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take? Perform suctioning for up to four passes. Apply suction to the catheter when advancing it into the trachea. Preoxygenate the client with 100% oxygen for up to 3 min. Limit each suction pass to 25 seconds.

Preoxygenate the client with 100% oxygen for up to 3 min. To prevent hypoxemia, the nurse should preoxygenate the client with 100% oxygen for 30 seconds to 3 min prior to suctioning.

A nurse is assessing a client who is taking oxacillin to treat an infection. The nurse should recognize which of the following findings is a manifestation of an allergic reaction? Pruritus Diarrhea Dark urine Fever

Pruritus An allergic reaction is an immune response that can manifest as pruritus and urticaria and can progress to anaphylaxis.

A nurse is caring for a client who is undergoing a lumbar puncture. Which of the following is the priority action for the nurse take to maintain privacy for the client? Close the door to the client's room. Pull the curtains around the client's bed. Ask family members to leave the room. Use sterile drapes to cover the client.

Pull the curtains around the client's bed. Pulling the curtains around the client's bed assures privacy for the client should someone open the door or enter the room.

A nurse on a medical-surgical unit is providing care for a group of clients. The nurse should delegate collection of which of the following specimens to the assistive personnel (AP)? Wound drainage for culture Urine from an indwelling catheter Blood for PaCO2 Random stool specimen

Random stool specimen The nurse should delegate collection of a random stool specimen to the AP because it does not require the skills of a licensed nurse. However, the nurse, not the AP, should collect a stool specimen if a culture using a sterile swab is required

A nurse is caring for a client who is 1 day postoperative following a left radical mastectomy. Which of the following behaviors should alert the nurse to the possibility that the client is having difficulty adjusting to the loss of her breast? Refusing to look at the dressing or surgical incision Asking for pain medication every 3 hr Asking questions about the information on her postoperative care pamphlet Performing arm exercises once or twice a day

Refusing to look at the dressing or surgical incision Clients who refuse to look at the surgical incision or surgical dressing are having difficulty adjusting to the loss of a body part or with body disfigurement. This indicates the client is not yet ready to acknowledge the results of the surgery.

A nurse is caring for an infant who weighs 12 lb and is prescribed cefuroxime sodium 15mg/kg PO every 12 hr. Available is cefuroxime sodium oral solution 125mg/5mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) mL

STEP 5: Should the nurse convert the units of measurement? no STEP 6: Set up an equation and solve for X. X = Quantity/Have x Conversion (Have)/Conversion(Desired) x Desired/ X mL = 5 mL/6125 mg x 83 mg/ X = 3.32 STEP 8: Reassess to determine whether the amount to administer makes sense. If there are 125 mg/5 mL and the amount prescribed is 83 mg, it makes sense to administer 3.3 mL. The nurse should administer cefuroxime 3.3 mL every 12 hr.

A nurse is instructing a group of clients about nutrition. The nurse should include that which of the following foods is a good source of high-quality protein? Soybeans Grains Legumes Green vegetables

Soybeans The nurse should instruct that soybeans and soybean products are high-quality, or complete, sources of proteins. Complete proteins contain all nine essential amino acids required for growth and maintenance of the body.

Demonstrate using the device and observe the staff returning the demonstration. The most effective strategy to ensure the staff nurses can perform a psychomotor skill, such as using an infusion pump, is to show them how to use the device and provide the opportunity for a return demonstration.

Step 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 2,600 mLX mL/hr = 8 hr Step 4: Solve for X. X mL/hr = 325 mL/hr Step 5: Round if necessary. Step 6: Reassess to determine if the amount to administer makes sense. If the amount prescribed is 2,600 mL to infuse over 8 hr, it makes sense to administer 325 mL/hr.

A nurse is preparing to administer liquid famotidine 20 mg PO every 6 hr for a client who has GERD. Available is famotidine 40 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Step 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 5 mL20 mgX mL = × 40 mg1 dose Step 4: Solve for X. X mL = 2.5 mL Step 5: Round if necessary. Step 6: Reassess to determine whether the amount to administer makes sense. If there are 40 mg/5 mL and the prescription reads 20 mg, it makes sense to administer 2.5 mL. The nurse should administer famotidine 2.5 mL PO.

A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed consent? The client's partner The client The client's daughter, who is the primary caregiver The client's son, who has a durable power of attorney

The client If the client appears competent, and understands the procedure, the client can sign for informed consent. The nurse should verify that the client gives consent voluntarily, the signature on the consent is the client's, and the client appears competent. If the client were disoriented and not competent, the person who has durable power of attorney should sign informed consent.

A nurse is caring for a client in the emergency department. Nursing Notes: 1030: The client complains of fatigue, vertigo, and shortness of breath with daily activities. Current vital signs are: blood pressure 86/46 mm Hg, pulse rate 100/min, respiratory rate 28/min. Oxygen saturation 94% on 2 L via nasal cannula. Client has an 18 g capped IV in the right antecubital space. There is a new prescription for 0.9% sodium chloride at 125 mL/hr. There is also a prescription for the transfusion of 2 units of packed RBCs; the first unit has been ordered from the blood bank. Oxygen is to be titrated to maintain an oxygen saturation of 92%. A nurse has received the following report about a client that they will be admitting to the medical-surgical unit. Click to highlight the findings in the transfer report that require immediate action by the nurse when the client arrives.

The client's complaints of fatigue, vertigo, and shortness of breath with daily activities do not need to be addressed immediately. The client's blood pressure, pulse rate, and respiratory rate do need to be addressed immediately. The respiratory rate indicates tachypnea and the hypotension and tachycardia indicate possible hypovolemia. The client's oxygen saturation does not need to be addressed immediately. The saturation meets the prescription of maintaining an oxygen saturation of 92%. 0.9% sodium chloride at 125 mL/hr should be started immediately. Crystalloid fluids help maintain an adequate fluid and electrolyte balance. 0.9% sodium chloride in water is a replacement solution used to increase plasma volume and can be infused with any blood product. Prepare bag of fluid and pump to initiate IV solution to increase intravascular fluid and prep for blood administration.

A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction? The first 2 min The final 2 min The first 15 min The final 15 min

The first 15 min The nurse should remain in the room during the first 15 min of the infusion, which is the most critical time period for monitoring a client for a transfusion reaction. Severe reactions usually occur during the infusion of the first 50 mL of blood.

A nurse is assessing a client who had left femoral cardiac angiography. Identify where the nurse will palpate to assess the most distal pulse on the affected side. (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)

The most distal pulse refers to the pulse that is at the farthest point on the affected extremity. The dorsalis pedis pulse on the anterior foot is the most distal pulse below the femoral artery. Because the client had left-sided angiography, the correct answer will be the left pedal pulse.

A nurse in a clinic is caring for an older adult client. Nurses Notes The client reports nausea, vomiting, diarrhea, and weakness over the past 4 days. Skin warm, dry, and scaly. Skin turgor poor. Dark circles noted under eyes. Oral mucosa dry with thick, white coating on tongue. Alert and oriented at present but states has "been foggy last couple of days and vision has been blurry." Heart sounds distant with frequent early beat. Lungs clear to auscultation. No peripheral edema noted. Abdomen soft and flat with hypoactive bowel sounds. Generalized abdominal tenderness with palpation. Voids small amount dark yellow odorous urine. History of congestive heart failure, recurrent UTIs, and benign prostate hypertrophy. Current Medications: Furosemide 20 mg PO daily Digoxin 0.125 mg PO daily Finasteride 5 mg PO daily Vital Signs Temperature: 38° C (100.4° F) Pulse rate: 54/min Respiratory rate: 22/min BP: 102/64 mm Hg Pulse oximetry: 94% on room air Diagnostic Results Electrolytes Sodium: 136 mEq/L (136 to 145 mEq/L) Potassium: 3.1 mEq/L (3.5 to 5 mEq/L) Chloride: 110 mEq/L (98 to 106 mEq/L) Magnesium: 1.2 mEq/L (1.3 to 2.1 mEq/L) Digoxin 3 ng/L (0.5 to 2 ng/L) Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

The nurse should initiate a peripheral venous access and place the client on a cardiac monitor because the client is most likely experiencing digoxin toxicity, which can include manifestations of nausea, vomiting, diarrhea, and mental and visual disturbances. The nurse should monitor the client for dysrhythmias and monitor the client's electrolytes because digoxin toxicity and hypokalemia cause an increase in cardiac automaticity that can result in ectopic beats.

A nurse is caring for a client who is being admitted to the medical-surgical unit from the emergency department. The nurse is reviewing the client's medical records Diagnostic Results HbA1c 8.4% (less than 7% for diabetics) Blood glucose 235 mg/dL (74 to 106 mg/dL) Hemoglobin 14.2 g/dL (12 to 18 g/dL) Hematocrit 42.6% (37 to 52%) Total WBC count 6000/mm3 (5000 to 10,000/mm3) HDL 75 mg/dL (greater than 55 mg/dL) LDL 124 mg/dL (less than 130 mg/dL) BNP 52 pg/ml (less than 100 pg/mL) Chest x-ray: Clear. No evidence of infiltrates. Medication Administration Record Glargine U 100 25 units subcutaneous at bedtimeFingerstick/random blood glucose before breakfast & bedtime with regular insulin subcutaneous sliding scale coverage: Less than 160 mg/dL: no coverage160 to 220 mg/dL: 2 units221 to 280 mg/dL: 3 units281 to 340 mg/dL: 6 units341to 400 mg/dL: 8 unitGreater than 400: call physician Aldactone 50 mg PO twice dailyDigoxin 0.25 mg PO every morningCarvedilol 25 mg PO twice daily Vital Signs BP 120/72 mm HgTemperature 36.8º C (98.2º F)Pulse rate 88/minRespirations 20/min Nurses' Notes Client received to emergency department from home via private vehicle. Reports fatigue, blurred vision, dizziness, and headache x 2 days. Reports running out of blood glucose strips and Humulin regular insulin due to lack of financial means. States that they are afraid of possible falls from fatigue and dizziness. Lives at home alone. Orders received; will increase glargine from 20 units to 25 units at bedtime. Other meds taken at home remain the same at this time. UrinalysisResultExpected Reference RangeAppearanceClearClearColorAmberYellowpH5.84.6 to 8.0Specific gravity1.0121.005 to 1.030Leucocyte esteraseNegativeNegative NitratesNoneNoneCrystalsNoneNoneCastsNoneNoneGlucose0NegativeWBC00 to 4 per low-power fieldRBC0less than or equal to 2 Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

The nurse should teach the client signs of hyperglycemia and assess their feet for sensation because the client is most likely experience type 1 diabetes mellitus because the HgA1c is elevated to a level indicating only fair diabetic control and the fingerstick blood glucose level is high, which is indicative of diabetes. The nurse will need to assess for the potential diabetic complication of peripheral neuropathy in the feet. The nurse should monitor urinary output and fingerstick blood glucose. This will allow the nurse to determine whether the medication and diet are effective in controlling the client's glucose levels.

A nurse is teaching an older adult client who has herpes zoster about the order of occurrence of findings associated with this disorder. Identify the order in which the findings typically occur. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) Crusted lesions Paresthesia Postherpetic neuralgia Redness and swelling Vesicles Weeping blisters

The usual presentation of herpes zoster begins with paresthesias. Then, redness and swelling develops before the vesicles appear along the affected nerve. These vesicles usually open and begin to drain for a few days before they crust over and healing begins. Many older adult clients develop postherpetic neuralgia (pain along the nerve) for months after the lesions disappear.

A nurse in the emergency department is caring for a client who is experiencing manifestations of a myocardial infarction (MI). Which of the following laboratory tests should the nurse expect the provider to prescribe? Troponin Creatinine kinase (CK) Brain natriuretic peptide (BNP) C-reactive protein

Troponin Troponin is released by the myocardial muscle when injury occurs. Troponin is not present in the body at any other time, making it very specific to cardiac injury. Troponin levels in the blood can rise within 2 to 3 hr of the onset of an MI. This allows for a quick diagnosis and is the gold standard when treating client's who have suspected MI.

A nurse is instructing the mother of a toddler who has iron-deficiency anemia to increase iron in the child's diet in addition to the prescribed iron supplement. Which of the following foods should the nurse recommend? Skim milk Bananas Tuna fish Cucumbers

Tuna fish Good sources of iron that are more readily absorbed than plant sources include seafood, meat, and eggs.

A nurse is providing discharge teaching to a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse include? Avoid using moisturizing lotions on the skin. Wash the hair with a mild protein shampoo. Apply powder liberally to sensitive skin areas. Use a sun-blocking agent with a sun protection factor of at least 15.

Wash the hair with a mild protein shampoo. Clients who have SLE are prone to hair loss. They should use a mild protein shampoo and avoid treatments that can damage the hair and scalp, such as dyes and permanents.

A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor? Confusion Weakness Increased intracranial pressure Increased urinary output

Weakness Generalized weakness of the diaphragmatic and intercostal muscles may produce respiratory distress or predispose the client to respiratory infections.

A nurse in the emergency department is triaging clients following a mass casualty event. The nurse should identify which of the following clients as emergent? A client who has a punctured femoral artery A client who has multiple fractures A client who has a red rash over his abdomen A client who reports severe flank pain radiating to the groin

client who has a punctured femoral artery A client who has a punctured femoral artery requires immediate attention because it is life-threatening; therefore, the nurse should identify this client as emergent or red-tagged.