hesi

Primary aldosteronism

- Aldosterone secreting tumor - patient exhibits profound alkalosis and hypokalemia - Hypertension is the most prominent and almost a universal sign of aldosterorism - Hypokalemic alkalosis may decrease serum calcium level resulting in tetany and paresthesia - - Glucose intolerance may occur leading to hyperglycemia - The urine volume is excessive, leading to polyuria - Serum by contrast becomes concentrated leading to polydipsia

Huntington's disease symptoms

-Uncoordinated movement of limbs (stops when asleep) -Decrease in mitochondrial function -Excess of dopamine (lack of GABA) -Short term memory problems -Degeneration of brain (prefrontal cortex)

ventricular ectopy (PVC)

A ventricular ectopic beat (VEB) is an extra heart-beat originating in the lower chamber of the heart. This beat, also called a premature ventricular contraction (PVC), occurs before the beat triggered by the heart's normal function

Which instruction should the nurse teach a female client about the prevention of toxic shock syndrome?

A. "Get immunization against human papillomavirus (HPV)." B. "Change your tampon frequently." C. "Empty your bladder after intercourse." D. "Obtain a yearly flu vaccination." Rationale: Certain strains of Staphylococcus aureus produce a toxin that can enter the bloodstream through the vaginal mucosa. Changing the tampon frequently reduces the exposure to these toxins, which are the primary cause of toxic shock syndrome. Option A helps prevent cervical cancer, not toxic shock syndrome. Option C can lessen the incidence of urinary tract infection. Option D can help prevent some individuals from contracting the flu and pneumonia, but no relationship to toxic shock syndrome has been proven.

The nurse is administering a nystatin suspension for stomatitis. Which instruction will the nurse provide to the client when administering this medication?

A. "Hold the medication in your mouth for a few minutes before swallowing it." B. "Do not drink or eat milk products for 1 hour prior to taking this medication." C. "Dilute the medication with juice to reduce the unpleasant taste and odor." D. "Take the medication before meals to promote increased absorption." Rationale: Nystatin suspension is prescribed for fungal infections of the mouth. The client should swish the medication in the mouth for 2 minutes and then swallow. Option B does not affect administration of this medication. The medication should not be diluted because this will reduce its effectiveness. Option D is not necessary.

The nurse is giving preoperative instructions to a 14-year-old client scheduled for surgery to correct a spinal curvature. Which statement by the client best demonstrates that learning has taken place?

A. "I will read all the teaching booklets you gave me before surgery." B. "I have had surgery before, so I know what to expect afterward." C. "All the things people have told me will help me take care of my back." D. "Let me show you the method of turning I will use after surgery." Rationale: The outcome of learning is best demonstrated when the client not only verbalizes an understanding but can also provide a return demonstration. A 14-year-old client may or may not follow through with option A, and there is no measurement of learning. Option B may help the client understand the surgical process, but the type of surgery may have been very different, with differing postoperative care. In option C, the client may be saying what the nurse wants to hear without expressing any real understanding of what to do after surgery.

During a health fair, a male client with emphysema tells the nurse that he fatigues easily. Assessment reveals marked clubbing of the fingernails and an increased anteroposterior chest diameter. Which instruction is best to provide the client?

A. "Pace your activities and schedule rest periods." B. "Increase the amount of oxygen you use at night." C. "Obtain medical evaluation for antibiotic therapy." D. "Reduce your intake of fluids containing caffeine." Rationale: Manifestations of emphysema include an increase in AP diameter (referred to as a barrel chest), nail bed clubbing, and fatigue. The nurse can provide instructions to promote energy management, such as pacing activities and scheduling rest periods. Option B may result in a decreased drive to breathe. The client is not exhibiting any symptoms of infection, so option C is not necessary. Option D is less beneficial than option A.

A home health nurse knows that a 70-year-old male client who is convalescing at home following a hip replacement is at risk for developing pressure ulcers. Which physical characteristic of aging puts the client at risk?

A. 16% increase in overall body fat B. Reduced melanin production C. Thinning of the skin, with loss of elasticity D. Calcium loss in the bones Rationale: Thin nonelastic skin is an important factor in pressure formation. The proportion of body fat to lean mass increases with age and might help decrease ulcer tendency. Option B causes gray hair. Option D can contribute to broken bones, but it is probably not a factor in pressure ulcer formation.

The nurse is performing hourly neurologic checks for a client with a head injury. Which new assessment finding warrants immediate intervention by the nurse?

A. A unilateral pupil that is dilated and nonreactive to light B. Client cries out when awakened by a verbal stimulus C. Client demonstrates a loss of memory of the events leading up to the injury D. Onset of nausea, headache, and vertigo Rationale: Any change in pupil size and reactivity is an indication of increasing intracranial pressure and should be reported to the health care provider immediately. Option B is a normal response to being awakened. Options C and D are common manifestations of head injury and are of less immediacy than option A.

when assigning clients on a medical-surgical floor to an RN and a PN, it is best for the charge nurse to assign which client to the PN?

A. A young adult with bacterial meningitis with recent seizures B. An older adult client with pneumonia and viral meningitis C. A female client in isolation with meningococcal meningitis D. A male client 1 day postoperative after drainage of a brain abscess Rationale: The most stable client is option B. Options A, C, and D are all at high risk for increased intracranial pressure and require the expertise of the RN for assessment and management of care.

A client with hypertension has been receiving ramipril (Altace), 5 mg PO, daily for 2 weeks and is scheduled to receive a dose at 0900. At 0830, the client's blood pressure is 120/70 mm Hg. Which action should the nurse take?

A. Administer the prescribed dose at the scheduled time. B. Hold the dose and contact the health care provider. C. Hold the dose and recheck the blood pressure in 1 hour. D. Check the health care provider's prescription to clarify the dose. Rationale: The client's blood pressure is within normal limits, indicating that the ramipril, an antihypertensive, is having the desired effect and should be administered. Options B and C would be appropriate if the client's blood pressure was excessively low (<100 mm Hg systolic) or if the client were exhibiting signs of hypotension such as dizziness. This prescribed dose is within the normal dosage range, as defined by the manufacturer; therefore, option D is not necessary.

The nurse is caring for a client with a fractured right elbow. Which assessment finding has the highest priority and requires immediate intervention?

A. Ecchymosis over the right elbow area B. Deep unrelenting pain in the right arm C. An edematous right elbow D. The presence of crepitus in the right elbow Rationale: Compartment syndrome is a condition involving increased pressure and constriction of the nerves and vessels within an anatomic compartment, causing pain uncontrolled by opioids and neurovascular compromise. Option A is an expected finding. Option C related to compartment syndrome cannot be seen, and any visible edema is an expected finding related to the injury. Option D is an expected finding.

When a nurse assesses a client receiving total parenteral nutrition (TPN), which laboratory value is most important for the nurse to monitor regularly?

A. Albumin B. Calcium C. Glucose D. Alkaline phosphatase Rationale: TPN solutions contain high concentrations of glucose, so the blood glucose level is often monitored as often as q6h because of the risk for hyperglycemia. Option A is monitored periodically because an increase in the albumin level, a serum protein, is generally a desired effect of TPN. Option B may be added to TPN solutions, but calcium imbalances are not generally a risk during TPN administration. Option D may be decreased in the client with malnutrition who receives TPN, but abnormal values, reflecting liver or bone disorders, are not a common complication of TPN administration.

A central venous catheter has been inserted via a jugular vein, and a radiograph has confirmed placement of the catheter. A prescription has been received for a medication STAT, but IV fluids have not yet been started. Which action should the nurse take prior to administering the prescribed medication?

A. Assess for signs of jugular venous distention. B. Obtain the needed intravenous solution. C. Flush the line with heparinized solution. D. Flush the line with normal saline. Rationale: Medication can be administered via a central line without additional IV fluids. The line should first be flushed with a normal saline solution to ensure patency. Insufficient evidence exists on the effectiveness of flushing catheters with heparin. Option A will not affect the decision to administer the medication and is not a priority. Administration of the medication STAT is of greater priority than option B.

A hospitalized client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He begins to cough and produces a moderate amount of white sputum. Which action should the nurse take first?

A. Auscultate the client's breath sounds. B. Turn off the continuous feeding pump. C. Check placement of the nasogastric tube. D. Measure the amount of residual feeding. Rationale: A productive cough may indicate that the feeding has been aspirated. The nurse should first stop the feeding to prevent further aspiration. Options A, C, and D should all be performed before restarting the tube feeding if no evidence of aspiration is present and the tube is in place.

A client with cirrhosis develops increasing pedal edema and ascites. Which dietary modification is most important for the nurse to teach this client?

A. Avoid high-carbohydrate foods. B. Decrease intake of fat-soluble vitamins. C. Decrease caloric intake. D. Restrict salt and fluid intake. Rationale: Salt and fluid restrictions are the first dietary modifications for a client who is retaining fluid as manifested by edema and ascites. Options A, B, and C will not affect fluid retention.

A 25-year-old client was admitted yesterday after a motor vehicle collision. Neurodiagnostic studies have shown a basal skull fracture in the middle fossa. Assessment on admission revealed both halo and Battle signs. Which new symptom indicates that the client is likely to be experiencing a common life-threatening complication associated with a basal skull fracture?

A. Bilateral jugular venous distention B. Oral temperature of 102° F C. Intermittent focal motor seizures D. Intractable pain in the cervical region Clients with basilar skull fractures are at high risk for infection of the brain, as indicated by an increased oral temperature, because the fracture leaves the meninges open to bacterial invasion. Clients may experience options C and D, but these findings do not pose as great a life-threatening risk as infection. Jugular distention is not a typical complication of basal skull fractures.

Which age-related change in the older adult has the highest safety implication for the client?

A. Change in height B. Hair loss C. Stooped posture D. Age spots Rationale: Stooped posture results in the upper torso becoming the center of gravity for older persons. The center of gravity for adults is the hips. However, as a person grows older, a stooped posture is common because of changes caused by osteoporosis and normal bone degeneration. Furthermore, the knees, hips, and elbows flex. This age-related change can put the older adult at risk for falls. Options A, B, and D are age-related changes but are not high safety concerns.

Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old man who is in good health overall?

A. Complete blood count reveals increased white blood cell (WBC) and decreased red blood cell (RBC) counts. B. Chemistries reveal an increased serum bilirubin level with slightly increased liver enzyme levels. C. Urinalysis reveals slight protein in the urine and bacteriuria, with pyuria. D. Serum electrolytes reveal a decreased sodium level and increased potassium level. Rationale: In older adults, the protein found in urine slightly rises, probably as a result of kidney changes or subclinical urinary tract infections, and clients frequently experience asymptomatic bacteriuria and pyuria as a result of incomplete bladder emptying. Laboratory findings in options A, B, and D are not considered to be normal findings in an older adult.

The nurse is counseling a healthy 30-year-old female client regarding osteoporosis prevention. Which activity would be most beneficial in achieving the client's goal of osteoporosis prevention?

A. Cross-country skiing B. Scuba diving C. Horseback riding D. Kayaking Rationale: Weight-bearing exercise is an important measure to reduce the risk of osteoporosis. Of the activities listed, cross-country skiing includes the most weight-bearing, whereas options B, C, and D involve less.

The nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12 hours after chest tube insertion for hemothorax. What is the best initial action for the nurse to take?

A. Document this expected decrease in drainage. B. Clamp the chest tube while assessing for air leaks. C. Milk the tube to remove any excessive blood clot buildup. D. Assess for kinks or dependent loops in the tubing. Rationale: The least invasive nursing action should be performed first to determine why the drainage has diminished. Option A is completed after assessing for any problems causing the decrease in drainage. Option B is no longer considered standard protocol because the increase in pressure may be harmful to the client. Option C is an appropriate nursing action after the tube has been assessed for kinks or dependent loops.

The nurse is conducting an osteoporosis screening clinic at a health fair. What information should the nurse provide to individuals who are at risk for osteoporosis? (Select all that apply.)

A. Encourage alcohol and smoking cessation. B. Suggest supplementing diet with vitamin E. C. Promote regular weight-bearing exercises. D. Implement a home safety plan to prevent falls. E. Propose a regular sleep pattern of 8 hours nightly. Rationale: Options A, C, and D are factors that decrease the risk for developing osteoporosis. Vitamin D and calcium are important supplements to aid in the decrease of bone loss. Regular sleep patterns are important to overall health but are not identified with a decreasing risk for osteoporosis.

Which content about self-care should the nurse include in the teaching plan of a female client who has genital herpes? (Select all that apply.)

A. Encourage annual physical and Pap smear. B. Take antiviral medication as prescribed. C. Use condoms to avoid transmission to others. D. Warm sitz baths may relieve itching. E. Use Nystatin suppositories to control itching. F. Use a douche with weak vinegar solution to decrease itching. Rationale: The nurse should include (A, B, C, and D) in the teaching plan of a female client with genital herpes. (E) is specific for Candida infections, and option (F) is used to treat Trichomonas.

A client is diagnosed with an acute small bowel obstruction. Which assessment finding requires the most immediate intervention by the nurse?

A. Fever of 102° F B. Blood pressure of 150/90 mm Hg C. Abdominal cramping D. Dry mucous membranes Rationale: A sudden increase in temperature is an indicator of peritonitis. The nurse should notify the health care provider immediately. Options B, C, and D are also findings that require intervention by the nurse but are of less priority than option A. Option B may indicate a hypertensive condition but is not as acute a condition as peritonitis. Option C is an expected finding in clients with small bowel obstruction and may require medication. Option D indicates probable fluid volume deficit, which requires fluid volume replacement.

A client with chronic asthma is admitted to the PACU complaining of pain at a level of 8 on a 1 to 10 scale, with a blood pressure of 124/78 mm Hg, pulse of 88 beats/min, and respirations of 20 breaths/min. The PACU recovery prescription is "Morphine, 2 to 4 mg IV push, while in recovery for pain level over 5." Which intervention should the nurse implement?

A. Give the medication as prescribed to decrease the client's pain. B. Call the anesthesia provider for a different medication for pain. C. Use nonpharmacologic techniques before giving the medication. D. Reassess the pain level in 30 minutes and medicate if it remains elevated. Rationale: The nurse should call the provider for a different medication because morphine is a histamine-releasing opioid and should be avoided when the client has asthma. Option A is unsafe because it puts the client at risk for an asthma exacerbation. Even if the drug were safe for the client, options C and D both disregard the prescription and the client's need for pain relief in the immediate postoperative period.

An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that this client's tongue is somewhat cracked and his eyeballs appear sunken into his head. Which nursing intervention is indicated?

A. Help the client determine ways to increase his fluid intake. B. Obtain an appointment for the client to have an eye examination. C. Instruct the client to use oxygen at night and increase the humidification. D. Schedule the client for tests to determine his sensitivity to cat hair. Rationale: Clients with COPD should ingest 3 L of fluids daily but may experience a fluid deficit because of shortness of breath. The nurse should suggest creative methods to increase the intake of fluids, such as having fruit juices in disposable containers readily available. Option B is not indicated. Humidified oxygen will not effectively treat the client's fluid deficit, and there is no indication that the client needs supplemental oxygen at night. These symptoms are not indicative of option D and may unnecessarily upset the client, who depends on his pet for socialization.

Which abnormal laboratory finding indicates that a client with diabetes needs further evaluation for diabetic nephropathy?

A. Hypokalemia B. Microalbuminuria C. Elevated serum lipid levels D. Ketonuria Rationale: Microalbuminuria is the earliest sign of diabetic nephropathy and indicates the need for follow-up evaluation. Hyperkalemia, not option A, is associated with end-stage renal disease caused by diabetic nephropathy. Option C may be elevated in end-stage renal disease. Option D may signal the onset of diabetic ketoacidosis (DKA).

A client diagnosed with chronic kidney disease (CKD) 2 years ago is regularly treated at a community hemodialysis facility. Before his scheduled dialysis treatment, which electrolyte imbalance should the nurse anticipate?

A. Hypophosphatemia B. Hypocalcemia C. Hyponatremia D. Hypokalemia Rationale: Hypocalcemia develops in CKD because of chronic hyperphosphatemia, not option A. Increased phosphate levels cause the peripheral deposition of calcium and resistance to vitamin D absorption needed for calcium absorption. Prior to dialysis, the nurse would expect to find the client hypernatremic and hyperkalemic, not with option C or D.

The nurse on a medical-surgical unit is receiving a client from the postanesthesia care unit (PACU) with a Penrose drain. Before choosing a room for this client, which information is most important for the nurse to obtain?

A. If suctioning will be needed for drainage of the wound B. If the family would prefer a private or semiprivate room C. If the client also has a Hemovac in place D. If the client's wound is infected Rationale: The fact that the client has a Penrose drain should alert the nurse to the possibility that the surgical wound is infected. Penrose drains provide a sinus tract or opening and are often used to provide drainage of an abscess. To avoid contamination of another postoperative client, it is most important to place any client with an infected wound in a private room. A Penrose drain does not require option A. Although option B is helpful information, it does not have the priority of option D. A Hemovac is used to drain fluid from a dead space and is not a determinant for the room assignment.

Based on the clinical manifestations of Cushing syndrome, which nursing intervention would be appropriate for a client who is newly diagnosed with Cushing syndrome?

A. Monitor blood glucose levels daily. B. Increase intake of fluids high in potassium. C. Encourage adequate rest between activities. D. Offer the client a sodium-enriched menu. Rationale: Cushing syndrome results from a hypersecretion of glucocorticoids in the adrenal cortex. Clients with Cushing syndrome often develop diabetes mellitus. Monitoring of serum glucose levels assesses for increased blood glucose levels so that treatment can begin early. A common finding in Cushing syndrome is generalized edema. Although potassium is needed, it is generally obtained from food intake, not by offering potassium-enhanced fluids. Fatigue is usually not an overwhelming factor in Cushing syndrome, so an emphasis on the need for rest is not indicated A low-calorie, low-carbohydrate, low-sodium diet is not recommended.

The nurse is caring for a client who is one day post-acute myocardial infarction. The client is receiving oxygen at 2 L/min via nasal cannula and has a peripheral saline lock. The nurse notes that the client is having eight premature ventricular contractions (PVCs) per minute. Which intervention should the nurse implement first?

A. Obtain an IV pump for antiarrhythmic infusion. B. Increase the client's oxygen flow rate. C. Prepare for immediate countershock. D. Gather equipment for endotracheal intubation. Rationale: Increasing the oxygen flow rate provides more oxygen to the client's myocardium and may decrease myocardial irritability as manifested by the frequent PVCs. Option A can be delegated and is a lower priority action than option B. Defibrillation may eventually be necessary, but option C is not the immediate treatment for frequent PVCs. Option D may become necessary if the client stops breathing but is not indicated at this time.

A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which nursing intervention has the highest priority?

A. Place the client on NPO status. B. Assess the client's temperature. C. Obtain a stool specimen. D. Administer IV fluids. Rationale: A client with acute severe diverticulitis is at risk for peritonitis and intestinal obstruction and should be made NPO to reduce risk of intestinal rupture. Options B, C, and D are important but are less of a priority than option A, which is implemented to prevent a severe complication.

One day after a Billroth II surgery, a male client suddenly grabs his right chest and becomes pale and diaphoretic. Vital signs are assessed as blood pressure 100/80 mm Hg, pulse 110 beats/min, and respirations 36 breaths/min. Which action is most important for the nurse to take?

A. Provide a paper bag for his hyperventilation. B. Administer a prescribed PRN analgesic. C. Have the client drink a glass of sweetened fruit juice. D. Apply oxygen at 2 L via nasal cannula. Rationale: Pulmonary embolism and pneumothorax are risks associated with major abdominal surgery. The nurse should immediately provide oxygen while performing further assessment. A rapid respiratory rate should not be treated as hyperventilation. Option B should not be administered until more ominous causes are ruled out or treated. There is no evidence that the client is hypoglycemic.

The nurse witnesses a baseball player receive a blunt trauma to the back of the head with a softball. What assessment data should the nurse collect immediately?

A. Reactivity of deep tendon reflexes, comparing upper with lower extremities B. Vital sign readings, excluding blood pressure if needed equipment is unavailable C. Memory of events that occurred before and after the blow to the head D. Ability to open the eyes spontaneously before any tactile stimuli are given Rationale: The level of consciousness (LOC) should be established immediately when a head injury has occurred. Spontaneous eye opening is a simple measure of alertness that indicates that arousal mechanisms are intact. Option A is not the best indicator of LOC. Although option B is important, vital signs are not the best indicators of LOC and can be evaluated after the client's LOC has been determined. Option C can be assessed after LOC has been established by assessing eye opening.

When educating a client after a total laryngectomy, which instruction would be most important for the nurse to include in the discharge teaching?

A. Recommend that the client carry suction equipment at all times. B. Instruct the client to have writing materials with him at all times. C. Tell the client to carry a medical alert card that explains his condition. D. Caution the client not to travel outside the United States alone. Rationale: Neck breathers carry a medical alert card that notifies health care personnel of the need to use mouth to stoma breathing in the event of a cardiac arrest in this client. Mouth to mouth resuscitation will not establish a patent airway. Options A and D are not necessary. There are many alternative means of communication for clients who have had a laryngectomy; dependence on writing messages is probably the least effective.

A client is ready for discharge following the creation of an ileostomy. Which instruction should the nurse include in discharge teaching?

A. Replace the stoma appliance every day. B. Use warm tap water to irrigate the ileostomy. C. Change the bag when the seal is broken. D. Measure and record the ileostomy output. Rationale: A seal must be maintained to prevent leakage of irritating liquid stool onto the skin. Option A is excessive and can cause skin irritation and breakdown. Ileostomies produce liquid fecal drainage, so option B is not necessary. Option D is not needed

Which condition should the nurse anticipate as a potential problem in a female client with a neurogenic bladder?

A. Stress incontinence B. Infection C. Painless gross hematuria D. Peritonitis Rationale: Infection is the major complication resulting from stasis of urine and subsequent catheterization. Option A is the involuntary loss of urine through an intact urethra as a result of a sudden increase in intraabdominal pressure. Option C is the most common symptom of bladder cancer. Option D is the most common and serious complication of peritoneal dialysis.

After attending a class on reducing cancer risk factors, a client selects bran flakes with 2% milk and orange slices from a breakfast menu. In evaluating the client's learning, the nurse affirms that the client has made good choices and makes what additional recommendation?

A. Switch to skim milk. B. Switch to orange juice. C. Add a source of protein. D. Add herbal tea. Rationale: Dietary recommendations to reduce cancer risk include reduced consumption of fats, with increased consumption of fruits, vegetables, and fiber. Option A promotes reduced fat consumption. Orange slices provide more fiber than orange juice. Options B, C, and D are not standard recommendations for reducing cancer risk

In caring for a client with acute diverticulitis, which assessment data warrants immediate nursing intervention?

A. The client has a rigid hard abdomen and elevated WBC. B. The client has left lower quadrant pain and an elevated temperature. C. The client is refusing to eat any of the meal and is complaining of nausea. D. The client has not had a bowel movement in 2 days and has a soft abdomen. Rationale: A hard rigid abdomen and elevated WBC is indicative of peritonitis, which is a medical emergency and should be reported to the health care provider immediately. Options B and C are expected clinical manifestations of diverticulitis. Option D does not warrant immediate intervention.

The nurse is assessing a male client with acute pancreatitis. Which finding requires the most immediate intervention by the nurse?

A. The client's amylase level is three times higher than the normal level. B. While the nurse is taking the client's blood pressure, he has a carpal spasm. C. On a 1 to 10 scale, the client tells the nurse that his epigastric pain is at 7. D. The client states that he will continue to drink alcohol after going home. Rationale: A positive Trousseau sign indicates hypocalcemia and always requires further assessment and intervention, regardless of the cause (40% to 75% of those with acute pancreatitis experience hypocalcemia, which can have serious, systemic effects). A key diagnostic finding of pancreatitis is serum amylase and lipase levels that are two to five times higher than the normal value. Severe boring pain is an expected symptom for this diagnosis, but dealing with the hypocalcemia is a priority over administering an analgesic. Long-term planning and teaching do not have the same immediate importance as a positive Trousseau sign.

Which description of symptoms is characteristic of a client diagnosed with trigeminal neuralgia (tic douloureux)?

A. Tinnitus, vertigo, and hearing difficulties B. Sudden, stabbing, severe pain over the lip and chin C. Unilateral facial weakness and paralysis D. Difficulty in chewing, talking, and swallowing Rationale: Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock, in the area innervated by one or more branches of the trigeminal nerve (cranial V). Option A would be characteristic of Ménière syndrome (cranial nerve VIII). Option C would be characteristic of Bell palsy (cranial nerve VII). Option D would be characteristic of disorders of the hypoglossal (cranial nerve XII).

A family member was taught to suction a client's tracheostomy prior to the client's discharge from the hospital. Which observation by the nurse indicates that the family member is capable of correctly performing the suctioning technique?

A. Turns on the continuous wall suction to 190 mm Hg. B. Inserts the catheter until resistance or coughing occurs. C. Withdraws the catheter while maintaining suctioning. D. Reclears the tracheostomy after suctioning the mouth Rationale: Option B indicates correct technique for performing suctioning. Suction pressure should be between 80 and 120 mm Hg, not 190 mm Hg. The catheter should be withdrawn 1 to 2 cm at a time with intermittent, not continuous, suction. Option D introduces pathogens unnecessarily into the tracheobronchial tree.

The nurse is assessing a client who presents with jaundice. Which assessment finding is most important for the nurse to follow up?

A. Urine specific gravity of 1.03 B. Frothy, tea-colored urine C. Clay-colored stools D. Elevated serum amylase and lipase levels Rationale: Obstructive cholelithiasis and alcoholism are the two major causes of pancreatitis, and elevated serum amylase and lipase levels indicate pancreatic injury. Option A is a normal finding. Options B and C are expected findings related to jaundice.

A 77-year-old female client is admitted to the hospital with confusion and anorexia of several days' duration. She has symptoms of nausea and vomiting and is currently complaining of a headache. The client's pulse rate is 43 beats/min. The nurse is most concerned about the client's history related to which medication?

A. Warfarin B. Ibuprofen C. Nitroglycerin D. Digoxin Rationale: Older persons are particularly susceptible to the buildup of cardiac glycosides, such as digoxin or digitoxin (medications derived from digitalis), to a toxic level in their systems. Toxicity can cause anorexia, nausea, vomiting, diarrhea, headache, and fatigue. Options A, B, and C are unlikely to result in the symptoms described.

The nurse teaches a client with type 2 diabetes nutritional strategies to decrease obesity. Which food items chosen by the client indicate understanding of the teaching? (Select all that apply.)

A. White bread B. Salmon C. Broccoli D. Whole milk E. Banana Rationale: Options B, C, and E provide fresh fruits, lean meats and fish, vegetables, whole grains, and low-fat dairy products. All are recommended by the American Diabetes Association (ADA) and are a part of the My Plate guidelines recommended by the U.S. Department of Agriculture (USDA). Whole milk is high in fat and is not recommended by the ADA. White bread is milled, a process that removes the essential nutrients. It should be avoided for weight loss and is a poor choice for the client with diabetes.

Which nursing action is necessary for the client with a flail chest?

A. Withhold prescribed analgesic medications. B. Percuss the fractured rib area with light taps. C. Avoid implementing pulmonary suctioning. D. Encourage coughing and deep breathing. Rationale: Treatment of flail chest is focused on preventing atelectasis and related complications of compromised ventilation by encouraging coughing and deep breathing. This condition is typically diagnosed in clients with three or more rib fractures, resulting in paradoxic movement of a segment of the chest wall. Option C should not be avoided because suctioning is necessary to maintain pulmonary toilet in clients who require mechanical ventilation. Option A should not be withheld. Option B should not be applied because the fractures are clearly visible on the chest radiograph.

Zolpidem tartrate, 1.75 mg PRN at bedtime, is prescribed for rest. The scored tablets are labeled 3.5 mg per tablet. How many tablets should the nurse plan to administer?

A. ½ tablet B. 1 tablet C. 1½ tablets D. 2 tablets Rationale: 1.75 is ordered. 3.5 is available. 1.75/3.5 time one tab equlas 05. Or one half tablet. Options B, C, and D are incorrect.

The nurse is completing an admission interview for a client with Parkinson disease. Which question will provide additional information about manifestations that the client is likely to experience?

A. "Have you ever experienced any paralysis of your arms or legs?" B. "Do you have frequent blackout spells?" C. "Have you ever been frozen in one spot, unable to move?" D. "Do you have headaches, especially ones with throbbing pain?" Rationale: Clients with Parkinson disease frequently experience difficulty in initiating, maintaining, and performing motor activities. They may even experience being rooted to the spot and unable to move. Parkinson disease does not typically cause option A, B, or D.

The nurse is preparing a teaching plan for a group of healthy adults. Which individual is most likely to maintain optimum health?

A. A teacher whose blood glucose levels average 126 mg/dL daily with oral antidiabetic drugs B. An accountant whose blood pressure averages 140/96 mm Hg and who says he does not have time to exercise C. A stock broker whose total serum cholesterol level dropped to 290 mg/dL with diet modifications D. A recovering IV heroin user who contracted hepatitis more than 10 years ago Rationale: The diabetic teacher has assumed responsibility for self-care, so among those listed, he or she is the most likely to maintain optimum health. Option B has expressed a lack of interest in health promotion. Option C continues to demonstrate a high-risk cholesterol level despite a reported attempt at dietary modifications. Previous IV drug use and a history of hepatitis make this individual a health risk despite the fact that the individual is in recovery.

When assigning clients on a medical-surgical floor to an RN and a PN, it is best for the charge nurse to assign which client to the PN?

A. A young adult with bacterial meningitis with recent seizures B. An older adult client with pneumonia and viral meningitis C. A female client in isolation with meningococcal meningitis D. A male client 1 day postoperative after drainage of a brain abscess Rationale: The most stable client is option B. Options A, C, and D are all at high risk for increased intracranial pressure and require the expertise of the RN for assessment and management of care.

The nurse observes ventricular fibrillation on telemetry and, on entering the client's bathroom, finds the client unconscious on the floor. Which intervention should the nurse implement first?

A. Administer an antidysrhythmic medication. B. Start cardiopulmonary resuscitation. C. Prepare for mechanical ventilation. D. Assess the client's pulse oximetry. Rationale: Ventricular fibrillation is a life-threatening dysrhythmia, and CPR should be started immediately until the crash cart arrives. Options A and C are appropriate, but CPR is the priority action until a defibrillator is available, which is the most effective treatment for ventricular fibrillation. The client is dying, and option D does not address the seriousness of this situation.

A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid ventricular response. Based on this finding, the nurse anticipates assisting the physician with which treatment?

A. Administer lidocaine, 75 mg intravenous push. B. Perform synchronized cardioversion. C. Defibrillate the client as soon as possible. D. Administer atropine, 0.4 mg intravenous push. Rationale: With uncontrolled atrial fibrillation, the treatment of choice is synchronized cardioversion to convert the cardiac rhythm back to normal sinus rhythm. Option A is a medication used for ventricular dysrhythmias. Option C is not for a client with atrial fibrillation; it is reserved for clients with life-threatening dysrhythmias, such as ventricular fibrillation and unstable ventricular tachycardia. Option D is the drug of choice in symptomatic sinus bradycardia, not atrial fibrillation.

In assessing a client with an arteriovenous (AV) shunt who is scheduled for dialysis today, the nurse notes the absence of a thrill or bruit at the shunt site. What action should the nurse take?

A. Advise the client that the shunt is intact and ready for dialysis as scheduled. B. Encourage the client to keep the shunt site elevated above the level of the heart. C. Notify the health care provider of the findings immediately. D. Flush the site at least once with a heparinized saline solution. Rationale: Absence of a thrill or bruit indicates that the shunt may be obstructed. The nurse should notify the health care provider so that intervention can be initiated to restore function of the shunt. Option A is incorrect. Option B will not resolve the obstruction. An AV shunt is internal and cannot be flushed without access using special needles.

A client who is receiving an angiotensin-converting enzyme (ACE) inhibitor for hypertension calls the clinic and reports the recent onset of a cough to the nurse. Which action should the nurse implement?

A. Advise the client to come to the clinic immediately for further assessment. B. Instruct the client to discontinue use of the drug and to make an appointment at the clinic. C. Suggest that the client learn to accept the cough as a side effect to a necessary prescription. D. Encourage the client to keep taking the drug until seen by the health care provider. Rationale: Coughing is a common side effect of ACE inhibitors and is not an indication to discontinue the medication. Immediate evaluation is not needed. Antihypertensive medications should not be stopped abruptly because rebound hypertension may occur. Option C is demeaning because the cough may be very disruptive to the client, and other antihypertensive medications may produce the desired effect without the adverse effect.

A 43-year-old homeless, malnourished female client with a history of alcoholism is transferred to the ICU. She is placed on telemetry, and the rhythm strip shown is obtained. The nurse palpates a heart rate of 160 beats/min, and the client's blood pressure is 90/54 mm Hg. Based on these findings, which IV medication should the nurse administer?

A. Amiodarone (Cordarone) B. Magnesium sulfate C. Lidocaine (Xylocaine) D. Procainamide (Pronestyl) Rationale: Because the client has chronic alcoholism, she is likely to have hypomagnesemia. Option B is the recommended drug for torsades de pointes, which is a form of polymorphic ventricular tachycardia (VT) usually associated with a prolonged QT interval that occurs with hypomagnesemia. Options A and D increase the QT interval, which can cause the torsades to worsen. Option C is the antiarrhythmic of choice in most cases of drug-induced monomorphic VT, not torsades.

The nurse is reviewing routine medications taken by a client with chronic angle-closure glaucoma. Which medication prescription should the nurse question?

A. Antianginal with a therapeutic effect of vasodilation B. Anticholinergic with a side effect of pupillary dilation C. Antihistamine with a side effect of sedation D. Corticosteroid with a side effect of hyperglycemia Rationale: Clients with angle-closure glaucoma should not take medications that dilate the pupil because this can precipitate acute and severely increased intraocular pressure. Options A, C, and D do not cause increased intracranial pressure, which is the primary concern with angle-closure glaucoma.

A client with congestive heart failure and atrial fibrillation develops ventricular ectopy with a pattern of 8 ectopic beats/min. Which action should the nurse take based on this observation?

A. Assess for bilateral jugular vein distention. B. Increase oxygen flow via nasal cannula. C. Administer PRN furosemide (Lasix). D. Auscultate for a pleural friction rub. Rationale: This client should have the oxygen flow immediately increased to promote oxygenation of the myocardium. Ventricular ectopy, characterized by multiple PVCs, is often caused by myocardial ischemia exacerbated by hypokalemia. The nurse would expect the client in congestive heart failure to have some degree of option A, which does not exacerbate the ectopy. Option C could create a more severe hypokalemia, which could increase the ectopy. The client is not exhibiting signs of option D.

A female client who received a nephrotoxic drug is admitted with acute renal failure and asks the nurse if she will need dialysis for the rest of her life. Which pathophysiologic consequence should the nurse explain that supports the need for temporary dialysis until acute tubular necrosis subsides?

A. Azotemia B. Oliguria C. Hyperkalemia D. Nephron obstruction Rationale: CKD is characterized by progressive and irreversible destruction of nephrons, frequently caused by hypertension and diabetes mellitus. Nephrotoxins cause acute tubular necrosis, a reversible acute renal failure, which creates renal tubular obstruction from endothelial cells that are sloughed or become edematous. The obstruction of urine flow will resolve with the return of an adequate glomerular filtration rate, and when it does, dialysis will no longer be needed. Options A, B, and C are manifestations seen in the acute and chronic forms of kidney disease.

The nurse initiates neurologic checks for a client who is at risk for neurologic compromise. Which manifestation typically provides the first indication of altered neurologic function?

A. Change in level of consciousness B. Increasing muscular weakness C. Changes in pupil size bilaterally D. Progressive nuchal rigidity Rationale: A decrease or change in the level of consciousness is usually the first indication of neurologic deterioration. Options B and C may also occur but are much less likely to be the first sign of neurologic compromise. Option D is often a sign of meningitis.

During the shift report, the charge nurse informs a nurse that she has been assigned to another unit for the day. The nurse begins to sigh deeply and tosses about her belongings as she prepares to leave, making it known that she is very unhappy about being floated to the other unit. What is the best immediate action for the charge nurse to take?

A. Continue with the shift report and talk to the nurse about the incident at a later time. B. Ask the nurse to call the house supervisor to see if she must be reassigned. C. Stop the shift report and remind the nurse that all staff are floated equally. D. Inform the nurse that her behavior is disruptive to the rest of the staff. Rationale: Continuing with the shift report is the best immediate action because it allows the nurse who was floated some cooling off time. At a later time (after the nurse has cooled off) the charge nurse should discuss the conduct of the nurse in private. Option B encourages the nurse to shirk the float assignment. Option C is disruptive. Reprimanding the nurse in front of the staff would increase the nurse's hostility, so the nurse should be counseled in private.

During the change of shift report, the charge nurse reviews the infusions being received by clients on the oncology unit. The client receiving which infusion should be assessed first?

A. Continuous IV infusion of magnesium B. One-time infusion of albumin C. Continuous epidural infusion of morphine D. Intermittent infusion of IV vancomycin Rationale: All four of these clients have the potential to have significant complications. The client with the morphine epidural infusion is at highest risk for respiratory depression and should be assessed first. Option A can cause hypotension. The client receiving option B is at lowest risk for serious complications. Although option D can cause nephrotoxicity and phlebitis, these problems are not as immediately life threatening as option C.

A resident in a long-term care facility is diagnosed with hepatitis B. Which intervention should the nurse implement with the staff caring for this client?

A. Determine if all employees have had the hepatitis B vaccine series. B. Explain that this type of hepatitis can be transmitted when feeding the client. C. Assure the employees that they cannot contract hepatitis B when providing direct care. D. Tell the employees that wearing gloves and a gown are required when providing care. Rationale: Hepatitis B vaccine should be administered to all health care providers. Hepatitis A (not hepatitis B) can be transmitted by fecal-oral contamination. There is a chance that staff could contract hepatitis B if exposed to the client's blood and/or body fluids; therefore, option C is incorrect. There is no need to wear gloves and gowns except with blood or body fluid contact.

Which statement reflects the highest priority nursing diagnosis for an older client recently admitted to the hospital for a new-onset cardiac dysrhythmia?

A. Diarrhea related to medication side effects B. Anxiety related to fear of recurrent anginal episodes C. Altered nutrition related to high serum lipid levels D. Risk for injury related to syncope and confusion Rationale: The loss of cardiac function in aging decreases cardiac output, so dysrhythmias, particularly tachycardias, are poorly tolerated. With onset of a tachycardic or bradycardic dysrhythmia, cardiac output is compromised further, placing the client at risk of syncope and falling, as well as confusion. Option A is of high priority but less so than maintaining client safety. Clients may experience option B as a result of a newly diagnosed cardiac condition, but this nursing diagnosis does not have the priority of option D. Option C also does not have the priority of option D.

A 62-year-old woman who lives alone tripped on a rug in her home and fractured her hip. Which predisposing factor most likely contributed to the fracture in the proximal end of her femur?

A. Failing eyesight resulting in an unsafe environment B. Renal osteodystrophy resulting from chronic kidney disease (CKD) C. Osteoporosis resulting from declining hormone levels D. Cerebral vessel changes causing transient ischemic attacks Rationale: The most common cause of a fractured hip in older women is osteoporosis, resulting from reduced calcium in the bones as a result of hormonal changes in the perimenopausal years. Option A may or may not have contributed to the accident, but eye changes were not involved in promoting the hip fracture. Option B is not a common condition of older people but is associated with CKD. Although option D may result in transient ischemic attacks (TIAs) or stroke, it will not result in fragility of the bones, as does osteoporosis.

The nurse includes frequent oral care in the plan of care for a client scheduled for an esophagogastrostomy for esophageal cancer. This intervention is included in the client's plan of care to address which nursing diagnosis?

A. Fluid volume deficit B. Self-care deficit C. Risk for infection D. Impaired nutrition Rationale: The primary reason for performing frequent mouth care preoperatively is to reduce the risk of postoperative infection because these clients may be regurgitating retained food particles, blood, or pus from the tumor. Meticulous oral care should be provided several times a day before surgery. Although oral care will be of benefit to the client who may also be experiencing option A, B, or D, these problems are not the primary reason for the provision of frequent oral care.

A client is being discharged following radioactive seed implantation for prostate cancer. What is the most important information that the nurse should provide to this client's family?

A. Follow exposure precautions. B. Encourage regular meals. C. Collect all urine. D. Avoid touching the client. Rationale: Clients being treated for prostate cancer with radioactive seed implants should be instructed regarding the amount of time and distance needed to prevent excessive exposure that would pose a hazard to others. Option B is a good suggestion to promote adequate nutrition but is not as important as option A. Option C is unnecessary. Contact with the client is permitted but should be brief to limit radiation exposure.

The nurse receives the client's next scheduled bag of TPN labeled with the additive NPH insulin. Which action should the nurse implement?

A. Hang the solution at the current rate. B. Refrigerate the solution until needed. C. Prepare the solution with new tubing. D. Return the solution to the pharmacy. Rationale: Only regular insulin is administered by the IV route, so the TPN solution containing NPH insulin should be returned to the pharmacy. Options A, B, and C are not indicated because the solution should not be administered.

A nurse is assisting an 82-year-old client with ambulation and is concerned that the client may fall. Which area contains the older person's center of gravity?

A. Head and neck B. Upper torso C. Bilateral arms D. Feet and legs Rationale: Stooped posture results in the upper torso becoming the center of gravity for older persons. The center of gravity for adults is the hips. However, as a person grows older, a stooped posture is common because of changes caused by osteoporosis and normal bone degeneration. Furthermore, the knees, hips, and elbows flex. The head and neck and feet and legs are not the center of gravity in the older adult. Although the arms comprise a part of the upper torso, they do not reflect the best and most complete answer.

A postoperative client receives a Schedule II opioid analgesic for pain. Which assessment finding requires the most immediate intervention by the nurse?

A. Hypoactive bowel sounds with abdominal distention B. Client reports continued pain of 8 on a 10-point scale C. Respiratory rate of 12 breaths/min, with O2 saturation of 85% D. Client reports nausea after receiving the medication Rationale: Administration of a Schedule II opioid analgesic can result in respiratory depression, which requires immediate intervention by the nurse to prevent respiratory arrest. Options A, B, and D require action by the nurse but are of less priority than option C.

A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place. When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff?

A. Immediately after feeding B. Just prior to tube feeding C. Continuous inflation is required D. Inflation is not required Rationale: The cuff should be inflated before the feeding to block the trachea and prevent food from entering if oral feedings are started while a cuffed tracheostomy tube is in place. It should remain inflated throughout the feeding to prevent aspiration of food into the respiratory system. Options A and D place the client at risk for aspiration. Option C places the client at risk for tracheal wall necrosis.

A client is placed on a mechanical ventilator following a cerebral hemorrhage, and vecuronium bromide, 0.04 mg/kg every 12 hours IV, is prescribed. What is the priority nursing diagnosis for this client?

A. Impaired communication related to paralysis of skeletal muscles B. High risk for infection related to increased intracranial pressure C. Potential for injury related to impaired lung expansion D. Social isolation related to inability to communicate Rationale: To increase the client's tolerance of endotracheal intubation and/or mechanical ventilation, a skeletal muscle relaxant such as vecuronium is usually prescribed. Option A is a serious outcome because the client cannot communicate his or her needs. Although this client might also experience option D, it is not a priority when compared with option A. Infection is not related to increased intracranial pressure. The respirator will ensure that the lungs are expanded, so option C is incorrect.

Which change in laboratory values indicates to the nurse that a client with rheumatoid arthritis may be experiencing an adverse effect of methotrexate (Mexate) therapy?

A. Increase in rheumatoid factor B. Decrease in hemoglobin level C. Increase in blood glucose level D. Decrease in erythrocyte sedimentation rate (ESR; sed rate) Rationale: Methotrexate is an immunosuppressant. A common side effect is bone marrow depression, which would be reflected by a decrease in the hemoglobin level. Option A indicates disease progression but is not a side effect of the medication. Option C is not related to methotrexate. Option D indicates that inflammation associated with the disease has diminished.The nurse is planning care for a client with diabetes mellitus who has gangrene of the toes to the midfoot.

A 74-year-old male client is admitted to the intensive care unit (ICU) with a diagnosis of respiratory failure secondary to pneumonia. Currently, he is ventilator-dependent, with settings of tidal volume (VT) of 750 mL and an intermittent mandatory ventilation (IMV) rate of 10 breaths/min. Arterial blood gas (ABG) results are as follows: pH, 7.48; PaCO2, 30 mm Hg; PaO2, 64 mm Hg; HCO3, 25 mEq/L; and FiO2, 0.80. Which intervention should the nurse implement first?

A. Increase the ventilator VT to 850 mL. B. Decrease the ventilator IMV to a rate of 8 breaths/min. C. Reduce the FiO2 to 0.70 and redraw ABGs. D. Add 5 cm positive end-expiratory pressure (PEEP). Rationale: Adding PEEP helps improve oxygenation while reducing FiO2 to a less toxic level. Options A, B, and C will not result in improved oxygenation and could cause further complications for this client, who is experiencing respiratory failure.

The nurse is caring for a critically ill client with cirrhosis of the liver who has a nasogastric tube draining bright red blood. The nurse notes that the client's serum hemoglobin and hematocrit levels are decreased. Which additional change in laboratory data should the nurse expect?

A. Increased serum albumin level B. Decreased serum creatinine C. Decreased serum ammonia level D. Increased liver function test results Rationale: The breakdown of glutamine in the intestine and the increased activity of colonic bacteria from the digestion of proteins increase ammonia levels in clients with advanced liver disease, so removal of blood, a protein source, from the intestine results in a reduced level of ammonia. Options A, B, and D will not be significantly affected by the removal of blood.

An emaciated homeless client presents to the emergency department complaining of a productive cough, with blood-tinged sputum and night sweats. Which action is most important for the emergency department triage nurse to implement for this client?

A. Initiate airborne infection precautions. B. Place a surgical mask on the client. C. Don an isolation gown and latex gloves. D. Start protective (reverse) isolation precautions. Rationale: This client is exhibiting classic symptoms of tuberculosis (TB), and the client is from a high-risk population for TB. Therefore, airborne infection precautions, which are indicated for TB, should be used with this client. Option B is used with droplet precautions. There is no evidence that option C or D would be warranted at this time.

A tornado warning alarm has been activated at the local hospital. Which action should the charge nurse working on a surgical unit implement first?

A. Instruct the nursing staff to close all window blinds and curtains in clients' rooms. B. Move clients and visitors into the hallways and close all doors to clients' rooms. C. Visually confirm the location of the tornado by checking the windows on the unit. D. Assist all visitors with evacuation down the stairs in a calm and orderly manner. Rationale: In the event of a tornado, all persons should be moved into the hallways, away from windows, to prevent flying debris from causing injury. Although option A may help decrease the amount of flying debris, it is not safe to leave clients in rooms with closed blinds; option B is a higher priority at this time. Hospital staff should stay away from windows to avoid injury and should focus on client evacuation into hallways rather than option C. Option D is not the first action that should be taken.

A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last 2 hours. Which action should the nurse take first?

A. Irrigate the nasogastric tube with sterile normal saline. B. Reposition the client on her side. C. Advance the nasogastric tube 5 cm. D. Administer an intravenous antiemetic as prescribed. Rationale: The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention, repositioning the client, should be attempted first, followed by options A and C, unless either of these interventions is contraindicated. If these measures are unsuccessful, the client may require option D.

What is the correct location for placement of the hands for manual chest compressions during cardiopulmonary resuscitation (CPR) on the adult client?

A. Just above the xiphoid process, on the upper third of the sternum B. Below the xiphoid process, midway between the sternum and the umbilicus C. Just above the xiphoid process, on the lower third of the sternum D. Below the xiphoid process, midway between the sternum and the first rib Rationale: The correct placement of the hands for chest compressions in CPR is just above the notch where the ribs meet the sternum on the lower part of the sternum. Option A is too high. Option B would not compress the heart. Option D would likely cause damage to both structures, possibly causing a puncture of the heart, and would not render effective compressions.

An older client is admitted with a diagnosis of bacterial pneumonia. Which symptom should the nurse report to the health care provider after assessing the client?

A. Leukocytosis and febrile B. Polycythemia and crackles C. Pharyngitis and sputum production D. Confusion and tachycardia Rationale: The onset of pneumonia in the older client may be signaled by general deterioration, confusion, increased heart rate, and/or increased respiratory rate. Options A, B, and C are often absent in the older client with bacterial pneumonia.

An older male client comes to the outpatient clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg that is warm to the touch, and the nurse suspects that the client may have thrombophlebitis. Which additional assessment is most important for the nurse to perform?

A. Measure the client's calf circumference. B. Auscultate the client's breath sounds. C. Observe for ecchymosis and petechiae. D. Obtain the client's blood pressure. All these techniques provide useful assessment data. The most important is to auscultate the client's breath sounds because the client may have a pulmonary embolus secondary to the thrombophlebitis. Option A may provide data that support the nurse's suspicion of thrombophlebitis. Option C is the least helpful assessment because bruising is not a typical finding associated with thrombophlebitis. Option D is always useful in evaluating the client's response to a problem but is of less immediate priority than breath sound auscultation.

The nurse assesses a postoperative client whose skin is cool, pale, and moist. The client is very restless and has scant urine output. Oxygen is being administered at 2 L/min, and a saline lock is in place. Which intervention should the nurse implement first?

A. Measure the urine specific gravity. B. Obtain IV fluids for infusion per protocol. C. Prepare for insertion of a central venous catheter. D. Auscultate the client's breath sounds. Rationale: The client is at risk for hypovolemic shock because of the postoperative status and is exhibiting early signs of shock. A priority intervention is the initiation of IV fluids to restore tissue perfusion. Options A, C, and D are all important interventions but are of lower priority than option B.

Client census is often used to determine staffing needs. Which method of obtaining census determination for a particular unit provides the best formula for determining long-range staffing patterns?

A. Midnight census B. Oncoming shift census C. Average daily census D. Hourly census Rationale: An average daily census is determined by trend data and takes into account seasonal and daily fluctuations, so it is the best method for determining staffing needs. Options A and B provide data at a certain point in time, and that data could change quickly. It is unrealistic to expect to obtain an hourly census, and such data would only provide information about a certain point in time.

The nurse notes that a client who is scheduled for surgery the next morning has an elevated blood urea nitrogen (BUN) level. Which condition is most likely to have contributed to this finding?

A. Myocardial infarction 2 months ago B. Anorexia and vomiting for the past 2 days C. Recently diagnosed type 2 diabetes mellitus D. Skeletal traction for a right hip fracture Rationale: The blood urea nitrogen (BUN) level indicates the effectiveness of the kidneys in filtering waste from the blood. Dehydration, which could be caused by vomiting, would cause an increased BUN level. Option A would affect serum enzyme levels, not the BUN level. Option C would primarily affect the blood glucose level; renal failure that could increase the BUN level would be unlikely in a client newly diagnosed with type 2 diabetes. Effects of option D might affect the complete blood count (CBC) but would not directly increase the BUN level.

A client with type 2 diabetes takes metformin (Glucophage) daily. The client is scheduled for major surgery requiring general anesthesia the next day. The nurse anticipates which approach to manage the client's diabetes best while the client is NPO during the perioperative period?

A. NPO except for metformin and regular snacks B. NPO except for oral antidiabetic agent C. Novolin N insulin subcutaneously twice daily D. Regular insulin subcutaneously per sliding scale Rationale: Regular insulin dosing based on the client's blood glucose levels (sliding scale) is the best method to achieve control of the client's blood glucose while the client is NPO and coping with the major stress of surgery. Option A increases the risk of vomiting and aspiration. Options B and C provide less precise control of the blood glucose level.

A practical nurse (PN) tells the charge nurse in a long-term facility that she does not want to be assigned to one particular resident. She reports that the male client keeps insisting that she is his daughter and begs her to stay in his room. What is the best managerial decision?

A. Notify the family that the resident will have to be discharged if his behavior does not improve. B. Notify administration of the PN's insubordination and need for counseling about her statements. C. Ask the PN what she has done to encourage the resident to believe that she is his daughter. D. Reassign the PN until the resident can be assessed more completely for reality orientation. Rationale: Temporary reassignment is the best option until the resident can be examined and his medications reviewed. He may have worsening cerebral dysfunction from an infection or electrolyte imbalance. Option A is not the best option because the family cannot control the resident's actions. The administration may need to know about the situation, but not as a case of insubordination. Implying that the PN is somehow creating the situation is inappropriate until a further evaluation has been conducted.

The nurse is observing an unlicensed assistive personnel (UAP) performing morning care for a bedridden client with Huntington disease. Which care measure is most important for the nurse to supervise?

A. Oral care B. Bathing C. Foot care D. Catheter care Rationale: The client with Huntington disease experiences problems with motor skills such as swallowing and is at high risk for aspiration, so the highest priority for the nurse to observe is the UAP's ability to perform oral care safely. Options B, C, and D do not necessarily require registered nurse (RN) supervision because they do not ordinarily pose life-threatening consequences.

A 63-year-old client with type 2 diabetes mellitus is admitted for treatment of an ulcer on the heel of the left foot that has not healed with wound care. The nurse observes that the entire left foot is darker in color than the right foot. Which additional symptom should the nurse expect to find?

A. Pedal pulses will be weak or absent in the left foot. B. The client will state that the left foot is usually warm. C. Flexion and extension of the left foot will be limited. D. Capillary refill of the client's left toes will be brisk. Rationale: Symptoms associated with decreased blood supply are weak or absent pedal and tibial pulses. The client with diabetes experiences vascular scarring as a result of atherosclerotic changes in the peripheral vessels. This results in compromised perfusion to the dependent extremities, which further delays wound healing in the affected foot. Although flexion and extension may be limited, depending on the degree of damage, this is not always the case. Options B and D are signs of adequate perfusion of the foot, which would not be expected in this client.

The home health nurse is assessing a male client being treated for Parkinson disease with carbidopa-levodopa. The nurse observes that he does not demonstrate any apparent emotion when speaking and rarely blinks. Which intervention should the nurse implement?

A. Perform a complete cranial nerve assessment. B. Instruct the client that he may be experiencing medication toxicity. C. Document the presence of these assessment findings. D. Advise the client to seek immediate medical evaluation. Rationale: A masklike expression and infrequent blinking are common clinical features of parkinsonism. The nurse should document these expected findings. Options A and D are not necessary. Signs of toxicity of levodopa-carbidopa, include dyskinesia, hallucinations, and psychosis.

A client in the emergency department is bleeding profusely from a gunshot wound to the abdomen. What action should the nurse immediately take to promote maintenance of the client's blood pressure above a systolic pressure of 90 mm Hg?

A. Place the client in a 45-degree Trendelenburg position to promote cerebral blood flow. B. Turn the client prone to place pressure on the abdominal wound to help staunch the bleeding. C. Maintain the client in a supine position to reduce diaphragmatic pressure and visualize the wound. D. Put the client on the right side to apply pressure to the liver and spleen to stop hemorrhaging. Rationale: Placing the client in a supine position reduces diaphragmatic pressure, thereby enhancing oxygenation, and allows for visualization of the abdominal wound. Option A compromises diaphragmatic expansion and inhibits pressoreceptor activity. Option B places the client at risk of evisceration of the abdominal wound and increased bleeding. Option D will not stop internal bleeding in the liver and spleen caused by the gunshot wound.

The nurse is assessing a 75-year-old client for symptoms of hyperglycemia. Which symptom of hyperglycemia is an older adult most likely to exhibit?

A. Polyuria B. Polydipsia C. Weight loss D. Infection Rationale: Signs and symptoms of hyperglycemia in older adults may include fatigue, infection, and evidence of neuropathy (e.g., sensory changes). The nurse needs to remember that classic signs and symptoms of hyperglycemia, such as options A, B, and C and polyphagia, may be absent in older adults.

During assessment of a client in the intensive care unit, the nurse notes that the client's breath sounds are clear on auscultation, but jugular vein distention and muffled heart sounds are present. Which intervention should the nurse implement?

A. Prepare the client for a pericardial tap. B. Administer intravenous furosemide (Lasix). C. Assist the client to cough and breathe deeply. D. Instruct the client to restrict oral fluid intake. Rationale: The client is exhibiting symptoms of cardiac tamponade, a collection of fluid in the pericardial sac that results in a reduction in cardiac output, which is a potentially fatal complication of pericarditis. Treatment for tamponade is a pericardial tap. Lasix IV is not indicated for treatment of pericarditis. Because the client's breath sounds are clear, option C is not a priority. Fluids are frequently increased in the initial treatment of tamponade to compensate for the decrease in cardiac output, but this is not the same priority as option A.

Which consideration is most important when the nurse is assigning a room for a client being admitted with progressive systemic sclerosis (scleroderma)?

A. Provide a room that can be kept warm. B. Make sure that the room can be kept dark. C. Keep the client close to the nursing unit. D. Select a room that is visible from the nurses' desk. Rationale: Abnormal blood flow in response to cold (Raynaud phenomenon) is precipitated in clients with scleroderma. Option B is not a significant factor. Stress can also precipitate the severe pain of Raynaud phenomenon, so a quiet environment is preferred to option C, which is often very noisy. Option D is not necessary.

The nurse is interviewing a client who is taking interferon-alfa-2a (Roferon-A) and ribavirin (Virazole) combination therapy for hepatitis C. The client reports experiencing overwhelming feelings of depression. Which action should the nurse implement first?

A. Recommend mental health counseling. B. Review the medication actions and interactions. C. Assess for the client's daily activity level. D. Provide information regarding a support group. Rationale: Interferon-alfa-2a and ribavirin combination therapy can cause severe depression; therefore, it is most important for the nurse to review the medication effects and report these to the health care provider. Options A, C, and D might be implemented after the physiologic aspects of the situation have been assessed.

The nurse is preparing a 45-year-old client for discharge from a cancer center following ileostomy surgery for colon cancer. Which discharge goal should the nurse include in this client's discharge plan?

A. Reduce the daily intake of animal fat to 10% of the diet within 6 weeks. B. Exhibit regular, soft-formed stool within 1 month. C. Demonstrate the irrigation procedure correctly within 1 week. D. Attend an ostomy support group within 2 weeks. Rationale: Attending a support group will be beneficial to the client and should be encouraged because adaptation to the ostomy can be difficult. This goal is attainable and is measurable. Option A is not specifically related to ileostomy care. The client with an ileostomy will not be able to accomplish option B. Option C is not necessary

What is the most important nursing priority for a client who has been admitted for a possible kidney stone?

A. Reducing dairy products in the diet B. Straining all urine C. Measuring intake and output D. Increasing fluid intake Rationale: Straining all urine is the most important nursing action to take in this case. Encouraging fluid intake is important for any client who may have a kidney stone, but it is even more important to strain all urine. Straining urine will enable the nurse to determine when the kidney stone has been passed and may prevent the need for surgery. Option C is not the highest priority action. Option A is usually not recommended until the stone is obtained and the content of the stone is determined. Even then, dietary restrictions are controversial.

The nurse is planning care for a client with diabetes mellitus who has gangrene of the toes to the midfoot. Which goal should be included in this client's plan of care?

A. Restore skin integrity. B. Prevent infection. C. Promote healing. D. Improve nutrition. Rationale: The prevention of infection is a priority goal for this client. Gangrene is the result of necrosis (tissue death). If infection develops, there is insufficient circulation to fight the infection and the infection can result in osteomyelitis or sepsis. Because tissue death has already occurred, options A and C are unattainable goals. Option D is important but of less priority than option B.

During report, the nurse learns that a client with tumor lysis syndrome is receiving an IV infusion containing insulin. Which assessment should the nurse complete first?

A. Review the client's history for diabetes mellitus. B. Observe the extremity distal to the IV site. C. Monitor the client's serum potassium and blood glucose levels. D. Evaluate the client's oxygen saturation and breath sounds. Rationale: Clients with tumor lysis syndrome may experience hyperkalemia, requiring the addition of insulin to the IV solution to reduce the serum potassium level. It is most important for the nurse to monitor the client's serum potassium and blood glucose levels to ensure that they are not at dangerous levels. Options A, B, and D provide valuable assessment data but are of less priority than option C.

In assessing a client diagnosed with primary aldosteronism, the nurse expects the laboratory test results to indicate a decreased serum level of which substance?

A. Sodium B. Phosphate C. Potassium D. Glucose Rationale: Clients with primary aldosteronism exhibit a profound decline in serum levels of potassium; hypokalemia; hypertension is the most prominent and universal sign. The serum sodium level is normal or elevated, depending on the amount of water resorbed with the sodium. Option B is influenced by parathyroid hormone (PTH). Option D is not affected by primary aldosteronism.

A client diagnosed with angina pectoris complains of chest pain while ambulating in the hallway. Which action should the nurse implement first?

A. Support the client to a sitting position. B. Ask the client to walk slowly back to the room. C. Administer a sublingual nitroglycerin tablet. D. Provide oxygen via nasal cannula. Rationale: The nurse should safely assist the client to a resting position and then perform options C and D. The client must cease all activity immediately, which will decrease the oxygen requirement of the myocardial muscle. After these interventions are implemented, the client can be escorted back to the room via wheelchair or stretcher.

The nurse assesses a client who has been prescribed furosemide (Lasix) for cardiac disease. Which electrocardiographic change would be a concern for a client taking a diuretic?

A. Tall, spiked T waves B. A prolonged QT interval C. A widening QRS complex D. Presence of a U wave Rationale: A U wave is a positive deflection following the T wave and is often present with hypokalemia (low potassium level). Options A, B, and C are all signs of hyperkalemia.

When developing a discharge teaching plan for a client after the insertion of a permanent pacemaker, the nurse writes a goal of "The client will verbalize symptoms of pacemaker failure." Which behavior indicates that the goal has been met?

A. The client demonstrates the procedures to change the rate of the pacemaker using a magnet. B. The client carries a card in his wallet stating the type and serial number of the pacemaker. C. The client tells the nurse that it is important to report redness and tenderness at the insertion site. D. The client states that changes in the pulse and feelings of dizziness are significant changes. Rationale: Changes in pulse rate and/or rhythm may indicate pacer failure. Feelings of dizziness may be caused by a decreased heart rate, leading to decreased cardiac output. The rate of a pacemaker is not changed by a client, although the client may be familiar with this procedure as explained by his health care provider. Option B is an important step in preparing the client for discharge but does not demonstrate knowledge of the symptoms of pacer failure. Option C indicates symptoms of possible incisional infection or irritation but does not indicate pacer failure.

A 55-year-old male client has been admitted to the hospital with a medical diagnosis of chronic obstructive pulmonary disease (COPD). Which risk factor is the most significant in the development of this client's COPD?

A. The client's father was diagnosed with COPD in his 50s. B. A close family member contracted tuberculosis last year. C. The client smokes one to two packs of cigarettes per day. D. The client has been 40 pounds overweight for 15 years. Rationale: Smoking, considered to be a modifiable risk factor, is the most significant risk factor for the development of COPD. The exact mechanism of genetic and hereditary implications for the development of COPD is still under investigation, although exposure to similar predisposing factors (e.g., smoking or inhaling secondhand smoke) may increase the likelihood of COPD incidence among family members. Options B and D do not exceed the risks associated with cigarette smoking in the development of COPD.

A 58-year-old client who has no health problems asks the nurse about receiving the pneumococcal vaccine. Which statement given by the nurse would offer the client accurate information about this vaccine?

A. The vaccine is given annually before the flu season to those older than 50 years. B. The immunization is administered once to older adults or those at risk for illness. C. The vaccine is for all ages and is given primarily to those persons traveling overseas to areas of infection. D. The vaccine will prevent the occurrence of pneumococcal pneumonia for up to 5 years. Rationale: It is usually recommended that persons older than 65 years and those with a history of chronic illness should receive the vaccine once in their lifetime. Some recommend receiving the vaccine at 50 years of age. The influenza vaccine is given once a year. Although the vaccine might be given to a person traveling overseas, that is not the main rationale for administering the vaccine. The vaccine is usually given once in a lifetime, but with immunosuppressed clients or clients with a history of pneumonia, revaccination is sometimes required.

The nurse is caring for a client with a chest tube to water seal drainage that was inserted 10 days ago because of a ruptured bullae and pneumothorax. Which finding should the nurse report to the health care provider before the chest tube is removed?

A. Tidaling of water in water seal chamber B. Bilateral muffled breath sounds at bases C. Temperature of 101° F D. Absence of chest tube drainage for 2 days Rationale: Tidaling (rising and falling of water with respirations) in the water seal chamber should be reported to the health care provider before the chest tube is removed to rule out an unresolved pneumothorax or persistent air leak, which is characteristic of a ruptured bullae caused by abnormally wide changes in negative intrathoracic pressure. Option B may indicate hypoventilation from chest tube discomfort and usually improves when the chest tube is removed. Option C usually indicates an infection, which may not be related to the chest tube. Option D is an expected finding.

A client with alcohol-related liver disease is admitted to the unit. Which prescription should the nurse call the health care provider about for reverification for this client?

A. Vitamin K1, 5 mg IM daily B. High-calorie, low-sodium diet C. Fluid restriction to 1500 mL/day D. Nembutal sodium at bedtime for rest Rationale: Sedatives such as pentobarbital are contraindicated for clients with liver damage and can have dangerous consequences. Option A is often prescribed because the normal clotting mechanism is damaged. Option B is needed to help restore energy to the debilitated client. Sodium is often restricted because of edema. Fluids are restricted to decrease ascites, which often accompanies cirrhosis, particularly in the later stages of the disease.

azotemia

excessive) urea and nitrogenous substances in the blood

thrombophlebitis

inflammation of a vein associated with a clot formation

pericardiocentesis aka pericardial tap

surgical puncture to aspirate fluid from the sac surrounding the heart