HESI Med Surgical Practice (evolve)

The nurse is caring for a client with peptic ulcer disease (PUD). Which assessment should the nurse identify and document that is consistent with PUD? (Select all that apply). a. Hematemesis. b. Gastric pain on an empty stomach. c. Colic-like pain with fatty food ingestion. d. Intolerance of spicy foods. e. Diarrhea and stearrhea.

a. Hematemesis. b. Gastric pain on an empty stomach. d. Intolerance of spicy foods. Manifestations of PUD include hematemesis, gastric pain, and spicy food intolerance.

A client who is admitted to the emergency department with a possible tension pneumothorax after a motor vehicle collision is having multiple diagnostic tests. Which finding requires immediate action by the nurse? a. Serum amylase of 132 units/L. b. Serum sodium of 134 mEq/L. c. Chest x-ray indicating a mediastinal shift. d. Abdominal x-ray with air noted throughout intestines.

c. Chest x-ray indicating a mediastinal shift. Immediate action is required for findings of a mediastinal shift, which can precipitate life-threatening cardiovascular collapse as the great cardiac vessels become kinked and compressed due to the tension pneumothorax.

A female client admitted with abdominal pain is diagnosed with cholelithiasis. The client asks the nurse what she should expect as a common treatment. Which recommended plan of care should the nurse provide the client? a. Rest with liquid diet only. b. Drugs such as ursodiol. c. Cholecystectomy via laparoscopy. d. LaVeen vena caval shunt.

c. Cholecystectomy via laparoscopy. The nurse should explain to the client that gall bladder surgical removal is most often recommended via laparoscopic excision.

The nurse recognizes which client group is at the greatest risk for developing a urinary tract infection (UTI)? (Rank from highest risk to lowest risk.) 1. Older females. 2. Older males. 3. School-age females. 4. Adolescent males.

1. Older females 2. School-age females 3. Older males 4. Adolescent males Hypoestrogenism and alkalotic urine are other age-related factors that put older women at the highest risk for UTIs. School-age girls (6 to 12 years) are at risk for UTIs due to a higher prevalence of taking baths instead of showers, but these risks can be controlled in this population as well as hypoestrogenism and alkalotic urine. Older men are at risk due to possible obstruction of the bladder due to benign prostatic hypertrophy (BPH). Adolescent males (12 to 19 years) are the lowest at risk for a UTI.All individuals regardless of gender and/or age are at risk if the following conditions exist: vesicoureteral reflux, neuromuscular conditions, like Parkinson's disease, previous brain attacks, or the use of anticholinergic medications can all cause incomplete bladder emptying which can create bacterial overgrowth. Fecal and urinary incontinence contributes to poor perineal hygiene and bacterial growth.

The nurse is providing discharge instructions to a client who has undergone a left orchiectomy for testicular cancer. Which statement indicates that the client understands his postoperative care and prognosis? a. "I should continue to perform testicular self-examination (TSE) monthly on my remaining testicle." b. "I should wear an athletic supporter and cup to prevent testicular cancer in my remaining testicle." c. "I should always use a condom because I am at increased risk for acquiring a sexually transmitted disease." d. "I should make sure my sons know how to perform TSE because they are at increased risk for this type of cancer."

a. "I should continue to perform testicular self-examination (TSE) monthly on my remaining testicle." Although testicular cancer protocols, such as surgery, radiation, or chemotherapy, focus on the primary site of testicular cancer, these treatments do not reduce the risk of testicular cancer in the remaining testicle, so early recognition is the best prevention. The client's understanding is reflected in the statement to perform monthly TSE for changes in size, shape, or consistency of the testis that may indicate early cancer.

The nurse is caring for a young adult who is having an oral glucose tolerance test (OGTT). Which laboratory result should the nurse assess as a normal value for the two-hour postprandial result? a. 140 mg/dL. b. 160 mg/dL. c. 180 mg/dL. d. 200 mg/dL.

a. 140 mg/dL. The two-hour postprandial level should be less than 140 mg/dL for a young adult client.

Which client should be further assessed for an ectopic pregnancy? a. A 24-year-old with shoulder and lower abdominal quadrant pain. b. A 33-year-old with intermittent lower abdominal cramping. c. A 20-year-old with fever and right lower abdominal colic. d. A 40-year-old with jaundice and right lower abdominal pain.

a. A 24-year-old with shoulder and lower abdominal quadrant pain. A 24-year-old with sudden onset of lower abdominal quadrant pain should be assessed for an ectopic pregnancy. The pain can also be referred to the shoulder and may be associated with vaginal bleeding.

When planning care for a client with right renal calculi, which nursing problem has the highest priority? a. Acute pain related to movement of the stone. b. Impaired urinary elimination related to the obstructed flow of urine. c. Risk for infection related to urinary stasis. d. Deficient knowledge related to the need for prevention of recurrence of calculi.

a. Acute pain related to movement of the stone. The nursing problem of the highest priority is "Acute pain related to the renal calculi's movement".

The home health nurse is assessing a client with terminal lung cancer who is receiving hospice care. Which activity should be assigned to the hospice practical nurse (PN)? a. Administer medications for pain relief, shortness of breath, and nausea. b. Clarify family members' feelings about the meaning of the client's behaviors and symptoms. c. Develop a plan of care after assessing the needs of the client and family. d. Teach the family to recognize restlessness and grimacing as signs of client discomfort.

a. Administer medications for pain relief, shortness of breath, and nausea. Hospice care provides symptom management and pain control during the dying process and enhances the quality of life for a client who is terminally ill. Administering medication and monitoring for therapeutic and adverse effects is within the scope of practice for the PN. Scope of practice guidelines vary by state and country and should be consulted when delegating.

A client with heart failure is prescribed digoxin 0.125 mg PO. The client's apical heart rate is 70 beats per minute, respirations are 18 breaths per minute and blood pressure is 125/75 mmHg. Which action should the nurse implement next? a. Administer the medication. b. Inform the healthcare provider. c. Review the vital sign flowsheet. d. Reassess the apical heart rate.

a. Administer the medication. Obtaining the apical heart rate is a common parameter prior to administering digoxin, which may indicate early digoxin toxicity if the heart rate is less than 60 beats per minute, so the dose should be administered since the client is not demonstrating any signs of toxicity.

The nurse is teaching a client diagnosed with peripheral arterial disease. Which genitourinary system complication should the nurse include in the teaching? a. Altered sexual response. b. Sterility. c. Urinary incontinence. d. Decreased pelvic muscle tone.

a. Altered sexual response. Peripheral arterial disease (PAD) is a cardiovascular condition characterized by narrowing of the arteries and reduced blood flow to the extremities. PAD is known to alter the blood flow to the male's penis and is associated with erectile dysfunction in men.

A client arrives at the emergency department for treatment of injuries sustained in a motor vehicle collision. The nurse notes the asymmetrical expansion of the chest wall during respiration. Which action should the nurse implement next? a. Auscultate the lungs bilaterally. b. Inspect the overall skin color. c. Palpate for tactile fremitus. d. Percuss the chest for resonance.

a. Auscultate the lungs bilaterally. Chest trauma may result in the development of pneumothorax. After noting the asymmetric expansion of the chest wall, the nurse should auscultate the lungs to determine if the client can move air through all of the lung fields.

A female client is recently diagnosed with Sarcoidosis. The client tells the nurse that she does not understand why she has this. When teaching about the occurrence of sarcoidosis, the nurse should include that sarcoidosis most commonly occurs in which ethnic group of women? a. Black women. b. Caucasian women. c. Asian women. d. Hispanic women.

a. Black women. Sarcoidosis, an autoimmune inflammatory disease affecting multiple organs, has shown familial tendency due to multiple genes that together increase the susceptibility of developing the disease. In the United States, sarcoidosis more commonly affects Black Americans than white Americans and is twice as common in Black-American women as in Black-American men.

Which instruction should the nurse include in the discharge teaching for a client who needs to perform the self-catheterization technique at home? a. Catheterize every 4 to 6 hours. b. Maintain sterile technique. c. Use the Crede maneuver before catheterization. d. Drink 500 mL of fluid within 2 hours of catheterization.

a. Catheterize every 4 to 6 hours. The average interval between catheterizations for adults is every 4 to 6 hours. Although the sterile technique is indicated in healthcare facilities, the clean technique is often followed by the client when performing self-catheterization at home.

A male client comes into the clinic with a history of penile discharge with painful, burning urination. Which action should the nurse implement? a. Collect a culture of the penile discharge. b. Palpate the inguinal lymph nodes gently. c. Observe for scrotal swelling and redness. d. Express the discharge to determine color.

a. Collect a culture of the penile discharge. Penile discharge with painful urination is commonly associated with gonorrhea. The nurse should collect a culture of the penile discharge to determine the cause of these symptoms. The cause must be determined or confirmed through culture to identify the organism and ensure effective treatment.

The nurse is assessing a client who is bedfast and refuses to turn or move from a supine position. How should the nurse assess the client for possible dependent edema? a. Compress the flank and upper buttocks. b. Measure the client's abdominal girth. c. Gently palpate the lower abdomen. d. Apply light pressure over the shins.

a. Compress the flank and upper buttocks. Dependent edema collects in dependent areas, such as the flank and upper buttocks of the client who is persistently flat in bed. By compressing these areas, the nurse can determine if any pitting edema is present.

Which assessment finding is of greatest concern to the nurse who is caring for a client with stomatitis? a. Cough brought on by swallowing. b. Sore throat caused by speaking. c. Painful and dry oral cavity. d. Unintended weight loss.

a. Cough brought on by swallowing. A cough brought on by swallowing is a sign of dysphagia, which is a finding of particular concern in a client with stomatitis. Dysphagia can cause numerous problems, including airway obstruction, and should be reported to the healthcare provider immediately.

A client has been told that there is cataract formation over his both eyes. Which finding should the nurse expect when assessing the client? a. Decreased color perception. b. Presence of floaters. c. Loss of central vision. d. Reduced peripheral vision.

a. Decreased color perception. Decreased color perception occurs with cataract formation. Cataract formation is also associated with blurred vision and a global loss of vision that is so gradual that the client may not be aware of it.

The unlicensed assistive personnel (UAP) reports that an 87-year-old female client who is sitting in a chair at the bedside has an oral temperature of 97.2 °F (36.2 °C). Which intervention should the nurse implement? a. Document the temperature reading on the vital sign graphic sheet. b. Report the temperature to the healthcare provider immediately. c. Instruct the UAP to take the client's temperature again in 30 minutes. d. Advise the UAP to assist the client in returning to her bed.

a. Document the temperature reading on the vital sign graphic sheet. A subnormal temperature of 97.2 °F (36.2 °C) (orally) is a common finding in older clients, so the nurse should document the findings and continue with the plan of care.

Which dietary assessment finding is most important for the nurse to address when caring for a client with diabetic nephropathy? a. Drinks a six-pack of beer every day. b. Enjoys a hamburger once a month. c. Eats fortified breakfast cereal daily. d. Consumes beans and rice every day.

a. Drinks a six-pack of beer every day. Drinking six beers every day is the dietary assessment finding most important for the nurse to address when caring for a client with diabetic nephropathy. The usual can of beer is 12 ounces (360 mL). Clients with diabetes are recommended to drink no more than 12 ounces of beer per day because beer contains carbohydrates that can create unhealthy fluctuations in blood glucose and promote poor glucose control. Nephropathy is exacerbated by poor blood glucose control.

When teaching a client with breast cancer about the prescribed radiation therapy for treatment, which information is important to include? a. Dry, itchy skin changes may occur. b. There is a possibility of long bone pain. c. Permanent pigment changes to the breast may result. d. A low-residue diet may be ordered to reduce the likelihood of diarrhea.

a. Dry, itchy skin changes may occur. Side effects from radiation to the breast most often include temporary skin changes such as dryness, tenderness, redness, swelling, and pruritus

The nurse is assessing common complications related to a client's recent diagnosis, systemic lupus erythematosus (SLE). Which symptom should the nurse instruct the client to report immediately? a. Fever related to infection. b. Weight loss and anorexia. c. Depressed mood. d. Break in tissue integrity.

a. Fever related to infection. Secondary infections are a major concern with SLE clients due to the use of corticosteroids and chemotherapeutic agents, which suppresses the immune system, so reporting fever and infections should be reported immediately.

A young adult female reports that she is experiencing a lack of appetite, hypersomnia, stress incontinence, and irritability. Which symptom is not frequently associated with PMS? a. Heart palpitations. b. Anorexia. c. Hypersomnia. d. Stress incontinence.

a. Heart palpitations. Characteristic features of premenstrual syndrome include behavioral changes/irritability, sleeplessness, increased appetite and food cravings, and oliguria or enuresis. While heart palpitations can occur at times with PMS, it is not a characteristic finding.

A client with osteoarthritis requests information from the nurse about which type of exercise regimen would be most beneficial for him. The nurse should communicate which information? a. Low-impact exercise, walking, swimming, and water aerobics. b. Repetitive strength-building exercises with weights or resistance bands. c. Circuit training alternating with frequent rest periods. d. High-impact aerobic exercise.

a. Low-impact exercise, walking, swimming, and water aerobics. Low-impact exercises such as walking or swimming, that do not put additional pressure and strain or cause further harm to damaged joints, are most beneficial to clients with osteoarthritis. Strength-building exercises, circuit training, and high-impact aerobics may cause too much stress on the joint areas and subsequently increase inflammation and damage.

The nurse is caring for a client scheduled to undergo the insertion of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks the nurse to explain how a PEG tube differs from a gastrostomy tube (GT). Which explanation best describes how they are different? a. Method of insertion. b. Location of the tubes. c. Diameter of the tubes. d. Procedure for feedings.

a. Method of insertion. The best explanation of how a PEG tube differs from a GT is by the method of insertion. GT insertion involves making an incision in the wall of the abdomen and suturing the tube to the gastric wall. A PEG tube is more commonly used due to the fact it does not require general anesthesia and is less invasive due to being inserted with endoscopic visualization through the esophagus into the stomach and then pulled through a small incision in the abdominal wall and held in place by a tiny plastic device called a "bumper" that holds the tube in place inside the stomach and a small water-filled balloon which keeps the stomach in place against the abdominal wall.

While caring for a client who has esophageal varices, which nursing intervention is most important for the nurse to implement? a. Monitor infusing IV fluids and any replacement blood products. b. Prepare for esophagogastroduodenoscopy (EGD). c. Maintain the client on strict bedrest. d. Insert a nasogastric tube (NGT) for intermittent suction.

a. Monitor infusing IV fluids and any replacement blood products. Maintaining hemodynamic stability in a client with esophageal varices can precipitate a life-threatening crisis if esophageal varies leak or rupture and can result in hemorrhage. The priority is assessing and monitoring infusions of IV fluids and any replacement blood products.

The nurse is preparing a client for orthopedic surgery on the left leg and completing a safety checklist before transport to the operating room. Which items should the nurse remove from the client? (Select all that apply.) a. Nail polish. b. Hearing aids may be left in place so the client can hear all instructions but should be removed prior to induction. c. Wedding band. d. Left leg brace. e. Contact lenses. f. Partial dentures.

a. Nail polish. b. Hearing aids may be left in place so the client can hear all instructions but should be removed prior to induction. e. Contact lenses. f. Partial dentures. The removal of nail polish provides more accurate pulse oximetry readings and evaluation of capillary refill. Hearing aids, contact lenses, and partial dentures are removed to prevent damage, loss or misplacement, or injury during surgery. Ideally, give the client's significant other the contact lenses if they are not disposable ones, hearing aids, and partial dentures once placed in an appropriately labeled container to hold for safekeeping. If no significant other is able to hold onto the items, then secure them in an appropriate and safe place.

Which assessment finding should most concern the nurse who is monitoring a client two hours after a thoracentesis? a. New onset of coughing. b. Low resting heart rate. c. Distended neck veins. d. Decreased shallow respirations.

a. New onset of coughing. A pneumothorax (partial or complete lung collapse) is the potential complication of a thoracentesis. Manifestations of a pneumothorax include the new onset of a nagging cough, tachycardia, and an increased shallow respiration rate.

A male client with sickle cell anemia, who has been hospitalized for another health problem, tells the nurse he has had an erection for over 4 hours. Which action should the nurse implement first? a. Notify the client's healthcare provider. b. Document the finding in the client record. c. Prepare a warm enema solution for rectal instillation. d. Obtain a large bore needle for aspiration of the corpora cavernosa.

a. Notify the client's healthcare provider. Priapism, a urologic emergency, is common during sickle cell crisis due to sickle cells clogging the microcirculation in the penis, causing a reduction of blood flow and oxygenation to the penis, so the healthcare provider should be first notified immediately. The prescribed therapy may consist of noninvasive measures such as applying ice to the penis, instilling a warm solution enema to increase outflow in the corpora cavernosa, and giving pain medications. If noninvasive measures do not work, then needle aspiration of the corpora cavernosa is implemented by the healthcare provider.

A client who is admitted to the coronary care unit with a myocardial infarction (MI) begins to develop increased pulmonary congestion, an increase in heart rate from 80 to 102 beats per minute, and cold, clammy skin. Which action should the nurse implement? a. Notify the healthcare provider. b. Increase the IV flow rate. c. Place the client in the supine position. d. Prepare the client for emergency echocardiography.

a. Notify the healthcare provider. Increased pulmonary congestion, increased heart rate, and cold, clammy skin in a client with a myocardial infarction indicate impending cardiogenic shock related to heart failure, a common complication of MI. The healthcare provider should be notified immediately for emergency interventions for this life-threatening complication.

During the assessment of a client who is 24 hours post hemicolectomy with a temporary colostomy, the nurse determines that the client's stoma is dry and dark red in color. Which action should the nurse implement? a. Notify the surgeon. b. Document the assessment. c. Secure a colostomy pouch over the stoma. d. Place petrolatum gauze dressing over the stoma.

a. Notify the surgeon. The stoma should appear reddish pink and moist, which indicates circulatory perfusion to the surgical diversion of the intestine. If the stoma becomes dry, firm, flaccid, or dark red or purple, the stoma is ischemic, and the surgeon should be notified immediately.

Which action should the nurse implement on the scheduled day of surgery for a client with type 1 diabetes mellitus (DM)? a. Obtain a prescription for an adjusted dose of insulin. b. Administer an oral antidiabetic agent. c. Give an insulin dose using the parameters of a sliding scale. d. Withhold insulin while the client is NPO.

a. Obtain a prescription for an adjusted dose of insulin. Stressors, such as surgery, increase serum glucose levels. A client with type 1 DM who is NPO for scheduled surgery should receive a prescribed adjusted dose of insulin.

A client with a recent history of blood in his stools is scheduled for a proctoscopy/sigmoidoscopy. The nurse should implement which protocols to prepare the client for this procedure? (Select all that apply.) a. Obtain consent for the procedure. b. Initiate preoperative sedation. c. Begin fast the morning of the procedure. d. Administer an enema before the procedure. e. Provide a clear-liquid diet 48 hours before the procedure.

a. Obtain consent for the procedure. c. Begin fast the morning of the procedure. d. Administer an enema before the procedure. e. Provide a clear-liquid diet 48 hours before the procedure. The usual preoperative preparation for proctoscopy/sigmoidoscopy entails obtaining the client's consent to the procedure, a clear liquid diet for 24 to 48 hours prior to the procedure, administration of an enema, and fasting on the morning of the procedure.

A 40-year-old female client has a history of smoking. Which finding should the nurse identify as a risk factor for myocardial infarction? a. Oral contraceptives. b. Senile osteopenia. c. Levothyroxine therapy. d. Pernicious anemia.

a. Oral contraceptives. Women older than 35 years old who smoke and take oral contraceptives have an increased risk of myocardial infarction or stroke.

The nurse is assisting the healthcare provider (HCP) with the removal of a chest tube. Which intervention has the highest priority and should be anticipated by the nurse after the removal of the chest tube? a. Prepare the client for a chest x-ray at the bedside. b. Review arterial blood gases after removal. c. Elevate the head of the bed to 45 degrees. d. Assist with disassembling the drainage system.

a. Prepare the client for a chest x-ray at the bedside. A chest x-ray should be performed immediately after the removal of a chest tube to ensure lung expansion has been maintained after its removal.

The nurse should explain to a client with lung cancer that pleurodesis is performed to achieve which expected outcome? a. Prevent the formation of effusion fluid. b. Remove fluid from the intrapleural space. c. Debulk tumor to maintain patency of air passages. d. Relieve empyema after pneumonectomy.

a. Prevent the formation of effusion fluid. Instillation of a sclerosing agent to create pleurodesis is aimed at preventing the formation of a pleural effusion by causing the pleural spaces to be sealed together, thereby preventing the accumulation of pleural fluid.

During the initial outbreak of genital herpes simplex for a female client, which should be the nurse's primary focus in planning care? a. Promotion of comfort. b. Prevention of pregnancy. c. Instruction in condom use. d. Information about transmission.

a. Promotion of comfort. The initial outbreak of genital herpes simplex in a woman causes severe discomfort. The promotion of comfort is the first priority.

Which assessment is most important for the nurse to perform on a client who is hospitalized for Guillain-Barre syndrome that is rapidly progressing? a. Respiratory effort. b. Unsteady gait. c. Intensity of pain. d. Ability to eat.

a. Respiratory effort. Guillain-Barre syndrome causes paralysis or weakness that typically starts at the feet and progresses upwards. As the condition progresses, the nurse must ensure that the client is able to breathe effectively.

The nurse is caring for a client with tuberculosis (TB) who is taking a combination drug regimen. The client complains about taking "so many pills." Which information should the nurse provide to the client about the prescribed treatment? a. The development of resistant strains of TB is decreased with a combination of drugs. b. Compliance with the medication regimen is challenging but should be maintained. c. Side effects are minimized with the use of a single medication but are less effective. d. The treatment time is decreased from 6 months to 3 months with this standard regimen.

a. The development of resistant strains of TB is decreased with a combination of drugs. Combination therapy is necessary to decrease the development of resistant strains of TB and ensure treatment efficacy.

The nurse is assessing a client with a chest tube that is attached to suction and a closed drainage system. Which finding is most important for the nurse to further assess? a. Upper chest subcutaneous emphysema. b. Tidaling (fluctuation) of fluid in the water-seal chamber. c. Constant air bubbling in the suction-control chamber. d. Pain rated "8" (0 to 10) at the insertion site.

a. Upper chest subcutaneous emphysema. Subcutaneous emphysema is a complication and indicates air is leaking beneath the skin surrounding the chest tube.

The nurse is caring for a client who developed oliguria and was diagnosed with sepsis and dehydration 48 hours ago. Which assessment finding indicates to the nurse that the client is stabilizing? a. Urine output of 40 mL/hour. b. Apical pulse 100 beats per minute and blood pressure 76/42 mmHg. c. Urine specific gravity 1.001. d. Tented skin on the dorsal surface of hands.

a. Urine output of 40 mL/hour. A decrease in urinary output is a sign of dehydration. When the urine output returns to a normal range, no less than 30 mL/hour, the client's kidneys are perfusing adequately which indicates the client's status is stabilizing.

Which intervention should the nurse implement that best confirms the placement of an endotracheal tube (ETT)? a. Use an end-tidal CO2 detector. b. Auscultate for bilateral breath sounds. c. Obtain pulse oximeter reading. d. Check symmetrical chest movement.

a. Use an end-tidal CO2 detector. The end-tidal carbon dioxide detector indicates the presence of CO2 tidal by a color change or a number indicated on the detector, which is supporting evidence that the ETT is in the trachea, not the esophagus.

The nurse is assessing a client admitted from the emergency room with gastrointestinal bleeding related to peptic ulcer disease (PUD). Which physiological factors can produce ulceration? (Select all that apply.) a. Vagal stimulation. b. An increased level of stress. c. Decreased duodenal inhibition. d. Hypersecretion of hydrochloric acid. e. An increased number of parietal cells.

a. Vagal stimulation. c. Decreased duodenal inhibition. d. Hypersecretion of hydrochloric acid. e. An increased number of parietal cells. Hypersecretion of gastric juices and an increased number of parietal cells that stimulate secretion are most often the causes of ulceration. Vagal stimulation and decreased duodenal inhibition also increase the secretion of caustic fluids.

Which assessment finding should the nurse identify that indicates a client with an acute asthma exacerbation is beginning to improve after treatment? a. Wheezing becomes louder. b. Cough remains unproductive. c. Vesicular breath sounds decrease. d. Bronchodilators stimulate coughing.

a. Wheezing becomes louder. In an acute asthma attack, airflow may be so significantly restricted that breath sounds and wheezing is diminished. If the client is successfully responding to bronchodilators and respiratory treatments, wheezing should become louder as the airflow increases in the airways. As the airways open and mucous is mobilized in response to treatment, the cough should become more productive.

Which findings are within the expected parameters of a normal urinalysis for an older adult? (Select all that apply.) a. pH 6. b. Nitrate small. c. Protein small. d. Sugar negative. e. Bilirubin negative. f. Specific gravity 1.015.

a. pH 6. d. Sugar negative. e. Bilirubin negative. f. Specific gravity 1.015. A pH of 6.0 is within the normal pH range for urine. Glucosuria and bilirubinuria are abnormal and should be negative upon urinalysis. Normal changes associated with aging include decreased creatinine clearance and decreased concentrating and diluting abilities which influence the normal range of urine specific gravity, 1.001 to 1.035. Although common health problems associated with aging include renal insufficiency, urinary incontinence, urinary tract infection, and enlarged prostate, these are indicative of pathology which should be treated.

A couple trying to cope with an infertility problem wants to know what can be done to preserve emotional equilibrium. Which is the best response for the nurse to provide? a. "Tell your friends and family so that they can help you." b. "Get involved with a support group. I will give you some names." c. "Talk only to other friends who are infertile since only they can help." d. "Start adoption proceedings immediately since obtaining an infant is very difficult."

b. "Get involved with a support group. I will give you some names." A support group provides a safe haven for the couple to share their feelings and experience and gain insight from others dealing with the same experience and let's them know they are not alone in their situation.

A client with acute appendicitis is experiencing anxiety and loss of sleep about missing the final examination week at college. Which outcome is most important for the nurse to include in the plan of care? a. Sleeping six to eight hours. b. Achieve a sense of control. c. Utilize problem-solving skills. d. Increased focus of attention.

b. Achieve a sense of control. The experience of psychological discomfort may be as real as physical pain for the client and should be seen as a priority in care. Because the client is experiencing anxiety, achieving a sense of control is the overall outcome of this client's nursing care plan.

The nurse is caring for a client with acute pancreatitis and assesses the admission laboratory results. Which laboratory value should the nurse anticipate being elevated with this diagnosis? a. Triglycerides. b. Amylase. c. Creatinine. d. Uric acid.

b. Amylase. An elevated amylase level is associated with acute pancreatitis.

The nurse directs an unlicensed assistive personnel (UAP) to obtain the vital signs of a client who returns to the unit after having a mastectomy for cancer. Which information should the nurse provide the UAP? a. Elevate the arm with an IV infusing on the operative side with a pillow. b. Apply the blood pressure cuff to the arm on the non-operative side. c. Position the arm on the operative side close to the body. d. Collect a fingerstick blood specimen from the arm on the operative side.

b. Apply the blood pressure cuff to the arm on the non-operative side. The nurse gives the UAP the following instructions when providing care to a post-op mastectomy client. Blood pressure readings should be obtained from the arm on the nonoperative side to reduce the risk of injury to the extremity that may have compromised lymphatic drainage postoperatively. The arm on the operative side of the mastectomy should be elevated on a pillow above the level of the right atrium to facilitate lymphatic drainage.

A client with a chronic infection of Hepatitis C virus (HCV) is scheduled for a liver biopsy. Which intervention should the nurse perform after the procedure? a. Progress activity as soon as possible. b. Assess for signs of bleeding and hypovolemia. c. Place the client in the left lateral position. d. Monitor blood pressure, pulse and breathing every 4 hours.

b. Assess for signs of bleeding and hypovolemia. Assessment for signs of bleeding should be implemented because internal bleeding is the greatest risk following a liver biopsy.

The nurse completes a visual inspection of a client's abdomen. Which technique should the nurse perform next in the abdominal examination? a. Percussion. b. Auscultation. c. Deep palpation. d. Light palpation.

b. Auscultation. Auscultation of the client's abdomen is performed next because manual manipulation of the abdomen can stimulate peristalsis and create an inaccurate assessment of bowel sounds heard during auscultation.

The nurse is caring for a client with non-Hodgkin's lymphoma who is receiving chemotherapy. Laboratory results reveal a platelet count of 10,000/mL. Which action should the nurse implement? a. Encourage fluids to 3000 mL/day. b. Check stools for occult blood. c. Provide oral hygiene every 2 hours. d. Check for fever every 4 hours.

b. Check stools for occult blood. Platelet counts less than 100,000/mm3 are indicative of thrombocytopenia, a common side effect of chemotherapy. A client with thrombocytopenia should be assessed frequently for occult bleeding in the emesis, sputum, feces, urine, nasogastric secretions, or wounds.

A client with sickle cell anemia is admitted with severe abdominal pain and the diagnosis is sickle cell crisis. Which is the most important nursing action to implement? a. Limit the client's intake of oral fluids and food. b. Evaluate the effectiveness of narcotic analgesics. c. Encourage the client to ambulate as tolerated. d. Teach the client about the prevention of crises.

b. Evaluate the effectiveness of narcotic analgesics. Pain management is the priority for a client during sickle cell crisis. Continuous narcotic analgesics are the mainstay of pain control, which should be evaluated frequently to determine if the client's pain is adequately controlled.

The nurse is caring for a client with end-stage liver disease who is being assessed for the presence of asterixis. To assess the client for asterixis, which position should the nurse ask the client to demonstrate? a. Extend the left arm laterally with the left palm upward. b. Extend the arm, dorsiflex the wrist, and extend the fingers. c. Extend the arms and hold this position for 30 seconds. d. Extend arms with both legs adducted to shoulder width.

b. Extend the arm, dorsiflex the wrist, and extend the fingers. Asterixis (flapping tremor, liver flap) is a hand-flapping tremor that is often seen frequently in hepatic encephalopathy. The tremor is induced by extending the arm and dorsiflexing the wrist causing rapid, non-rhythmic extension and flexion of the wrist while attempting to hold position.

An older female client is admitted with atrophic vaginitis and perineal cutaneous candidiasis. Which is the priority nursing problem for this client? a. Risk for injury. b. Impaired comfort. c. Disturbed body image. d. Ineffective health maintenance.

b. Impaired comfort. In menopausal women, the vaginal mucous membrane responds to low estrogen levels causing the vaginal walls to become thinner, drier, and susceptible to infection which leads to atrophic vaginitis. Perineal cutaneous candidiasis contributes to other manifestations of vaginal infections, such as vaginal irritation, burning, pruritus, increased leukorrhea, bleeding, and dyspareunia, which supports the primary nursing problem, "Impaired comfort".

A college student who is diagnosed with a vaginal infection and vulva irritation describes the vaginal discharge as having a "cottage-cheese" appearance. Which prescription should the nurse implement first? a. Cleanse the perineum with warm soapy water 3 times per day. b. Instill the first dose of nystatin vaginally per applicator. c. Perform glucose measurement using a capillary blood sample. d. Obtain a blood specimen for sexually transmitted diseases (STDs).

b. Instill the first dose of nystatin vaginally per applicator. Candidiasis, also known as a yeast infection, is characterized by a white, vaginal discharge with a "cottage-cheese" appearance, and vaginal nystatin should be implemented first to initiate treatment to provide relief of symptoms.

A client's prostate-specific antigen (PSA) exam result showed a PSA density of 0.13 ng/mL. Which conclusion regarding this lab data is accurate? a. Probable prostatitis. b. Low risk for prostate cancer. c. The presence of cancer cells. d. A biopsy of the prostate is indicated.

b. Low risk for prostate cancer. Clients with a PSA density of less than 0.15 ng/mL are considered at low risk for prostate cancer.

The nurse is providing instructions about log rolling to a client who returns to the postoperative unit after a lumbar laminectomy. Which explanation should the nurse give the client about this technique? a. Helps to minimize pain and anxiety. b. Maintains correct spinal alignment to protect the surgical area. c. Prevents dizziness while stabilizing the spine. d. Allows the nurse to move the client freely without assistance.

b. Maintains correct spinal alignment to protect the surgical area. Log-rolling technique maintains the spine in a straight superior-inferior plane that aligns the spine without movement while protecting the surgical area, which is especially important when the procedure involves bone grafts that may take several weeks for the bone to fuse.

The nurse is caring for a client who is two days postoperative. Which observation should alert the nurse to call the Rapid Response Team (RRT)? a. Fresh bleeding noted on abdominal surgical wound dressing. b. Pulse change from 85 to 160 beats/minute lasting more than 10 minutes. c. Temperature of 103.1 °F (39.5 °C) and white blood cell (WBC) count of 16,000 mm3. d. Weakness, diaphoresis, complaints of feeling faint. BP 100/56 mmHg.

b. Pulse change from 85 to 160 beats/minute lasting more than 10 minutes. The RRT should be called to intervene for a client with an acute life-threatening change, such as a pulse change resulting in tachycardia for a prolonged time in a post-operative client.

The nurse is evaluating a client who presents with symptoms of viral gastroenteritis. Which assessment finding should the nurse report to the healthcare provider? a. Dry mucous membranes and lips. b. Rebound abdominal tenderness over the right lower quadrant. c. Dizziness when client ambulates from a sitting position. d. Poor skin turgor over the client's wrist.

b. Rebound abdominal tenderness over the right lower quadrant. Right lower quadrant (RLQ) rebound abdominal tenderness may be related to acute appendicitis and should be reported to the healthcare provider.

The nurse is providing postoperative instructions for a female client after a mastectomy. Which information should the nurse include in the teaching plan? (Select all that apply.) a. Empty surgical drains once a week using procedure gloves. b. Report inflammation of the incision site or the affected arm. c. Wear clothing with snug sleeves over the arm on the operative side. d. Avoid lifting more than 4.5 kg (10 pounds) or reaching above her head.

b. Report inflammation of the incision site or the affected arm. d. Avoid lifting more than 4.5 kg (10 pounds) or reaching above her head. Part of a client's s/p mastectomy teaching plan should include reporting evidence of inflammation at the incision site or the affected arm, and avoiding lifting or reaching above their head.

The nurse is caring for a client with human immunodeficiency virus (HIV) infection who develops Mycobacterium avium complex (MAC). Which is the most significant desired outcome for this client? a. Free from injury of drug side effects. b. Return to pre-illness weight. c. Adequate oxygenation. d. Maintenance of intact perineal skin.

b. Return to pre-illness weight. MAC is an opportunistic infection that presents as a tuberculosis-like pulmonary process. MAC is a major contributing factor to the development of wasting syndrome, so the most significant desired outcome is the client's return to a pre-illness weight using oral, enteral, or parenteral supplementation as needed.

The nurse is preparing discharge instructions for a client who is going home with a surgical wound on the coccyx that is healing by secondary intention. Which is the priority nursing problem that should guide the discharge instruction plan? a. Acute pain. b. Risk for infection. c. Disturbed body image. d. Risk for deficient fluid volume.

b. Risk for infection. A wound healing by secondary intention is an open wound that is at risk for infection and the location of the wound near the anal area increases the risk for infection even more so.

A client is admitted to the hospital with a traumatic brain injury after his head violently struck a brick wall during a gang fight. Which finding is most important for the nurse to assess further? a. A scalp laceration oozing blood. b. Serosanguineous nasal drainage. c. Headache rated "10" on a 0 to 10 scale. d. Dizziness, nausea, and transient confusion.

b. Serosanguineous nasal drainage. Any nasal discharge following a head injury should be evaluated to determine the presence of cerebral spinal fluid which would indicate a tear in the dura making the client susceptible to meningitis.

A client with chest pain, dizziness, and vomiting for the last 2 hours is admitted for evaluation for Acute Coronary Syndrome (ACS). Which cardiac biomarker should the nurse anticipate to be elevated if the client experienced myocardial damage? a. Creatine Kinase (CK-MB). b. Serum troponin. c. Myoglobin. d. Ischemia-modified albumin.

b. Serum troponin Troponin is the most sensitive and specific test for myocardial damage. Troponin elevation is more specific than CK-MB.

A man who smokes two packs of cigarettes a day wants to know if smoking is contributing to the difficulty that he and his wife are having getting pregnant. Which information is best for the nurse to provide? (Select all that apply.) a. Only marijuana cigarettes affect sperm count. b. Smoking can decrease the quantity and quality of sperm. c. The first semen analysis should be repeated to confirm sperm counts. d. Cessation of smoking improves general health and fertility. e. Sperm specimens should be collected in 2 subsequent days.

b. Smoking can decrease the quantity and quality of sperm. c. The first semen analysis should be repeated to confirm sperm counts. d. Cessation of smoking improves general health and fertility. The use of tobacco, alcohol, and marijuana may affect a man's sperm counts.

A client, who speaks very little English, is being discharged following surgery. Which nurse should the nurse manager assign to provide the discharge instructions for the client? a. A graduate registered nurse (RN) with three weeks of experience. b. The registered nurse (RN) case manager for the unit with 1 year's experience. c. A "floating" registered nurse (RN) with five years of nursing experience. d. A Korean-American practical nurse (PN) with six years of nursing experience.

b. The registered nurse (RN) case manager for the unit with 1 year's experience. The RN case manager is the best-qualified nurse to assess and provide discharge educational needs, obtain resources for the client, enhance coordination of care, and prevent fragmentation of care.

The nurse assesses a long-term resident of a nursing home and finds the client has a fungal infection (candidiasis) beneath both breasts. To prevent hospital-associated infection, which protocol should the nurse review with the rest of the staff? a. Follow contact isolation procedures. b. Wash hands after caring for the client. c. Wear gloves when providing personal care. d. Restrict pregnant staff or visitors into the room.

b. Wash hands after caring for the client. The organism Candida albicans causes this infection and is part of the normal flora on the skin of most adults. Good handwashing is all that is needed to prevent nosocomial spread.

A 24-year-old female client diagnosed with a human papillomavirus infection (HPV) is angry at her ex-boyfriend and says she is not going to tell him that he is infected. Which response is best for the nurse to provide? a. "You do not have to tell him because this is not a reportable disease." b. "Because there is no cure for this disease, telling him is of no benefit to him or to you." c. "Even though you are angry, he should be told, so he can take precautions to prevent the spread of infection." d. "You should tell him, so he can feel as guilty and miserable as you do now, knowing that you have this disease."

c. "Even though you are angry, he should be told, so he can take precautions to prevent the spread of infection." Anger is a common emotional reaction when confronted with the diagnosis of an STI, and often lay blame and project this anger at the sexual partner. Although HPV is not a reportable disease in many states, all contacts should be informed of the infection, treatment, transmission, and precautions to minimize infecting others.

A client who has a chronic cough with blood-tinged sputum returns to the unit after a bronchoscopy. Which nursing interventions should be implemented in the immediate postprocedural period? a. Keep the client on bed rest for eight hours. b. Check vital signs every 15 minutes for two hours. c. Allow the client nothing by mouth until the gag reflex returns. d. Encourage fluid intake to promote the elimination of the contrast media.

c. Allow the client nothing by mouth until the gag reflex returns. The nasal pharynx and oral pharynx are anesthetized with local anesthetic spray prior to bronchoscopy, and the bronchoscope is coated with lidocaine gel to inhibit the gag reflex and prevent laryngeal spasm during insertion. The client should be NPO until the client's gag reflex returns to prevent aspiration from any oral intake or secretions.

Based on an analysis of the client's rhythm, atrial fibrillation, the nurse should prepare the client for which treatment protocol? a. Diuretic therapy. b. Pacemaker implantation. c. Anticoagulation therapy. d. Cardiac catheterization.

c. Anticoagulation therapy. The client is experiencing atrial fibrillation, and the nurse should prepare the client for anticoagulation therapy which should be prescribed before rhythm control therapies to prevent cardioembolic events which result from blood pooling in the fibrillating atria.

A client who had abdominal surgery two days ago has prescriptions for intravenous morphine sulfate 4 mg every 2 hours and a clear liquid diet. The client complains of feeling distended and has sharp, cramping gas pains. Which nursing intervention should be implemented? a Obtain a prescription for a laxative. b. Withhold all oral fluid and food. c. Assist the client to ambulate in the hall. d. Administer the prescribed morphine sulfate.

c. Assist the client to ambulate in the hall. Postoperative abdominal distention is caused by decreased peristalsis as a result of handling the intestine during surgery, limited dietary intake before and after surgery, and anesthetic and analgesic agents. Peristalsis is stimulated, flatus passed and distention minimized by implementing early and frequent ambulation.

The nurse is preparing a teaching plan for a client with newly diagnosed glaucoma and a history of allergic rhinitis. Which information is most important for the nurse to provide the client about using over-the-counter (OTC) medications for allergies? a. Notify your healthcare provider if there is an increase in heart rate. b. Increase fluid intake while taking an antihistamine or decongestant. c. Avoid allergy medications that contain pseudoephedrine or phenylephrine. d. Ophthalmic lubricating drops may be used for eye dryness due to allergy medications.

c. Avoid allergy medications that contain pseudoephedrine or phenylephrine. OTC allergy medications may contain ephedrine, phenylephrine, or pseudoephedrine, which can cause adrenergic side effects, such as increased intraocular pressure, so a client with glaucoma should avoid using these OTC medications.

Which finding should the nurse identify as an indication of carbon monoxide poisoning in a client who experienced a burn injury during a house fire? a. Pulse oximetry reading of 80%. b. Expiratory stridor and nasal flaring. c. Cherry red color to the mucous membranes. d. Presence of carbonaceous particles in sputum.

c. Cherry red color to the mucous membranes. The saturation of hemoglobin molecules with carbon monoxide molecules, instead of oxygen molecules, and the subsequent vasodilation-induced cherry red color of the mucous membranes is an indication of carbon monoxide poisoning.

The nurse is caring for a male client who had an inguinal herniorrhaphy 3 hours ago. The nurse determines the client's lower abdomen is distended and assesses dullness to percussion. Which is the priority nursing action? a. Assessment of the client's vital signs. b. Document the finding as the only action. c. Determine the time the client last voided. d. Insert a rectal tube for the passage of flatus.

c. Determine the time the client last voided. Swelling at the surgical site in the immediate postoperative period can impact the bladder and prostate area causing the client to experience difficulty voiding due to pressure on the urethra. To provide additional data supporting bladder distention, the last time the client voided should be determined next.

A client with a history of hypertension, myocardial infarction, and heart failure is admitted to the surgical intensive care unit after coronary artery bypass surgery graft (CABG). The nurse determines the client's serum potassium level is 4.5 mEq/L. Which action should the nurse implement? a. Notify the healthcare provider. b. Decrease the IV solution flow rate. c. Document the finding as the only action. d. Administer potassium replacement as prescribed.

c. Document the finding as the only action. Coronary artery bypass surgery graft (CABG) places a client at risk for hypokalemia from hemodilution, nasogastric suction, or diuretic therapy, so the serum potassium level is maintained between 4 and 5 mEq/L to avoid dysrhythmias. Documentation of the normal finding is indicated at this time.

A female client with type 2 diabetes mellitus reports dysuria. Which assessment finding is most important for the nurse to report to the healthcare provider? a. Suprapublic pain and distention. b. Bounding pulse at 100 beats/minute. c. Fingerstick glucose of 300 mg/dL. d. Small vesicular perineal lesions.

c. Fingerstick glucose of 300 mg/dL. Elevated fingerstick glucose levels need to be reported to the healthcare provider, so a plan of care can be adjusted to treat the elevated glucose level. Also, elevated glucose levels spill into the urine and provide a medium for bacterial growth.

A client who returns to the unit after having a percutaneous coronary intervention (PCI) with balloon angioplasty, complains of acute chest pain. Which action should the nurse implement next? a. Inform the healthcare provider. b. Obtain a 12-lead electrocardiogram. c. Give a sublingual nitroglycerin tablet. d. Administer prescribed analgesic.

c. Give a sublingual nitroglycerin tablet. After a percutaneous coronary intervention (PCI) with balloon angioplasty, a client who experiences acute chest pain may be experiencing cardiac ischemia related to re-stenosis, stent thrombosis, or acute coronary syndrome involving any coronary artery. The first action is to administer nitroglycerin to dilate the coronary arteries and increase myocardial oxygenation.

The nurse is caring for a client with multiple trauma after a motor vehicle collision. The nurse learns that the client has secondary syphilis. Which precautions should the nurse implement? a. A mask should be worn by anyone entering the client's room. b. Handwashing is required before and after contact with the client. c. Gloves should be worn during direct contact with the client's skin. d. No precautions in addition to standard precautions are necessary.

c. Gloves should be worn during direct contact with the client's skin. The secondary stage of syphilis is a systemic blood-borne disease that presents with skin lesions and rashes that may drain the highly contagious spirochete, so gloves should be worn during direct contact with the client's skin. The client should be placed on "contact precautions".

A client in an ambulatory clinic describes awaking in the middle of the night with difficulty breathing and shortness of breath related to paroxysmal nocturnal dyspnea. Which underlying condition should the nurse identify in the client's history? a. Chronic bronchitis. b. Gastroesophageal reflux disease (GERD). c. Heart failure (HF). d. Chronic pancreatitis.

c. Heart failure (HF). Paroxysmal nocturnal dyspnea is classic sign of heart failure and is secondary to fluid overload associated with heart failure which causes pulmonary edema

A client with primary dysmenorrhea has several medications at home. She calls the clinic to ask the nurse which medication should she use for her pain. Which option should the nurse recommend as the first choice in the management of this client's pain? a. Aspirin. b. Codeine. c. Ibuprofen. d. Acetaminophen.

c. Ibuprofen. Ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID) provides the most effective relief for primary dysmenorrhea because it has antiprostaglandin properties.

The nurse is caring for a client who returns to the unit following a colonoscopy. Which finding should the nurse report to the healthcare provider immediately? a. Large amounts of expelled flatus with mucus. b. Tympanic abdomen and hyperactive bowel sounds. c. Increased abdominal pain with rebound tenderness. d. Complaint of feeling weak with watery diarrheal stools.

c. Increased abdominal pain with rebound tenderness. Positive rebound tenderness following a colonoscopy may be an indication of perforation and the development of peritonitis and requires follow-up immediately.

A client with rheumatoid arthritis is prescribed piroxicam, a nonsteroidal antiinflammatory drug (NSAID). Which effect is characteristic of NSAIDs used for treating rheumatoid arthritis? a. Production of replacement cartilage is stimulated. b. Further destruction of the articular cartilage is prevented. c. Inflammation is reduced by inhibiting prostaglandin synthesis. d. Bradykinin is inhibited, thereby reducing acute and chronic pain.

c. Inflammation is reduced by inhibiting prostaglandin synthesis. Nonsteroidal antiinflammatory drugs (NSAIDs) are used for treating rheumatoid arthritis by inhibiting the synthesis of prostaglandins and providing relief from the associated pain.

The nurse is caring for a client after transurethral resection of the prostate (TURP) and determines the client's urinary catheter is not draining. What should the nurse implement? a. Reposition the catheter drainage tubing. b. Encourage the client to drink oral fluids. c. Irrigate the catheter. d. Change drainage unit tubing.

c. Irrigate the catheter. Obstruction of urinary flow after a TURP is most often due to blood clots, and sterile irrigation should be implemented to remove the clots that are blocking the catheter.

A nurse is preparing to insert an IV catheter after applying a eutectic mixture of lidocaine and prilocaine (EMLA), a topical anesthetic cream. Which action should the nurse take to maximize its therapeutic effect? a. Rub a liberal amount of cream into the skin thoroughly. b. Cover the skin with a gauze dressing after applying the cream. c. Leave the cream on the skin for 1 to 2 hours before the procedure. d. Use the smallest amount of cream necessary to numb the skin surface.

c. Leave the cream on the skin for 1 to 2 hours before the procedure. Topical anesthetic creams, such as EMLA, should be applied to the puncture site at least 60 minutes to 2 hours before the insertion of an IV catheter.

The nurse is caring for a client with aplastic anemia who is hospitalized for weight loss and generalized weakness. Laboratory values show a white blood count (WBC) of 2,500/mm3 and a platelet count of 160,000/mm3. Which intervention is the primary focus in the client's plan of care for the nurse to implement? a. Assist with frequent ambulation. b. Encourage visitors to visit. c. Maintain strict protective precautions. d. Avoid peripheral injections.

c. Maintain strict protective precautions. The client should be under strict protective transmission precautions because the WBC values are low and normal WBC levels are 4,000-10,000/mm3, so the client is at an increasingly high risk for infection.

An 85-year-old male client comes to the clinic for his annual physical exam and renewal of antihypertensive medication prescriptions. The client's radial pulse rate is 104 beats/minute. Which additional assessment should the nurse complete? a. Palpate the pedal pulse volume. b. Count the brachial pulse rate. c. Measure the blood pressure. d. Assess for a carotid bruit.

c. Measure the blood pressure. Elderly clients who take antihypertensive medications often experience side effects, such as hypotension, which causes tachycardia, a compensatory mechanism to maintain adequate cardiac output, so the client's blood pressure should be measured.

Which preexisting diagnosis places a client at the greatest risk of developing superior vena cava syndrome? a. Carotid stenosis. b. Steatosis hepatitis. c. Metastatic cancer. d. Clavicular fracture.

c. Metastatic cancer. Superior vena cava syndrome occurs when the superior vena cava (SVC) is compressed by outside structures, such as a growing tumor that impedes the return of blood flow to the heart. Superior vena cava syndrome is likely to occur with metastatic cancer from a primary tumor in the upper lobe of the right lung that compresses the superior vena cava.

A client with acute osteomyelitis has undergone surgical debridement of the diseased bone and asks the nurse how long will antibiotics have to be administered. Which information should the nurse communicate? a. Oral antibiotics for 2 to 4 months, then for dental procedure prophylaxis. b. Parenteral antibiotics for 4 to 6 weeks, then oral antibiotics for up to 1 year. c. Parenteral antibiotics for 4 to 8 weeks, then oral antibiotics for 4 to 8 weeks. d. Parenteral antibiotics for 2 to 3 weeks, then oral antibiotics for 4 weeks.

c. Parenteral antibiotics for 4 to 8 weeks, then oral antibiotics for 4 to 8 weeks. Treatment of acute osteomyelitis requires the administration of high doses of parenteral antibiotics for 4 to 8 weeks, followed by oral antibiotics for another 4 to 8 weeks.

A nurse is preparing a teaching plan for a client who is postmenopausal. Which measure is most important for the nurse to include to prevent osteoporosis? a. Take a multivitamin daily. b. Use only low fat milk products. c. Perform weight resistance exercises. d. Bicycle for at least 3 miles every day.

c. Perform weight resistance exercises. Weight-bearing on the skeletal system stimulates bone formation, so recommending weight-resistance exercise is the most important in the prevention of osteoporosis in postmenopausal women.

A client with type II diabetes arrives at the clinic with a blood glucose of 50 mg/dL. The nurse provides the client with 6 ounces of orange juice. In 15 minutes the client's capillary glucose is 74 mg/dL. Which action should the nurse take? a. Obtain a specimen for a serum glucose level. b. Administer insulin per sliding scale. c. Provide cheese and bread to eat.' d. Collect a glycosylated hemoglobin specimen.

c. Provide cheese and bread to eat.' Once blood glucose is greater than 70 mg/dl, the client should eat a regularly scheduled meal or a snack that contains protein and carbohydrates to help prevent hypoglycemia from recurring.

The nurse is teaching a client about precautions for a new prescription for lovastatin. Which symptom should the nurse instruct the client to report to the healthcare provider immediately? a. Terrible nightmares. b. Increased nocturia. c. Severe muscle pain. d. Visual disturbances.

c. Severe muscle pain. A potential, serious side effect of statin therapy that is used to lower both LDL-C and triglyceride levels is rhabdomyolysis, which is manifested by severe muscle pain and aching.

Which finding should the nurse report to the healthcare provider for a client with a circumferential extremity burn? a. Full thickness burns rather than partial thickness. b. Supinates extremity but is unable to fully pronate the extremity. c. Slow capillary refill in the digits with absent distal pulse points. d. Inability to distinguish sharp versus dull sensations in the extremity.

c. Slow capillary refill in the digits with absent distal pulse points. A circumferential burn can form an eschar that results from burn exudate fluid that dries and acts as a tourniquet as fluid shifts occur in the interstitial tissue. As edema increases tissue pressure, blood flow to the distal extremity is compromised, which is manifested by slow capillary refill and absent distal pulses, so the healthcare provider should be notified about any compromised circulation that requires escharotomy.

The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing action should be included in the plan of care? a. Perform active range of motion three times daily. b. Monitor for Battle's sign every four hours. c. Teach measures to avoid the Valsalva maneuver. d. Maintain the head of bed in a flat position.

c. Teach measures to avoid the Valsalva maneuver. The Valsalva maneuver, straining with bowel movements while holding one's breath, increases intracerebral pressure (ICP) which may induce bleeding or rupture of cerebral blood vessels.

Which is the priority nursing action while caring for a client on a ventilator when an electrical fire occurs in the intensive care unit? a. Tell another staff member to bring extinguishing equipment to the bedside. b. Close the doors to the client's area when attempting to extinguish the fire. c. Use a bag-valve-mask resuscitator while removing the client from the area. d. Implement an emergency protocol to remove the client from the ventilator.

c. Use a bag-valve-mask resuscitator while removing the client from the area. A client on a ventilator should have respirations maintained with a manual bag-valve-mask resuscitator while being moved away from the oxygen wall outlet and fire source.

A client in the preoperative holding area receives a prescription for midazolam IV. The nurse determines that the surgical consent form needs to be signed by the client. Which action should the nurse implement? a. Give the drug and allow the client to read and sign the consent form. b. Counter-sign the client's initials on the consent form after giving the drug. c. Withhold the drug until the client validates understanding of the surgical procedure and signs the consent form. d. Call the healthcare provider to explain the surgical procedure before the client signs the consent.

c. Withhold the drug until the client validates understanding of the surgical procedure and signs the consent form. Midazolam, a benzodiazepine sedative, is commonly used for conscious sedation intraoperatively and interferes with the client's cognition and level of consciousness, so the consent form should be signed before the drug is administered.

Which sexually transmitted infection (STI) should the nurse include in a client's teaching plan about the risk for cervical cancer? a. Neisseria gonorrhoea. b. Chlamydia trachomatis. c. Herpes simplex virus. d. Human papillomavirus.

d. Human papillomavirus. According to the CDC (2017), it is estimated at least 80% of all women who are sexually active will contract the Human papillomavirus (HPV) in their lifetime. Certain types of HPV have been suspected to cause cervical cancer and HPV strain 16 and 18 have been identified to cause 70% of cervical cancers.

The nurse is assessing a client with a cuffed tracheostomy tube in place who is breathing spontaneously. To evaluate if the client can tolerate cuff deflation to promote speaking and swallowing, which action should the nurse implement? a. Ask the client to try to speak. b. Assess for respiratory distress. c. Auscultate for pulmonary crackles after the client drinks a small amount of clear water. d. Observe the client for coughing colored sputum after drinking a small amount of colored water.

d. Observe the client for coughing colored sputum after drinking a small amount of colored water. To evaluate the risk for aspiration after the cuff is deflated, the client should be instructed to swallow a small amount of colored water, then observed for coughing up colored sputum, or the tracheostomy should be suctioned for the presence of colored water.

The nurse obtains a client's history that includes a right mastectomy and radiation therapy for cancer of the breast 10 years ago. Which current health problem potentially could be a consequence of radiation therapy? a. Asthma. b. Myocardial infarction. c. Chronic esophagitis with gastroesophageal reflux. d. Pathologic fracture of two ribs on the right chest.

d. Pathologic fracture of two ribs on the right chest. The ribs lie in the radiation pathway and lose density over time, becoming thin and brittle, so the occurrence of two right-sided ribs with pathological fractures resulting without evidence of trauma is related to radiation damage.

The nurse is planning preoperative teaching for a client who will undergo a radical neck dissection and total laryngectomy. Which information has the greatest priority for this client? a. Prognosis after treatment is excellent. b. Techniques for esophageal speech are relatively easy to learn with practice. c. The stoma should never be covered after this type of surgery. d. There is a radical change in appearance as a result of this surgery.

d. There is a radical change in appearance as a result of this surgery. Radical neck dissection is the removal of lymphatic drainage channels and nodes, sternocleidomastoid muscle, spinal accessory nerve, jugular vein, and submandibular area. The overall outcome of this type of surgery causes the neck to be disfigured, so the radical change in appearance, "Alteration in body image" will be a priority in the care of this client.