Lippincott Comp test 2ЁЯТХЁЯТХ
34. Atropine sulfate (Atropine) is contraindi- cated in all but which one of the following clients? I 1. A client with diabetes. I 2. A client with glaucoma. I 3. A client with urine retention. I 4. A client with bowel obstruction.
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27. The nurse is developing a plan to teach a client deep-breathing exercises to expand collapsed alveoli and prevent postoperative atelectasis and pneumonia. Which of the following steps should be included? Select all that apply. I 1. Splint or support the incision to promote maximal comfort. 2. Inhale slowly through the nostrils; exhale through pursed lips. 3. Hold the breath for about 5 seconds to expand the alveoli. 4. Repeat this breathing method 5 to 10 times hourly. 5. Close one nostril while inhaling.
1, 2, 3, 4
106. A client with emphysema has been admitted to the hospital. The nurse should assess the client further for: I 1. Frequent coughing. I 2. Bronchospasms. I 3. Underweight appearance. I 4. Copious sputum.
106. 3. The client with emphysema is commonly underweight in appearance. It is theorized that weight loss is caused by the increased energy required to support the work of breathing. Frequent coughing, bronchospasms, and copious sputum are clinical manifestations of chronic bronchitis.
108. The nurse is participating in a blood pressure screening event. After three separate readings taken at least 2 minutes apart, the nurse determines that a client has a blood pressure of 160/90 mm Hg. The nurse should advise the client to: I 1. Have blood pressure evaluated within 1 month. I 2. Begin an exercise program. I 3. Examine lifestyle to decrease stress. I 4. Schedule a complete physical immediately.
108. 1. The client with a systolic blood pressure of 160 to 179 mm Hg should be evaluated by a health care professional within 1 month of the screening. The client with a diastolic blood pressure of 90 to 99 mm Hg should be rechecked within 2 months. Exercise and stress reduction may be desirable activities, but it is first necessary to evaluate the cause of elevated blood pressure. In the absence of other symptoms, it is not necessary to have the cli- ent evaluated immediately.
11. A client is admitted to the emergency depart- ment with crushing chest injuries sustained in a car accident. Which of the following signs indicates a possible pneumothorax? I 1. Cheyne-Stokes respirations. I 2. Increased fremitus. I 3. Diminished or absent breath sounds on the affected side. I 4. Decreased sensation on the affected side.
11. 3. Accumulation of air in the pleural cavity after a crushing chest injury may be assessed by uni- lateral diminished or absent breath sounds. Cheyne- Stokes respirations with periods of apnea commonly precede death. They indicate heart failure or brain death. Fremitus is increased with lung consolidation and decreased with pleural effusion or pneumotho- rax. Pain occurs at the injury site and increases with inspiration.
110. The nurse is teaching a client who is taking dexamethasone (Decadron) for cerebral edema about early symptoms of Cushing's disease. The nurse should advise the client to report which of the fol- lowing is a symptom of hyperadrenocorticism? I 1. Hypotension. I 2. Increased urinary frequency. I 3. Increased muscle mass. I 4. Easy bruising.
110. 4. The client taking dexamethasone needs to know the early signs of Cushing's disease, which include easy bruising, moonface, buffalo hump, and osteoporosis. Loss of collagen makes the skin weaker and thinner; therefore, the client bruises more easily. The nurse should instruct the client to report any of these signs to the physician. Hyperten- sion is a symptom of Cushing's disease, and muscle mass is decreased. Increased urinary frequency is not a symptom of Cushing's disease.
113. A client who has asthma is taking albuterol (Ventolin) to treat bronchospasms. The nurse should assess the client for which of the following adverse effects that can occur as a result of taking this drug? Select all that apply. I 1. Lethargy. I 2. Nausea. I 3. Headache. I 4. Nervousness. I 5. Constipation.
113. 2, 3, 4. Albuterol is a beta-adrenergic agonist. Possible adverse effects include nausea, headache, and nervousness as well as insomnia and vomiting. Constipation is not associated with this drug. The client will not become lethargic; instead, he may experience restlessness.
120. During an emergency, a physician has asked for I.V. calcium to treat a client with hypocalcemia. The nurse should: I 1. Hand the physician calcium chloride for I.V. I 2. I 3. I 4. use. Check with the physician for his complete order. Hand the physician calcium gluconate for I.V. use. Hand the physician the kind of calcium avail- able on the unit.
120. 2. The nurse should first check with the physician for the complete order of calcium because calcium chloride has a concentration of 13.6 mEq of calcium per gram and calcium gluconate has 4.65 mEq of calcium per gram. The nurse can always offer the doctor the type of calcium available after the conversion in calcium has been made; other- wise, the error could be fatal.
121. The nurse is administering an I.V. potassium chloride supplement to a client who has heart fail- ure. When developing a plan of care for this client, which of the following should the nurse incorpo- rate? I1. Hyperkalemia will intensify the action of the client's digoxin (Lanoxin) preparation. I 2. The client's potassium levels will be unaf- fected by his potassium-sparing diuretic. I 3. The administration of the I.V. potassium chloride should not exceed 10 mEq/hour or a concentration of 40 mEq/L. I 4. Metabolic alkalosis will increase the client's serum potassium levels.
121. 3. When administering I.V. potassium chloride, the administration should not exceed 10 mEq/hour or a concentration of 40 mEq/L via a peripheral line. These limits are extremely impor- tant to prevent the development of hyperkalemia and the possibility of cardiac dysrhythmias. In some situations, with dangerously low serum potassium levels, the client may need cardiac monitoring and more than 10 mEq of potassium per hour. Potassium-sparing diuretics may lead to hyperkalemia because they affect the kidney's abil- ity to excrete excess potassium. Metabolic alkalo- sis can cause potassium to shift into the cells, thus decreasing the client's serum potassium levels. Hypokalemia can lead to digoxin toxicity.
122. A client is receiving morphine sulfate by a patient-controlled analgesia (PCA) system after a left lower lobectomy about 4 hours ago. The client reports moderately severe pain in his left thorax that worsens when he coughs. The nurse's first course of action is to: 1. Reassure the client that the PCA system is working and will relieve his pain. 2. Encourage the client to rest; no further assess- ment is needed. 3. Assess the pain systematically with the hospi- tal-approved scale. 4. Encourage the client to ignore the pain and sleep because pain is expected after this type of surgery.
122. 3. Systematic pain assessment is necessary for adequate pain management in the postoperative client. Guidelines from the Agency for Healthcare Research and Quality recommend that facilities adopt a pain assessment scale to facilitate pain man- agement. Even though the client is receiving mor- phine sulfate by PCA, assessment is needed if he is experiencing pain. Encouraging the client to rest or to ignore pain without further assessment is not a sufficient intervention.
127. The nurse should complete which of the following assessments on a client who has received tissue plasminogen activator or alteplase recombi- nant (Activase) therapy? 1. Neurologic signs frequently throughout the course of therapy. Excessive bleeding every hour for the first 8 hours. Blood glucose level. Arterial blood gas values.
127. 1. The nurse needs to assess neurologic status throughout the therapy. Altered sensorium or neu- rologic changes may indicate intracranial bleeding for the client who has received tissue plasminogen activator or alteplase. The nurse should carefully check for bleeding every 15 minutes during the first hour of therapy, every 15 to 30 minutes during the next 9 hours, and at least every 4 hours during the duration of therapy. Bleeding may occur from sites of invasive procedures or from body orifices. The blood glucose level does not need to be evaluated. Arterial blood gas values relate to acid base status and oxygenation and are avoided due to the inva- siveness of arterial puncture at this time.
128. During the emergent stage of burn manage- ment for a client with burns of 30 percent of the body the nurse should assess the client for which of the following? Select all that apply. I 1. Hyponatremia. I 2. Hyperkalemia. I 3. Hypoglycemia. I 4. Increased hematocrit. I 5. "Fever spikes."
128. 2, 4, 5. In the emergent phase of burn man- agement, hyperkalemia develops as a result of the destruction of red blood cells. The hematocrit is increased in response to the plasma loss that has occurred and the resulting hemoconcentration. Ini- tially, hyponatremia may occur as sodium shifts into the interstitial spaces. "Fever spikes" of 102 to 103 degrees are common during this stage. The client will have hyperglycemia due to decreased levels of insulin production.
129. A 6-year-old child is to have a cardiac cathe- terization and asks the nurse if it will hurt. Which of the following statements provides the nurse with the best guide for responding to the child's question? I 1. "The medication used to numb the insertion site will sting." 2. "A momentary sharp pain usually occurs when the catheter enters the heart." 3. "Most 6-year-olds feel some discomfort dur- ing the procedure." 4. "It's a painless procedure, although a tingling sensation may be felt in the extremities."
129. 1. The nurse should explain that the child will feel a stinging when the numbing medicine is inserted into the area around the introduction site of the catheter. There may also be a feeling of pressure when the catheter is introduced. Because the child will be sedated and will feel little during the proce- dure, telling the child that a momentary sharp pain is felt on entering the heart is inappropriate. A tingling sensation in the extremities is not felt.
131. After a nasogastric (NG) tube has been inserted, the nurse can most accurately determine that the tube is in the proper place if which of the following can be demonstrated? I 1. The client is no longer gagging or coughing. I 2. The pH of the aspirated fluid is measured. 3. Thirty milliliters of normal saline can be injected without difficulty. 4. A whooshing sound is auscultated when 10 mL of air is inserted.
131. 2. Measuring the pH of the aspirated gas- tric fluid is the most accurate determination of the placement of the NG tube. A pH lower than 4 indicates that the tube is in the stomach. Whether or not the client is gagging or coughing is not an accurate way to determine if the tube is placed cor- rectly. No fluids should be inserted into the tube until the placement has been determined. Insert- ing air into the tube and listening for the resulting whoosh can be used, but this is not as accurate as pH measurement.
133. Which of the following should be considered the highest priority during the first 24 hours postop- eratively for the client who had a total laryngectomy due to cancer of the larynx? I 1. Provide adequate nourishment. I 2. Prevent skin breakdown. I 3. Maintain proper bowel elimination. I 4. Maintain a patent airway.
133. 4. During the first 24 hours after a total laryn- gectomy, maintaining a patent airway is a priority goal. After a total laryngectomy, the client will have a tracheostomy with increased secretions and will require suctioning and tracheostomy care. Provid- ing adequate nutrition, preventing skin breakdown, and maintaining proper bowel elimination will be appropriate as the client recovers, but maintaining a patent airway is the initial priority goal.
136. The nurse should adjust a client's heparin dose according to a prescribed anticoagulation order based on maintaining which laboratory value at what therapeutic level for anticoagulant therapy? I 1. Partial thromboplastin time, 1.5 to 2.5 times the normal control. I 2. Prothrombin time, 1.5 to 2.5 times the normal control. I 3. International Normalized Ratio, 2 to 3 sec- onds. I 4. Thrombin clotting time, 10 to 15 seconds.
136. 1. The nurse should adjust the heparin dose to maintain the client's partial thromboplastin time between 1.5 and 2.5 times the normal control. The prothrombin time and International Normalized Ratio are used to maintain therapeutic levels of war- farin (Coumadin), oral anticoagulation therapy. The thrombin clotting time is used to confirm dissemi- nated intravascular coagulation.
138. The nurse realizes that a medication error has been made and a client has received the wrong medication. What should be the nurse's first action when realizing an error has been made? I 1. Assess the client's condition. I 2. Notify the physician of the error. I 3. Complete an incident report. I 4. Report the error to the unit manager.
138. 1. The nurse's first response to the error is to assess the client for any untoward reactions as a result of the error. Notifying the physician and unit manager of the error as well as completing an inci- dent report are all appropriate later actions, but the first action is to assess the client.
141. The nurse administers a tap water enema to a client. While the solution is being infused, the client has abdominal cramping. What should be the nurse's first response? I 1. Clamp the tubing and carefully withdraw the tube. 2. Temporarily stop the infusion and have the client take deep breaths. 3. Raise the height of the enema container. 4. Rub the client's abdomen gently until the cramps subside.
141. 2. If the client begins to experience abdomi- nal cramping during administration of the enema fluid, the nurse's first action is to temporarily stop the infusion and have the client take a few deep breaths. After the cramping subsides, the nurse can continue with the enema solution. If the cramping does not subside, the nurse should clamp the tub- ing and remove it. Raising the height of the con- tainer will increase the flow of fluid and cause the cramping to increase. Rubbing the abdomen while infusing the enema fluid will not stop the cramp- ing.
142. In preparing for insertion of a peripheral I.V. catheter, the nurse must select an appropriate site. Which of the following areas should the nurse try first if an appropriate vein is found? I 1. Back of the hand. I 2. Inner aspect of the elbow. I 3. Inner aspect of the forearm. I 4. Outer aspect of the forearm.
142. 1. When inserting an I.V. catheter needle, the nurse initially uses veins low on the hand or arm if available, unless contraindicated. Should the I.V. fluid infiltrate or the vein become irritated at this insertion site, veins higher on the arm are still available for use. After a vein higher up on the arm has been damaged, veins below it cannot be used.
155. Which of the following laboratory findings is present in nephrotic syndrome? I 1. Decreased total serum protein. I 2. Hypercalcemia. I 3. Hyperglycemia. I 4. Decreased hematocrit.
155. 1. A decreased total serum protein occurs as extensive amounts of protein are excreted from the body through the urine. Clients may develop hypocalcemia. Hyperglycemia is not a find- ing related to nephrotic syndrome. A decreased hematocrit is not a finding related to nephrotic syndrome.
159. A client undergoes a nephrectomy. In the immediate postoperative period, which nursing intervention has the highest priority? I 1. Monitoring blood pressure. I 2. Encouraging the use of the incentive spirometer. I 3. Assessing urine output hourly. I 4. Checking the flank dressing for urine drainage.
159. 3. After a nephrectomy, a specific aspect of immediate postoperative management includes monitoring urine output at least hourly. Monitoring blood pressure and encouraging the use of incen- tive spirometry are other important considerations, but because of the surgical disruption of the urinary system, urine output is a priority. Measurement of urine output should also include an estimation of the amount of urine drainage on the flank dressing.
162. A client in severe respiratory distress is admitted to the hospital. When assessing the client, the nurse should: I 1. Conduct a complete health history. I 2. Complete a comprehensive physical examination. I 3. Delay assessment until client's respiratory distress is resolved. I 4. Focus assessment on the respiratory system and distress.
162. 4. During an episode of acute respiratory dis- tress, it is important that the nurse focus the assess- ment on the client's respiratory system and distress to quickly address the client's problem. Conducting a complete health history and a comprehensive physical examination can be deferred until the cli- ent's condition is stabilized. It is not appropriate to delay all assessments until the respiratory distress is resolved because the nurse must have data to guide treatment.
166. A client with a new ileal conduit asks the nurse when he needs to wear his appliance. Which of the following responses by the nurse is correct? I 1. "You need to wear your appliance all the time." I 2. "You need to wear your appliance after you irrigate." I 3. "It is only necessary to wear your appliance at night." I 4. "The appliance must be worn after your meals."
166. 1. An ileal conduit is a urinary diversion that requires the client to wear an appliance, or pouch, at all times because urine drains continuously. Ileal conduits are not irrigated. The urinary drainage is affected by fluid intake, not meals.
174. A 25-year-old has been diagnosed with hyper- trophic cardiomyopathy. The nurse should assess the client for: I 1. Angina. I 2. Fatigue and shortness of breath. I 3. Abdominal pain. I 4. Hypertension.
171. 1. The nurse's most appropriate response is to acknowledge and validate the client's concerns. Questioning the client's fears is not a therapeutic response and can make the client feel defensive. False reassurance that the client should not be afraid disregards the client's fears and does not promote further communication between the client and nurse. Dismissing the client's feelings and tell- ing the client to relax does not encourage sharing of feelings.
18. When caring for a child who has been receiv- ing long-term steroid therapy, the nurse should assess the child for: I 1. Usual behavior and temperament. I 2. Loss of weight from baseline. I 3. Development of truncal obesity. I 4. Demonstration of a growth spurt.
18. 3. One of the side effects of steroid therapy is fat deposition on the trunk and face, produc- ing classic Cushingoid signs. Therefore, the nurse should expect to find truncal obesity. Steroids also can cause altered moods or mood swings. Typically, long-term steroid use results in weight gain. Steroids may inhibit the action of growth hormone. There- fore, a growth spurt is not likely.
40. A client who is scheduled for an open chole- cystectomy has a 20-pack-year history of smoking. For which postoperative complication is the client most at risk? I 1. Deep vein thrombosis. I 2. Atelectasis and pneumonia. I 3. Delayed wound healing. I 4. Prolonged immobility.
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45. The nurse teaches a client who had cystos- copy about the urge to void when the procedure is over. What other teaching should be included? I 1. Ignore the urge to void. I 2. Force fluids. I 3. Ask for the bedpan. I 4. Ring for assistance to the bathroom.
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61. The nurse is assessing a client recovering from anesthesia. Which of the following is an early indicator of hypoxemia? I 1. Somnolence. I 2. Restlessness. I 3. Chills. I 4. Urgency.
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9. The client tells the nurse that he is allergic to shellfish. The nurse should ask the client if he is also allergic to: I 1. All other seafood. I 2. Iodine skin preparations. I 3. Caffeine. I 4. Alcohol-based skin preparations.
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93. The nurse assesses a client who has just received morphine sulfate. The client's blood pres- sure is 90/50 mm Hg; pulse rate, 58 bpm; respiration rate, 4 breaths/minute. The nurse should check the client's chart for an order to administer? I 1. Flumazenil (Romazicon). I 2. Naloxone hydrochloride (Narcan). I 3. Doxacurium (Nuromax). I 4. Remifentanil (Ultiva).
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7. An elderly man experiences a thrombotic cerebrovascular accident and subsequent flaccid hemiplegia of his right side. When planning his care, rehabilitation begins: I 1. As soon as anticoagulant therapy is started. I 2. When the client is admitted to the hospital. I 3. When the client can first work cooperatively with health care personnel. I 4. As directed by the physical therapist.
2 7. 2. Rehabilitation for a client who has sus- tained a cerebrovascular accident begins at the time he is admitted to the hospital. The first goal of reha- bilitation should be to help prevent deformities. This goal is achieved through such techniques as position- ing the client properly in bed, changing his position frequently, and supporting all parts of his body in proper alignment. Passive range-of-motion exercises may also be started, unless contraindicated.
21. A client is taking phenytoin (Dilantin) as an antiepileptic medication. The nurse should instruct the client to obtain: I 1. Increased iron. I 2. Increased calcium. I 3. Frequent dental examinations. I 4. Frequent eye examinations.
21. 3. Phenytoin causes hyperplasia of the gums, and the client needs frequent dental examinations and meticulous oral hygiene. Phenytoin therapy may contribute to a folic acid deficiency, but it is not related to iron or calcium metabolism. A need for frequent eye examinations is not related to the side effects of phenytoin.
22. The nurse should establish baseline data on a client who is starting on long-term gentamicin sulfate (Garamycin) therapy. Which of the following is least important for assessment screening in this client? I 1. Visual acuity. I 2. Vestibular function. I 3. Renal function. I 4. Auditory function.
22. 1. Visual acuity is not affected by long-term gentamicin sulfate therapy. The nurse should estab- lish baseline data for vestibular, renal, and auditory function because gentamicin sulfate is ototoxic and causes renal toxicity.
25. The nurse is auscultating S1 and S2 in a cli- ent. Identify the area where the nurse should hear S1 the loudest.
25. S1 is loudest at the mitral area.
26. The nurse instructs a client with coronary artery disease in the proper use of nitroglycerin (Nitrostat). At the onset of chest pain, the client should: I 1. Call 911 when three nitroglycerin tablets I 2. I 3. I 4. taken every 5 minutes are ineffective. Call 911 when five nitroglycerin tablets taken every 5 minutes are ineffective. Take three nitroglycerin tablets, 10 minutes apart, and call 911. Go to the emergency department if three nitroglycerin tablets are ineffective.
26. 1. Nitroglycerin (Nitrostat) tablets should be taken 5 minutes apart for three doses; if this is inef- fective, 911 should be called to obtain an ambulance
27. A diet high in which of the following food substances contributes to increases in serum cholesterol? I 1. Polyunsaturated fat. I 2. Saturated fat. I 3. Monounsaturated fat. I 4. Phospholipids.
27. 2. Saturated fats raise blood cholesterol. Polyunsaturated fats maintain blood cholesterol. Monounsaturated fats may help to maintain or lower blood cholesterol. Phospholipids do not have an effect on cholesterol but act as emulsifiers, keeping fats dispersed in water.
53. The nurse in the postanesthesia care unit notes that one of the client's pupils is larger than the other. The nurse should: 1. Rate the client on the Glasgow Coma Scale. I 2. Administer oxygen. I 3. Check the client's baseline data. I 4. Call the surgeon.
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66. The physician ordered I.V. naloxone (Narcan) to reverse the respiratory depression from morphine administration. After administration of the naloxone the nurse should: I 1. Check respirations in 5 minutes because naloxone is immediately effective in relieving respiratory depression. 2. Check respirations in 30 minutes because the effects of morphine will have worn off by then. 3. Monitor respirations frequently for 4 to 6 hours because the client may need repeated doses of naloxone. 4 Monitor respirations each time the client receives morphine sulfate 10 mg I.M.
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67. The nurse should monitor the surgical client closely for which clinical manifestation with the administration of naloxone (Narcan)? I 1. Dizziness. I 2. Biliary colic. I 3. Bleeding. I 4. Urine retention.
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6. The nurse must be aware that adverse drug reactions in the elderly client may be underesti- mated because: 1. Adverse reactions rarely have an atypical presentation. 2. Cognitive impairment is an expected finding in the elderly client. 3. Physical or psychological symptoms are attributed to the effects of aging. 4. Excess sedation is difficult to assess in the elderly client.
3 6. 3. The elderly client commonly has vague or atypical responses to medications and diseases that are erroneously attributed to aging. A new cogni- tive change needs to be investigated and is not an expected change with aging. Changes in a client's behavior should be investigated to see whether there is a relation to excessive sedation. The nurse can interview the family members to obtain information.
34. The nurse reviews the peak and trough serum levels from a client who is receiving gentamicin sulfate (Garamycin) in order to: I 1. Adjust the dosage to the therapeutic range. I 2. Avoid allergic reactions. I 3. Prevent side effects. I 4. Reach therapeutic levels more quickly.
34. 1. Peak and trough serum levels are used to adjust the dosage within a therapeutic range.
35. A client with a history of diabetes mellitus and chronic obstructive pulmonary disease should have which of the following immunizations? I 1. Influenza. I 2. Hepatitis A. I 3. Measles-mumps-rubella. I 4. Varicella.
35. 1. The client with diabetes and a chronic respiratory condition is most at risk for influenza and should receive the vaccine yearly. Diabetes and chronic respiratory conditions do not increase the risk of hepatitis A. An adult client is not as likely to need the measles-mumps-rubella or varicella immu- nizations, but titers can be checked if the client has not had childhood immunizations or the disease.
50. A client arrives from surgery to the postanes- thesia care unit. Which of the following respiratory assessments should the nurse complete first? I 1. Oxygen saturation. I 2. Respiratory rate. I 3. Breath sounds. I 4. Airway flow.
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12. A client who is to receive general anesthesia has a serum potassium level of 5.8 mEq/L. What should be the nurse's first response? I 1. Call the surgeon. I 2. Send the client to surgery. I 3. Make a note on the front of the chart. I 4. Notify the anesthesiologist.
4 12. 4. The nurse should notify the anesthesiolo- gist because a serum potassium level of 5.8 mEq/L places the client at risk for arrhythmias when under general anesthesia. The surgeon may be notified; however, the anesthesiologist will make the decision about whether to proceed with surgery. The nurse should not automatically send a client with abnor- mal laboratory findings to surgery because the pro- cedure may be canceled. Once the client is inside the operating room and sterile supplies have opened up for the procedure, the client is usually charged. The nurse should call ahead of time to communicate the abnormal laboratory result instead of placing a note on the front of the chart. A note would not be seen until after the client has been transported to the operating room and the supplies have been opened.
4. After a bronchoscopy with biopsy, the nurse assesses the client. Which of the following signs should be reported immediately to the physician? I 1. Green sputum. I 2. Dry cough. I 3. Hemoptysis. I 4. Laryngeal stridor.
4 4. 4. Laryngeal stridor is characteristic of respi- ratory distress from inflammation and swelling after bronchoscopy. It must be reported immediately. Green sputum indicates infection and would occur 3 to 5 days after bronchoscopy. A mild cough or hemoptysis is typical after bronchoscopy. If a tis- sue biopsy specimen was obtained, sputum may be blood-streaked for several days.
41. A client is receiving a unit of packed red blood cells. Before the transfusion started, the client's blood pressure was 90/50 mm Hg, pulse rate 100 bpm, respirations 20 breaths/minute, and temperature 98┬░ F (36.7┬░ C). Fifteen minutes after the transfusion starts, the client's blood pressure is 92/54 mm Hg, pulse 100 bpm, respirations 18 breaths/minute, and temperature is 101.4┬░ F (38.6┬░ C). The nurse should first:
41. 1. The nurse's first action should be to clamp off the transfusion because the client is having a transfusion reaction. It is most important that the client not receive any more blood. Other mea- sures may be appropriate after the blood has been stopped. The nurse should raise the head of the bed if the client becomes short of breath. There is no need for antibiotic therapy for a blood transfu- sion related to a temperature spike. The nurse can provide a cool washcloth for a headache or fever; however, this is not a priority.
42. Which of the following findings in a client receiving opioid epidural analgesia would lead the nurse to notify the physician? Select all that apply. 1. Blood pressure of 80/40 mm Hg; baselineblood pressure of 110/60 mm Hg. 2. Respiratory rate of 14 breaths/minute; base- line respiratory rate of 18 breaths/minute. 3. Report of crushing headache. 4. 1.5 cc of blood aspirated from the catheter before the bolus injection. 5. Pain rating of 3 on a scale of 1 to 10.
42. 1, 3, 4. A drop in blood pressure to 80/40 mm Hg is significant and should be reported to the phy- sician. Hypotension and vasodilation may occur as a result of sympathetic nerve blockage along with the pain nerve blockage. A report of a crushing headache suggests that the epidural catheter may be dislodged and in the subarachnoid space rather than the epidural space. The physician also should be notified anytime more than 1 mL of fluid or blood is aspirated from the catheter before a bolus injection. A respiratory rate of 14 breaths/minute, although somewhat decreased from baseline, is within accept- able parameters. However, if the rate drops to 10 breaths/minute or less, the physician should be noti- fied. A pain rating of 3 out of 10 suggests that pain is being relieved with the epidural analgesia.
47. A client experienced a pneumothorax after the placement of a central venous pressure line. Which of the following assessments supports a medical diagnosis of pneumothorax? I 1. Sudden, sharp pain on the affected side. I 2. Tracheal deviation toward the affected side. I 3. Bradypnea and elevated blood pressure. I 4. Presence of crackles and wheezes.
47. 1. Signs and symptoms of a pneumotho- rax include sudden, sharp pain with breathing or coughing on the affected side, tachypnea, dyspnea, diminished or absent breath sounds on the affected side, tachycardia, anxiety, and restlessness. Tracheal deviation away from the affected side indicates a tension pneumothorax, which is a medical emer- gency.
51. An 80-year-old client is admitted with nausea and vomiting. He has a history of heart failure and is being treated with digoxin (Lanoxin). He tells the nurse he has been nauseated for a week and began vomiting 2 days ago. Laboratory values indicate that he has hypokalemia. Because of these clinical find- ings, the nurse should assess the client carefully for signs of which of the following conditions? I 1. Chronic renal failure. I 2. Exacerbation of heart failure. I 3. Digoxin toxicity. I 4. Metabolic acidosis.
51. 3. Nausea and vomiting, along with hypokalemia, are likely indicators of digoxin toxic- ity. Hypokalemia is a common cause of digoxin tox- icity; therefore, serum potassium levels should be carefully monitored if the client is taking digoxin. The earliest clinical signs of digoxin toxicity are anorexia, nausea, and vomiting. Bradycardia, other dysrhythmias, and visual disturbances are also common signs. Chronic renal failure usually causes hyperkalemia. With persistent vomiting, the client is more likely to develop metabolic alkalosis than metabolic acidosis.
54. A client exhibits increased restlessness. The results of the arterial blood gas test are as follows: pH, 7.52; partial pressure of carbon dioxide, 38 mm Hg; bicarbonate, 34 mg/L. The nurse should plan care based on the fact that these findings indicate which of the following acid-base imbalances? I 1. Respiratory alkalosis. I 2. Respiratory acidosis. I 3. Metabolic acidosis. I 4. Metabolic alkalosis.
54. 4. The pH of 7.52 indicates that the body is in a state of alkalosis. The partial pressure of carbon dioxide value is normal and the bicarbonate value is elevated. The increased bicarbonate value indicates that the acid-base imbalance is metabolic alkalosis. Restlessness can be a clinical finding in metabolic alkalosis.
56. When teaching a client with chronic renal failure who is taking antibiotics about signs and symptoms of potential nephrotoxicity to report, the nurse should encourage the client to promptly report which of the following changes in the urine? Select all that apply. I 1. Straw-colored. I 2. Cloudy. I 3. Smoky. I 4. Pink.
56. 2,3,4. The client who is taking potentially nephrotoxic antibiotics should notify the health care provider iff the urine is cloudy, smoky, or pink; early signs of nephrotoxicity are manifested by changes in urine color. Straw-colored urine is nor- mal.
59. Which of the following interventions will be most effective in reducing a client's fluid volume excess? I 1. Low-sodium diet. I 2. Monitoring serum electrolytes daily. I 3. Restricting fluid intake. I 4. Elevation of the client's feet.
59. 1. In clients with excess fluid volume, sodium restriction may be necessary to promote fluid loss. Monitoring electrolytes daily may be appropriate but will not reduce the excess fluid. Restricting fluid intake will not reduce retained fluids; increased fluids will increase urine output and promote improved fluid balance. Elevating the client's feet helps promote venous return and fluid reabsorption but in itself will not reduce the volume of excess fluid.
64. Which of the following is the priority for a client in addisonian crisis? I 1. Controlling hypertension. I 2. Preventing irreversible shock. I 3. Preventing infection. I 4. Relieving anxiety.
64. 2. Addison's disease is caused by a deficiency of adrenal corticosteroids and can result in severe hypotension and shock because of uncontrolled loss of sodium in the urine and impaired mineralocor- ticoid function. This results in loss of extracellular fluid and dangerously low blood volume. Glucocor- ticoids must be administered to reverse hypoten- sion. Preventing infection is not an appropriate goal of care in this life-threatening situation. Relieving anxiety is appropriate when the client's condition is stabilized, but the calm, competent demeanor of the emergency department staff will be initially reassuring.
65. Which of the following would be an expected finding in a client with adrenal crisis (addisonian crisis)? I 1. Fluid retention. I 2. Pain. I 3. Peripheral edema. I 4. Hunger.
65. 2. Adrenal hormone deficiency can cause profound physiologic changes. The client may experience severe pain (headache, abdominal pain, back pain, or pain in the extremities). Inhibited gluconeogenesis commonly produces hypoglycemia, and impaired sodium retention causes decreased, not increased, fluid volume. Edema would not be expected. Gastrointestinal disturbances, including nausea and vomiting, are expected findings in Addi- son's disease, not hunger.
67. The nurse teaches the client with iron deficiency anemia that food sources with high iron content include: I 1. Cheese. I 2. Squash. I 3. Eggs. I 4. Beef.
67. 4. Beef, liver, iron-fortified cereals, and spin- ach are iron-rich foods. Cheese, squash, and eggs are not significant sources of iron.
72. The nurse walks into the room and finds that a client who has just had surgery is diaphoretic, appears to have no respirations, and has a barely palpable pulse. What is the most appropriate imme- diate response? I 1. Call a code. I 2. Open the airway. I 3. Start rescue breathing. I 4. Start cardiac compressions.
72. 2. The most appropriate immediate response is to open the airway. The nurse then should look, listen, and feel for respirations. Noting none, the nurse calls a code and attempts ventilations with a bag mask or mask with a one-way valve until the full code team responds. Using standard precautions with the mask protects the nurse from
76. The client is started on simvastatin (Zocor) as a component of cholesterol management. Which of the following laboratory tests needs to be monitored while on this therapy? I 1. Complete blood count. I 2. Serum glucose. I 3. Total protein. I 4. Liver function tests.
76. 4. Liver function tests, including aspartate transaminase (AST) should be monitored before therapy, 6 to 12 weeks after initiation of therapy or after dose elevation, and then every 6 months. If AST levels increase to three times normal, therapy should be discontinued. Simvastatin does not influ- ence serum glucose, complete blood count, or total protein. Serum cholesterol and triglyceride levels should be evaluated before initiating therapy, after 4 to 6 weeks of therapy, and periodically thereafter.
78. A client is taking large doses of aspirin daily to treat her rheumatoid arthritis. Which of the fol- lowing side effects should the nurse instruct her to report? I 1. Abdominal cramps. I 2. Tinnitus. I 3. Rash. I 4. Hypotension.
78. 2. Tinnitus or ringing in the ears is a sign of aspirin toxicity and should be reported. Clients should be instructed to take aspirin as prescribed and to avoid overdosage. Gastrointestinal symptoms associated with aspirin include nausea, heartburn, and epigastric discomfort caused by gastric irrita- tion. Abdominal cramps, rash, and hypotension are not related to aspirin therapy.
79. A client is transferred from the coronary care unit to the step-down unit. Which of the following is not necessary in the transfer report? I 1. The client needs oxygen at 2 L/minute. I 2. The client has a do not resuscitate order. I 3. The client uses the bedpan. I 4. The client has four grandchildren.
79. 4. The nurse does not need to know that the client has four grandchildren in the transfer report because this is not information needed to help with the client's continuity of care.
38. Which of the following complications is associated with a tracheostomy? I 1. Decreased cardiac output. I 2. Damage to the laryngeal nerve. I 3. Pneumothorax. I 4. Acute respiratory distress syndrome.
8. 2. Tracheostomy tubes are associated with several potential complications, including laryngeal nerve damage, bleeding, and infection. Tracheos- tomy tubes do not cause decreased cardiac output, pneumothorax, or acute respiratory distress syn- drome.
89. The nurse should prepare the client for which of the following during the immediate post- operative care after reversal of a colostomy? Select all that apply. I 1. Nasogastric (NG) tube attached to low inter-mittent suction. 2. Administration of I.V. fluids. Daily measurement of abdominal girth. Calculation of intake and output every 8 hours. Assessment of vital signs every 6 hours.
89. 1, 2, 4. After bowel surgery, an NG tube attached to low intermittent suction is used to remove gastric fluids. The amount of fluid from the NG tube suction is important because it contributes to the client's overall fluid and electrolyte balance. I.V. fluids are used to maintain hydration, and intake and output is measured to determine hydra- tion status. Postoperative vital signs are assessed more frequently than every 6 hours. Bowel sounds will be auscultated to determine when they return. Measuring abdominal girth is not necessary follow- ing colostomy reversal.
9. When administering blood, the nurse must check the name on the label of the blood with the name on the client's: I 1. Wristband with a family member present. I 2. Wristband in the presence of another nurse. I 3. Medical chart with the unit clerk. I 4. Medication administration record with the pharmacist.
9. 2. Two nurses must verify the name and label of the blood with the client's wristband.
95. Which of the following is a priority for a cli- ent who has just had a myocardial infarction? I 1. Low-back training program. I 2. Risk modification education. I 3. Strength training program. I 4. Jogging exercise program.
95. 2. Cardiac rehabilitation includes client and family education and individualized activity coun- seling. Generally, the educational programs focus on presenting all of the risk factors associated with coronary artery disease. Low-back training is associ- ated with a back injury recovery program. A strength training or jogging exercise program is not appropri- ate immediately after a cardiac event.
92. Which of the following interventions should the nurse implement for pulmonary emboli prophy- laxis? I 1. Have the client perform leg exercises every hour while awake. I 2. Encourage the client to cough and deep- breathe. I 3. Massage the calves of the client's legs. I 4. Have the client wear antiembolism stockings when out of bed.
I 1. Have the client perform leg exercises every
