Med Surg. II Final Exam

The client has end-stage liver failure secondary to alcoholic cirrhosis. Which complication indicates the client is at risk for developing hepatic encephalopathy? 1. Gastrointestinal bleeding. 2. Hypoalbuminemia. 3. Splenomegaly. 4. Hyperaldosteronism

. 1. Blood in the intestinal tract is digested as a protein, which increases serum ammonia levels and increases the risk of developing hepatic encephalopathy

Which statement indicates discharge teaching has been effective for the client who is postoperative TURP? 1. "I will call the surgeon if I experience any difficulty urinating." 2. "I will take my Proscar daily, the same as before my surgery." 3. "I will continue restricting my oral fluid intake." 4. "I will take my pain medication routinely even if I do not hurt."

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The client returned from surgery after having a TURP and has a P 110, R 24, BP 90/40, and cool and clammy skin. Which interventions should the nurse implement? Select all that apply. 1. Assess the urine in the continuous irrigation drainage bag. 2. Decrease the irrigation fluid in the continuous irrigation catheter. 3. Lower the head of the bed while raising the foot of the bed. 4. Contact the surgeon to give an update on the client's condition. 5. Check the client's postoperative creatinine and BUN

1 - the nurse should assess the drain postop 3. the head of the bed should be lowered and the hot should be elevated to shunt blood to the central circulating system 4. The surgeon needs to be notified of the change in condition

The client asks, "What does an elevated PSA test mean?" On which scientific rationale should the nurse base the response? 1. An elevated PSA can result from several different causes. 2. An elevated PSA can be only from prostate cancer. 3. An elevated PSA can be diagnostic for testicular cancer. 4. An elevated PSA is the only test used to diagnose BPH

1 -An elevated PSA can be from urinary retention, BPH, prostate cancer, or prostate infarct.

Which statement indicates the client diagnosed with calcium phosphate renal calculi understands the discharge teaching for ways to prevent future calculi formation? 1. "I should increase my fluid intake, especially in warm weather." 2. "I should eat foods containing cocoa and chocolate." 3. "I will walk about a mile every week and not exercise often." 4. "I should take one (1) vitamin a day with extra calcium."

1 -An increased fluid intake ensuring 2 to 3 L of urine a day prevents the stone-forming salts from becoming concentrated enough to precipitate.

Which intervention should the nurse include when preparing a teaching plan for the client with chronic prostatitis? 1. Sit in a warm sitz bath for 10 to 20 minutes several times daily. 2. Sit in the chair with the feet elevated for two (2) hours daily. 3. Drink at least 3,000 mL of oral fluids, especially tea and coffee, daily. 4. Stop broad-spectrum antibiotics as soon as the symptoms subside.

1 -The client should sit in a warm sitz bath for 10 to 20 minutes several times each day to provide comfort and assist with healing.

The client receiving dialysis is complaining of being dizzy and light-headed. Which action should the nurse implement first? 1. Place the client in the Trendelenburg position. 2. Turn off the dialysis machine immediately. 3. Bolus the client with 500 mL of normal saline. 4. Notify the health-care provider as soon as possible.

1 -The nurse should place the client's chair with the head lower than the body, which will shunt blood to the brain; this is the Trendelenburg position.

Which data should the nurse expect to assess in the client who had an upper gastrointestinal (UGI) series? 1. Chalky white stools. 2. Increased heart rate. 3. A firm hard abdomen. 4. Hyperactive bowel sounds

1. A UGI series requires the client to swallow barium, which passes through the intestines, making the stools a chalky white color.

The client is diagnosed with hypothyroidism. Which signs/symptoms should the nurse expect the client to exhibit? 1. Complaints of extreme fatigue and hair loss. 2. Exophthalmos and complaints of nervousness. 3. Complaints of profuse sweating and flushed skin. 4. Tetany and complaints of stiffness of the hands.

1. A decrease in thyroid hormone causes decreased metabolism, which leads to fatigue and hair loss

Which interventions should be included in the discharge teaching for a client who had a total hip replacement? Select all that apply. 1. Discuss the client's weight-bearing limits. 2. Request the client demonstrate use of assistive devices. 3. Explain the importance of increasing activity gradually. 4. Instruct the client not to take medication prior to ambulating. 5. Tell the client to ambulate with open-toed house shoes.

1. Clients need to understand the amount of weight bearing to prevent injury. 2. Teaching the safe use of assistive devices is necessary prior to discharge. 3. Increases in activity should occur slowly to prevent complications.

The nurse is performing discharge teaching for a client diagnosed with Cushing's disease. Which statement by the client demonstrates an understanding of the instructions? 1. "I will be sure to notify my health-care provider if I start to run a fever." 2. "Before I stop taking the prednisone, I will be taught how to taper it off." 3. "If I get weak and shaky, I need to eat some hard candy or drink some juice." 4. "It is fine if I continue to participate in weekend games of tackle football."

1. Cushing's syndrome/disease predisposes the client to develop infections as a result of the immunosuppressive nature of the disease.

The nurse identifies the client problem "risk for imbalanced body temperature" for the client diagnosed with hypothyroidism. Which intervention should be included in the plan of care? 1. Discourage the use of an electric blanket. 2. Assess the client's temperature every two (2) hours. 3. Keep the room temperature cool. 4. Space activities to promote rest.

1. External heat sources (heating pads, electric or warming blankets) should be discouraged because they increase the risk of peripheral vasodilation and vascular collapse

The nurse is administering a pancreatic enzyme to the client diagnosed with chronic pancreatitis. Which statement best explains the rationale for administering this medication? 1. It is an exogenous source of protease, amylase, and lipase. 2. This enzyme increases the number of bowel movements. 3. This medication breaks down in the stomach to help with digestion. 4. Pancreatic enzymes help break down fat in the small intestine.

1. Pancreatic enzymes enhance the digestion of starches (carbohydrates) in the gastrointestinal tract by supplying an exogenous (outside) source of the pancreatic enzymes protease, amylase, and lipase.

Which sign/symptom should the nurse expect to find in a client diagnosed with ulcerative colitis? 1. Twenty bloody stools a day. 2. Oral temperature of 102˚F. 3. Hard, rigid abdomen. 4. Urinary stress incontinence

1. The colon is ulcerated and unable to absorb water, resulting in bloody diarrhea. Ten (10) to 20 bloody diarrhea stools is the most common symptom of ulcerative colitis.

The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? 1. An oral anticoagulant medication. 2. A beta blocker medication. 3. An anti-hyperuricemic medication. 4. A thrombolytic medication.

1. The nurse would anticipate an oral anticoagulant, warfarin (Coumadin), to be prescribed to help prevent thrombi formation in the atria secondary to atrial fibrillation. The thrombi can become embolic and may cause a TIA or CVA (stroke).

The client is diagnosed with Crohn's disease, also known as regional enteritis. Which statement by the client supports this diagnosis? 1. "My pain goes away when I have a bowel movement." 2. "I have bright red blood in my stool all the time." 3. "I have episodes of diarrhea and constipation." 4. "My abdomen is hard and rigid and I have a fever."

1. The terminal ileum is the most common site for regional enteritis, which causes right lower quadrant pain that is relieved by defecation.

The client has chronic atrial fibrillation. Which discharge teaching should the nurse discuss with the client? 1. Instruct the client to use a soft-bristle toothbrush. 2. Discuss the importance of getting a monthly partial thromboplastin time (PTT). 3. Teach the client about signs of pacemaker malfunction. 4. Explain to the client the procedure for synchronized cardioversion.

1.A client with chronic atrial fibrillationwill be taking an anticoagulant to helpprevent clot formation. Therefore, theclient is at risk for bleeding and shouldbe instructed to use a soft-bristletoothbrush.

The nurse is assessing the client diagnosed with congestive heart failure. Whichlaboratory data would indicate that the client is in severe congestive heart failure? 1. An elevated B-type natriuretic peptide (BNP). 2. An elevated creatine kinase (CK-MB). 3. A positive D-dimer. 4. A positive ventilation/perfusion (V/Q) scan

1.BNP is a specific diagnostic test. Levelshigher than normal indicate congestiveheart failure, with the higher the num-ber, the more severe the CHF.

The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan?Select all that apply 1. Position the client to prevent shoulder adduction. 2. Turn and reposition the client every shift. 3. Encourage the client to move the affected side. 4. Perform quadriceps exercises three (3) times a day. 5. Instruct the client to hold the fingers in a fist.

1.Placing a small pillow under the shoulder will prevent the shoulder from adducting toward the chest and developing a contracture. 3. The client should not ignore the paralyzed side, and the nurse must encourage the client to move it as much as possible; a written schedule may assist the client in exercising.

The PACU nurse is receiving the client from the OR. Which intervention should the nurse implement first? 1. Assess the client's breath sounds. 2. Apply oxygen via nasal cannula. 3. Take the client's blood pressure. 4. Monitor the pulse oximeter reading.

1.The airway should be assessed first.When caring for a client, the nurseshould follow the ABCs: airway,breathing, and circulation.

Which foods should the nurse recommend to a client when discussing sources of dietary calcium? 1. Yogurt and dark-green, leafy vegetables. 2. Oranges and citrus fruits. 3. Bananas and dried apricots. 4. Wheat bread and bran.

1.The best dietary sources of calcium are milk and other dairy products. Other sources include oysters; canned sardines or salmon; beans; cauliflower; and dark-green, leafy vegetables.

The client diagnosed with renal calculi is scheduled for a 24-hour urine specimen collection. Which interventions should the nurse implement? Select all that apply. 1. Check for the ordered diet and medication modifications. 2. Instruct the client to urinate, and discard this urine when starting collection. 3. Collect all urine during 24 hours and place in appropriate specimen container. 4. Insert an indwelling catheter in client after having the client empty the bladder. 5. Instruct the UAP to notify the nurse when the client urinates

1.The health-care provider may order certain foods and medications when obtaining a 24-hour urine collection to evaluate for calcium oxalate or uric acid. 2. When the collection begins, the client should completely empty the bladder and discard this urine. The test is started after the bladder is empty. 3. All urine for 24 hours should be saved and put in a container with preservative, refrigerated, or placed on ice as indi- cated. Not following specific instructions will result in an inaccurate test result.

The nurse is assessing a client experiencing motor loss as a result of a left-sided cere-brovascular accident (CVA). Which clinical manifestations would the nurse document? 1. Hemiparesis of the client's left arm and apraxia. 2. Paralysis of the right side of the body and ataxia. 3. Homonymous hemianopsia and diplopia. 4. Impulsive behavior and hostility toward family

2 - The most common motor dysfunction of a CVA is paralysis of one side of the body, hemiplegia; in this case with a left-sided CVA, the paralysis would affect the right side. Ataxia is an impaired ability to coordinate movement.

The nurse in the dialysis center is initiating the morning dialysis run. Which client should the nurse assess first? 1. The client who has hemoglobin of 9.8 g/dL and hematocrit of 30%. 2. The client who does not have a palpable thrill or auscultated bruit. 3. The client who is complaining of being exhausted and is sleeping. 4. The client who did not take antihypertensive medication this morning

2 - This client's dialysis access is compromised and he or she should be assessed first.

The client is admitted to the intensive care department diagnosed with myxedema coma. Which assessment data warrant immediate intervention by the nurse? 1. Serum blood glucose level of 74 mg/dL. 2. Pulse oximeter reading of 90%. 3. Telemetry reading showing sinus bradycardia. 4. The client is lethargic and sleeps all the time.

2. A pulse oximeter reading of less than 93% is significant. A 90% pulse oximeter reading indicates a PaO2 of approximately 60 on an arterial blood gas test; this is severe hypoxemia and requires immediate intervention.

The nurse at a freestanding health care clinic is caring for a 56-year-old male client who is homeless and is a type 2 diabetic controlled with insulin. Which action is an example of client advocacy? 1. Ask the client if he has somewhere he can go and live. 2. Arrange for someone to give him insulin at a local homeless shelter. 3. Notify Adult Protective Services about the client's situation. 4. Ask the HCP to take the client off insulin because he is homeless.

2. Client advocacy focuses support on the client's autonomy. Even if the nurse disagrees with his living on the street, it is the client's right. Arranging for someone to give him his insulin provides for his needs and allows his choices

The client diagnosed with acute pancreatitis is being discharged home. Which statement by the client indicates the teaching has been effective? 1. "I should decrease my intake of coffee, tea, and cola." 2. "I will eat a low-fat diet and avoid spicy foods." 3. "I will check my amylase and lipase levels daily." 4. "I will return to work tomorrow but take it easy."

2. High-fat and spicy foods stimulate gastric and pancreatic secretions and may precipitate an acute pancreatic attack.

The client with type 2 diabetes controlled with biguanide oral diabetic medication is scheduled for a computed tomography (CT) scan with contrast of the abdomen to evaluate pancreatic function. Which intervention should the nurse implement? 1. Provide a high-fat diet 24 hours prior to test. 2. Hold the biguanide medication for 48 hours prior to test. 3. Obtain an informed consent form for the test. 4. Administer pancreatic enzymes prior to the test

2. Hold biguanide medication for 48 hours prior to test. Rationale: Biguanide medication must be held for a test with contrast medium because it increases the risk of lactic acidosis, which leads to renal problems.

Which signs/symptoms should make the nurse suspect the client is experiencing a thyroid storm? 1. Obstipation and hypoactive bowel sounds. 2. Hyperpyrexia and extreme tachycardia. 3. Hypotension and bradycardia. 4. Decreased respirations and hypoxia.

2. Hyperpyrexia (high fever) and heart rate above 130 beats per minute are signs of thyroid storm, a severely exaggerated hyperthyroidism

Which type of precaution should the nurse implement to protect from being exposed to any of the hepatitis viruses? 1. Airborne Precautions. 2. Standard Precautions. 3. Droplet Precautions. 4. Exposure Precautions

2. Standard Precautions apply to blood, all body fluids, secretions, and excretions, except sweat, regardless of whether they contain visible blood.

The client is admitted to rule out Cushing's syndrome. Which laboratory tests should the nurse anticipate being ordered? 1. Plasma drug levels of quinidine, digoxin, and hydralazine. 2. Plasma levels of ACTH and cortisol. 3. A 24-hour urine for metanephrine and catecholamine. 4. Spot urine for creatinine and white blood cells.

2. The adrenal gland secretes cortisol and the pituitary gland secretes adrenocorticotropic hormone (ACTH), a hormone used by the body to stimulate the production of cortisol.

The nursing manager is making assignments for the OR. Which case should the manager assign to the inexperienced nurse? 1. The client having open-heart surgery. 2. The client having a biopsy of the breast. 3. The client having laser eye surgery. 4. The client having a laparoscopic knee repair.

2. The case of a client having a biopsy of the breast would be a good case for an inexperienced nurse because it is simple

Which electrolyte replacement should the nurse anticipate being ordered by the health-care provider in the client diagnosed with DKA who has just been admitted to the ICU? 1. Glucose. 2. Potassium. 3. Calcium. 4. Sodium.

2. The client in DKA loses potassium from increased urinary output, acidosis, catabolic state, and vomiting. Replacement is essential for preventing cardiac dysrhythmias secondary to hypokalemia.

The UAP on the medical floor tells the nurse the client diagnosed with DKA wants something else to eat for lunch. Which intervention should the nurse implement? 1. Instruct the UAP to get the client additional food. 2. Notify the dietitian about the client's request. 3. Request the HCP increase the client's caloric intake. 4. Tell the UAP the client cannot have anything else.

2. The client will not be compliant with the diet if he or she is still hungry. Therefore, the nurse should request the dietitian talk to the client to try to adjust the meals so the client will adhere to the diet.

The client is diagnosed with an acute exacerbation of ulcerative colitis. Which intervention should the nurse implement? 1. Provide a low-residue diet. 2. Rest the client's bowel. 3. Assess vital signs daily. 4. Administer antacids orally.

2. Whenever a client has an acute exacerbation of a gastrointestinal disorder, the first intervention is to place the bowel on rest. The client should be NPO with intravenous fluids to prevent dehydration.

Which statement by the client diagnosed with coronary artery disease indicates that the client understands the discharge teaching concerning diet? 1. "I will not eat more than six (6) eggs a week." 2. "I should bake or grill any meats I eat." 3. "I will drink eight (8) ounces of whole milk a day." 4. "I should not eat any type of pork products."

2.The American Heart Association rec-ommends a low-fat, low-cholesteroldiet for a client with coronary arterydisease. The client should avoid any fried foods, especially meats, and bake, broil, or grill any meat.

Which statement would be an expected outcome for the postoperative client who had general anesthesia? 1. The client will be able to sit in the chair for 30 minutes. 2. The client will have a pulse oximetry reading of 97% on room air. 3. The client will have a urine output of 30 mL per hour. 4. The client will be able to distinguish sharp from dull sensations.

2.The anesthesia machine takes over thefunction of the lungs during surgery, sothe expected outcome should directlyreflect the client's respiratory status;the alveoli can collapse, causing atelectasis

The nurse is working on an orthopedic floor. Which client should the nurse assess first after the change-of-shift report? 1. The 84-year-old female with a fractured right femoral neck in Buck's traction. 2. The 64-year-old female with a left total knee replacement who has confusion. 3. The 88-year-old male post-right total hip replacement with an abduction pillow. 4. The 50-year-old postop client with a continuous passive motion (CPM) device.

2.This is an abnormal occurrence from this information. This client should be seen first because confusion is a symptom of hypoxia.

The nurse is caring for the client diagnosed with chronic kidney disease (CKD) who is experiencing metabolic acidosis. Which statement best describes the scientific rationale for metabolic acidosis in this client? 1. There is an increased excretion of phosphates and organic acids, which leads to an increase in arterial blood pH. 2. A shortened life span of red blood cells because of damage secondary to dialysis treatments in turn leads to metabolic acidosis. 3. The kidney cannot excrete increased levels of acid because they cannot excrete ammonia or cannot reabsorb sodium bicarbonate. 4. An increase in nausea and vomiting causes a loss of hydrochloric acid and the respiratory system cannot compensate adequately.

3 - This is the correct scientific rationale for metabolic acidosis occurring in the client with CKD.

A 78-year-old client is admitted to the emergency department with numbness andweakness of the left arm and slurred speech. Which nursing intervention is priority? 1. Prepare to administer recombinant tissue plasminogen activator (rt-PA) 2. Discuss the precipitating factors that caused the symptoms. 3. Schedule for a STAT computed tomography (CT) scan of the head. 4. Notify the speech pathologist for an emergency consul

3 -A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. If a CVA is diagnosed, the CT scan can determine if it is a hemorrhagic or ischemic accident and guide treatment.

The male client diagnosed with CKD has received the initial dose of erythropoietin, a biologic response modifier, 1 week ago. Which complaint by the client indicates the need to notify the health-care provider? 1. The client complains of flu-like symptoms. 2. The client complains of being tired all the time. 3. The client reports an elevation in his blood pressure. 4. The client reports discomfort in his legs and back.

3 -After the initial administration of erythropoietin, a client's antihyperten- sive medications may need to be adjusted. Therefore, this complaint requires notification of the HCP. Erythropoietin therapy is contraindi- cated in clients with uncontrolled hypertension.

The laboratory data reveal a calcium phosphate renal stone for a client diagnosed with renal calculi. Which discharge teaching intervention should the nurse implement? 1. Encourage the client to eat a low-purine diet and limit foods such as organ meats. 2. Explain the importance of not drinking water two (2) hours before bedtime. 3. Discuss the importance of limiting vitamin D-enriched foods. 4. Prepare the client for extracorporeal shock wave lithotripsy (ESWL

3 -Dietary changes for preventing renal stones include reducing the intake of the primary substance forming the calculi. In this case, limiting vitamin D will inhibit the absorption of calcium from the gastrointestinal tract.

The client diagnosed with renal calculi is scheduled for lithotripsy. Which postprocedure nursing task is the most appropriate to delegate to the UAP? 1. Monitor the amount, color, and consistency of urine output. 2. Teach the client about care of the indwelling Foley catheter. 3. Assist the client to the car when being discharged home. 4. Take the client's postprocedural vital signs

3 -The UAP could assist the client to the car once the discharge has been completed.

The client receiving hemodialysis is being discharged home from the dialysis center. Which instruction should the nurse teach the client? 1. Notify the HCP if oral temperature is 102˚F or greater. 2. Apply ice to the access site if it starts bleeding at home. 3. Keep fingernails short and try not to scratch the skin. 4. Encourage significant other to make decisions for the client

3 -Uremic frost, which results when the skin attempts to take over the function of the kidneys, causes itching, which can lead to scratching possibly resulting in a break in the skin.

The client who is postoperative TURP asks the nurse, "When will I know if I will be able to have sex after my TURP?" Which response is most appropriate by the nurse? 1. "You seem anxious about your surgery." 2. "Tell me about your fears of impotency." 3. "Potency can return in six (6) to eight (8) weeks." 4. "Did you ask your doctor about your concern?"

3 This is usually the length of time clients need to wait prior to having sexual intercourse; this is the information the client wants to know.

The client diagnosed with type 1 diabetes is receiving Humalog, a rapid-acting insulin, by sliding scale. The order reads blood glucose level: <150, zero (0) units; 151 to 200, three (3) units; 201 to 250, six (6) units; >251, contact health-care provider. The unlicensed assistive personnel (UAP) reports to the nurse the client's glucometer reading is 189. How much insulin should the nurse administer to the client?

3 units

The nurse is caring for the immediate postoperative client who had a laparoscopic cholecystectomy. Which task could the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Check the abdominal dressings for bleeding. 2. Increase the IV fluid if the blood pressure is low. 3. Ambulate the client to the bathroom. 4. Auscultate the breath sounds in all lobes

3. A day surgery client can be ambulated to the bathroom, so this task can be delegated to the UAP.

The nurse has been assigned to care for a client diagnosed with peptic ulcer disease. Which assessment data require further intervention? 1. Bowel sounds auscultated fifteen (15) times in one (1) minute. 2. Belching after eating a heavy and fatty meal late at night. 3. A decrease in systolic BP of 20 mm Hg from lying to sitting. 4. A decreased frequency of distress located in the epigastric region.

3. A decrease of 20 mm Hg in blood pressure after changing position from lying, to sitting, to standing is orthostatic hypotension. This could indicate the client is bleeding.

The client diagnosed with ulcerative colitis is prescribed a low-residue diet. Which meal selection indicates the client understands the diet teaching? 1. Grilled hamburger on a wheat bun and fried potatoes. 2. A chicken salad sandwich and lettuce and tomato salad. 3. Roast pork, white rice, and plain custard. 4. Fried fish, whole grain pasta, and fruit salad.

3. A low-residue diet is a low-fiber diet. Products made of refined flour or finely milled grains, along with roasted, baked, or broiled meats, are recommended

The nurse is discussing osteoporosis with a group of women. Which factor will the nurse identify as a nonmodifiable risk factor? 1. Calcium deficiency. 2. Tobacco use. 3. Female gender. 4. High alcohol intake.

3. A nonmodifiable risk factor is a factor the client cannot do anything to alter or change. Approximately 50% of all women will experience an osteo- porosis-related fracture in their lifetime.

The nurse writes a problem of "altered body image" for a 34-year-old client diagnosed with Cushing's disease. Which intervention should be implemented? 1. Monitor blood glucose levels prior to meals and at bedtime. 2. Perform a head-to-toe assessment on the client every shift. 3. Use therapeutic communication to allow the client to discuss feelings. 4. Assess bowel sounds and temperature every four (4) hours.

3. Allowing the client to ventilate feelings about the altered body image is the most appropriate intervention. The nurse cannot do anything to help the client's buffalo hump or moon face.

The nurse is admitting a client diagnosed with primary adrenal cortex insufficiency (Addison's disease). Which clinical manifestations should the nurse expect to assess? 1. Moon face, buffalo hump, and hyperglycemia. 2. Hirsutism, fever, and irritability. 3. Bronze pigmentation, hypotension, and anorexia. 4. Tachycardia, bulging eyes, and goiter.

3. Bronze pigmentation of the skin, particularly of the knuckles and other areas of skin creases, occurs in Addison's disease. Hypotension and anorexia also occur with Addison's disease.

Which gastrointestinal assessment data should the nurse expect to find when assessing the client in end-stage liver failure? 1. Hypoalbuminemia and muscle wasting. 2. Oligomenorrhea and decreased body hair. 3. Clay-colored stools and hemorrhoids. 4. Dyspnea and caput medusae.

3. Clay-colored stools and hemorrhoids are gastrointestinal effects of liver failure.

The nurse is planning the care of a client diagnosed with lower esophageal sphincter dysfunction. Which dietary modifications should be included in the plan of care? 1. Allow any of the client's favorite foods as long as the amount is limited. 2. Have the client perform eructation exercises several times a day. 3. Eat four (4) to six (6) small meals a day and limit fluids during mealtimes. 4. Encourage the client to consume a glass of red wine with one (1) meal a day

3. Clients should eat small, frequent meals and limit fluids with the meals to prevent reflux into the esophagus from a distended stomach.

The client has had a liver biopsy. Which postprocedure intervention should the nurse implement? 1. Instruct the client to void immediately. 2. Keep the client NPO for eight (8) hours. 3. Place the client on the right side. 4. Monitor BUN and creatinine level.

3. Direct pressure is applied to the site, and then the client is placed on the right side to maintain site pressure

The client diagnosed with type 2 diabetes is admitted to the intensive care unit with hyperosmolar hyperglycemic nonketonic syndrome (HHNS) coma. Which assessment data should the nurse expect the client to exhibit? 1. Kussmaul's respirations. 2. Diarrhea and epigastric pain. 3. Dry mucous membranes. 4. Ketone breath odor.

3. Dry mucous membranes are a result of the hyperglycemia and occur with both HHNS and DKA.

The client received 10 units of Humulin R, a fast-acting insulin, at 0700. At 1030 the unlicensed assistive personnel (UAP) tells the nurse the client has a headache and is really acting "funny." Which intervention should the nurse implement first? 1. Instruct the UAP to obtain the blood glucose level. 2. Have the client drink eight (8) ounces of orange juice. 3. Go to the client's room and assess the client for hypoglycemia. 4. Prepare to administer one (1) ampule 50% dextrose intravenously

3. Go to the client's room and assess the client for hypoglycemia. Rationale: Regular insulin peaks in 2 to 4 hours. Therefore, the nurse should think about the possibility the client is having a hypoglycemic reaction and should assess the client. The nurse should not delegate nursing to UAP if client is unstable.

The client one (1) day postoperative total hip replacement complains of hearing a "popping sound" when turning. Which assessment data should the nurse report immediately to the surgeon? 1. Dark red-purple discoloration. 2. Equal length of lower extremities. 3. Groin pain in the affected leg. 4. Edema at the incision site.

3. Groin pain or increasing discomfort in the affected leg and the "popping sound" indicate the leg has dislocated, which should be reported immediately to the HCP for a possible closed reduction.

The nurse is discussing ways to prevent diabetic ketoacidosis with the client diagnosed with type 1 diabetes. Which instruction is most important to discuss with the client? 1. Refer the client to the American Diabetes Association. 2. Do not take any over-the-counter medications. 3. Take the prescribed insulin even when unable to eat because of illness. 4. Explain the need to get the annual flu and pneumonia vaccines.

3. Illness increases blood glucose levels; therefore, the client must take insulin and consume high-carbohydrate foods such as regular Jell-O, regular popsicles, and orange juice.

The charge nurse is making client assignments in the intensive care unit. Which client should be assigned to the most experienced nurse? 1. The client with type 2 diabetes who has a blood glucose level of 348 mg/dL. 2. The client diagnosed with type 1 diabetes who is experiencing hypoglycemia. 3. The client with DKA who has multifocal premature ventricular contractions. 4. The client with HHNS who has a plasma osmolarity of 290 mOsm/L.

3. Multifocal PVCs, which are secondary to hypokalemia and can occur in clients with DKA, are a potentially life-threatening emergency. This client needs an experienced nurse.

The nurse is discussing complications of chronic pancreatitis with a client diagnosed with the disease. Which complication should the nurse discuss with the client? 1. Diabetes insipidus. 2. Crohn's disease. 3. Narcotic addiction. 4. Peritonitis.

3. Narcotic addiction is related to the frequent, severe pain episodes often occurring with chronic pancreatitis which require narcotics for relief

The client diagnosed with Cushing's disease has undergone a unilateral adrenalectomy. Which discharge instructions should the nurse discuss with the client? 1. Instruct the client to take the glucocorticoid and mineralocorticoid medications as prescribed. 2. Teach the client regarding sexual functioning and androgen replacement therapy. 3. Explain the signs and symptoms of infection and when to call the health-care provider. 4. Demonstrate turn, cough, and deep-breathing exercises the client should perform every (2) hours.

3. Notifying the HCP if signs/symptoms of infection develop is an instruction given to all surgical clients on discharge.

The client is admitted to the medical department with a diagnosis of R/O acute pancreatitis. Which laboratory values should the nurse monitor to confirm this diagnosis? 1. Creatinine and BUN. 2. Troponin and CK-MB. 3. Serum amylase and lipase. 4. Serum bilirubin and calcium.

3. Serum amylase increases within two (2) to 12 hours of the onset of acute pancreatitis to two (2) to three (3) times normal and returns to normal in three (3) to four (4) days; lipase elevates and remains elevated for seven (7) to 14 days.

The client is one (1) hour post-endoscopic retrograde cholangiopancreatogram (ERCP). Which intervention should the nurse include in the plan of care? 1. Instruct the client to cough forcefully. 2. Encourage early ambulation. 3. Assess for return of a gag reflex. 4. Administer held medications.

3. The ERCP requires an anesthetic spray be used prior to insertion of the endoscope. If medications, food, or fluid are given orally prior to the return of the gag reflex, the client may aspirate.

Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Draw the serum liver function test. 2. Evaluate the client's intake and output. 3. Perform the bedside glucometer check. 4. Help the ward clerk transcribe orders.

3. The UAP can perform a bedside glucometer check, but the nurse must evaluate the result and determine any action needed.

Which nursing task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel? 1. Teach Credé's maneuver to the client needing to void. 2. Administer the tube feeding to the client who is quadriplegic. 3. Assist with bowel training by placing the client on the bedside commode. 4. Observe the client demonstrating self-catheterization technique.

3. The assistant can place the client on the bedside commode as part of bowel training; the nurse is responsible for the training but can delegate this task.

The nurse is assessing the feet of a client with long-term type 2 diabetes. Which assessment data warrant immediate intervention by the nurse? 1. The client has crumbling toenails. 2. The client has athlete's foot. 3. The client has a necrotic big toe. 4. The client has thickened toenails.

3. The client has a necrotic big toe. Rationale: A necrotic big toe indicates "dead" tissue. The client does not feel pain, does not realize the injury, and does not seek treatment. Increased blood glucose levels decrease the oxygen supply needed to heal the wound and increases the risk for developing infection.

The client is diagnosed with an acute exacerbation of IBD. Which priority intervention should the nurse implement first? 1. Weigh the client daily and document in the client's chart. 2. Teach coping strategies such as dietary modifications. 3. Record the frequency, amount, and color of stools. 4. Monitor the client's oral fluid intake every shift.

3. The severity of the diarrhea helps determine the need for fluid replacement. The liquid stool should be measured as part of the total output

The client is diagnosed with end-stage liver failure. The client asks the nurse, "Why is my doctor decreasing the doses of my medications?" Which statement is the nurse's best response? 1. "You are worried because your doctor has decreased the dosage." 2. "You really should ask your doctor. I am sure there is a good reason." 3. "You may have an overdose of the medications because your liver is damaged." 4. "The half-life of the medications is altered because the liver is damaged."

3. This is the main reason the HCP decreases the client's medication dose and is an explanation appropriate for the client.

The client with type 2 diabetes is prescribed prednisone, a steroid, for an acute exacerbation of inflammatory bowel disease. Which intervention should the nurse discuss with the client? 1. Take this medication on an empty stomach. 2. Notify the HCP if experiencing a moon face. 3. Take the steroid medication as prescribed. 4. Notify the HCP if the blood glucose is over 160

3. This medication must be tapered off to prevent adrenal insufficiency; therefore, the client must take this medication as prescribed.

The nurse is preparing to administer the following medications. Which medication should the nurse question administering? 1. The thyroid hormone to the client who does not have a T3, T4 level. 2. The regular insulin to the client with a blood glucose level of 210 mg/dL. 3. The loop diuretic to the client with a potassium level of 3.3 mEq/L. 4. The cardiac glycoside to the client who has a digoxin level of 1.4 mg/dL.

3. This potassium level is below normal, which is 3.5 to 5.5 mEq/L. Therefore, the nurse should question administering this medication because loop diuretics cause potassium loss in the urine.

The client is being evaluated for osteoporosis. Which diagnostic test is the most accurate when diagnosing osteoporosis? 1. X-ray of the femur. 2. Serum alkaline phosphatase. 3. Dual-energy x-ray absorptiometry (DEXA). 4. Serum bone Gla-protein test.

3. This test measures bone density in the lumbar spine or hip and is considered to be highly accurate.

. The nurse assesses a large amount of red drainage on the dressing of a client who is six (6) hours postoperative open cholecystectomy. Which intervention should the nurse implement? 1. Measure the abdominal girth. 2. Palpate the lower abdomen for a mass. 3. Turn client onto side to assess for further drainage. 4. Remove the dressing to determine the source.

3. Turning the client to the side to assess the amount of drainage and possible bleeding is important prior to contacting the surgeon.

Which assessment data would indicate to the nurse that the client would be at riskfor a hemorrhagic stroke? 1. A blood glucose level of 480 mg/dL. 2. A right-sided carotid bruit. 3. A blood pressure of 220/120 mm Hg. 4. The presence of bronchogenic carcinoma.

3. Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a ruptured blood vessel inside the cranium.

Which medication order should the nurse question in the client diagnosed with untreated hypothyroidism? 1. Thyroid hormones. 2. Oxygen. 3. Sedatives. 4. Laxatives.

3. Untreated hypothyroidism is characterized by an increased susceptibility to the effects of most hypnotic and sedative agents; therefore, the nurse should question this medication.

The nurse must obtain surgical consent forms for the scheduled surgery. Which client would not be able to consent legally to surgery? 1. The 65-year-old client who cannot read or write. 2. The 30-year-old client who does not understand English. 3. The 16-year-old client who has a fractured ankle. 4. The 80-year-old client who is not oriented to the day

3.A 16-year-old client is not legally able togive permission for surgery unless theadolescent has been given an emancipatedstatus by a judge. This information wasnot given in the stem

The charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a new graduate nurse? 1. The 44-year-old client diagnosed with a myocardial infarction. 2. The 65-year-old client admitted with unstable angina. 3. The 75-year-old client scheduled for a cardiac catheterization. 4. The 50-year-old client complaining of chest pain

3.A new graduate should be able to com-plete a preprocedure checklist and getthis client to the catheterization laboratory

The male nurse is helping his friend cut wood with an electric saw. His friend cuts two fingers of his left hand off with the saw. Which action should the nurse implement first? 1. Wrap the left hand with towels and apply pressure. 2. Instruct the friend to hold his hand above his head. 3. Apply pressure to the radial artery of the left hand. 4. Go into the friend's house and call 911.

3.Applying direct pressure to the artery above the amputated parts will help decrease the bleeding immediately and is the first intervention the nurse should implement. Then the nurse should instruct the client to hold the hand above the head, apply towels, and call 911.

The postoperative client is transferred from the PACU to the surgical floor. Which action should the nurse implement first? 1. Apply antiembolism hose to the client. 2. Attach the drain to 20 cm suction. 3. Assess the client's vital signs. 4. Listen to the report from the anesthesiologist.

3.Assessing the client's status after transfer from the PACU should be the nurse's first intervention.

The nurse finds small, fluid-filled lesions on the margins of the client's surgical dressing. Which statement is the most appropriate scientific rationale for this occurrence? 1. These were caused by the cautery unit in the operating room. 2. These are papular wheals from herpes zoster. 3. These are blisters from the tape used to anchor the dressing. 4. These macular lesions are from a latex allergy.

3.Fluid filled blisters are from a reaction to the tape and usually occur along the margins of the dressing where the tape was applied.

The client is taking calcium carbonate (Tums) to help prevent further development of osteoporosis. Which teaching should the nurse implement? 1. Encourage the client to take Tums with at least eight (8) ounces of water. 2. Teach the client to take Tums with the breakfast meal only. 3. Instruct the client to take Tums 30 to 60 minutes before a meal. 4. Discuss the need to get a monthly serum calcium level.

3.Free hydrochloric acid is needed for calcium absorption; therefore, Tums should be taken on an empty stomach.

Which assessment data indicate the postoperative client who had spinal anesthesia is suffering a complication of the anesthesia? 1. Loss of sensation at the lumbar (L5) dermatome. 2. Absence of the client's posterior tibial pulse. 3. The client has a respiratory rate of eight (8). 4. The blood pressure is within 20% of client's baseline.

3.If the effects of the spinal anesthesiamove up rather than down the spinalcord, respirations can be depressed andeven blocked.

The elderly client has coronary artery disease. Which question should the nurse ask the client during the client teaching? 1. "Do you have a daily bowel movement?" 2. "Do you get yearly chest x-rays?" 3. "Are you sexually active?" 4. "Have you had any weight change?

3.Sexual activity is a risk factor forangina resulting from coronary arterydisease. The client's being elderlyshould not affect the nurse's assess-ment of the client's concerns aboutsexual activity.

The client is exhibiting sinus bradycardia, is complaining of syncope and weakness,and has a BP of 98/60. Which collaborative treatment should the nurse anticipate being implemented? 1. Administer a thrombolytic medication. 2. Assess the client's cardiovascular status. 3. Prepare for insertion of a pacemaker. 4. Obtain a permit for synchronized cardioversion

3.The client is symptomatic and will require a pacemaker

The recovery room nurse is caring for a client who has just had a left BKA. Which intervention should the nurse implement? 1. Assess the client's surgical dressing every two (2) hours. 2. Do not allow the client to see the residual limb. 3. Keep a large tourniquet at the client's bedside. 4. Perform passive range-of-motion exercises to the right leg.

3.The large tourniquet can be used if the residual limb begins to hemorrhage either internally or externally.

The circulating nurse observes the surgical scrub technician remove a sponge from the edge of the sterile field with a clamp and place the sponge and clamp in a designated area. Which action should the nurse implement? 1. Place the sponge back where it was. 2. Tell the technician not to waste supplies. 3. Do nothing because this is the correct procedure. 4. Take the sponge out of the room immediately.

3.The technician followed the correctprocedure. Sponges are counted tomaintain client safety, so all spongesmust be kept together to repeat thecount before the incision site is su-tured. The sponge must be removed,not used, and placed in a designatedarea to be counted later

The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the most experienced registered nurse? 1. The client diagnosed with congestive heart failure who is being discharged in the morning. 2. The client who is having frequent incontinent liquid bowel movements and vomiting. 3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62. 4. The client who is complaining of chest pain with inspiration and a nonproductive cough

3.This client is exhibiting signs/symptomsof shock, which makes this client themost unstable. An experienced nurseshould care for this client.

The nurse is assessing a client in the day surgery unit who states, "I am really afraid of having this surgery. I'm afraid of what they will find." Which statement would be the best therapeutic response by the nurse? 1. "Don't worry about your surgery. It is safe." 2. "Tell me why you're worried about your surgery." 3. "Tell me about your fears of having this surgery." 4. "I understand how you feel. Surgery is frightening."

3.This statement focuses on the emotionwhich the client identified and is therapeutic

Which situation demonstrates the circulating nurse acting as the client's advocate? 1. Plays the client's favorite audio book during surgery. 2. Keeps the family informed of the findings of the surgery. 3. Keeps the operating room door closed at all times. 4. Calls the client by the first name when the client is recovering.

3.This would keep the client's dignity bymaintaining privacy. With this action,the nurse is speaking for the clientwhile the client cannot speak as a re-sult of anesthesia; this is an example of client advocacy.

Which nursing diagnosis is priority for the client who has undergone a TURP? 1. Potential for sexual dysfunction. 2. Potential for an altered body image. 3. Potential for chronic infection. 4. Potential for hemorrhage.

4

The client diagnosed with CKD is receiving peritoneal dialysis. Which assessment data warrant immediate intervention by the nurse? 1. Inability to auscultate a bruit over the fistula. 2. The client's abdomen is soft, is nontender, and has bowel sounds. 3. The dialysate being removed from the client's abdomen is clear. 4. The dialysate instilled was 1,500 mL and removed was 1,500 mL.

4 -Because the client is in ESRD, fluid must be removed from the body, so the output should be more than the amount instilled. These assessment data require intervention by the nurse.

Which data support to the nurse the client's diagnosis of acute bacterial prostatitis? 1. Terminal dribbling. 2. Urinary frequency. 3. Stress incontinence. 4. Sudden fever and chills.

4 -Clients with acute bacterial prostatitis will frequently experience a sudden onset of fever and chills. Clients with chronic prostatitis have milder symptoms.

The nurse is developing a nursing care plan for the client diagnosed with CKD. Which nursing problem is priority for the client? 1. Low self-esteem. 2. Knowledge deficit. 3. Activity intolerance. 4. Excess fluid volume.

4 -Excess fluid volume is priority because of the stress placed on the heart and vessels, which could lead to heart failure, pulmonary edema, and death.

The nurse caring for a client diagnosed with CKD writes a client problem of "noncompliance with dietary restrictions." Which intervention should be included in the plan of care? 1. Teach the client the proper diet to eat while undergoing dialysis. 2. Refer the client and significant other to the dietitian. 3. Explain the importance of eating the proper foods. 4. Determine the reason for the client not adhering to the diet

4 -Noncompliance is a choice the client has a right to make, but the nurse should determine the reason for the noncompliance and then take appropriate actions based on the client's rationale

The client is diagnosed with an acute episode of ureteral calculi. Which client problem is priority when caring for this client? 1. Fluid volume loss. 2. Knowledge deficit. 3. Impaired urinary elimination. 4. Alteration in comfort.

4 -Pain is priority. The pain can be so severe a sympathetic response may occur, causing nausea; vomiting; pallor; and cool, clammy skin.

The client had surgery to remove a kidney stone. Which laboratory assessment data warrant immediate intervention by the nurse? 1. A serum potassium level of 3.8 mEq/L. 2. A urinalysis shows microscopic hematuria. 3. A creatinine level of 0.8 mg/100 mL. 4. A white blood cell count of 14,000/mm3.

4 -The white blood cell count is elevated; normal is 5,000 to 10,000/mm3.

The client with a TURP who has a continuous irrigation catheter complains of the need to urinate. Which intervention should the nurse implement first? 1. Call the surgeon to inform the HCP of the client's complaint. 2. Administer the client a narcotic medication for pain. 3. Explain to the client this sensation happens frequently. 4. Assess the continuous irrigation catheter for patency.

4 The nurse should always assess any complaint before dismissing it as a commonly occurring problem.

The client is in the preicteric phase of hepatitis. Which signs/symptoms should the nurse expect the client to exhibit during this phase? 1. Clay-colored stools and jaundice. 2. Normal appetite and pruritus. 3. Being afebrile and left upper quadrant pain. 4. Complaints of fatigue and diarrhea.

4. "Flu-like" symptoms are the first complaints of the client in the preicteric phase of hepatitis, which is the initial phase and may begin abruptly or insidiously.

The nurse is planning care for a client experiencing agnosia secondary to a cerebrovas-cular accident. Which collaborative intervention will be included in the plan of care? 1. Observe the client swallowing for possible aspiration. 2. Position the client in a semi-Fowler's position when sleeping. 3. Place a suction setup at the client's bedside during meals 4. Refer the client to an occupational therapist for evaluation.

4. A collaborative intervention is an intervention in which another health-care discipline—in this case, occupational therapy—is used in the care of the client.

The nurse is administering morning medications at 0730. Which medication should have priority? 1. A proton pump inhibitor. 2. A nonnarcotic analgesic. 3. A histamine receptor antagonist. 4. A mucosal barrier agent

4. A mucosal barrier agent must be administered on an empty stomach for the medication to coat the stomach.

Which problem is highest priority for the nurse to identify in the client who had an open cholecystectomy surgery? 1. Alteration in nutrition. 2. Alteration in skin integrity. 3. Alteration in urinary pattern. 4. Alteration in comfort.

4. Acute pain management is the highest priority client problem after surgery because pain may indicate a life-threatening problem.

The nurse is providing an in-service on thyroid disorders. One of the attendees asks the nurse, "Why don't the people in the United States get goiters as often?" Which statement by the nurse is the best response? 1. "It is because of the screening techniques used in the United States." 2. "It is a genetic predisposition rare in North Americans." 3. "The medications available in the United States decrease goiters." 4. "Iodized salt helps prevent the development of goiters in the United States."

4. Almost all of the iodine entering the body is retained in the thyroid gland. A deficiency in iodine will cause the thyroid gland to work hard and enlarge, which is called a goiter. Goiters are commonly seen in geographical regions having an iodine deficiency. Most table salt in the United States has iodine added.

The client diagnosed with end-stage liver failure is admitted with hepatic encephalopathy. Which dietary restriction should be implemented by the nurse to address this complication? 1. Restrict sodium intake to 2 g/day. 2. Limit oral fluids to 1,500 mL/day. 3. Decrease the daily fat intake. 4. Reduce protein intake to 60 to 80 g/day

4. Ammonia is a by-product of protein metabolism and contributes to hepatic encephalopathy. Reducing protein intake should decrease ammonia levels.

The nurse has administered an antibiotic, a proton pump inhibitor, and Pepto-Bismol for peptic ulcer disease secondary to H. pylori. Which data would indicate to the nurse the medications are effective? 1. A decrease in alcohol intake. 2. Maintaining a bland diet. 3. A return to previous activities. 4. A decrease in gastric distress.

4. Antibiotics, proton pump inhibitors, and Pepto-Bismol are administered to decrease the irritation of the ulcerative area and cure the ulcer. A decrease in gastric distress indicates the medication is effective.

The nurse is preparing the plan of care for the client with a closed fracture of the right arm. Which problem is most appropriate for the nurse to identify? 1. Risk for ineffective coping related to the inability to perform ADLs. 2. Risk for compartment syndrome-related injured muscle tissue. 3. Risk for infection related to exposed bone and tissue. 4. Risk for complications related to compromised neurovascular status.

4. Assessing and preventing complica- tions related to the neurovascular compromise is the most appropriate intervention because, if there are no complications, a closed fracture should heal without problems.

The client diagnosed with IBD is prescribed sulfasalazine (Asulfidine), a sulfonamide antibiotic. Which statement best describes the rationale for administering this medication? 1. It is administered rectally to help decrease colon inflammation. 2. This medication slows gastrointestinal motility and reduces diarrhea. 3. This medication kills the bacteria causing the exacerbation. 4. It acts topically on the colon mucosa to decrease inflammation.

4. Asulfidine is poorly absorbed from the gastrointestinal tract and acts topically on the colonic mucosa to inhibit the inflammatory process

The nurse is developing a plan of care for the client diagnosed with acquired immunodeficiency syndrome (AIDS) who has developed an infection in the adrenal gland. Which client problem is highest priority? 1. Altered body image. 2. Activity intolerance. 3. Impaired coping. 4. Fluid volume deficit

4. Fluid volume deficit (dehydration) can lead to circulatory impairment and hyperkalemia.

The school nurse is discussing methods to prevent an outbreak of hepatitis A with a group of high school teachers. Which action is the most important to teach the high school teachers? 1. Do not allow students to eat or drink after each other. 2. Drink bottled water as much as possible. 3. Encourage protected sexual activity. 4. Sing the happy birthday song while washing hands

4. Hepatitis A is transmitted via the fecal-oral route. Good hand washing helps to prevent its spread. Singing the happy birthday song takes approximately 30 seconds, which is how long an individual should wash his or her hands.

Which assessment data support to the nurse the client's diagnosis of gastric ulcer? 1. Presence of blood in the client's stool for the past month. 2. Reports of a burning sensation moving like a wave. 3. Sharp pain in the upper abdomen after eating a heavy meal. 4. Complaints of epigastric pain 30 to 60 minutes after ingesting food.

4. In a client diagnosed with a gastric ulcer, pain usually occurs 30 to 60 minutes after eating, but not at night. In contrast, a client with a duodenal ulcer has pain during the night often relieved by eating food. Pain occurs 1 to 3 hours after meals.

The nurse is discharging a client who had a total hip replacement. Which statement indicates further teaching is needed? 1. "I should not cross my legs because my hip may come out of the socket." 2. "I will call my HCP if I have a sudden increase in pain." 3. "I will sit on a chair with arms and a firm seat." 4. "After three (3) weeks, I don't have to worry about infection."

4. Infections are possible months after surgery. Clients should monitor temperatures and report any signs of infection.

The client is diagnosed with an SCI and is scheduled for a magnetic resonance imaging (MRI) scan. Which question would be most appropriate for the nurse to ask prior to taking the client to the diagnostic test? 1. "Do you have trouble hearing?" 2. "Are you allergic to any type of dairy products?" 3. "Have you eaten anything in the last eight (8) hours?" 4. "Are you uncomfortable in closed spaces?"

4. MRI scans are often done in a very confined space; many people who have claustrophobia must be medicated or even rescheduled for the procedure in an open MRI machine, which may be available if needed.

The client diagnosed with osteoporosis asks the nurse, "Why does smoking cigarettes cause my bones to be brittle?" Which response by the nurse is most appropriate? 1. "Smoking causes nutritional deficiencies which contribute to osteoporosis." 2. "Tobacco causes an increase in blood supply to the bones, causing osteoporosis." 3. "Smoking low-tar cigarettes will not cause your bones to become brittle." 4. "Nicotine impairs the absorption of calcium, causing decreased bone strength."

4. Nicotine slows the production of osteoblasts and impairs the absorption of calcium, contributing to decreased bone density.

The nurse is preparing a client diagnosed with GERD for discharge following an esophagogastroduodenoscopy. Which statement indicates the client understands the discharge instructions? 1. "I should not eat for at least one (1) day following this procedure." 2. "I can lie down whenever I want after a meal. It won't make a difference." 3. "The stomach contents won't bother my esophagus but will make me nauseous." 4. "I should avoid orange juice and eating tomatoes until my esophagus heals."

4. Orange juice and tomatoes are acidic, and the client diagnosed with GERD should avoid acidic foods until the esophagus has had a chance to heal.

The nurse is discussing the importance of exercising with a client diagnosed with type 2 diabetes whose diabetes is well controlled with diet and exercise. Which information should the nurse include in the teaching about diabetes? 1. Eat a simple carbohydrate snack before exercising. 2. Carry peanut butter crackers when exercising. 3. Encourage the client to walk 20 minutes three (3) times a week. 4. Perform warmup and cool-down exercises.

4. Perform warmup and cool-down exercises. Rationale: All clients who exercise should perform warmup and cool-down exercises to help prevent muscle strain and injury.

Which problems should the nurse include in the plan of care for the client diagnosed with peptic ulcer disease to observe for physiological complications? 1. Alteration in bowel elimination patterns. 2. Knowledge deficit in the causes of ulcers. 3. Inability to cope with changing family roles. 4. Potential for alteration in gastric emptying.

4. Potential for alteration in gastric emptying is caused by edema or scarring associated with an ulcer, which may cause a feeling of "fullness," vomiting of undigested food, or abdominal distention.

The client has been diagnosed with a cerebrovascular accident (stroke). The client'swife is concerned about her husband's generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge? 1. Obtain a rubber mat to place under the dinner plate. 2. Purchase a long-handled bath sponge for showering. 3. Purchase clothes with Velcro closure devices. 4. Obtain a raised toilet seat for the client's bathroom

4. Raising the toilet seat is modifying the home and addresses the client's weakness in being able to sit down and get up without straining muscles or requiring lifting assistance from the wife.

The client is four (4) hours postoperative open cholecystectomy. Which data warrant immediate intervention by the nurse? 1. Absent bowel sounds in all four (4) quadrants. 2. The T-tube has 60 mL of green drainage. 3. Urine output of 100 mL in the past three (3) hours. 4. Refusal to turn, deep breathe, and cough.

4. Refusing to turn, deep breathe, and cough places the client at risk for pneumonia. This client needs immediate intervention to prevent complications

The nurse has written an outcome goal "demonstrates tolerance for increasedactivity" for a client diagnosed with congestive heart failure. Which intervention should the nurse implement to assist the client to achieve this outcome? 1. Measure intake and output. 2. Provide two (2)-g sodium diet. 3. Weigh client daily. 4. Plan for frequent rest periods.

4. Scheduling activities and rest periodsallows the client to participate in his orher own care and addresses the desiredoutcome.

Which statement by the client diagnosed with hepatitis warrants immediate intervention by the clinic nurse? 1. "I will not drink any type of beer or mixed drink." 2. "I will get adequate rest so I don't get exhausted." 3. "I had a big hearty breakfast this morning." 4. "I took some cough syrup for this nasty head cold."

4. The client needs to understand some types of cough syrup have alcohol and all alcohol must be avoided to prevent further injury to the liver; therefore, this statement requires intervention.

The client is diagnosed with acute pancreatitis. Which health-care provider's admitting order should the nurse question? 1. Bedrest with bathroom privileges. 2. Initiate IV therapy of D5W at 125 mL/hr. 3. Weigh client daily. 4. Low-fat, low-carbohydrate diet

4. The client will be NPO, which will decrease stimulation of the pancreatic enzymes, resulting in decreased autodigestion of the pancreas, therefore decreasing pain.

Which nursing intervention should be included in the plan of care for the client diagnosed with hyperthyroidism? 1. Increase the amount of fiber in the diet. 2. Encourage a low-calorie, low-protein diet. 3. Decrease the client's fluid intake to 1,000 mL/day. 4. Provide six (6) small, well-balanced meals a day

4. The client with hyperthyroidism has an increased appetite; therefore, wellbalanced meals served several times throughout the day will help with the client's constant hunger.

The nurse is caring for a client diagnosed with GERD. Which nursing interventions should be implemented? 1. Place the client prone in bed and administer nonsteroidal anti-inflammatory medications. 2. Have the client remain upright at all times and walk for 30 minutes three (3) times a week. 3. Instruct the client to maintain a right lateral side-lying position and take antacids before meals. 4. Elevate the head of the bed 30 degrees and discuss lifestyle modifications with the client.

4. The head of the bed should be elevated to allow gravity to help in preventing reflux. Lifestyle modifications of losing weight, making dietary modifications, attempting smoking cessation, discontinuing the use of alcohol, and not stooping or bending at the waist all help to decrease reflux

The nurse is caring for the client who has had a total hip replacement. Which data indicate the surgical treatment is effective? 1. The client states the pain is at a "3" on a 1-to-10 scale. 2. The client has a limited ability to ambulate. 3. The client's left leg is shorter than the right leg. 4. The client ambulates to the bathroom.

4. The hip should have functional motion and client should be able to ambulate to the bathroom. This indicates surgical treatment has been effective.

Which statement by the client diagnosed with a fractured ulna indicates to the nurse the client needs further teaching? 1. "I need to eat a high-protein diet to ensure healing." 2. "I need to wiggle my fingers every hour to increase circulation." 3. "I need to take my pain medication before my pain is too bad." 4. "I need to keep this immobilizer on when lying down only."

4. The immobilizer should be kept on at all times. This indicates the client does not understand the teaching and needs the nurse to provide more instruction.

The 85-year-old client diagnosed with a stroke is complaining of a severe headache.Which intervention should the nurse implement first? 1. Administer a nonnarcotic analgesic. 2. Prepare for STAT magnetic resonance imaging (MRI). 3. Start an intravenous infusion with D5W at 100 mL/hr. 4. Complete a neurological assessment

4. The nurse must complete a neurological assessment to help determine the cause of the headache before taking any further action.

Which statement made by the client makes the nurse suspect the client is experiencing hyperthyroidism? 1. "I just don't seem to have any appetite anymore." 2. "I have a bowel movement about every 3 to 4 days." 3. "My skin is really becoming dry and coarse." 4. "I have noticed all my collars are getting tighter."

4. The thyroid gland (in the neck) enlarges as a result of the increased need for thyroid hormone production; an enlarged gland is called a goiter.

45. The nurse is caring for clients on a surgical unit. Which nursing task is most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? 1. Help the client with a 2-day postop amputation put on the prosthesis. 2. Request the UAP double-check a unit of blood to be hung. 3. Change the surgical dressing on the client with a Syme's amputation. 4. Ask the UAP to take the client to the physical therapy department.

4. The unlicensed assistive personnel (UAP) could take a client to another department in the hospital.

The nurse is caring for a client six (6) hours postoperative right total knee replacement. Which data should the nurse report to the surgeon? 1. A total of 100 mL of red drainage in the autotransfusion drainage system. 2. Pain relief after using the patient-controlled analgesia (PCA) pump. 3. Cool toes, distal pulses palpable, and pale nailbeds bilaterally. 4. Urinary output of 60 mL of clear yellow urine in three (3) hours.

4. The urinary output is not adequate; therefore, the surgeon needs to be notified. This is only 20 mL/hr. The minimum should be 30 mL/hr.

Which arterial blood gas results should the nurse expect in the client diagnosed with diabetic ketoacidosis? 1. pH 7.34, PaO2 99, PaCO2 48, HCO3 24. 2. pH 7.38, PaO2 95, PaCO2 40, HCO3 22. 3. pH 7.46, PaO2 85, PaCO2 30, HCO3 26. 4. pH 7.30, PaO2 90, PaCO2 30, HCO3 18.

4. This ABG indicates metabolic acidosis, which is expected in a client diagnosed with diabetic ketoacidosis.

Which outcome should the nurse identify for the client scheduled to have a cholecystectomy? 1. Decreased pain management. 2. Ambulate first day postoperative. 3. No break in skin integrity. 4. Knowledge of postoperative care.

4. This would be an expected outcome for the client scheduled for surgery. This indicates preoperative teaching has been effective

The nurse is preparing the preoperative client for a total hip replacement (THR). Which intervention should the nursing implement postoperatively? 1. Keep an abduction pillow in place between the legs at all times. 2. Cough and deep breathe at least every four (4) to five (5) hours. 3. Turn to both sides every two (2) hours to prevent pressure ulcers. 4. Sit in a high-seated chair for a flexion of less than 90 degrees.

4. Using a high-seated toilet and chair will help prevent dislocation by limiting the flexion to less than 90 degrees.

The client diagnosed with HHNS was admitted yesterday with a blood glucose level of 780 mg/dL. The client's blood glucose level is now 300 mg/dL. Which intervention should the nurse implement? 1. Increase the regular insulin IV drip. 2. Check the client's urine for ketones. 3. Provide the client with a therapeutic diabetic meal. 4. Notify the HCP to obtain an order to decrease insulin

4. When the glucose level is decreased to around 300 mg/dL, the regular insulin infusion therapy is decreased. Subcutaneous insulin will be administered per sliding scale.

The circulating nurse and the scrub technician find a discrepancy in the sponge count. Which action should the circulating nurse take first? 1. Notify the client's surgeon. 2. Complete an occurrence report. 3. Contact the surgical manager. 4. Re-count all sponges.

4.A re-count of sponges may lead to thediscovery of the cause of the presumederror. Usually it is just a miscount or aresult of a sponge being placed in a location other than the sterile field,such as the floor or a lower shelf

Which violation of surgical asepsis would require immediate intervention by the circulating nurse? 1. Surgical supplies were cleaned and sterilized prior to the case. 2. The circulating nurse is wearing a long-sleeved sterile gown. 3. Masks covering the mouth and nose are being worn by the surgical team. 4. The scrub nurse setting up the sterile field is wearing artificial nails.

4.According to the Centers for DiseaseControl and Prevention (CDC), the Association of Operating RoomNurses (AORN), and the Associationfor Practitioners in Infection Control, artificial nails harbor microorganisms,which increase the risk for infection

The charge nurse is making shift assignments. Which postoperative client should be assigned to the most experienced nurse? 1. The 4-year-old client who had a tonsillectomy and is able to swallow fluids. 2. The 74-year-old client with a repair of the left hip who is unable to ambulate. 3. The 24-year-old client who had an uncomplicated appendectomy the previous day. 4. The 80-year-old client with small bowel obstruction and congestive heart failure.

4.An older client with a chronic diseasewould be a complicated case, requiringthe care of a more experienced nurse

The nurse is preparing a client for surgery. Which intervention should the nurse implement first? 1. Check the permit for the spouse's signature. 2. Take and document intake and output. 3. Administer the "on call" sedative. 4. Complete the preoperative checklist

4.Completing the preoperative checklisthas the highest priority to ensure all details are completed without omissions

The intensive care nurse is caring for a client with a T1 SCI. When the nurse elevates the head of the bed 30 degrees, the client complains of lightheadedness and dizziness. The client's vital signs are T 99.2 ̊F, P 98, R 24, and BP 84/40. Which action should the nurse implement? 1. Notify the health-care provider ASAP. 2. Calm the client down by talking therapeutically. 3. Increase the IV rate by 50 mL/hour. 4. Lower the head of the bed immediately.

4.For the first two (2) weeks after an SCI above T7, the blood pressure tends to be unstable and low; slight elevations of the head of the bed can cause profound hypotension; therefore, the nurse should lower the head of the bed immediately.

Which intervention should the nurse implement when defibrillating a client who is in ventricular fibrillation? 1. Defibrillate the client at 50, 100, and 200 joules. 2. Do not remove the oxygen source during defibrillation. 3. Place petroleum jelly on the defibrillator pads. 4. Shout "all clear" prior to defibrillating the client

4.If any member of the health-care teamis touching the client or the bed duringdefibrillation, that person could possi-bly be shocked. Therefore, the nurseshould shout "all clear."

Which data indicate to the nurse the client who is one (1) day postoperative right total hip replacement is progressing as expected? 1. Urine output was 160 mL in the past eight (8) hours. 2. Paralysis and parasthesia of the right leg. 3. T 99.0˚F, P 98, R 20, and BP 100/60. 4. Lungs are clear bilaterally in all lobes.

4.Lung sounds which are clear bilaterallyin all lobes indicate the client has ade-quate gas exchange, which preventspostoperative complications and indi-cates effective nursing care.

The 84-year-old client is a resident in a long-term care facility. Which intervention should be implemented to help prevent complications secondary to osteoporosis? 1. Keep the bed in the high position. 2. Perform passive range-of-motion exercises. 3. Turn the client every two (2) hours. 4. Provide nighttime lights in the room.

4.Nighttime lights will help prevent the client from falling; fractures are the number-one complication of osteoporosis.

The client newly diagnosed with osteoporosis is prescribed calcitonin by nasal spray. Which assessment data indicate to the nurse an adverse effect of the medication? 1. The client complains of nausea and vomiting. 2. The client is drinking two (2) glasses of milk a day. 3. The client has a runny nose and nasal itching. 4. The client has had numerous episodes of nosebleeds.

4.Nosebleeds are adverse effects and should be reported to the client's HCP.

A person's right thumb was accidentally severed with an axe. The amputated right thumb was recovered. Which action by the nurse preserves the thumb so it could possibly be reattached in surgery? 1. Place the right thumb directly on some ice. 2. Put the right thumb in a glass of warm water. 3. Wrap the thumb in a clean piece of material. 4. Secure the thumb in a plastic bag and place on ice.

4.Placing the thumb in a plastic bag will protect it and then placing the plastic bag on ice will help preserve the thumb so it may be reconnected in surgery. Do not place the amputated part directly on ice because this will cause necrosis of viable tissue.

The client who is one (1) day postoperative coronary artery bypass surgery isexhibiting sinus tachycardia. Which intervention should the nurse implement? 1. Assess the apical heart rate for one (1) full minute. 2. Notify the client's cardiac surgeon. 3. Prepare the client for synchronized cardioversion. 4. Determine if the client is having pain

4.Sinus tachycardia means the sinoatrialnode is the pacemaker, but the rate isgreater than 100 because of pain, anxiety, or fever. The nurse must determine the cause and treat appro-priately. There is no specific medica-tion for sinus tachycardia

The nurse and an unlicensed assistive personnel (UAP) are caring for four clients ona telemetry unit. Which nursing task would be best for the nurse to delegate to theUAP? 1. Assist the client to go down to the smoking area for a cigarette. 2. Transport the client to the intensive care unit via a stretcher. 3. Provide the client going home discharge-teaching instructions. 4. Help position the client who is having a portable x-ray done

4.The UAP can assist the x-ray techni-cian in positioning the client for theportable x-ray. This does not requirejudgment

Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Complete the preoperative checklist. 2. Assess the client's preoperative vital signs. 3. Teach the client about coughing and deep breathing. 4. Assist the client to remove clothing and jewelry 4. Assist the client to remove clothing and jewelry

4.The UAP can remove clothing and jewelry

The male client is diagnosed with coronary artery disease (CAD) and is prescribedsublingual nitroglycerin. Which statement indicates the client needs more teaching? 1. "I should keep the tablets in the dark-colored bottle they came in." 2. "If the tablets do not burn under my tongue, they are not effective." 3. "I should keep the bottle with me in my pocket at all times." 4. "If my chest pain is not gone with one tablet, I will go to the ER."

4.The client should take one tablet everyfive (5) minutes and, if no relief occursafter the third tablet, have someonedrive him to the emergency depart-ment or call 911

The nurse is caring for a client scheduled for total hip replacement. Which behavior indicates the need for further preoperative teaching? 1. The client uses the diaphragm and abdominal muscles to inhale through the nose and exhale through the mouth. 2. The client demonstrates dorsiflexion of the feet, flexing of the toes, and moves the feet in a circular motion. 3. The client uses the incentive spirometer and inhales slowly and deeply so the piston rises to the preset volume. 4. The client gets out of bed by lifting straight upright from the waist and then swings both legs along the side of the bed.

4.The correct way to get out of bedpostoperatively is to roll onto the side,grasp the side rail to maneuver to theside, and then push up with one handwhile swinging the legs over the side.The client needs further teaching.

The client who had a total knee replacement is being discharged home. To which multidisciplinary team member should the nurse refer the client? 1. The occupational therapist. 2. The physiatrist. 3. The recreational therapist. 4. The home health nurse.

4.The home health care nurse will be able to assess the client in the home and make further referrals if necessary.

The nurse enters the room of the client diagnosed with congestive heart failure. Theclient is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis.Which intervention would the nurse implement first? 1. Sponge the client's forehead. 2. Obtain a pulse oximetry reading. 3. Take the client's vital signs. 4. Assist the client to a sitting position

4.The nurse must first put the client in asitting position to decrease the workloadof the heart by decreasing venous returnand maximizing lung expansion. Then, the nurse could take vital signs and check the pulse oximeter and then sponge the client's forehead

Which laboratory result would require immediate intervention by the nurse for the client scheduled for surgery? 1. Calcium 9.2 mg/dL. 2. Bleeding time 2 minutes. 3. Hemoglobin 15 g/dL. 4. Potassium 2.4 mEq/L.

4.This potassium level is low and shouldbe reported to the health-care providerbecause potassium is important formuscle function, including the cardiacmuscle.

The client with CKD is placed on a fluid restriction of 1,500 mL/day. On the 7 a.m. to 7 p.m. shift the client drank an eight (8)-ounce cup of coffee, 4 ounces of juice, 12 ounces of tea, and 2 ounces of water with medications. What amount of fluid can the 7 p.m. to 7 a.m. nurse give to the client? _____________

720 ml

The nurse empted 2,000 mL from the drainage bag of a continuous irrigation of a client who had a transurethral resection of the prostate (TURP). The amount of irrigation in the bag hanging was 3,000 mL at the beginning of the shift. There was 1,800 mL left in the bag eight (8) hours later. What is the correct urine output at the end of the eight (8) hours? _________

800 ml

The nurse administered 28 units of Humalin N, an intermediate-acting insulin, to a client with type 1 diabetes at 1600. Which intervention should the nurse implement? a. Ensure the client eats a bedtime snack b. determine how much food the client ate at lunch c. Perform a glucometer reading at 0700 d. offer the client protein after administration

A. Ensure the client eats a bedtime snack.Rationale - Humulin N peaks in 6 to 8 hours, making the client at risk for hypoglycemia around midnight, which is why the client should receive a bedtime snack. This snack will prevent nighttime hypoglycemia

The client diagnosed with Cushing's disease has developed 1+ peripheral edema. The client has received intravenous fluids at 100 mL/hr via IV pump for the past 79 hours. The client received IVPB medication in 50 mL of fluid every 6 hours for 15 doses. How many mL of fluid did the client receive? ________

The client has received 8,650 mL of intravenous fluid.

The client diagnosed with CKD has a new arteriovenous fistula in the left forearm. Which intervention should the nurse implement? 1. Teach the client to carry heavy objects with the right arm. 2. Perform all laboratory blood tests on the left arm. 3. Instruct the client to lie on the left arm during the night. 4. Discuss the importance of not performing any hand exercises.

1 -Carrying heavy objects in the left arm could cause the fistula to clot by putting undue stress on the site, so the client should carry objects with the right arm.

The client two (2) hours postoperative laparoscopic cholecystectomy is complaining of severe pain in the right shoulder. Which nursing intervention should the nurse implement? 1. Apply a heating pad to the abdomen for 15 to 20 minutes. 2. Administer morphine sulfate intravenously after diluting with saline. 3. Contact the surgeon for an order to x-ray the right shoulder. 4. Apply a sling to the right arm, which was injured during surgery.

1. A heating pad should be applied for 15 to 20 minutes to assist the migration of the CO2 used to insufflate the abdomen. Shoulder pain is an expected occurrence

Which client would the nurse identify as being most at risk for experiencing a CVA? 1. A 55-year-old African American male. 2. An 84-year-old Japanese female. 3. A 67-year-old Caucasian male. 4. A 39-year-old pregnant female

1. African Americans have twice the rate of CVAs as Caucasians and men have a higher incidence than women; African Americans suffer more extensive damage from a CVA than do people of other cul- tural groups.

The nurse manager of a medical-surgical unit is asked to determine if the unit should adopt a new care delivery system. Which behavior is an example of an autocratic style of leadership? 1. Call a meeting and educate the staff on the new delivery system being used. 2. Organize a committee to investigate the various types of delivery systems. 3. Wait until another unit has implemented the new system and see if it works out. 4. Discuss with the nursing staff if a new delivery system should be adopted.

1. An autocratic style is one in which the person in charge makes the decision without consulting anyone else

The client with a right AKA is being taught how to toughen the residual limb. Which intervention should the nurse implement? 1. Instruct the client to push the residual limb against a pillow. 2. Demonstrate how to apply an elastic bandage around the residual limb. 3. Encourage the client to apply vitamin B12 to the surgical incision. 4. Teach the client to elevate the residual limb at least three (3) times a day.

1. Applying pressure to the end of the residual limb will help toughen the limb. Gradually pushing the residual limb against harder and harder surfaces is done in preparation for prosthesis training.

The home health nurse is completing the admission assessment for a 76-year-old client diagnosed with type 2 diabetes controlled with 70/30 insulin. Which intervention should be included in the plan of care? 1. Assess the client's ability to read small print. 2. Monitor the client's serum PT level. 3. Teach the client how to perform a hemoglobin A1c test daily. 4. Instruct the client to check the feet weekly.

1. Assess the client's ability to read small print. Rationale: Age-related visual changes and diabetic retinopathy could cause the client to have difficulty in reading and drawing up insulin dosage accurately.

Which physical examination should the nurse implement first when assessing the client diagnosed with peptic ulcer disease? 1. Auscultate the client's bowel sounds in all four quadrants. 2. Palpate the abdominal area for tenderness. 3. Percuss the abdominal borders to identify organs. 4. Assess the tender area progressing to nontender.

1. Auscultation should be used prior to palpation or percussion when assessing the abdomen. Manipulation of the abdomen can alter bowel sounds and give false information.

Which signs and symptoms should the nurse report to the health-care provider for the client recovering from an open cholecystectomy? Select all that apply. 1. Clay-colored stools. 2. Yellow-tinted sclera. 3. Amber-colored urine. 4. Wound approximated. 5. Abdominal pain.

1. Clay-colored stools are caused by recurring stricture of the common bile duct, which is a sign of postcholecystectomy syndrome. 2. Yellow-tinted sclera and skin indicate residual effects of stricture of the common bile duct, which is a sign of post-cholecystectomy syndrome 5. Abdominal pain indicates a residual effect of a stricture of the common bile duct, inflammation, or calculi, which is a sign of post-cholecystectomy syndrome.

. The nurse is planning the care of a client diagnosed with Addison's disease. Which intervention should be included? 1. Administer steroid medications. 2. Place the client on fluid restriction. 3. Provide frequent stimulation. 4. Consult physical therapy for gait training.

1. Clients diagnosed with Addison's disease have adrenal gland hypofunction. The hormones normally produced by the gland must be replaced. Steroids and androgens are produced by the adrenal gland.

. Which oral medication should the nurse question before administering to the client with peptic ulcer disease? 1. E-mycin, an antibiotic. 2. Prilosec, a proton pump inhibitor. 3. Flagyl, an antimicrobial agent. 4. Tylenol, a nonnarcotic analgesic

1. E-mycin is irritating to stomach, and its use in a client with peptic ulcer disease should be questioned

The public health nurse is discussing hepatitis B with a group in the community. Which health promotion activities should the nurse discuss with the group? Select all that apply. 1. Do not share needles or equipment. 2. Use barrier protection during sex. 3. Get the hepatitis B vaccine. 4. Obtain immune globulin injections. 5. Avoid any type of hepatotoxic medications.

1. Hepatitis B can be transmitted by sharing any type of needles, especially those used by drug abusers. 2. Hepatitis B can be transmitted through sexual activity; therefore, the nurse should recommend abstinence, mutual monogamy, or barrier protection. 3. Three doses of hepatitis B vaccine provide immunity in 90% of healthy adults.

The client diagnosed with liver failure is experiencing pruritus secondary to severe jaundice. Which action by the unlicensed assistive personnel (UAP) warrants intervention by the nurse? 1. The UAP is assisting the client to take a hot soapy shower. 2. The UAP applies an emollient to the client's legs and back. 3. The UAP puts mittens on both hands of the client. 4. The UAP pats the client's skin dry with a clean towel.

1. Hot water increases pruritus, and soap will cause dry skin, which increases pruritus; therefore, the nurse should discuss this with the UAP.

The nurse is caring for an adult client diagnosed with GERD. Which condition is the most common comorbid disease associated with GERD? 1. Adult-onset asthma. 2. Pancreatitis. 3. Peptic ulcer disease. 4. Increased gastric emptying

1. Of adult-onset asthma cases, 80% to 90% are caused by gastroesophageal reflux disease (GERD)

The 32-year-old male client with a traumatic left AKA is being discharged from the rehabilitation department. Which discharge instructions should be included in the teaching? Select all that apply. 1. Report any pain not relieved with analgesics. 2. Eat a well-balanced diet and increase protein intake. 3. Be sure to attend all outpatient rehabilitation appointments. 4. Encourage the client to attend a support group for amputations. 5. Stay at home as much as possible for the first couple of months.

1. Pain not relieved with analgesics could indicate complications or could be phantom pain. 2. A well-balanced diet promotes wound healing, especially a diet high in protein. 3. The client must keep appointments in outpatient rehabilitation to continue to improve physically and emotionally. 4. A support group may help the client adjust to life with an amputation.

The nurse is preparing to administer a.m. medications to clients. Which medication should the nurse question before administering? 1. Pancreatic enzymes to the client who has finished breakfast. 2. The pain medication, morphine, to the client who has a respiratory rate of 20. 3. The loop diuretic to the client who has a serum potassium level of 3.9 mEq/L. 4. The beta blocker to the client who has an apical pulse of 68 bpm.

1. Pancreatic enzymes must be administered with meals to enhance the digestion of starches and fats in the gastrointestinal tract.

The nurse is performing an admission assessment on a client diagnosed with GERD. Which signs and symptoms would indicate GERD? 1. Pyrosis, water brash, and flatulence. 2. Weight loss, dysarthria, and diarrhea. 3. Decreased abdominal fat, proteinuria, and constipation. 4. Midepigastric pain, positive H. pylori test, and melena.

1. Pyrosis is heartburn, water brash is the feeling of saliva secretion as a result of reflux, and flatulence is gas—all symptoms of GERD.

The 68-year-old client diagnosed with hyperthyroidism is being treated with radioactive iodine therapy. Which interventions should the nurse discuss with the client? 1. Explain it will take up to a month for symptoms of hyperthyroidism to subside. 2. Teach the iodine therapy will have to be tapered slowly over one (1) week. 3. Discuss the client will have to be hospitalized during the radioactive therapy. 4. Inform the client after therapy the client will not have to take any medication.

1. Radioactive iodine therapy is used to destroy the overactive thyroid cells. After treatment, the client is followed closely for three (3) to four (4) weeks until the euthyroid state is reached

In assessing a client with a T12 SCI, which clinical manifestations would the nurseexpect to find to support the diagnosis of spinal shock? 1. No reflex activity below the waist. 2. Inability to move upper extremities. 3. Complaints of a pounding headache. 4. Hypotension and bradycardia

1. Spinal shock associated with SCI represents a sudden depression of reflex activity below the level of the injury. T12 is just above the waist; therefore, no reflex activity below the waist would be expected.

The nurse writes the problem "imbalanced nutrition: less than body requirements" for the client diagnosed with hepatitis. Which intervention should the nurse include in the plan of care? 1. Provide a high-calorie intake diet. 2. Discuss total parenteral nutrition (TPN). 3. Instruct the client to decrease salt intake. 4. Encourage the client to increase water intake.

1. Sufficient energy is required for healing. Adequate carbohydrate intake can spare protein. The client should eat approximately 16 carbohydrate kilocalories for each kilogram of ideal body weight daily

The client diagnosed with IBD is prescribed total parental nutrition (TPN). Which intervention should the nurse implement? 1. Check the client's glucose level. 2. Administer an oral hypoglycemic. 3. Assess the peripheral intravenous site. 4. Monitor the client's oral food intake

1. TPN is high in dextrose, which is glucose; therefore, the client's blood glucose level must be monitored closely.

The nurse is caring for a client with a right total knee repair. Which intervention should the nurse implement? 1. Monitor the continuous passive motion machine. 2. Apply thigh-high TED hose bilaterally. 3. Place the abductor pillow between the legs. 4. Encourage the family to perform ADLs for the client.

1. The CPM machine is used to ensure the client has adequate range of motion in the knee postoperatively.

A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurseimplement? 1. Administer a stool softener b.i.d. 2. Encourage the client to cough hourly. 3. Monitor neurological status every shift. 4. Maintain the dopamine drip to keep BP at 160/90.

1. The client is at risk for increased intracranial pressure whenever performing the Valsalva maneuver, which will occur when straining during defecation. Therefore, stool softeners would be appropriate.

The nurse caring for a client diagnosed with GERD writes the client problem of "behavior modification." Which intervention should be included for this problem? 1. Teach the client to sleep with a foam wedge under the head. 2. Encourage the client to decrease the amount of smoking. 3. Instruct the client to take over-the-counter medication for relief of pain. 4. Discuss the need to attend Alcoholics Anonymous to quit drinking.

1. The client should elevate the head of the bed on blocks or use a foam wedge to use gravity to help keep the gastric acid in the stomach and prevent reflux into the esophagus. Behavior modification is changing one's behavior

The client diagnosed with Addison's disease is admitted to the emergency department after a day at the lake. The client is lethargic, forgetful, and weak. Which intervention should the nurse implement? 1. Start an IV with an 18-gauge needle and infuse NS rapidly. 2. Have the client wait in the waiting room until a bed is available. 3. Obtain a permit for the client to receive a blood transfusion. 4. Collect urinalysis and blood samples for a CBC and calcium level.

1. The client was exposed to wind and sun at the lake during the hours prior to being admitted to the emergency department. This predisposes the client to dehydration and an addisonian crisis. Rapid IV fluid replacement is necessary.

The nurse is caring for a client diagnosed with rule-out peptic ulcer disease. Which test confirms this diagnosis? 1. Esophagogastroduodenoscopy. 2. Magnetic resonance imaging. 3. Occult blood test. 4. Gastric acid stimulation.

1. The esophagogastroduodenoscopy (EGD) is an invasive diagnostic test which visualizes the esophagus, stomach, and duodenum to accurately diagnose an ulcer and evaluate the effectiveness of the client's treatment.

The nurse is preparing the care plan for a client with a fractured lower extremity. Which outcome is most appropriate for the client? 1. The client will maintain function of the leg. 2. The client will ambulate with assistance. 3. The client will be turned every two (2) hours. 4. The client will have no infection.

1. The expected outcome for a client with a fracture is maintaining the function of the extremity.

The public health nurse is teaching day-care workers. Which type of hepatitis is transmitted by the fecal-oral route via contaminated food, water, or direct contact with an infected person? 1. Hepatitis A. 2. Hepatitis B. 3. Hepatitis C. 4. Hepatitis D.

1. The hepatitis A virus is in the stool of infected people and takes up to two (2) weeks before symptoms develop.

The elderly client is admitted to the intensive care department diagnosed with severe HHNS. Which collaborative intervention should the nurse include in the plan of care? 1. Infuse 0.9% normal saline intravenously. 2. Administer intermediate-acting insulin. 3. Perform blood glucometer checks daily. 4. Monitor arterial blood gas results

1. The initial fluid replacement is 0.9% normal saline (an isotonic solution) intravenously, followed by 0.45% saline. The rate depends on the client's fluid volume status and physical health, especially of the heart.

The client is admitted to the ICU diagnosed with DKA. Which interventions should the nurse implement? Select all that apply. 1. Maintain adequate ventilation. 2. Assess fluid volume status. 3. Administer intravenous potassium. 4. Check for urinary ketones. 5. Monitor intake and output.

1. The nurse should always address the airway when a client is seriously ill. 2. The client must be assessed for fluid volume deficit and then for fluid volume excess after fluid replacement is started. 3. The electrolyte imbalance of primary concern is depletion of potassium. 4. Ketones are excreted in the urine; levels are documented from negative to large amount. Ketones should be monitored frequently. 5. The nurse must ensure the client's fluid intake and output are equal.

The nurse is caring for a client diagnosed with a fracture of the right distal humerus. Which data indicate a complication? Select all that apply. 1. Numbness and mottled cyanosis. 2. Paresthesia and paralysis. 3. Proximal pulses and point tenderness. 4. Coldness of the extremity and crepitus. 5. Palpable radial pulse and functional movement.

1. The nurse should assess for numbness and mottled cyanosis, which might indicate nerve damage. 2. The presence of paresthesia and paralysis indicates impaired circulation. 4. Coldness indicates decreased blood supply. Crepitus indicates air in subcutaneous tissue and is not expected.

The client is taken to the emergency department with an injury to the left arm. Which intervention should the nurse implement first? 1. Assess the nailbeds for capillary refill time. 2. Remove the client's clothing from the arm. 3. Call radiology for a STAT x-ray of the extremity. 4. Prepare the client for the application of a cast.

1. The nurse should assess the nailbeds for the capillary refill time. A prolonged time (greater than three [3] seconds) indicates impaired circulation to the extremity.

The client diagnosed with type 1 diabetes is found lying unconscious on the floor of the bathroom. Which intervention should the nurse implement first? 1. Administer 50% dextrose IVP. 2. Notify the health-care provider. 3. Move the client to the ICU. 4. Check the serum glucose level.

1. The nurse should assume the client is hypoglycemic and administer IVP dextrose, which will rouse the client immediately. If the collapse is the result of hyperglycemia, this additional dextrose will not further injure the client.

The client with an acute exacerbation of chronic pancreatitis has a nasogastric tube. Which interventions should the nurse implement? Select all that apply. 1. Monitor the client's bowel sounds. 2. Monitor the client's food intake. 3. Assess the client's intravenous site. 4. Provide oral and nasal care. 5. Monitor the client's blood glucose

1. The return of bowel sounds indicates the return of peristalsis, and the nasogastric suction is usually discontinued within 24 to 48 hours thereafter 3. The nurse should assess for signs of infection or infiltration. 4. Fasting and the N/G tube increase the client's risk for mucous membrane irritation and breakdown. 5. Blood glucose levels are monitored because clients with chronic pancreatitis can develop diabetes mellitus.

The nurse is developing a care plan for the client diagnosed with type 1 diabetes. The nurse identifies the problem "high risk for hyperglycemia related to noncompliance with the medication regimen." Which statement is an appropriate short-term goal for the client? 1. The client will have a blood glucose level between 90 and 140 mg/dL. 2. The client will demonstrate appropriate insulin injection technique. 3. The nurse will monitor the client's blood glucose levels four (4) times a day. 4. The client will maintain normal kidney function with 30-mL/hr urine output.

1. The short-term goal must address the response part of the nursing diagnosis, which is "high risk for hyperglycemia," and this blood glucose level is within acceptable ranges for a client who is noncompliant.

The charge nurse is monitoring client laboratory values. Which value is expected in the client with cholecystitis who has chronic inflammation? 1. An elevated white blood cell count. 2. A decreased lactate dehydrogenase. 3. An elevated alkaline phosphatase. 4. A decreased direct bilirubin level

1. The white blood cell count should be elevated in clients with chronic inflammation

The client in end-stage liver failure has vitamin K deficiency. Which interventions should the nurse implement? Select all that apply. 1. Avoid rectal temperatures. 2. Use only a soft toothbrush. 3. Monitor the platelet count. 4. Use small-gauge needles. 5. Assess for asterixis.

1. Vitamin K deficiency causes impaired coagulation; therefore, rectal thermometers should be avoided to prevent bleeding. 2. Soft-bristle toothbrushes will help prevent bleeding of the gums. 3. Platelet count, PTT/PT, and INR should be monitored to assess coagulation status. 4. Injections should be avoided, if at all possible, because the client is unable to clot, but if they are absolutely necessarily, the nurse should use small gauge needles

The nurse is teaching the client diagnosed with hyperthyroidism. Which information should be taught to the client? Select all that apply. 1. Notify the HCP if a three (3)-pound weight loss occurs in two (2) days. 2. Discuss ways to cope with the emotional lability. 3. Notify the HCP if taking over-the-counter medication. 4. Carry a medical identification card or bracelet. 5. Teach how to take thyroid medications correctly

1. Weight loss indicates the medication may not be effective and will probably need to be increased. 2. The client needs to know emotional highs and lows are secondary to hyperthyroidism. With treatment, this emotional lability will subside. 3. Any over-the-counter medications (for example, alcohol-based medications) may negatively affect the client's hyperthyroidism or medications being used for treatment. 4. This will help any HCP immediately know of the client's condition, especially if the client is unable to tell the HCP.

The nurse in the neurointensive care unit is caring for a client with a new C6 SCI who is breathing independently. Which nursing interventions should be implemented? Select all that apply. 1. Monitor the pulse oximetry reading. 2. Provide pureed foods six (6) times a day. 3. Encourage coughing and deep breathing. 4. Assess for autonomic dysreflexia. 5. Administer intravenous corticosteroids.

1. oxygen is administered initially to prevent hypoxemia, which can worsen the spinal cord injury; therefore, the nurse should determine how much oxygen is reaching the periphery. 3. Breathing exercises are supervised by the nurse to increase the strength and endurance of inspiratory muscles, especially those of the diaphragm. 5.Corticosteroids are administered to decrease inflammation, which will decrease edema, and help prevent edema from ascending up the spinal cord, causing breathing difficulties.

The diabetic educator is teaching a class on diabetes type 1 and is discussing sick-day rules. Which interventions should the diabetes educator include in the discussion? Select all that apply. 1. Take diabetic medication even if unable to eat the client's normal diabetic diet. 2. If unable to eat, drink liquids equal to the client's normal caloric intake. 3. It is not necessary to notify the health-care provider if ketones are in the urine. 4. Test blood glucose levels and test urine ketones once a day and keep a record. 5. Call the health-care provider if glucose levels are higher than 180 mg/dL.

1. take diabetic medication even if unable to eat the client's normal diabetic diet. Rationale: The most important issue to teach clients is to take insulin even if they are unable to eat. Glucose levels are increased with illness and stress 2. If unable to eat, drink liquids equal to the client's normal caloric intake. Rationale: The client should drink liquids such as regular cola or orange juice, or eat regular gelatin, which provide enough glucose to prevent hypoglycemia when receiving insulin. 5. Call the health care provider if glucose levels are higher than 180 mg/dL. Rationale: The HCP should be notified if the blood glucose level is this high. Regular insulin may need to be prescribed to keep the blood glucose level within acceptable range.

Which client teaching should the nurse implement for the client diagnosed withcoronary artery disease?Select all that apply. 1. Encourage a low-fat, low-cholesterol diet. 2. Instruct client to walk 30 minutes a day. 3. Decrease the salt intake to two (2) g a day. 4. Refer to counselor for stress reduction techniques. 5. Teach the client to increase fiber in the diet

1.A low-fat, low-cholesterol diet will help decrease the buildup of athero-sclerosis in the arteries. 2.Walking will help increase collateral circulation. 4.Stress reduction is encouraged for clients with CAD because this helps prevent excess stress on the heart muscle. 5.Increasing fiber in the diet will help remove cholesterol via the gastrointestinal system

Which problem should the nurse identify as priority for client who is one (1) day postoperative? 1. Potential for hemorrhaging. 2. Potential for injury. 3. Potential for fluid volume excess. 4. Potential for infection.

1.All clients who undergo surgery are atrisk for hemorrhaging, which is thepriority problem.

The nurse on the telemetry unit has just received the a.m. shift report. Which client should the nurse assess first? 1. The client diagnosed with myocardial infarction who has an audible S3hearts ound. 2. The client diagnosed with congestive heart failure who has 4+sacral pitting edema. 3. The client diagnosed with pneumonia who has a pulse oximeter reading of 94%. 4. The client with chronic renal failure who has an elevated creatinine level.

1.An S3heart sound indicates left ventric-ular failure, and the nurse must assessthis client first because it is an emergency situation.

The nurse is planning the care of the surgical client having conscious sedation. Which intervention has highest priority? 1. Assess the client's respiratory status. 2. Monitor the client's urinary output. 3. Take a 12-lead ECG prior to injection. 4. Attempt to keep the client focused.

1.Assessing the respiratory rate, rhythm,and depth is the most important action

The 62-year-old client diagnosed with type 2 diabetes who has a gangrenous right toe is being admitted for a below-the-knee amputation. Which nursing intervention should the nurse implement? 1. Assess the client's nutritional status. 2. Refer the client to an occupational therapist. 3. Determine if the client is allergic to IVP dye. 4. Start a 22-gauge Angiocath in the right arm.

1.For wound healing, a balanced diet with adequate protein and vitamins is essential, along with meals appropriate for type 2 diabetes.

The client is experiencing multifocal premature ventricular contractions. Whichantidysrhythmic medication would the nurse expect the health-care provider to orderfor this client?1. Lidocaine. 2. Atropine. 3. Digoxin. 4. Adenosine.

1.Lidocaine suppresses ventricular ectopy and is the drug of choice forventricular dysrhythmias

The nurse is interviewing a surgical client in the holding area. Which information should the nurse report to the anesthesiologist? Select all that apply. 1. The client has loose, decayed teeth. 2. The client is experiencing anxiety. 3. The client smokes two (2) packs of cigarettes a day. 4. The client has had a chest x-ray which does not show infiltrates. 5. The client reports using herbs.

1.Loose teeth or caries need to be re-ported to the anesthesiologist so he or she can make provisions to prevent breaking the teeth and causing the client to possibly aspirate pieces 3 Smokers are at a higher risk for complications from anesthesia. 5.Herbs—for example, St. John's wort,licorice, and ginkgo—have serious inter-actions with anesthesia and with bodilyfunctions such as coagulation

The nurse and the unlicensed assistive personnel (UAP) are working on the surgicalunit. Which task can the nurse delegate to the UAP? 1. Take routine vital signs on clients. 2. Check the Jackson Pratt insertion site. 3. Hang the client's next IV bag. 4. Ensure the client obtains pain relief.

1.Taking the vital signs of the stableclient may be delegated to the UAP

The client with coronary artery disease is prescribed a Holter monitor. Which intervention should the nurse implement? 1. Instruct client to keep a diary of activity, especially when having chest pain. 2. Discuss the need to remove the Holter monitor during a.m. care and showering. 3. Explain that all medications should be withheld while wearing a Holter monitor. 4. Teach the client the importance of decreasing activity while wearing the monitor

1.The Holter monitor is a 24-hour electrocardiogram, and the client mustkeep an accurate record of activity so that the health-care provider cancompare the ECG recordings with different levels of activity.

The Jewish client with peripheral vascular disease is scheduled for a left AKA. Which question is most important for the operating room nurse to ask the client? 1. "Have you made any special arrangements for your amputated limb?" 2. "What types of food would you like to eat while you're in the hospital?" 3. "Would you like a rabbi to visit you while you are in the recovery room?" 4. "Will you start checking your other foot at least once a day for cuts?"

1.The Jewish faith believes all body parts must be buried together. Therefore, many synagogues will keep amputated limbs until death occurs.

The nurse is teaching a class to pregnant teenagers. Which information is most important when discussing ways to prevent osteoporosis? 1. Take at least 1,200 mg of calcium supplements a day. 2. Eat foods low in calcium and high in phosphorus. 3. Osteoporosis does not occur until around age 50 years. 4. Remain as active as possible until the baby is born.

1.The National Institutes of Health (NIH) recommends a daily calcium intake of 1,200 to 1,500 mg/day for adolescents, young adults, and pregnant and lactating women.

The client's telemetry reading shows a P wave before each QRS complex and the rateis 78. Which action should the nurse implement? 1. Document this as normal sinus rhythm. 2. Request a 12-lead electrocardiogram. 3. Prepare to administer the cardiotonic digoxin PO. 4. Assess the client's cardiac enzymes.

1.The P wave represents atrial contrac-tion, and the QRS complex representsventricular contraction—a normaltelemetry reading. A rate between 60and 100 indicates normal sinus rhythm.Therefore, the nurse should documentthis as normal sinus rhythm and nottake any action.

Which activities are the circulating nurse's responsibilities in the operating room? 1. Monitor the position of the client, prepare the surgical site, and ensure the client's safety. 2. Give preoperative medication in the holding area and monitor the client's response to anesthesia. 3. Prepare sutures; set up the sterile field; and count all needles, sponges, and instruments. 4. Prepare the medications to be administered by the anesthesiologist and change the tubing for the anesthesia machine.

1.The circulating nurse has many responsibilities in the OR, including coordinating the activities in the OR;keeping the OR clean; ensuring thesafety of the client; and maintainingthe humidity, lighting, and safety of the equipment

The nurse requests the client to sign a surgical informed consent form for an emergency appendectomy. Which statement by the client indicates further teaching is needed? 1. "I will be glad when this is over so I can go home today." 2. "I will not be able to eat or drink anything prior to my surgery." 3. "I can practice relaxing by listening to my favorite music." 4. "I will need to get up and walk as soon as possible."

1.The client will be in the hospital for afew days. This is not a day-surgery pro-cedure. The client needs more teaching.

The client is admitted to the telemetry unit diagnosed with acute exacerbation ofcongestive heart failure (CHF). Which signs/symptoms would the nurse expect to findwhen assessing this client?1. Apical pulse rate of 110 and 4+pitting edema of feet. 2. Thick white sputum and crackles that clear with cough. 3. The client sleeping with no pillow and eupnea 4. Radial pulse rate of 90 and capillary refill time <3 seconds

1.The client with CHF would exhibittachycardia (apical pulse rate of 110),dependent edema, fatigue, third heartsounds, lung congestion, and change inmental status

The nurse is caring for the client who had a right shoulder replacement. Which data warrant immediate intervention? 1. The client's hemoglobin is 8.1 g/dL. 2. The client's white blood cell count is 9,000/mm3. 3. The client's creatinine level is 0.8 mg/dL. 4. The client's potassium level is 4.2 mEq/L.

1.The client's hemoglobin is near 8 g/dL, which indicates the client requires a blood transfusion. This information warrants intervention by the nurse.

Which signs/symptoms indicate to the nurse the client has developed osteoporosis? 1. The client has lost one (1) inch in height. 2. The client has lost 12 pounds in the last year. 3. The client's hands are painful to the touch. 4. The client's serum uric acid level is elevated.

1.The loss of height occurs as vertebral bodies collapse.

The unlicensed assistive personnel (UAP) reports a client with a fractured femur has "globs" floating in the urinal. What intervention should the nurse implement first? 1. Assess the client for dyspnea and altered mental status. 2. Obtain an arterial blood gas and order a portable chest x-ray. 3. Call the HCP for a ventilation/perfusion scan. 4. Instruct the UAP keep the client on strict bedrest.

1.The nurse should assess the client for signs of hypoxia from a fat embolism, which is what the nurse should anticipate from "globs" in the urine.

The 68-year-old client scheduled for intestinal surgery does not have clear fecal contents after three (3) tap water enemas. Which intervention should the nurse implement first? 1. Notify the surgeon of the client's status. 2. Continue giving enemas until clear. 3. Increase the client's IV fluid rate. 4. Obtain STAT serum electrolytes.

1.The nurse should contact the surgeonbecause the client is at risk for fluid and electrolyte imbalance after three (3) enemas. Clients who are NPO, elderly clients, and pediatricclients are more likely to have theseimbalances

The home health nurse is caring for a 28-year-old client with a T10 SCI who says, "I can't do anything. Why am I so worthless?" Which statement by the nurse would be the most therapeutic? 1. "This must be very hard for you. You're feeling worthless?" 2. "You shouldn't feel worthless—you are still alive." 3. "Why do you feel worthless? You still have the use of your arms." 4. "If you attended a work rehab program you wouldn't feel worthless."

1.Therapeutic communication addresses the client's feelings and attempts to allow the client to verbalize feelings; the nurse should be a therapeutic listener.

The nurse on the rehabilitation unit is caring for the following clients. Which client should the nurse assess first after receiving the change-of-shift report? 1. The client with a C6 SCI who is complaining of dyspnea and has crackles in the lungs. 2. The client with an L4 SCI who is crying and very upset about being discharged home. 3. The client with an L2 SCI who is complaining of a headache and feeling very hot. 4. The client with a T4 SCI who is unable to move the lower extremities.

1.This client has signs/symptoms of a respiratory complication and should be assessed first.

The circulating nurse is planning the care for an intraoperative client. Which statement is the expected outcome? 1. The client has no injuries from the OR equipment. 2. The client has no postoperative infection. 3. The client has stable vital signs during surgery. 4. The client recovers from anesthesia.

1.This expected outcome addresses thesafety of the client while in the OR.

The client with coronary artery disease asks the nurse, "Why do I get chest pain?"Which statement would be the most appropriate response by the nurse? 1. "Chest pain is caused by decreased oxygen to the heart muscle." 2. "There is ischemia to the myocardium as a result of hypoxemia." 3. "The heart muscle is unable to pump effectively to perfuse the body." 4. "Chest pain occurs when the lungs cannot adequately oxygenate the blood."

1.This is a correct statement presentedin layman's terms. When the coronaryarteries cannot supply adequate oxygento the heart muscle, there is chest pain

Which intervention is an example of a secondary nursing intervention when discussing osteoporosis? 1. Obtain a bone density evaluation test. 2. Perform non-weight-bearing exercises regularly. 3. Increase the intake of dietary calcium. 4. Refer clients to a smoking cessation program.

1.This is an example of a secondary nursing intervention, which includes screening for early detection.

The circulating nurse assesses tachycardia and hypotension in the client. Which interventions should the nurse implement? 1. Prepare ice packs and mix dantrolene sodium. 2. Request the defibrillator be brought into the OR. 3. Draw a PTT and prepare a heparin drip. 4. Obtain finger stick blood glucose immediately.

1.Unexplained tachycardia, hypotension, and elevated temperature are signs of malignant hyperthermia, which is treated with ice packs and dantrolene sodium.

The client is in ventricular fibrillation. Which interventions should the nurseimplement?Select all that apply. 1. Start cardiopulmonary resuscitation. 2. Prepare to administer the antidysrhythmic adenosine IVP. 3. Prepare to defibrillate the client. 4. Bring the crash cart to the bedside. 5. Prepare to administer the antidysrhythmic amiodarone IVP.

1.Ventricular fibrillation indicates the client does not have a heartbeat.Therefore, CPR should be instituted 3.Defibrillation is the treatment of choice for ventricular fibrillation. 4.The crash cart has the defibrillator and is used when performing advanced cardiopulmonary resuscitation. 5.Amiodarone is an antidysrhythmic thatis used in ventricular dysrhythmias.

The client diagnosed with renal calculi is admitted to the medical unit. Which intervention should the nurse implement first? 1. Monitor the client's urinary output. 2. Assess the client's pain and rule out complications. 3. Increase the client's oral fluid intake. 4. Use a safety gait belt when ambulating the client.

2 -Assessment is the first part of the nursing process and is priority. The renal colic pain can be so intense it can cause a vasovagal response, with resulting hypotension and syncope.

The nurse is caring for a client with a TURP. Which expected outcome indicates the client's condition is improving? 1. The client is using the maximum amount allowed by the PCA pump. 2. The client's bladder spasms are relieved by medication. 3. The client's scrotum is swollen and tender with movement. 4. The client has passed a large, hard, brown stool this morning

2 -Bladder spasms are common, but being relieved with medication indicates the condition is improving.

The nurse observes red urine and several large clots in the tubing of the normal saline continuous irrigation catheter for the client who is one (1) day postoperative TURP. Which intervention should the nurse implement? 1. Remove the indwelling catheter. 2. Titrate the NS irrigation to run faster. 3. Administer protamine sulfate IVP. 4. Administer vitamin K slowly.

2 -Increasing the irrigation fluid will flush out the clots and blood.

Which intervention is most important for the nurse to implement for the client diagnosed with rule-out renal calculi? 1. Assess the client's neurological status every two (2) hours. 2. Strain all urine and send any sediment to the laboratory. 3. Monitor the client's creatinine and BUN levels. 4. Take a 24-hour dietary recall during the client interview.

2 -Passing a renal stone may negate the need for the client to have lithotripsy or a surgical procedure. Therefore, all urine must be strained, and a stone, if found, should be sent to the laboratory to determine what caused the stone.

The male client diagnosed with CKD secondary to diabetes has been receiving dialysis for 12 years. The client is notified he will not be placed on the kidney transplant list. The client tells the nurse he will not be back for any more dialysis treatments. Which response by the nurse is most therapeutic? 1. "You cannot just quit your dialysis. This is not an option." 2. "Your angry at not being on the list, and you want to quit dialysis?" 3. "I will call your nephrologist right now so you can talk to the HCP." 4. "Make your funeral arrangements because you are going to die.

2 -Reflecting the client's feelings and re- stating them are therapeutic responses the nurse should use when addressing the client's issues.

Which clinical manifestations should the nurse expect to assess for the client diagnosed with a ureteral renal stone? 1. Dull, aching flank pain and microscopic hematuria. 2. Nausea; vomiting; pallor; and cool, clammy skin. 3. Gross hematuria and dull suprapubic pain with voiding. 4. The client will be asymptomatic.

2 -The severe flank pain associated with a stone in the ureter often causes a sympathetic response with associated nausea; vomiting; pallor; and cool, clammy skin.

The nurse is discussing kidney transplants with clients at a dialysis center. Which population is less likely to participate in organ donation? 1. Caucasian. 2. African American. 3. Asian. 4. Hispanic.

2 Many in the African American culture believe the body must be kept intact after death, and organ donation is rare among African Americans. This is also why a client of African American descent will be on a transplant waiting list longer than people of other races. This is because of tissue-typing compatibility. Remember, this does not apply to all African-Americans; every client is an individual.

The client is one (1) day postoperative TURP. Which task should the nurse delegate to the UAP? . Increase the irrigation fluid to clear clots from the tubing. 2. Elevate the scrotum on a towel roll for support. 3. Change the dressing on the first postoperative day. 4. Teach the client how to care for the continuous irrigation catheter

2-Elevating the scrotum on a towel for support is a task which can be delegated to the UAP.

The client has developed iatrogenic Cushing's disease. Which statement is the scientific rationale for the development of this diagnosis? 1. The client has an autoimmune problem causing the destruction of the adrenal cortex. 2. The client has been taking steroid medications for an extended period for another disease process. 3. The client has a pituitary gland tumor causing the adrenal glands to produce too much cortisol. 4. The client has developed an adrenal gland problem for which the health-care provider does not have an explanation

2. "Iatrogenic" means a problem has been caused by a medical treatment or procedure—in this case, treatment with steroids for another problem. Clients taking steroids over a period of time develop the clinical manifestations of Cushing's disease. Disease processes for which long-term steroids are prescribed include chronic obstructive pulmonary disease, cancer, and arthritis.

Which assessment data indicate to the nurse the client's gastric ulcer has perforated? 1. Complaints of sudden, sharp, substernal pain. 2. Rigid, boardlike abdomen with rebound tenderness. 3. Frequent, clay-colored, liquid stool. 4. Complaints of vague abdominal pain in the right upper quadrant

2. A rigid, boardlike abdomen with rebound tenderness is the classic sign/symptom of peritonitis, which is a complication of a perforated gastric ulcer.

Which instruction should the nurse discuss with the client who is in the icteric phase of hepatitis C? 1. Decrease alcohol intake. 2. Encourage rest periods. 3. Eat a large evening meal. 4. Drink diet drinks and juices.

2. Adequate rest is needed for maintaining optimal immune function.

The nurse is teaching a client recovering from a laparoscopic cholecystectomy. Which statement indicates the discharge teaching is effective? 1. "I will take my lipid-lowering medicine at the same time each night." 2. "I may experience some discomfort when I eat a high-fat meal." 3. "I need someone to stay with me for about a week after surgery." 4. "I should not splint my incision when I deep breathe and cough."

2. After removal of the gallbladder, some clients experience abdominal discomfort when eating fatty foods.

The client diagnosed with ulcerative colitis has an ileostomy. Which statement indicates the client needs more teaching concerning the ileostomy? 1. "My stoma should be pink and moist." 2. "I will irrigate my ileostomy every morning." 3. "If I get a red, bumpy, itchy rash I will call my HCP." 4. "I will change my pouch if it starts leaking."

2. An ileostomy will drain liquid all the time and should not routinely be irrigated. A sigmoid colostomy may need daily irrigation to evacuate feces.

Which assessment data indicate to the nurse the client recovering from an open cholecystectomy may require pain medication? 1. The client's pulse is 65 beats per minute. 2. The client has shallow respirations. 3. The client's bowel sounds are 20 per minute. 4. The client uses a pillow to splint when coughing.

2. An open cholecystecomy requires a large incision under the diaphragm. Deep breathing places pressure on the diaphragm and the incision, causing pain. Shallow respirations indicate inadequate pain control, and the nurse should intervene.

Which client problem has priority for the client diagnosed with acute pancreatitis? 1. Risk for fluid volume deficit. 2. Alteration in comfort. 3. Imbalanced nutrition: less than body requirements. 4. Knowledge deficit.

2. Autodigestion of the pancreas results in severe epigastric pain, accompanied by nausea, vomiting, abdominal tenderness, and muscle guarding.

The client diagnosed with liver problems asks the nurse, "Why are my stools claycolored?" On which scientific rationale should the nurse base the response? 1. There is an increase in serum ammonia level. 2. The liver is unable to excrete bilirubin. 3. The liver is unable to metabolize fatty foods. 4. A damaged liver cannot detoxify vitamins.

2. Bilirubin, the by-product of red blood cell destruction, is metabolized in the liver and excreted via the feces, which causes the feces to be brown in color. If the liver is damaged, the bilirubin is excreted via the urine and skin

The rehabilitation nurse caring for the client with an L1 SCI is developing the nursingcare plan. Which intervention should the nurse implement? 1. Keep oxygen via nasal cannula on at all times. 2. Administer low-dose subcutaneous anticoagulants. 3. Perform active lower extremity ROM exercises. 4. Refer to a speech therapist for ventilator-assisted speech

2. Deep vein thrombosis (DVT) is a potential complication of immobility, which can occur because the client cannot move the lower extremities as a result of the L1 SCI. Low-dose anticoagulation therapy (Lovenox) helps prevent blood from coagulating, thereby preventing DVTs.

The nurse is caring for a client with a right below-the-knee amputation. There is a large amount of bright red blood on the client's residual limb dressing. Which intervention should the nurse implement first? 1. Notify the client's surgeon immediately. 2. Assess the client's blood pressure and pulse. 3. Reinforce the dressing with additional dressing. 4. Check the client's last hemoglobin and hematocrit level.

2. Determining if the client is hemorrhaging is the first intervention. The nurse should check for signs of hypovolemic shock: decreased BP and increased pulse.

The nurse identifies the client problem "excess fluid volume" for the client in liver failure. Which short-term goal would be most appropriate for this problem? 1. The client will not gain more than two (2) kg a day. 2. The client will have no increase in abdominal girth. 3. The client's vital signs will remain within normal limits. 4. The client will receive a low-sodium diet.

2. Excess fluid volume could be secondary to portal hypertension. Therefore, no increase in abdominal girth would be an appropriate short-term goal, indicating no excess of fluid volume.

The client is diagnosed with expressive aphasia. Which psychosocial client problemwould the nurse include in the plan of care? 1. Potential for injury. 2. Powerlessness. 3. Disturbed thought processes. 4. Sexual dysfunction.

2. Expressive aphasia means that the client cannot communicate thoughts but understands what is being communicated; this leads to frustration, anger, depression, and the inability to verbalize needs, which, in turn, causes the client to have a lack of control and feel powerless.

. Which statement made by the client indicates to the nurse the client may be experiencing GERD? 1. "My chest hurts when I walk up the stairs in my home." 2. "I take antacid tablets with me wherever I go." 3. "My spouse tells me I snore very loudly at night." 4. "I drink six (6) to seven (7) soft drinks every day."

2. Frequent use of antacids indicates an acid reflux problem

The client with a history of peptic ulcer disease is admitted into the intensive care unit with frank gastric bleeding. Which priority intervention should the nurse implement? 1. Maintain a strict record of intake and output. 2. Insert a nasogastric tube and begin saline lavage. 3. Assist the client with keeping a detailed calorie count. 4. Provide a quiet environment to promote rest.

2. Inserting a nasogastric tube and lavaging the stomach with saline is the most important intervention because this directly stops the bleeding.

. Which expected outcome should the nurse include for a client diagnosed with peptic ulcer disease? 1. The client's pain is controlled with the use of NSAIDs. 2. The client maintains lifestyle modifications. 3. The client has no signs and symptoms of hemoptysis. 4. The client takes antacids with each meal.

2. Maintaining lifestyle changes such as following an appropriate diet and reducing stress indicate the client is complying with the medical regimen. Compliance is the goal of treatment to prevent complications.

The client with hepatitis asks the nurse, "I went to an herbalist, who recommended I take milk thistle. What do you think about the herb?" Which statement is the nurse's best response? 1. "You are concerned about taking an herb." 2. "The herb has been used to treat liver disease." 3. "I would not take anything that is not prescribed." 4. "Why would you want to take any herbs?"

2. Milk thistle has an active ingredient, silymarin, which has been used to treat liver disease for more than 2,000 years. It is a powerful oxidant and promotes liver cell growth

The male client tells the nurse he has been experiencing "heartburn" at night that awakens him. Which assessment question should the nurse ask? 1. "How much weight have you gained recently?" 2. "What have you done to alleviate the heartburn?" 3. "Do you consume many milk and dairy products?" 4. "Have you been around anyone with a stomach virus?"

2. Most clients with GERD have been selfmedicating with over-the-counter medications prior to seeking advice from a health-care provider. It is important to know what the client has been using to treat the problem.

The client diagnosed with inflammatory bowel disease has a serum potassium level of 3.4 mEq/L. Which action should the nurse implement first? 1. Notify the health-care provider. 2. Assess the client for muscle weakness. 3. Request telemetry for the client. 4. Prepare to administer potassium IV.

2. Muscle weakness may be a sign of hypokalemia; hypokalemia can lead to cardiac dysrhythmias and can be life threatening. Assessment is priority for a potassium level just below normal level, which is 3.5 to 5.5 mEq/L.

The health-care provider has ordered an angiotensin-converting enzyme (ACE)inhibitor for the client diagnosed with congestive heart failure. Which dischargeinstructions should the nurse include? 1. Instruct the client to take a cough suppressant if a cough develops. 2. Teach the client how to prevent orthostatic hypotension. 3. Encourage the client to eat bananas to increase potassium level. 4. Explain the importance of taking the medication with food

2. Orthostatic hypotension may occur withACE inhibitors as a result of vasodila-tion. Therefore, the nurse should in-struct the client to rise slowly and sit onthe side of the bed until equilibrium isrestored.

The client with a cervical fracture is being discharged in a halo device. Which teaching instruction should the nurse discuss with the client? 1. Discuss how to correctly remove the insertion pins. 2. Instruct the client to report reddened or irritated skin areas. 3. Inform the client that the vest liner cannot be changed. 4. Encourage the client to remain in the recliner as much as possible.

2. Reddened areas, especially under the brace, must be reported to the HCP because pressure ulcers can occur when wearing this appliance for an extended period.

Which assessment data indicate the client diagnosed with diabetic ketoacidosis is responding to the medical treatment? 1. The client has tented skin turgor and dry mucous membranes. 2. The client is alert and oriented to date, time, and place. 3. The client's ABG results are pH 7.29, PaCO2 44, HCO3 15. 4. The client's serum potassium level is 3.3 mEq/L.

2. The client's level of consciousness can be altered because of dehydration and acidosis. If the client's sensorium is intact, the client is getting better and responding to the medical treatment

The female nurse sticks herself with a contaminated needle. Which action should the nurse implement first? 1. Notify the infection control nurse. 2. Cleanse the area with soap and water. 3. Request postexposure prophylaxis. 4. Check the hepatitis status of the client.

2. The nurse should first clean the needle stick with soap and water and attempt stick bleed to help remove any virus injected into the skin.

The 34-year-old male client with an SCI is sharing with the nurse that he is worried about finding employment after being discharged from the rehabilitation unit. Which intervention should the nurse implement? 1. Refer the client to the American Spinal Cord Injury Association (ASIA). 2. Refer the client to the state rehabilitation commission. 3. Ask the social worker about applying for disability. 4. Suggest that the client talk with his significant other about this concern.

2. The rehabilitation commission of each state will help evaluate and determine if the client can receive training or education for another occupation after injury.

The client is admitted with end-stage liver failure and is prescribed the laxative lactulose (Chronulac). Which statement indicates the client needs more teaching concerning this medication? 1. "I should have two to three soft stools a day." 2. "I must check my ammonia level daily." 3. "If I have diarrhea, I will call my doctor." 4. "I should check my stool for any blood."

2. There is no instrument used at home to test daily ammonia levels. The ammonia level is a serum level requiring venipuncture and laboratory diagnostic equipment.

Which specific data should the nurse obtain from the client who is suspected of having peptic ulcer disease? 1. History of side effects experienced from all medications. 2. Use of nonsteroidal anti-inflammatory drugs (NSAIDs). 3. Any known allergies to drugs and environmental factors. 4. Medical histories of at least three (3) generations.

2. Use of NSAIDs places the client at risk for peptic ulcer disease and hemorrhage. NSAIDs suppress the production of prostaglandin in the stomach, which is a protective mechanism to prevent damage from hydrochloric acid.

The female client diagnosed with osteoporosis tells the nurse she is going to perform swim aerobics for 30 minutes every day. Which response is most appropriate by the nurse? 1. Praise the client for committing to do this activity. 2. Explain to the client walking 30 minutes a day is a better activity. 3. Encourage the client to swim every other day instead of daily. 4. Discuss with the client how sedentary activities help prevent osteoporosis.

2. Weight-bearing activity, such as walking, is beneficial in preventing or slowing bone loss. The mechanical force of weight-bearing exercises promotes bone growth.

The client admitted with a diagnosis of a fractured hip who is in Buck's traction is complaining of severe pain. Which intervention should the nurse implement? 1. Adjust the patient-controlled analgesia (PCA) machine for a lower dose. 2. Ensure the weights of the Buck's traction are off the floor and hang freely. 3. Raise the head of the bed to 45 degrees and the foot to 15 degrees. 4. Turn the client on the affected leg using pillows to support the other leg.

2. Weights from traction should be off the floor and hanging freely. Buck's traction is used to reduce muscle spasms preoperatively in clients who have fractured hips.

The client diagnosed with end-stage liver failure is admitted with esophageal bleeding. The HCP inserts and inflates a triple-lumen nasogastric tube (SengstakenBlakemore). Which nursing intervention should the nurse implement for this treatment? 1. Assess the gag reflex every shift. 2. Stay with the client at all times. 3. Administer the laxative lactulose (Chronulac). 4. Monitor the client's ammonia level.

2. While the balloons are inflated, the client must not be left unattended in case they become dislodged and occlude the airway. This is a safety issue.

The client is three (3) hours postoperative left AKA. The client tells the nurse, "My left foot is killing me. Please do something." Which intervention should the nurse implement? 1. Explain to the client his left leg has been amputated. 2. Medicate the client with a narcotic analgesic immediately. 3. Instruct the client on how to perform biofeedback exercises. 4. Place the client's residual limb in the dependent position.

2. phantom pain is caused by severing the peripheral nerves. The pain is real to the client, and the nurse needs to medicate the client immediately.

The nurse is preparing to administer a beta blocker to the client diagnosed withcoronary artery disease. Which assessment data would cause the nurse to question administering the medication? 1. The client has a BP of 110/70. 2. The client has an apical pulse of 56. 3. The client is complaining of a headache. 4. The client's potassium level is 4.5 mEq/L.

2.A beta blocker decreases sympatheticstimulation to the heart, thereby de-creasing the heart rate. An apical rateless than 60 indicates a lower-than-normal heart rate and should make thenurse question administering this med-ication because it will further decreasethe heart rate

The PACU nurse administers Narcan, an opioid antagonist, to a postoperative client. Which client problem should the nurse include to the plan of care based on this medication? 1. Alteration in comfort. 2. Risk for depressed respiratory pattern. 3. Potential for infection. 4. Fluid and electrolyte imbalance.

2.A client with respiratory depressiontreated with Narcan can have anotherepisode within 15 minutes after receiv-ing the drug as a result of the shorthalf-life of the medication

Which client problem has priority for the client with a cardiac dysrhythmia? 1. Alteration in comfort. 2. Decreased cardiac output. 3. Impaired gas exchange. 4. Activity intolerance

2.Any abnormal electrical activity of theheart causes decreased cardiac output

The client is in complete heart block. Which intervention should the nurse implement first? 1. Prepare to insert a pacemaker. 2. Administer atropine, an antidysrhythmic. 3. Obtain a STAT electrocardiogram (ECG). 4. Notify the health-care provider.

2.Atropine will decrease vagal stimula-tion and increase the heart rate.Therefore, it is the first intervention

The nurse is developing a nursing care plan for a client diagnosed with congestiveheart failure. A nursing diagnosis of "decreased cardiac output related to inability ofthe heart to pump effectively" is written. Which short-term goal would be best for theclient?The client will: 1. Be able to ambulate in the hall by date of discharge. 2. Have an audible S1and S2with no S3heard by end of shift. 3. Turn, cough, and deep breathe every two (2) hours. 4. Have a pulse oximeter reading of 98% by day two (2) of care

2.Audible S1and S2sounds are normal fora heart with adequate output. An audibleS3sound might indicate left ventricularfailure which could be life threatening.

The nurse is caring for a male client scheduled for abdominal surgery. Which interventions should the nurse include in the plan of care? Select all that apply. 1. Perform passive range-of-motion exercises. 2. Discuss how to cough and deep breathe effectively. 3. Tell the client he can have a meal in the PACU. 4. Teach ways to manage postoperative pain. 5. Discuss events which occur in the post-anesthesia care unit.

2.Coughing effectively aids in the removalof pooled secretions which can causepneumonia. Deep-breathing exercises keep the alveoli inflated and prevent atelectasis. 4.The client's postoperative pain should be kept within a tolerable range. 5.These interventions help decrease theclient's anxiety

Which interventions should the nurse implement for the client diagnosed with an open fracture of the left ankle? Select all that apply. 1. Apply an immobilizer snugly to prevent edema. 2. Apply an ice pack for 10 minutes and remove for 20 minutes. 3. Place the extremity in the dependent position to allow drainage. 4. Obtain an x-ray of the ankle after applying the immobilizer. 5. Administer tetanus toxoid, 0.5 mL intramuscularly, in the deltoid.

2.Ice packs should be applied 10 minutes on and 20 minutes off. This allows for vasoconstriction and decreases edema. Ice is a nonpharmacological pain management technique. 5. Anytime trauma occurs, tetanus should be considered. In an open fracture, this is an appropriate treatment

The 26-year-old male client in the PACU has a heart rate of 110 and a rising temperature, and complains of muscle stiffness. Which interventions should the nurse implement? Select all apply. 1. Give a back rub to the client to relieve stiffness. 2. Apply ice packs to the axillary and groin areas. 3. Prepare an ice slush for the client to drink. 4. Prepare to administer dantrolene, a smooth-muscle relaxant. 5. Reposition the client on a warming blanket.

2.Ice packs should be applied to the axillary and groin areas for a client experiencing malignant hyperthermia 4.Dantrolene is the drug of choice fortreatment.

The 27-year-old client has a right above-the-elbow amputation secondary to a boating accident. Which statement to the rehabilitation nurse indicates the client has accepted the amputation? 1. "I am going to sue the guy who hit my boat." 2. "The therapist is going to help me get retrained for another job." 3. "I decided not to get a prosthesis. I don't think I need it." 4. "My wife is so worried about me and I wish she weren't."

2.Looking toward the future and problem-solving indicate the client is accepting the loss.

Which intervention should the nurse implement when administering a loop diuretic to a client diagnosed with coronary artery disease? 1. Assess the client's radial pulse. 2. Assess the client's serum potassium level. 3. Assess the client's glucometer reading. 4. Assess the client's pulse oximeter reading.

2.Loop diuretics cause potassium to belost in the urine output. Therefore, the nurse should assess the client's potassium level, and if the client is hypokalemic, the nurse should ques-tion administering this medication

The nurse identifies the nursing diagnosis "risk for injury related to positioning" for the client in the operating room. Which nursing intervention should the nurse implement? 1. Avoid using the cautery unit which does not have a biomedical tag on it. 2. Carefully pad the client's elbows before covering the client with a blanket. 3. Apply a warming pad on the OR table before placing the client on the table. 4. Check the chart for any prescription or over-the-counter medication use.

2.Padding the elbows decreases pressure so nerve damage and pressure ulcers are prevented. This addresses the etiology of the nursing diagnosis

The nurse is assessing the client who is postoperative total knee replacement. Which assessment data warrant immediate intervention? 1. T 99 ̊F, HR 80, RR 20, and BP 128/76. 2. Pain in the unaffected leg during dorsiflexion of the ankle. 3. Bowel sounds heard intermittently in four quadrants. 4. Diffuse, crampy abdominal pain.

2.Pain with dorsiflexion of the ankle indicates deep vein thrombosis. This can be from immobility or surgery; therefore, pain should be assessed in both legs.

The nurse is discussing angina with a client who is diagnosed with coronary arterydisease. Which action should the client take first when experiencing angina? 1. Put a nitroglycerin tablet under the tongue. 2. Stop the activity immediately and rest. 3. Document when and what activity caused angina. 4. Notify the health-care provider immediately

2.Stopping the activity decreases theheart's need for oxygen and may helpdecrease the angina (chest pain).

The nurse is developing a discharge-teaching plan for the client diagnosed withcongestive heart failure. Which interventions should be included in the plan?Select all that apply. 1. Notify health-care provider of a weight gain of more than one (1) pound in a week. 2. Teach client how to count the radial pulse when taking digoxin, a cardiac glycoside. 3. Instruct client to remove the saltshaker from the dinner table. 4. Encourage client to monitor urine output for change in color to become dark. 5. Discuss the importance of taking the loop diuretic furosemide at bedtime

2.The client should not take digoxin if the radial pulse is less than 60. 3.The client should be on a low-sodiumdiet to prevent water retention.

The circulating nurse is positioning clients for surgery. Which client has the greatest potential for nerve damage? 1. The 16-year-old client in the dorsal recumbent position having an appendectomy. 2. The 68-year-old client in the Trendelenburg position having a cholecystectomy. 3. The 45-year-old client in the reverse Trendelenburg position having a biopsy. 4. The 22-year-old client in the lateral position having a nephrectomy.

2.The client's age, along with positioningwith increased weight and pressure on the shoulders, puts this client athigher risk.

The nurse in the holding area of the surgery department is interviewing a client who requests to keep his religious medal on during surgery. Which intervention should the nurse implement? 1. Notify the surgeon about the client's request to wear the medal. 2. Tape the medal to the client and allow the client to wear the medal. 3. Request the family member take the medal prior to surgery. 4. Explain taking the medal to surgery is against the policy.

2.The medal should be taped and theclient should be allowed to wear themedal because meeting spiritual needs is essential to this client's care.

The client diagnosed with congestive heart failure is complaining of leg cramps atnight. Which nursing interventions should be implemented? 1. Check the client for peripheral edema and make sure the client takes a diuretic early in the day. 2. Monitor the client's potassium level and assess the client's intake of bananas and orange juice. 3. Determine if the client has gained weight and instruct the client to keep the legs elevated. 4. Instruct the client to ambulate frequently and perform calf-muscle stretchingexercises daily

2.The most probable cause of the legcramping is potassium excretion as aresult of diuretic medication. Bananasand orange juice are foods that arehigh in potassium

The client is scheduled for a right femoral cardiac catheterization. Which nursing intervention should the nurse implement after the procedure? 1. Perform passive range-of-motion exercises. 2. Assess the client's neurovascular status. 3. Keep the client in high Fowler's position. 4. Assess the gag reflex prior to feeding the client.

2.The nurse must make sure that blood iscirculating to the right leg, so the clientshould be assessed for pulses, paresthe-sia, paralysis, coldness, and pallor.

The nurse instructs the client with a right BKA to lie on the stomach for at least 30 minutes a day. The client asks the nurse, "Why do I need to lie on my stomach?" Which statement is the most appropriate statement by the nurse? 1. "This position will help your lungs expand better." 2. "Lying on your stomach will help prevent contractures." 3. "Many times this will help decrease pain in the limb." 4. "The position will take pressure off your backside."

2.The prone position will help stretch the hamstring muscles, which will help prevent flexion contractures leading to problems when fitting the client for a prosthesis.

Which nursing intervention has the highest priority when preparing the client for a surgical procedure? 1. Pad the client's elbows and knees. 2. Apply soft restraint straps to the extremities. 3. Prepare the client's incision site. 4. Document the temperature of the room.

2.This action would prevent the clientfrom falling off the table, which is thehighest priority.

The client with a history of renal calculi calls the clinic and reports having burning on urination, chills, and an elevated temperature. Which instruction should the nurse discuss with the client? 1. Increase water intake for the next 24 hours. 2. Take two (2) Tylenol to help decrease the temperature. 3. Come to the clinic and provide a urinalysis specimen. 4. Use a sterile 4 × 4 gauze to strain the client's urine.

3 -A urinalysis can assess for hematuria, the presence of white blood cells, crystal fragments, or all three, which can determine if the client has a urinary tract infection or possibly a renal stone, with accompanying signs/symptoms of UTI.

The nurse is providing discharge teaching to the 12-year-old with a fractured humerus and the parents. Which information should the nurse include regarding cast care? 1. Keep the fractured arm at heart level. 2. Use a wire hanger to scratch inside the cast. 3. Apply an ice pack to any itching area. 4. Explain foul smells are expected occurrences.

3. Applying ice packs to the cast will relieve itching, and nothing should be placed down a cast to scratch. Skin becomes fragile inside the cast and is torn easily. Alteration in the skin's integrity can become infected.

An 88-year-old client is admitted to the orthopedic floor with the diagnosis of fractured pelvis. Which intervention should the nurse implement first? 1. Insert an indwelling catheter. 2. Administer a Fleet's enema. 3. Assess abdomen for bowel sounds. 4. Apply Buck's traction.

3. Assessing the bowel sounds should be the first intervention to determine if an ileus has occurred. This is a common complication of a fractured pelvis.

Which disease is the client diagnosed with GERD at greater risk for developing? 1. Hiatal hernia. 2. Gastroenteritis. 3. Esophageal cancer. 4. Gastric cancer.

3. Barrett's esophagus results from longterm erosion of the esophagus as a result of reflux of stomach contents secondary to GERD. This is a precursor to esophageal cancer

The nurse is completing discharge teaching to the client diagnosed with acute pancreatitis. Which instruction should the nurse discuss with the client? 1. Instruct the client to decrease alcohol intake. 2. Explain the need to avoid all stress. 3. Discuss the importance of stopping smoking. 4. Teach the correct way to take pancreatic enzymes.

3. Smoking stimulates the pancreas to release pancreatic enzymes and should be stopped.

The male client diagnosed with chronic pancreatitis calls and reports to the clinic nurse he has been having a lot of "gas," along with frothy and very foul-smelling stools. Which intervention should the nurse implement? 1. Explain this is common for chronic pancreatitis. 2. Ask the client to bring in a stool specimen to the clinic. 3. Arrange an appointment with the HCP for today. 4. Discuss the need to decrease fat in the diet so this won't happen

3. Steatorrhea (fatty, frothy, foul-smelling stool) is caused by a decrease in pancreatic enzyme secretion and indicates impaired digestion and possibly an increase in the severity of the pancreatitis. The client should see the HCP.

The client diagnosed with end-stage renal failure and ascites is scheduled for a paracentesis. Which client teaching should the nurse discuss with the client? 1. Explain the procedure will be done in the operating room. 2. Instruct the client a Foley catheter will have to be inserted. 3. Tell the client vital signs will be taken frequently after the procedure. 4. Provide instructions on holding the breath when the HCP inserts the catheter.

3. The client is at risk for hypovolemia; therefore, vital signs will be assessed frequently to monitor for signs of hemorrhaging.

The client diagnosed with Crohn's disease is crying and tells the nurse, "I can't take it anymore. I never know when I will get sick and end up here in the hospital." Which statement is the nurse's best response? 1. "I understand how frustrating this must be for you." 2. "You must keep thinking about the good things in your life." 3. "I can see you are very upset. I'll sit down and we can talk." 4. "Are you thinking about doing anything like committing suicide?"

3. The client is crying and is expressing feelings of powerlessness; therefore, the nurse should allow the client to talk.

The client diagnosed with hypothyroidism is prescribed the thyroid hormone levothyroxine (Synthroid). Which assessment data indicate the medication has been effective? 1. The client has a three (3)-pound weight gain. 2. The client has a decreased pulse rate. 3. The client's temperature is WNL. 4. The client denies any diaphoresis.

3. The client with hypothyroidism frequently has a subnormal temperature, so a temperature WNL indicates the medication is effective

The nurse is preparing a client diagnosed with GERD for surgery. Which information warrants notifying the HCP? 1. The client's Bernstein esophageal test was positive. 2. The client's abdominal x-ray shows a hiatal hernia. 3. The client's WBC count is 14,000/mm3. 4. The client's hemoglobin is 13.8 g/dL.

3. The client's WBC count is elevated, indicating a possible infection, which warrants notifying the HCP.

The client is immediate postprocedure endoscopic retrograde cholangiopancreatogram (ERCP). Which intervention should the nurse implement? 1. Assess for rectal bleeding. 2. Increase fluid intake. 3. Assess gag reflex. 4. Keep in supine position

3. The gag reflex will be suppressed as a result of the local anesthesia applied to the throat to insert the endoscope into the esophagus; therefore, the gag reflex must be assessed prior to allowing the client to resume eating or drinking.

The emergency department nurse is caring for a client diagnosed with HHNS who has a blood glucose of 680 mg/dL. Which question should the nurse ask the client to determine the cause of this acute complication? 1. "When is the last time you took your insulin?" 2. "When did you have your last meal?" 3. "Have you had some type of infection lately?" 4. "How long have you had diabetes?"

3. The most common precipitating factor is infection. The manifestations may be slow to appear, with onset ranging from 24 hours to 2 weeks.

The nurse is caring for an 80-year-old client admitted with a fractured right femoral neck who is oriented × 1. Which intervention should the nurse implement first? 1. Check for a positive Homans' sign. 2. Encourage the client to take deep breaths and cough. 3. Determine the client's normal orientation status. 4. Monitor the client's Buck's traction.

3. The nurse is not aware of the client's usual mental status so, before taking any further action, the nurse should determine what is normal or usual for this client.

Which assessment question is priority for the nurse to ask the client diagnosed with end-stage liver failure secondary to alcoholic cirrhosis? 1. "How many years have you been drinking alcohol?" 2. "Have you completed an advance directive?" 3. "When did you have your last alcoholic drink?" 4. "What foods did you eat at your last meal?"

3. The nurse must know when the client had the last alcoholic drink to be able to determine when and if the client will experience delirium tremens, the physical withdrawal from alcohol.

The nurse arrives at the site of a one-car motor-vehicle accident and stops to renderaid. The driver of the car is unconscious. After stabilizing the client's cervical spine, which action should the nurse take next? 1. Carefully remove the driver from the car. 2. Assess the client's pupils for reaction. 3. Assess the client's airway. 4. Attempt to wake the client up by shaking him

3. The nurse must maintain a patent air- way. Airway is the first step in resusci- tation.

The nurse and an unlicensed assistive personnel (UAP) are caring for a client withright-sided paralysis. Which action by the UAP requires the nurse to intervene? 1. The assistant places a gait belt around the client's waist prior to ambulating. 2. The assistant places the client on the back with the client's head to the side. 3. The assistant places a hand under the client's right axilla to move up in bed. 4. The assistant praises the client for attempting to perform ADLs independently

3. This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; the client should be pulled up by placing the arm underneath the back or using a lift sheet.

The charge nurse of an intensive care unit is making assignments for the night shift. Which client should be assigned to the most experienced intensive care nurse? 1. The client diagnosed with respiratory failure who is on a ventilator and requires frequent sedation. 2. The client diagnosed with lung cancer and iatrogenic Cushing's disease with ABGs of pH 7.35, PaO2 88, PaCO2 44, and HCO3 22. 3. The client diagnosed with Addison's disease who is lethargic and has a BP of 80/45, P 124, and R 28. 4. The client diagnosed with hyperthyroidism who has undergone a thyroidectomy two (2) days ago and has a negative Trousseau's sign.

3. This client has a low blood pressure and tachycardia. This client may be experiencing an addisonian crisis, a potentially life-threatening condition. The most experienced nurse should care for this client.

The charge nurse is making assignments. Staffing includes a registered nurse with five (5) years of medical-surgical experience, a newly graduated registered nurse, and two (2) unlicensed assistive personnel (UAPs). Which client should be assigned to the most experienced nurse? 1. The 39-year-old client diagnosed with lower esophageal dysfunction who is complaining of pyrosis. 2. The 54-year-old client diagnosed with Barrett's esophagus who is scheduled to have an endoscopy this morning. 3. The 46-year-old client diagnosed with gastroesophageal reflux disease who has wheezes in all five (5) lobes. 4. The 68-year-old client who is three (3) days postoperative for hiatal hernia and needs to be ambulated four (4) times today

3. This client is exhibiting symptoms of asthma, a complication of GERD. This client should be assigned to the most experienced nurse.

The client diagnosed with acute pancreatitis is in pain. Which position should the nurse assist the client to assume to help decrease the pain? 1. Recommend lying in the prone position with legs extended. 2. Maintain a tripod position over the bedside table. 3. Place in side-lying position with knees flexed. 4. Encourage a supine position with a pillow under the knees

3. This fetal position decreases pain caused by the stretching of the peritoneum as a result of edema.

The nurse is caring for a client diagnosed with hemorrhaging duodenal ulcer. Which collaborative interventions should the nurse implement? Select all that apply. 1. Perform a complete pain assessment. 2. Assess the client's vital signs frequently. 3. Administer a proton pump inhibitor intravenously. 4. Obtain permission and administer blood products. 5. Monitor the intake of a soft, bland diet.

3. This is a collaborative intervention the nurse should implement. It requires an order from the HCP. 4. Administering blood products is collaborative, requiring an order from the HCP

The client with a C6 SCI is admitted to the emergency department complaining of a severe pounding headache and has a BP of 180/110. Which intervention should the emergency department nurse implement? 1. Keep the client flat in bed. 2. Dim the lights in the room. 3. Assess for bladder distention. 4. Administer a narcotic analgesic.

3. This is an acute emergency caused by exaggerated autonomic responses to stimuli and only occurs after spinal shock has resolved in the client with a spinal cord injury above T6. The most common cause is a full bladder.

The nurse is assessing the client diagnosed with congestive heart failure. Whichsigns/symptoms would indicate that the medical treatment has been effective? 1. The client's peripheral pitting edema has gone from 3+to 4+. 2. The client is able to take the radial pulse accurately. 3. The client is able to perform ADLs without dyspnea. 4. The client has minimal jugular vein distention

3.Being able to perform activities of dailyliving (ADLs) without shortness ofbreath (dyspnea) would indicate theclient's condition is improving. Theclient's heart is a more effective pumpand can oxygenate the body better with-out increasing fluid in the lungs.

The surgical client's vital signs are T 98˚F, P 106, R 24, and BP 88/40. The client is awake and oriented times three (3) and the skin is pale and damp. Which intervention should the nurse implement first? 1. Call the surgeon and report the vital signs. 2. Start an IV of D5RL with 20 mEq KCl at 125 mL/hr. 3. Elevate the feet and lower the head. 4. Monitor the vital signs every 15 minutes

3.By lowering the head of the bed andraising the feet, the blood is shunted tothe brain until volume-expanding fluidscan be administered, which is the first intervention for a client who ishemorrhaging

The unlicensed assistive personnel (UAP) reports the vital signs for a first-daypostoperative client as T 100.8 ̊F, P 80, R 24, and BP 148/80. Which intervention would be most appropriate for the nurse to implement? 1. Administer the antibiotic earlier than scheduled. 2. Change the dressing over the wound. 3. Have the client turn, cough, and deep breathe every two (2) hours. 4. Encourage the client to ambulate in the hall

3.Having the client turn, cough, anddeep breathe is the best interventionfor the nurse to implement because, ifa client has a fever within the first day,it is usually caused by a respiratoryproblem.

The telemetry nurse is unable to read the telemetry monitor at the nurse's station.Which intervention should the telemetry nurse implement first? 1. Go to the client's room to check the client. 2. Instruct the primary nurse to assess the client. 3. Contact the client on the client call system. 4. Request the nursing assistant to take the crash cart to the client's room

3.If the client answers the call light andis not experiencing chest pain, thenthere is probably a monitor artifact,which is not a life-threatening emer-gency. After talking with the client,send a nurse to the room to check themonitor.

The nurse is caring for a client with a fractured left tibia and fibula. Which data should the nurse report to the health-care provider immediately? 1. Localized edema and discoloration occurring hours after the injury. 2. Generalized weakness and increasing sensitivity to touch. 3. Dorsalis pedal pulse cannot be located with a Doppler and increasing pain. 4. Pain relieved after taking four (4) mg hydromorphone, a narcotic analgesic.

3.If the nurse cannot hear the pedal pulse with a Doppler and the client's pain is increasing, the nurse should notify the health-care provider. These are signs of neurovascular compromise.

The client is exhibiting ventricular tachycardia. Which intervention should the nurse implement first? 1. Administer lidocaine, an antidysrhythmic, IVP. 2. Prepare to defibrillate the client. 3. Assess the client's apical pulse and blood pressure. 4. Start basic cardiopulmonary resuscitation

3.The nurse must assess the apical pulseand blood pressure to determine if theclient is in cardiac arrest and then treatas ventricular fibrillation. If the client'sheart is beating, the nurse would thenadminister lidocaine

The client shows ventricular fibrillation on the telemetry at the nurse's station.Which action should the telemetry nurse implement first? 1. Administer epinephrine IVP. 2. Prepare to defibrillate the client. 3. Call a STAT code. 4. Start cardiopulmonary resuscitation.

3.The nurse must call a code that acti-vates the crash cart being brought tothe room and a team of health-careproviders that will care for the clientaccording to an established protocol

The nurse is completing a preoperative assessment on a male client who states, "I am allergic to codeine." Which intervention should the nurse implement first? 1. Apply an allergy bracelet on the client's wrist. 2. Label the client's allergies on the front of the chart. 3. Ask the client what happens when he takes the codeine. 4. Document the allergy on the medication administration record

3.The nurse should first assess theevents which occurred when the clienttook this medication because manyclients think a side effect, such as nausea, is an allergic reaction.

The nurse is discussing the importance of exercise with the client diagnosed withcoronary artery disease. Which intervention should the nurse implement? 1. Perform isometric exercises daily. 2. Walk for 15 minutes three (3) times a week. 3. Do not walk outside if it is less than 40 ̊F. 4. Wear open-toed shoes when ambulating.

3.When it is cold outside, vasoconstric-tion occurs, and this will decrease oxygen to the heart muscle. Therefore,the client should not exercise when itis cold outside.

An 18 year old female client, 5'4" tall, weighing 113 kg, comes into the clinic for a nonhealing wound on her lower leg, which she has had for two weeks. Which disease process should the nurse suspect the client has developed? a. Type 1 diabetes b. Type 2 diabetes c. gestational diabetes d. acanthosis nigricans

b. Type 2 Diabetes. Rationale: Type 2 diabetes is a disorder usually occurring around the age of 40, but it is now being detected in children and young adults as a result of obesity and sedentary lifestyles. Nonhealing wounds are a hallmark sign of type 2 diabetes. This client weighs 248.6 p

The client diagnosed with type 1 diabetes has a glycoslayted hemoglobin (A1C) of 8.1%. Which interpretation should the nurse make based off of this result? a. This result is below normal levels b. this result is within normal levels c. this result is above recommended levels d. this result is dangerously high

c. This result is above recommended levels Rationale: . This result parallels a serum blood glucose level of approximately 180 to 200 mg/dL. An A1c is a blood test reflecting average blood glucose levels over a period of three (3) months; clients with elevated blood glucose levels are at risk for developing long-term complications.