Medical surgical ATI proctored exam review

INR

0.7-1.8; 2-3 if on warfarin (coumadin) therapy

Non-modifiable risk factors ( Page 3 ATI )

1) Age 2) Gender 3) Genetics 4) Developmental level

A nurse is planning to implement droplet precautions for a client who has manifestations of pertussis. Which of the following interventions should the nurse include when contributing to the plan of care? 1) Apply a mask on the client if transportation is needed. 2) Wear an N95 mask when entering the client's room. 3) Wear a mask when working within 4 feet of the client. 4) Don a gown when visiting the client.

1) Apply a mask on the client if transportation is needed. - The nurse should apply a mask to the client who has manifestations of pertussis during transport to prevent exposure to others. - The nurse should wear an N95 mask when caring for a client who has been placed on airborne precautions, such a client who has tuberculosis. - The nurse should wear a surgical mask when working within 1 m (3 feet) of the client who has manifestations of pertussis. - The nurse should wear a gown when providing direct care to a client if there is potential for soiling clothes during contact. However, it is not required for the care of the client who requires droplet precautions; unwarranted use of the gown increases costs.

A nurse is collecting data from a client who has hypothyroidism. Which of the following manifestations should the nurse anticipate? 1) Bradycardia 2) Weight loss 3) Insminia 4) Blurred vision

1) Bradycardia - The nurse should identify that bradycardia is a manifestation of hypothyroidism that is caused by a decrease in the client's metabolic rate. - The nurse should identify that weight loss is a manifestation of hyperthyroidism caused by an increase in the client's metabolic rate. - The nurse should identify that insomnia is a manifestation of hyperthyroidism that is caused by an increase in the client's metabolic rate. - The nurse should identify that blurred vision is a manifestation of hyperthyroidism.

A nurse is reinforcing teaching with a family of a client who has a cervical injury and has a halo vest in place. Which of the following safety precautions should the nurse include in the teaching? 1) Change the sheepskin liner weekly 2) Clean the pin sites every 72 hours 3) Tighten the traction bar as needed 4) Use the halo ring to reposition the client when in bed.

1) Change the sheepskin liner weekly - The nurse should provide instruction regarding the care and maintenance of the vest. The instruction should include changing the sheepskin liner when soiled, or at least once per week, to prevent skin irritation. - The nurse should instruct the family to clean the pin sites every day to decrease the risk for infection. - The nurse should instruct the family to call a provider if the pins or traction bar is loose. The pin sites or traction bar supports should not be manipulated in any way because it could cause injury to the client. - The nurse should instruct the family to never lift or reposition the client by pulling on the halo ring, which can cause further cervical injury.

A nurse is assisting with the care of a client who had a cardiac catheterization via the right femoral artery. Which of the following actions should the nurse take to prevent post-procedure complications. Select all that apply 1) Check the client's peripheral pulses 2) Maintain the pressure dressing 3) Monitor the insertion site for bleeding 4) Restrict the client's fluid intake 5) Position the affected extremity at a 45 degree angle.

1) Check the client's peripheral pulses - The nurse should assess the client's peripheral pulses to help identify signs of arterial occlusion. 2) Maintain the pressure dressing - The nurse should maintain the client's pressure dressing to prevent hemorrhaging and allow for the cannulation site to heal. 3) Monitor the insertion site for bleeding - The nurse should monitor the client's insertion site for manifestations of hemorrhaging. - The nurse should keep the client flat with the affected extremity extended, not flexed. - The nurse should encourage fluid intake for the client following the cardiac catheterization to assist with evacuating the contrast medium from the client's system.

A nurse is caring for a client who has a history of breast cancer. The client asks the nurse about birth control. Which of the following methods of birth control is contraindicated with this client? 1) Combination oral contraceptives 2) Intrauterine device 3) Latex condom 4) Contraceptive sponge

1) Combination oral contraceptives - The nurse should identify that combination oral contraceptives are contraindicated for this client because they increase estrogen levels, which can stimulate the growth of any remaining cancerous breast cells. - The nurse should identify that the use of an intrauterine device requires the client to check the placement monthly and is not contraindicated for this client. - The nurse should identify that the use of latex condoms is contraindicated for clients, or their partners, who are allergic to latex. However, it is not contraindicated for this client. - The nurse should identify that prolonged use of a contraceptive sponge can increase the risk for toxic shock syndrome. However, it is not contraindicated for this client.

A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an IV contrast agent. Which of the following laboratory findings should the nurse report to the provider prior to the procedure? 1) Creatinine 1.9 mg/dl 2) Sodium 136 3) Potassium 4.8 4) Calcium 10 mg/dl

1) Creatinine 1.9mg/dl - Creatinine 1.9 mg/dL is not within the expected reference range. Therefore, the nurse should report the finding to the provider before the client has a CT scan with an IV contrast agent. This finding places the client at risk for developing contrast-induced nephropathy. - Sodium 136 mEq/L is within the expected reference range. Therefore, the nurse does not need to report this finding to the provider before the client has a CT scan with an IV contrast agent. - Potassium 4.8 mEq/L is within the expected reference range. Therefore, the nurse does not need to report this finding to the provider before the client has a CT scan with an IV contrast agent. - Calcium 10 mg/dL is within the expected reference range. Therefore, the nurse does not need to report this finding to the provider before the client has a CT scan with an IV contrast agent.

Dopamine side effects

1) Dysrhythmia 2) Angina

Beta 1 receptors

Help stimulate the heart Beta I - You have 1 heart Stimulate the heart and increase the heart rate Used for treating: 1) AV block 2) Cardiac arrest DRUG: Epinephrine:Triggers the Beta 1 receptors Cause increase heart rate

Beta II receptors

Help stimulate the heart and lungs Beta II You have 2 Lungs Causes: 1) Bronchodilation in the lungs 2) Causes uterine smooth muscle to relax 3) Asthma situation DRUG: Epinephrine:Triggers the Beta II receptors Cause bronchodilation and treat Asthma

pH

7.35-7.45

Digoxin therapeutic level

0.5-2.0

Creatinine

0.6 - 1.2

Lithium level

0.6-1.2

Calcium normal level

9.0 - 10.5

Chloride normal level

98 -106

HbA1c (glycosylated hemoglobin)

<6% *>6.5% indicated DM

TB: Priority action for a client in the emergency department

-Wear an N95 or HEPA respirator -Place client in negative airflow room and implement airborne precautions -use barrier protection when the risk of hand or clothing contamination exists

Pulmonary Embolism: Risk factors for DVT

- Long term immobility - Oral contraceptives - Pregnancy - Tobacco use - Hypercoagulabilty - Obesity - Surgery - Heart failure or chronic A-Fib - Autoimmune hemolytic anemia (sickle cell) - Long bone fractures - Advanced age

Electrode placement for ECG

- The nurse should identify that the Right Arm (RA) electrode should be positioned just below the right clavicle. - The nurse should identify that the Left Arm (LA) electrode should be positioned just below the left clavicle. - The nurse should identify that the V1 electrode should be placed in the 4th intercostal space just to the right of the sternum. Correct placement of the electrodes is vital in obtaining accurate information about the electrical activity of the heart. - The nurse should identify that the V2 electrode should be placed in the 4th intercostal space just to the left of the sternum.

Disorders of the male reproductive system: Complications of continuous irrigation following Trans-urethral Resection

- Urethral trauma - Urinary retention - Bleeding - Infection

A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking dantrolene to manage muscle spasms. which of the following interventions should the nurse include? 1) Encourage the client to complete ADL's 2) Apply hot packs to the client's muscles. 3) Schedule physical therapy in the afternoon. 4) Administer valerian to promote sleep.

1) Encourage the client to complete ADL's - The nurse should encourage the client to complete ADLs and provide assistance as needed. Performing self-care increases the client's independence, strength, and level of functioning. - The nurse should avoid exposing the client's muscles to extreme temperatures because it decreases muscle strength. - The nurse should schedule physical therapy and other activities in the morning when the client's strength is at its peak. Fatigue increases in the afternoon. - The nurse should schedule physical therapy and other activities in the morning when the client's strength is at its peak. Fatigue increases in the afternoon.

A nurse is collecting data from client who reports a 55 year old female client who reports vaginal dryness and hot flashes. The client is interested in trying hormone replacement therapy (HRT). Which of the following should the nurse recognize as a contraindication to HRT? 1) History of treatment of blood clots. 2) Topiramate use for migraine headaches 3) Increased serum cholesterol levels 4) Five year history of menopause manifestations

1) History of treatment of blood clots. - Estrogen increases the risk of blood clots. Therefore, a woman who has a history of blood clots should not receive HRT. - The nurse should identify that the use of topiramate to treat migraine headaches can cause decreased absorption of estrogen when used as a contraceptive. However, topiramate is not a contraindication to HRT. - The nurse should identify that one of the benefits of HRT is a decrease in LDL and an increase in HDL levels. Therefore, HRT is not contraindicated for a client who has increased serum cholesterol levels. - The nurse should identify that manifestations of menopause can last for 10 years or more and HRT is not contraindicated for a client whose menopause manifestations began 5 years ago.

What are the signs and symptoms of pulmonary embolism?

1) Hypotension 2) Tachycardia 3) Tachypnea

A nurse is contributing to the plan of care for a client who has a new prescription for nystatin suspension for oral candidiasis. Which of the following interventions should the nurse include in the plan? 1) Instruct the client to swish the medication in her mouth. 2) Use a commercial mouthwash before taking the medication. 3) Discontinue the medication as soon as the lesions are healed. 4) Combine the medication with mouthwash.

1) Instruct the client to swish the medication in her mouth. - The nurse should instruct the client to place half the dose in each side of her mouth, swish the medication, and then swallow. This action will allow the medication to coat the entire oral mucosa and treat the fungal infection. - The client should avoid commercial mouthwashes while the mouth infection is present because using mouthwash can increase pain and does not contribute to treatment of the infection. - The client should continue nystatin for two days after the lesions have healed. - The client should not mix nystatin with food because it will alter the absorption of the medication and prevent adequate coating of the oral lesions.

A nurse is caring for a client who has acute pancreatitis. While providing care, the nurse observes ecchymosis around the umbilicus. The nurse should identify that this is a manifestation of which of the following? 1) Intra-abdominal bleeding 2) Cirrhosis of the liver 3) Hyper motility of the bowel 4) Acute cholecystitis

1) Intra-abdominal bleeding - Ecchymosis around the umbilicus is a sign of intra-abdominal bleeding, which is a finding consistent with pancreatitis. - A client who has cirrhosis of the liver can have a manifestation of bluish varicose veins that radiate from the umbilicus, which can indicate portal hypertension. However, cirrhosis of the liver does not cause ecchymosis around the umbilicus. - A client who has hypermotility of the bowel can exhibit diarrhea as a manifestation, not ecchymosis around the umbilicus. - A client who has acute cholecystitis has an inflammation of the gallbladder that can indicate gallstones, but acute cholecystitis does not cause ecchymosis around the umbilicus.

A nurse is contributing to the plan of care for a client who is postoperative following a total knee arthroplasty. The client is using a continuous passive motion ( CPM) machine. Which of the following interventions should the nurse recommend for the plan of care? 1) Keep a sheepskin pad between the client's extremity and the CPM. 2) Align the frame joint of the CPM with the middle of the client's calf. 3) Check the cycle and range of motion settings at least every 12 hours. 4) Store the CPM machine on the floor when it is not in use.

1) Keep a sheepskin pad between the client's extremity and the CPM. - The nurse should plan to keep a sheepskin pad between the client's extremity and the CPM machine to protect the client's skin. The nurse should check the client's skin condition frequently while the client is using the CPM. - The nurse should plan to align the frame joint of the CPM with the client's knee joint to provide appropriate flexion and extension. - The nurse should plan to check the settings of the CPM machine at least every 8 hr. - The nurse should avoid placing the CPM machine on the floor, as this exposes it to potential contamination, which can increase the client's risk for infection.

A nurse is contributing to the plan of care for a client who was admitted to the neurologic unit following a stroke 3 hours ago. Which of the following interventions should the nurse identify as the priority. 1) Keep the client in a side-lying position. 2) Maintain the client's body alignment. 3) Assist the client with active range-of- motion exercises. 4) Encourage the client to participate in self care.

1) Keep the client in a side-lying position. - The greatest risk to the client following a stroke is aspiration. The nurse should position the client in a lateral, or side-lying position, which will allow any secretions to drain out of the mouth, decreasing the risk for aspiration. Additionally, the nurse should have suction available in the event that any secretions are present in the oral cavity. - The nurse should keep the client's body in alignment to maintain joint function and prevent skin breakdown caused by pressure on bony prominences. However, there is another intervention that is the priority. - The nurse should assist the client with active range-of-motion exercises and should provide passive range-of-motion exercises to the client's affected side to maintain joint mobility and improve muscle strength. However, there is another intervention that is the priority. - The nurse should encourage the client to complete self-care to the extent that he is able. Self-care promotes mobility of the joints and increases the client's feelings of independence and self-esteem. However, there is another intervention that is the priority.

A nurse is reinforcing teaching with a client who has Systemic Lupus Erthematosus (SLE) and is to begin taking mythylprednisolone orally. Which of the following statements should the nurse include in the teaching? 1) Limit contact with large groups of people. 2) Take medication on a empty stomach 3) Follow a low- protein diet 4) Avoid taking over the counter calcium supplements

1) Limit contact with large groups of people. - Glucocorticoids cause immunosuppression and may mask infection. The client should limit contact with sources of possible infections, such as large groups of people. - The client should take glucocorticoids with food to prevent gastrointestinal upset and bleeding. - It is not necessary for a client who has SLE and is taking a glucocorticoid to restrict protein intake. - Clients who take glucocorticoids are at risk for osteoporosis, so they should take additional vitamin D and calcium supplements.

A nurse is assisting a client who reports difficulty falling asleep. Which of the following activities should the nurse recommend to promote sleep? 1) Listen to soft music before sleeping. 2) Take a brisk walk before sleeping 3) Get out of bed if unable to fall asleep within 60 minutes. 4) Drink adequate amounts of fluid before sleeping.

1) Listen to soft music before sleeping. - Listening to soft music can help the client to relax and reduces environmental stressors. - The client should avoid stimulating activities, such as exercise, before bedtime. - The client should get out of bed after 30 min if unable to fall asleep. - The client should reduce fluids 2 to 4 hr before sleep. Drinking fluids before bedtime can cause the client to wake up during the night to use the bathroom.

A nurse is reviewing the laboratory results of a client who has type II diabetes mellitus. The nurse should identify that which of the following laboratory values indicates the client is at risk for delayed wound healing? 1) Prealbumin 12mg/dl 2) HBA1c 6% 3) WBC 8,000/mm3 4) Creatinine 0.8 mg/dl

1) Prealbumin 12mg/dl - This laboratory value is below the expected reference range, indicating that the client's protein status is inadequate and that he is at risk for delayed wound healing due to malnutrition. - This laboratory value indicates glycemic control and does not indicate that the client is at risk for delayed wound healing. The nurse should identify that elevated HbA1c levels can increase the risk for delayed wound healing. - This laboratory value is within the expected reference range and indicates immune function. The nurse should identify that an elevated WBC count increases the risk for delayed wound healing. This laboratory value is within the expected reference range and indicates adequate kidney function. The nurse should identify that the client who is diabetic is at increased risk for the development of renal failure, which can increase the risk for infection and delayed wound healing.

Triage priority setting

1) Red tag 2) Yellow Tag 3) Green tag 4) Black tag

A nurse is reinforcing discharge teaching about wound care with a family member of a client who is postoperative. Which of the following should the nurse include in the teaching? 1) Report purulent drainage to the provider. 2) Cleanse the wound with a cotton tip applicator. 3) Irrigate the wound with povidone iodine. 4) Administer an analgesic following wound care.

1) Report purulent drainage to the provider. - The nurse should remind the family member to report signs of infection, including purulent drainage. - The nurse should remind the family member to avoid using a cotton-tipped applicator to cleanse the wound because the fibers can become embedded in the wound, cause infection, and delay wound healing. - The nurse should remind the family member to irrigate the wound with 0.9% sodium chloride. - The nurse should remind the family member to administer an analgesic prior to wound care to prevent discomfort.

Modifiable risk factors ( Page 3 ATI )

1) Smoking 2) Exercise 3) Health education and awareness 4) Nutrition 5) Sex practices

A nurse enters the room of a client whose transfusion of packed RBC's was initiated 15 minutes ago by a RN. The client reports dyspnea and urticaria. Which of the following actions should the nurse preform first? 1) Stop the infusion 2) Administer antihistamine 3) Count the client's respiratory rate 4) Ask the client if chest pain is present

1) Stop the infusion - Evidence-based practice indicates the nurse should stop the infusion of the blood product as soon as manifestations occur because they can indicate a transfusion reaction. - The nurse should administer antihistamines when allergic transfusion manifestations are present. However, evidence-based practice indicates that the nurse should take a different action first. - The nurse should take the client's vital signs, which includes counting the client's respiratory rate. However, evidence-based practice indicates that the nurse should take a different action first. - The nurse should inquire about the presence of chest pain and other manifestations to determine the severity of the reaction. However, evidence-based practice indicates that the nurse should take a different action first.

Magnesium normal level

1.3 - 2.1

BUN

10-20 mg/dL >>>> Dehydration <<<< Fluid overload

Hemoglobin

12-18

Sodium normal level

136 - 145

Platelets

150,000-400,000 (Low platelets-risk for bleeding)

A nurse is collecting data from a client and notices several skin lesions. Which of the following findings should the nurse reports as possible melanoma? 1) Silvery white plaques 2) Irregular boarders 3) Raised edges 4) Scaly patches

2) Irregular boarders - The nurse should report irregular borders of a skin lesion to the provider because it can indicate malignant melanoma. - The nurse should report silvery white plaques as possible psoriasis. - The nurse should report raised edges of a skin lesion as possible basal cell carcinoma. - The nurse should report scaly patches as possible basal or squamous cell carcinoma.

A nurse is caring for a client and administers penicillin IM. The client begins exhibiting hives and has severe difficulty breathing. After establishing a patent airway, which of the following actions should the nurse take next? 1) Monitor the client's vital signs 2) Administer epinephrine 3) Administer an antihistamine 4) Monitor the client's oxygen saturation level.

2) Administer epinephrine - The greatest risk to the client is death from anaphylaxis. Therefore, the nurse should administer epinephrine to reduce bronchospasms and laryngeal edema. - The nurse should monitor the client's vital signs during the crisis to detect a decrease in blood pressure and an increase in respiratory effort. However, there is another action the nurse should take first. - The nurse should administer an antihistamine to treat the hives and reduce the histamine release. However, there is another action the nurse should take first. - The nurse should monitor the client's oxygen saturation level to ensure respiratory support. However, there is another action the nurse should take first.

A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis. Which of the following information should the nurse include in the teaching? 1) Sleep on a soft foam mattress. 2) Apply cold packs to the inflamed joints. 3) Participate in high impact exercises. 4) Carry a hand purse rather than a shoulder bag.

2) Apply cold packs to the inflamed joints. - The nurse should instruct the client to use both warm and cold packs on inflamed joints to decrease pain. - The nurse should instruct the client to sleep on a firm mattress to support the joints. - The nurse should instruct the client to participate in low-impact aerobic exercises, which will not inflame the client's joints. - The nurse should instruct the client to carry a shoulder bag, which places the stress on larger muscles.

A nurse is reinforcing teaching with a client who has Multiple Sclerosis and a new prescription for baclofen. Which of the following instructions should the nurse include in the teaching? 1) Take this medication on an empty stomach 2) Avoid stopping this medication suddenly. 3) Use Chamomile tea to alleviate insomnia. 4) Consume a low- purine diet

2) Avoid stopping this medication suddenly. - The nurse should instruct the client to avoid stopping baclofen suddenly because it can result in adverse reactions, including seizures, paranoia, and hallucinations. - The nurse should instruct the client to take baclofen with milk or food to minimize gastric upset. - The nurse should instruct the client to avoid chamomile because it can interact with baclofen to increase CNS depression. - The nurse should recommend a low-purine diet for a client who has gout and a prescription for colchicine.

A nurse is collecting data on a client who is scheduled for a cardiac cathertization. Which of the following laboratory levels should the nurse review prior to the procedure? 1) Phosphorus 2) BUN 3) TSH 4) Albumin

2) BUN - BUN levels indicate kidney function. Contrast media used during cardiac catheterization can cause renal failure. The nurse should review this laboratory level to determine if the client can tolerate the IV contrast dye during the procedure. - Phosphorus is an electrolyte that combines with calcium to maintain bone health and is involved as an energy source in metabolism. However, it is not impacted by contrast media used for cardiac catheterization. Therefore, the nurse does not need to review this laboratory level prior to a cardiac catheterization. - TSH levels determine thyroid function. However, it is not impacted by contrast media used for cardiac catheterization. Therefore, the nurse does not need to review this laboratory level prior to a cardiac catheterization. - Albumin levels determine the amount of protein the liver produces in the body and is an indication of hepatic function and nutritional status. However, it is not impacted by contrast media used for cardiac catheterization. Therefore, the nurse does not need to review this laboratory level prior to a cardiac catheterization.

A nurse is collecting data from a client who has chronic kidney disease with hyperkalemia. Which of the following findings should the nurse expect related to hyperkalcemia? 1) Anorexia 2) Bradycardia 3) Constipation 4) Polyuria

2) Bradycardia - The client who has hyperkalemia can have an irregular, slow heart rate, known as bradycardia. - Anorexia is a manifestation of hypokalemia. - Constipation is a manifestation of hypokalemia. - Polyuria is a manifestation of hypokalemia.

A nurse is preparing to administer furosemide to a client who has heart failure. Which of the following findings should the nurse report before administering the medication? 1) Elevated blood pressure 2) Decreased potassium 3) Elevated sodium 4) Decreased urine output

2) Decreased potassium - The nurse should notify the provider immediately of a decreased potassium level because potassium is lost when a diuretic such as furosemide is administered, which can cause hypokalemia. - The nurse should expect the client who has heart failure to have an elevated blood pressure and does not need to report this finding to the provider before administering the medication. Furosemide is a diuretic that should help to lower the client's blood pressure. - The nurse should report a decreased sodium level to the provider before administering the medication because furosemide can cause hyponatremia. - The nurse should expect the client who has heart failure to have a decreased urine output and does not need to report this finding to the provider before administering the medication. Furosemide is a diuretic, which should cause an increase in urine output for a client who has heart failure.

A nurse is caring for for a client who has a prescription for phenazopyridine. Which of the following findings should the nurse identify as a therapeutic effect of the medicine? 1) Prevents nerve stimulation to the bladder muscle. 2) Decreases pain during urination 3) Suppresses urge to void 4) Reduces bacteria in the urinary tract

2) Decreases pain during urination - Phenazopyridine reduces pain and burning during urination by exerting an anesthetic effect on the mucosa of the urinary tract. - Nerve stimulation to the bladder muscle is prevented with the use of an antispasmodic, such as hyoscyamine. - The urge to void is suppressed with the use of an antispasmodic for urinary incontinence, such as oxybutynin. - Bacteria in the urinary tract is reduced with the use of an antimicrobial medication, such as fosfomycin.

Prealbumin normal range

23 - 43

A nurse is assisting in the plan of care regarding bowel retraining for a client who has a cervical spinal cord injury. Which of the following interventions should the nurse plan to implement first? 1) Administer a suppository to the client 30 minutes prior to defecation time. 2) Determine the client's daily elimination habits. 3) Offer the client 4 oz of warm prune juice to promote elimination. 4) Provide dietary bulk to the client to ease the passage of stool.

2) Determine the client's daily elimination habits. - The first action the nurse should take using the nursing process is to collect data on the client's daily bowel elimination habits to establish a routine defecation time. - The nurse should administer a suppository to the client 30 min prior to defecation time to stimulate bowel elimination. However, there is another action the nurse should take first. - The nurse should offer the client warm prune juice to stimulate peristalsis to promote elimination. However, there is another action the nurse should take first. - The nurse should provide dietary bulk to the client to ease the passage of stool and stimulate bowel elimination. However, there is another action the nurse should take first.

A nurse is collecting data from a client who has kypokalemia. Which of the following findings should the nurse identify as the priority? 1) Abdominal pain 2) Dysrhythmia 3) Lethargy 4) Muscle weakness

2) Dysrhythmia - When using the airway, breathing, circulation approach to client care, the nurse should identify that the priority finding for a client who has hypokalemia is dysrhythmia. - The nurse should address abdominal pain to promote comfort for a client who has hypokalemia. However, another finding is the priority. - The nurse should address lethargy for a client who has hypokalemia to prevent injury. However, another finding is the priority. - The nurse should address muscle weakness to prevent injury for a client who has hypokalemia. However, another finding is the priority.

A nurse is caring for a client who has difficulty swallowing . Which of the following actions should the nurse implement to prevent aspiration? 1) Provide mouth care before meals 2) Give the client liquids with increased viscosity. 3) Tell the client to extend his neck when swallowing. 4) Provide small, frequent meals.

2) Give the client liquids with increased viscosity. - Thickened liquids are easier for the client to swallow and can prevent aspiration. - Mouth care can enhance the client's sense of taste, but it does not decrease the risk for aspiration. - The client should tilt his neck forward while swallowing to decrease the risk for aspiration. - Providing small, frequent meals can improve the client's nutritional intake, but it does not decrease the risk for aspiration.

A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. Which of the following statements indicates that the client is adhering to the nurse's instructions? 1) I use hot water bottles to keep my feet warm at night 2) I don't cross my legs anymore. 3) I apply rubbing alcohol to my feet everyday to prevent infection 4) I will wear clean, knee-high wool socks every day to help improve my circulation.

2) I don't cross my legs anymore. - Clients who have peripheral vascular disease should not cross their legs because it can impede circulation. - Clients who have peripheral vascular disease have decreased sensation of the affected extremities. Therefore, they are unable to detect the temperature of the water bottle, which increases the risk for burns. - Rubbing alcohol has a drying effect on skin and can increase cracking, allowing an entry point for infection. The client should apply lotions that do not contain alcohol. - Wool socks can result in perspiration, which puts the client at risk for developing a fungal infection. The client should use light-weight socks to promote arterial blood flow.

A nurse is reinforcing teaching with a client who has asthma. Which of the following statements indicates an understanding of the use of budesonide and albuterol inhalers? Select all that apply 1) I should use my budesonide inhaler before I use my albuterol inhaler. 2) I use my albuterol inhaler before I go swimming 3) Between office visits, I keep a record of how many times I use my albuterol inhaler. 4) I should expect to feel sleepy after using my albuterol inhaler. 5) I never forget to rinse my mouth after using my budesonide inhaler.

2) I use my albuterol inhaler before I go swimming - The client should use the albuterol inhaler before exercise to prevent exercise-induced bronchospasms. 3) Between office visits, I keep a record of how many times I use my albuterol inhaler. - The client should record the number of times that he uses his albuterol inhaler. This information can assist the provider to determine the effectiveness of the medication. 5) I never forget to rinse my mouth after using my budesonide inhaler. - The client should rinse his mouth after using a budesonide inhaler to reduce the risk for oral fungal infection. - The client should recognize that albuterol stimulates the sympathetic nervous system, which can cause nervousness and insomnia, along with increased heart rate and blood pressure. - The client should first use the albuterol inhaler, a bronchodilator, to open the airway and enhance the absorption of the budesonide, which is an inhaled corticosteroid.

A nurse is reinforcing teaching about glycosylated hemoglobin ( HbA1c ) testing with a client who has diabetes mellitus. Which of the following statements indicates that the client understands the teaching? 1) The HbA1c test can help to detect the presence of ketones in my body. 2) I will have my HbA1c checked twice per year 3) The HbA1c test should be performed 2 hours after I eat a meal that is high in carbohydrates. 4) I will plan to fast before I have my HbA1c tested

2) I will have my HbA1c checked twice per year - An HbA1c test provides the client's average glucose level for the preceding 3 months. The nurse should instruct the client to have her HbA1c tested twice yearly to manage her glucose. - The nurse should remind the client that urine testing can detect ketone bodies. - The nurse should remind the client that carbohydrate consumption is not required for HbA1c testing. - The nurse should remind the client that fasting is not required for HbA1c testing.

A nurse is reinforcing teaching about management of constipation with a client who had hypothyroidism. Which of the following should the nurse include in the teaching? 1) Maintain a fluid intake of 1200 mL per day 2) Increase intake of fiber- rich foods 3) Take a laxative every morning 4) Limit active to preserve energy

2) Increase intake of fiber- rich foods - The nurse should instruct the client to increase the amount of fiber-rich foods in his diet. Dried beans and brown rice are examples of fiber-rich foods. - The nurse should instruct the client to increase his fluid intake to 2,000 mL per day to maintain soft stools. - The nurse should instruct the client to initially take a laxative in the evening to stimulate the evacuation of stool. However, the nurse should instruct the client to use laxatives sparingly. - The nurse should instruct the client to increase activity to stimulate the evacuation of stool.

A nurse is monitoring a client who recently had a cast placed on his lower extremity for a bone fracture. Which of the following findings should the nurse recognize as abnormal? 1) Report a dull, throbbing pain 2) Lack of sensation between the first and second toes. 3) Capillary refill of three seconds in the nails of the toes. 4) Extremities that are cool bilaterally

2) Lack of sensation between the first and second toes. - Lack of sensation between the toes indicates peripheral nerve impairment and is an abnormal finding that can indicate the client has compartment syndrome. The nurse should notify the provider immediately. - Dull, throbbing pain is an expected finding for a client who has a bone fracture. - A capillary refill of 3 seconds in the nail beds of the toes is slowed but still within the expected reference range after application of a cast. - Cool, bilateral extremities are an indication of the client's overall body temperature and general circulatory status and are an expected finding.

A nurse is monitoring an older adult client who has a history of enlarged prostate and is experiencing suprapubic discomfort. Which of the following actions should the nurse take first? 1) Administer doxazosin 2) Palpate the abdomen 3) Insert an indwelling urinary catheter 4) Notify the primary care provider.

2) Palpate the abdomen When providing client care, the nurse should first use the least restrictive intervention. Therefore, the nurse should palpate the abdomen to determine if the client has a distended bladder from urinary retention. - The nurse may need to administer doxazosin to relax the smooth muscle of the bladder to increase urine flow. However, the nurse should use a less restrictive intervention first. - The nurse may need to insert an indwelling urinary catheter for a distended bladder. However, the nurse should use a less restrictive intervention first. - The nurse may need to notify the primary care provider if the client has a distended bladder. However, the nurse should use a less restrictive intervention first.

A nurse is caring for a client who is 1 day postoperative following a hip arthroplasty. The client is exhibiting hypotension, tachycardia, and tachypnea. The nurse should recognize that these findings indicate which of the following complications? 1) Paralytic ileus 2) Pulmonary embolism 3) Thrombphlebitis 4) Wound infection

2) Pulmonary embolism - Manifestations of a pulmonary embolism include hypotension, tachycardia, and tachypnea. - Paralytic ileus is the absence of bowel peristalsis, or movement. Hypotension, tachycardia, and tachypnea do not indicate a paralytic ileus. - Thrombophlebitis is the inflammation of a blood vessel, which can lead to a thrombus formation. Hypotension, tachycardia, and tachypnea do not indicate thrombophlebitis. - Manifestations of a wound infection include fever, inflammation of the incision, and foul-smelling drainage. Hypotension, tachycardia, and tachypnea do not indicate a wound infection in a client who is 1 day postoperative.

A nurse is caring for a client who has bacterial meningitis. Upon monitoring the client, which of the following findings should the nurse expect? 1) Flaccid neck 2) Red macular rash 3) Stooped posture with shuffling gait. 4) Mask like facial expressions

2) Red macular rash - The nurse should expect to find a red macular rash, sometimes called a petechial rash, which is a manifestation of meningococcal meningitis. - The nurse should recognize that nuchal rigidity, rather than a flaccid neck, is a manifestation of meningitis. - The nurse should recognize that a stooped posture with shuffling gait is a manifestation of Parkinson's disease, not a manifestation of meningitis. - The nurse should recognize that a mask like expression is a manifestation of Parkinson's disease, not a manifestation of meningitis.

A nurse is reinforcing discharge teaching with a client who has hearing loss. Which of the following actions should the nurse take when communicating with the client? 1) Accentuate vowel sounds by using a higher pitch when speaking. 2) Rephrase client instructions when not understood 3) Cup hands around the mouth and direct speech toward the client 4) Sit to the side of the client and speak instructions into her best ear.

2) Rephrase client instructions when not understood. - When communicating with a client who has hearing loss, the nurse should rephrase, rather than repeat, discharge instructions when they are not understood. - When communicating with a client who has hearing loss, the nurse should speak in a lower tone of voice and use a lower pitch. Higher pitched sounds can impede hearing by accentuating vowel sounds and concealing consonants. - When communicating with a client who has hearing loss, the nurse should keep hands away from the mouth to promote lip reading. - When communicating with a client who has hearing loss, the nurse should sit or stand facing the client on the same level so that the nurse's mouth and lips can be seen for lip reading.

Following a blood draw procedure for a fasting blood blood sugar (FBS) test, a client tells the nurse, : I'm glad they took my blood because I am really hungry. All I've had since midnight is water and some juice. Which of the following actions should the nurse take? 1) Ask the laboratory technician to repeat the test on the same specimen. 2) Reschedule the FBS test for early the next morning. 3) Offer the client breakfast then repeat the FBS request 4) Request that the phlebotomist obtain another specimen.

2) Reschedule the FBS test for early the next morning. - An FBS test requires the client to have no food or juice for at least 8 hr. The result of the FBS test would be invalid because the client drank juice during the fasting time period. The nurse should reinforce with the client to only drink water and have no food or other beverages for 8 hr before the phlebotomist obtains the blood specimen. - Repeating the test on the same specimen will yield the same result, which will also be invalid. - An FBS test requires the client to have no food or juice for at least 8 hr. The result of the FBS test would be invalid after the client had breakfast. - The client had juice within the past 8 hr. The nurse should request that the phlebotomist obtain another specimen when the client has ingested no food or other beverages for 8 hr.

A nurse is discussing health screening guidelines with an older adult client. Which of the following statements should the nurse include? 1) You should have your hearing checked every 2 years. 2) You should have your pneumococcal immunization every 10 years. 3) You should have a screening for glaucoma every 5 years. 4) You should have a physical examination every other year.

2) You should have your pneumococcal immunization every 10 years. - The nurse should remind the client to have a pneumococcal immunization at age 65 and every 10 years thereafter to protect her from acquiring pneumonia. - The nurse should remind the client to have her hearing checked every year. - The nurse should remind the client to have a screening for glaucoma every 2 to 3 years along with an annual visual acuity exam. - The nurse should remind the client to have a physical examination every year.

A nurse is caring for a client who had an acute ischemic stroke 1 day ago. Which of the following actions should the nurse take to reduce the risk for aspiration? 1) Place 2 tsp of food in the client's mouth at a time. 2) Provide a straw for drinking liquids 3) Allow 30 minutes of rest before meals 4) Serve foods at room temperature.

3) Allow 30 minutes of rest before meals - The nurse should allow the client to rest for 30 min before meals to prevent aspiration. - The nurse should place only 1 tsp of food in the client's mouth at a time. - The nurse should provide a cup for drinking liquids, rather than a straw. - The nurse should serve foods that are cold or heated. It is more difficult for the client to swallow food that is lukewarm or at room temperature.

A nurse is reinforcing discharge teaching to prevent dumping syndrome for a client following a partial gastrectomy for ulcers. Which of the following information should the nurse include in the teaching? 1) Exclude eating starchy vegetables 2) Avoid eating high protein meals 3) Avoid liquids at meal times 4) Plan to increase intake of sweetened fruits.

3) Avoid liquids at meal times - The nurse should remind the client to avoid drinking liquids at mealtimes to prevent the food from emptying into the small bowel too quickly. - The nurse should remind the client to include starchy vegetables in the meal plan to slow gastric emptying. - The nurse should remind the client to eat high-protein meals to help slow gastric emptying. - The nurse should remind the client to exclude sweetened fruits from the diet to help slow gastric emptying.

A nurse is assisting with the care of a client who is receiving 0.9% sodium chloride by continuous IV infusion. The client reports pain and swelling at the IV site. In which order should the nurse perform the following steps? 1) Stop the infusion 2) Withdraw the catheter 3) Check the IV site 4) Elevate the affected arm 5) Notify the charge nurse

3) Check the IV site 1) Stop the infusion 2) Withdraw the catheter 4) Elevate the affected arm 5) Notify the charge nurse

A nurse is collecting data from a client who has heart failure and is on digoxin. Which of the following outcomes from the medication should the nurse expect? 1) Increased heart rate 2) Decreased urinary output 3) Decreased shortness of breath 4) Increased weight

3) Decreased shortness of breath - The nurse should expect the client to have decreased shortness of breath. Digoxin increases the contractility of the heart, which decreases pulmonary congestion. - The nurse should expect the client's heart rate to decrease because digoxin decreases the client's sympathetic nerve tone, which slows the heart rate. - The nurse should expect the client to have an increase in urinary output because digoxin improves cardiac output and increases the client's renal blood flow through the kidneys, which results in an increased excretion of urine. - The nurse should expect the client's weight to decrease because of the increased excretion of fluid that is caused by improved cardiac output.

A nurse is contributing to the plan of care for a client who has a MRSA infection and is contact isolation precautions. Which of the following actions should the nurse take? 1) Remove gloves after leaving client's room. 2) Keep the door of the client's room closed at all times. 3) Have a designated stethoscope in the client's room. 4) Wear a mask when working within 1 meter ( 3 feet ) of the client.

3) Have a designated stethoscope in the client's room. - The nurse should designate equipment to leave in the client's room to avoid cross-contamination. The designated equipment should be disposed of or decontaminated before leaving the client's room. - The nurse should remove gloves before leaving the client's room. - The nurse should keep the door of a client's room closed at all times if the client requires airborne precautions. - The nurse should wear a mask when working within 1 m (3 feet) of a client who requires DROPLET precautions.

A nurse is assisting in the care of a client who has manifestations of sepsis. Which of the following provider prescriptions should the nurse implement first? 1) Collect a sputum specimen 2) Administer ceftriaxone 3) Initiate oxygen at 4L/min via nasal cannula 4) Obtain blood cultures

3) Initiate oxygen at 4L/min via nasal cannula - When using the airway, breathing, circulation approach to client care, the first action the nurse should take is to initiate oxygen. Clients who have manifestations of sepsis are often hypoxic, tachypneic, or have a PaCO2 level less than 32 mm Hg. The nurse should provide supplemental oxygen to keep the client's oxygen saturation levels at 95% or greater, which will maximize the ability of the hemoglobin to support the oxygen needs of the body. - The nurse should collect a sputum culture to identify the organism causing the client's infection. Antimicrobial sensitivities are obtained from the sputum culture to guide the provider in prescribing antibiotics. However, there is another prescription the nurse should implement first. - The nurse should administer antibiotics to treat the infection. A broad spectrum antibiotic, such as ceftriaxone, is administered when sepsis is suspected because it treats both gram-positive and -negative bacteria. After the results of the blood and sputum cultures are obtained, the provider will often change to a more specific antibiotic. However, there is another prescription the nurse should implement first. - The nurse should obtain blood cultures to identify the organism causing the client's infection. Antimicrobial sensitivities obtained from the blood cultures will guide the provider in prescribing treatment. However, there is another prescription the nurse should implement first.

A nurse is caring a client who is in Buck's traction. Which of the following interventions should the nurse perform to prevent skin breakdown? 1) Use hot water and antibacterial soap to bathe the client. 2) Massage the skin over the bony prominence's to promote circulation. 3) Keep the skin dry and free of perspiration 4) Limit the use of moisturizers on the skin over bony prominence's.

3) Keep the skin dry and free of perspiration - The nurse should not leave moisture on the skin for prolonged periods of time because it can cause skin breakdown. - The nurse should bathe the client in tepid water and use mild soap to prevent skin breakdown. - The nurse should not massage bony prominence's because it can cause skin damage. - The nurse should moisturize skin that is intact to help prevent cracks and breaks in the skin.

A nurse observes a client who is lying in a bed experiencing a tonic - clonic seizure. Which of the following actions should the nurse take? 1) Lower the side rails of client's bed. 2) Apply wrist restraints to the client 3) Loosen clothing around the client's neck. 4) Position the client in the semi fowlers position.

3) Loosen clothing around the client's neck. - The nurse should loosen clothing around the client's neck to maintain an open airway and prevent aspiration. - The nurse should leave the bed rails up to prevent the client from falling out of bed, which can cause injury. - The nurse should not apply restraints that can place the client at risk for a fracture injury. - The nurse should place the client in a lateral position to allow for the drainage of oral secretions and to maintain an open airway.

A nurse is contributing to the plan of care for a client who is having difficulty eating following a stroke. Which of the following interventions should the nurse plan to implement first? 1) Inform assistive personnel about proper positioning. 2) Provide nutritional supplements 3) Recommend a referral for a speech language pathologist. 4) Collaborate with a dietitian

3) Recommend a referral for a speech language pathologist. - The greatest risk to the client following a stroke is injury from aspiration. Therefore, the first intervention the nurse should include in the plan of care is to recommend a referral for a speech language pathologist. A speech language pathologist can conduct a swallow study to determine the client's risk for aspiration, provide teaching to the client regarding swallowing techniques, and recommend the consistency of foods and liquids. - The nurse should provide instruction to assistive personnel regarding proper positioning of the client during mealtimes. The client should be positioned upright during meals to help prevent aspiration and facilitate swallowing and should remain in this position for at least 45 min after eating. However, there is another intervention the nurse should plan to implement first. - The nurse should provide nutritional supplements as needed to ensure the client's nutritional needs are being met. However, there is another intervention the nurse should plan to implement first. - The nurse should collaborate with the dietitian to evaluate the client's nutritional status and incorporate the client's food likes and dislikes into the meal plan. However, there is another intervention the nurse should plan to implement first.

Potassium normal level

3.5 - 5.0

Albumin

3.5 -5 If lower than 3.5 patient nay be malnourshed or heptatic diseaae

Phosphorus normal level

30 - 4.5

aPTT

30-40 (<30=risk for clots, >40=risk for bleeding) Heparin

Hematocrit

37%-52%

A nurse is monitoring a client who is taking acarbose. Which of the following findings should the nurse identify as an adverse effect of the medication? 1) Polyuria 2) Renal insufficiency 3) Insomnia 4) Abdominal cramps

4) Abdominal cramps - Acarbose affects the gastrointestinal system. Therefore, the nurse should monitor the client for abdominal cramping, rumbling bowel sounds, and diarrhea as adverse effects of this medication. - Polyuria is an adverse effect of furosemide. - Long-term and high-dose use of acarbose can cause liver dysfunction, not renal insufficiency. - Insomnia is an adverse effect of methylphenidate.

A nurse is reinforcing discharge teaching with a client who has cirrhosis. Which of the following instructions should the nurse include? 1) Sleep lying flat on your back. 2) Consume a diet high in animal protein 3) You can take a acetaminophen for pain. 4) Consume foods low in sodium.

4) Consume foods low in sodium. - The nurse should instruct the client to consume foods low in sodium to reduce the development of edema and ascites. - The nurse should instruct the client to elevate the head of the bed while sleeping to prevent shortness of breath from the pressure of ascites or hydrothorax. - The nurse should instruct the client to increase vegetable proteins and reduce animal proteins in the diet to limit the development of encephalopathy. - The nurse should instruct the client to avoid taking any over-the-counter medications, including acetaminophen, which is toxic to the liver.

A nurse is assisting the charge nurse with developing an in-service about caring for clients who have internal sealed radiation implants. Which of the following information should the nurse include? 1) Pick up a radiation implant with a double-gloved hand if it becomes dislodged 2) Limit time spent in the client's room to 2 hours during an 8 hour shift 3) Restrict the time pregnant women are allowed in the clients room to 15 minutes 4) Dispose of radiation implants in a lead container

4) Dispose of radiation implants in a lead container - Lead impairs the emission of radiation. Therefore, the nurse should dispose of radiation implants in a lead container in accordance with facility protocol. - The nurse should use forceps to pick up a radiation implant if it becomes dislodged. - The nurse should limit time spent in the client's room to 30 min during an 8 hr shift. - Pregnant women and children should not be allowed to visit a client who is receiving internal radiation therapy because of the risk for exposure to radiation emissions.

A nurse is caring for a client who is receiving chemotherapy. The client mentions that she has lost her appetite because she has sores in her mouth and that food no longer tastes good. Which of the following suggestions to the client should the nurse make? 1) Consume foods that served hot rather than cold. 2) Drink water before and after each bite. 3) Rinse with a glycerin-based mouthwash before meals. 4) Eat several, small portioned meals daily

4) Eat several, small portioned meals daily - Clients who have difficulty eating because of pain or anorexia can usually tolerate small amounts of food at one time. Eating several small meals daily can increase the client's caloric intake. - Cold foods are usually tolerated better by a client who is receiving chemotherapy because they emit less odor. - The nurse should suggest that the client add gravy, broth, or sauces to foods to increase the moisture content of the food. Drinking water before and after each bite can lead to early satiety, which might cause the client to consume less food. - Clients who have sores in their mouths or mucositis should rinse with a solution of water and 0.9% sodium chloride, or with water and baking soda. Using a glycerin- or alcohol-based mouthwash can lead to irritation and burning of the oral mucosa.

A nurse is contributing to the plan of care for a client who has chronic obstructive pulmonary disease ( COPD) and is dyspneic. Which of the following interventions should the nurse include in the plan? 1) Direct the client to inhale with pursed lips 2) Instruct the client to lean back when coughing 3) Set the oxygen level at 5 L/min 4) Encourage abdominal breathing.

4) Encourage abdominal breathing. - The nurse should encourage abdominal breathing, which reduces the workload on the accessory muscles of respiration during dyspneic episodes. - The nurse should direct the client to exhale using pursed-lip breathing during dyspneic episodes to maintain positive airway pressure. - The nurse should instruct the client to lean forward and repeatedly "huff" followed by relaxed breathing to clear secretions during dyspneic episodes. - The nurse should set the oxygen therapy between 1 to 3 L/min to prevent the client's urge to breathe from decreasing during dyspneic episodes.

A nurse is caring for a client who is 24 hours postoperative following abdominal surgery and has an NG tube. Which of the following actions should the nurse plan to take to decrease the risk of postoperative complications? 1) Place one or two pillows beneath the clients knee's while he is in bed. 2) Offer sips of water to the client following oral care. 3) Massage the clients lower extremities with lotion every 2 hours. 4) Encourage the client to use an incentive spirometer every hour while awake.

4) Encourage the client to use an incentive spirometer every hour while awake. - The nurse should assist the client to use the incentive spirometer in addition to coughing and deep breathing every hour while awake for the first 24 hr postoperatively and at least every 2 hr while awake thereafter. An incentive spirometer will inflate the client's alveoli and improve ventilation to prevent postoperative pneumonia. - The nurse should elevate the foot of the bed slightly and apply prescribed compression stockings or sequential compression devices to promote venous return. However, pillows beneath the client's knees can create pressure and decrease venous return in the lower extremities, which can lead to thrombosis. - The nurse should provide frequent oral care and the use of moistened oral swabs to alleviate dry mucous membranes. However, oral fluids are contraindicated for a client who had abdominal surgery and has an NG tube. - The nurse should monitor the client's lower extremities for tenderness, warmth, or redness. However, massaging the client's lower extremities is contraindicated because, if there is a blood clot formation in the a lower extremity, it can loosen the clot and cause a pulmonary embolism.

A nurse is contributing to the plan of care for an older adult client who is at risk for osteoporosis. Which of the following interventions should the nurse include to prevent bone loss? 1) Massage bony prominence's 2) Encourage range of motion exercises 3) Increase fluid intake 4) Encourage weight bearing exercises

4) Encourage weight bearing exercises - Weight-bearing exercises, such as walking, can maintain bone mass by reducing bone demineralization, thus helping to prevent osteoporosis. - Massaging bony prominence's should be avoided because it can traumatize deep tissues. - Range-of-motion exercises are beneficial for general health and wellness, and they help to maintain flexibility and prevent contractures. However, range-of-motion exercises do not prevent bone loss. - Fluid intake is beneficial for general health and wellness, and it helps to treat some disorders. Caffeine and alcohol intake can increase the client's risk of developing osteoporosis. However, fluid intake does not prevent bone loss.

A nurse is participating in a health fair for older clients. Which of the immunizations should the nurse recommend for this age group? 1) Human papillomavirus ( HPV) 2) Meningococcal 3) Measles, mumps and rubella ( MMR) 4) Herpes zoster

4) Herpes zoster - The nurse should recommend the herpes zoster immunization for adults 60 years of age and older. - The nurse should recommend the HPV immunization for clients who are 9 to 26 years old. - The nurse should recommend the meningococcal immunization to college students and military recruits living in shared housing. - The nurse should recommend the MMR immunization to clients who were born after 1956.

A nurse is reinforcing teaching with a client who has mitral valve disease. Which of the following statements by the client indicates an understanding of the disease process? 1) I may develop excessive bruising 2) I should call my doctor if I get a headache 3) I may develop gastric reflux 4) I should call my doctor if my ankles swell.

4) I should call my doctor if my ankles swell. Swelling of the ankles can indicate heart failure. The client should report this finding to the provider. - A provider may prescribe anticoagulants to prevent thrombus formation on the valve, which can cause excessive bruising for a client who has mitral valve disease. However, excessive bruising is not a direct result of the disease. - Headaches are not a complication of mitral valve disease. - Mitral valve disease does not cause gastric reflux.

A nurse is caring for an older adult client who has a reddened area over the sacrum. Which of the following actions should the nurse take? 1) Massage the site with moisturizing lotion. 2) Place a doughnut-shaped cushion under the client's sacral area. 3) Apply a sterile gauze dressing to the site. 4) Minimize the time the head of the bed is elevated.

4) Minimize the time the head of the bed is elevated. - The nurse should minimize the time the head of the bed is elevated to reduce pressure on the sacral area. - The nurse should not massage nor apply moisturizing lotion to a reddened area because it can cause further skin injury. - The nurse should not place a donuts-type device under the client's sacral area because it can contribute to the development of a pressure injury. - The nurse should collect further data before determining what type of dressing is needed. - For a stage I pressure injury, skin preparation can be applied to preserve the integrity of the skin and prevent further direct injury. - Alternatively, a dressing such as a hydrocolloid or transparent dressing can be applied. - However, gauze dressings are not used in the treatment of a stage I pressure injury.

A nurse is reinforcing teaching with a client who has Gonorrhea. Which of the following information should the nurse include? 1) You can resume sexual activity as soon as you begin treatment. 2) You will not be at further risk for this infection following treatment. 3) Your partner will not require treatment for this infection. 4) You are at risk for infertility with this infection , regardless of treatment.

4) You are at risk for infertility with this infection , regardless of treatment. - The nurse should inform the client that there is a risk for infertility as a result of this infection. - The nurse should instruct the client to abstain from sexual contact until treatment is completed and cultures are negative. - The nurse should inform the client that immunity does not occur with this infection and that reoccurrence is possible. - The nurse should inform the client that sexual partners will require treatment to prevent the risk of reoccurrence of the infection.

A nurse in an oncology clinic is reinforcing teaching about Mohs surgery with a client who has skin cancer. Which of the following information should the nurse include in the teaching? 1) Mohs surgery is a palliative treatment for metastatic skin cancer. 2) Mohs surgery is the preferred treatment for melanoma skin cancer. 3) Mohs surgery uses liquid nitrogen to destroy the cancerous tissue. 4) Mohs surgery is a horizontal shaving of thin layers of the tumor.

4) Mohs surgery is a horizontal shaving of thin layers of the tumor. - Mohs surgery is performed to treat basal and squamous cell carcinoma. The procedure, which involves a horizontal shaving of thin layers of a tumor, has a high treatment rate. - Radiation, rather than Mohs surgery, can be used as a palliative treatment for metastatic skin cancer. - Mohs surgery is the preferred treatment for basal and squamous cell carcinoma. The preferred treatment for melanoma is a wide, full thickness surgical excision. - Cryosurgery, rather than Mohs surgery, uses liquid nitrogen to destroy cancerous tissue.

A nurse is assisting with discharge planning for a client who is postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the discharge plan? 1) Avoid lying on the operative side. 2) Expect decreased sensation for the first postoperative week. 3) Cross legs at the ankles 4) Obtain a raised toilet seat

4) Obtain a raised toilet seat - The nurse should instruct the client to use a raised toilet seat to avoid flexing the hip more than 90°, which increases the risk for dislocation. - The nurse should instruct the client that lying on the operative side is allowed but the client should place pillows between the legs to prevent dislocation of the hip. - The nurse should instruct the client to report decreased sensation in the affected foot or leg because this can indicate neurovascular compromise. - The nurse should instruct the client to avoid crossing her legs to prevent dislocation of the hip.

A nurse is caring for a client who has a compound fracture of the femur and was placed in a balanced suspension skeletal traction 4 days ago. Which of the following actions should the nurse take? 1) Remove the overbed trapeze 2) Keep the weights on a stable, flat surface 3) Remove the boot every 2 hours 4) Perform pin site care daily

4) Perform pin site care daily - The nurse should perform pin site care daily with chlorhexidine solution or use a solution according to facility protocol. The nurse should also monitor the pin sites for manifestations of infection. - The nurse should ensure the client has an overbed trapeze to aid in lifting the upper body off the bed when necessary and to help prevent skin breakdown of the heels and elbows with client repositioning. - The nurse should ensure the weights hang freely at all times. - The nurse should identify that balanced suspension skeletal traction is managed through the use of pins, pulleys, weights, and frames and that the client does not wear a boot.

A nurse is preparing to remove a client's NG tube. Which of the following interventions should the nurse take to decrease the risk of aspiration. 1) Instill 10ml of air through the NG tube 2) Place the client in a supine position. 3) Irrigate the NG tube 4) Pinch the NG tube

4) Pinch the NG tube - The nurse should pinch the NG tube to prevent secretions from draining into the client's throat, which can cause aspiration. - The nurse should instill 50 mL of air through the NG tube to remove mucus and gastric secretions from the tube and to prevent aspiration of these secretions. - The nurse should place the client in a sitting position to prevent the risk of aspiration. - The nurse should identify that irrigating the NG tube before removal can put the client at risk for aspiration and should be avoided.

A nurse in a long term care facility is collecting data from a client who reports fullness in the rectum and abdominal cramping. Which of the following findings should indicate to the nurse that the client might have a fecal impaction? 1) Rebound tenderness 2) Halitosis 3) Hemorrhoids 4) Small liquid stools

4) Small liquid stools - Small liquid stools can be the result of fecal material being expelled around an impaction. - Rebound tenderness is an indication of appendicitis. A client who has a fecal impaction can experience abdominal cramping and distention. - Halitosis, or bad breath, is associated with the ingestion of certain foods and medications, and it can also be an indication of infection. - Hemorrhoids indicate that the client is straining when defecating. However, the presence of hemorrhoids does not indicate fecal impaction.

A nurse is caring for a client who has terminal pancreatic cancer. The client states" I don't think I can on on any longer." Which of the following responses should the nurse make? 1) Can I get you something for the pain. 2) You should talk about this with your family. 3) Tomorrow will be a better day. 4) Tell me more about the way you are feeling.

4) Tell me more about the way you are feeling. - The nurse is establishing a trusting relationship by seeking clarification and encouraging the client to verbalize feelings. - The nurse should monitor the client's pain level and provide analgesics as needed. However, this response changes the subject, does not acknowledge the client's feelings, and is a barrier to a continued trusting relationship. - This response is an example of giving common advice and is dismissive of the client's feelings, which are barriers to a trusting relationship and open communication. - This response is an example of false reassurance and is dismissive of the client's feelings, provides false hope, and does not promote open communication.

A nurse is reinforcing teaching with a client who is taking insulin glargine. Which of the following information should the nurse include in the teaching? 1) This type of insulin can be used in a pump. 2) This insulin has an increased risk for hypoglycemia 3) This insulin can be mixed with short-acting insulin in a syringe 4) This type of insulin should be given at the same time every day.

4) This type of insulin should be given at the same time every day. - Insulin glargine is released in the body over a 24 hr period. The nurse should instruct the client to administer the insulin at the same time each day to maintain consistent serum levels for optimal therapeutic effect. - The nurse should inform the client insulin glargine is a long-acting insulin that is administered once daily at the same time and is not to be administered intravenously. - The nurse should inform the client that insulin glargine has a low risk for hypoglycemia because serum levels of the insulin do not peak and remain consistent over time. - The nurse should remind the client that insulin glargine should not be mixed with any other insulin.

RBC

4.2-6.1

WBC

5,000-10,000

Priorities: general rule

A - Airway - Secure the airway by head tilt , chin lift maneuver unless a fracture in cervical spinal. Brain injury or death in 3 - 5 minutes if airway not patent. B- Breathing - Auscultation of breath sounds, Chest expansion and respiratory effort, Rate and depth of respiration's, Look for chest trauma, Determine tracheal position, Check for jugular vein distension. C- Circulation - Heart rate, BP, Peripheral pulses, Cap refill. D - Disability - Clients level of consciousness with: 1) Glasgow coma scale a) <<< 8 Comatose state b) 3 Client totally unresponsive c) 15 A client within normal limits. E- Exposure - Hypothermia - Patient in cold icy water: 1) Remove wet clothing 2) Provide blankets 3) Increase the temperature of the room 4) Warm IV fluid going into the patient IF patient has had accidental or purposeful poisoning: 1) Activated charcoal 2) Gastric lavage 3) Whole bowel irrigation *** DO NOT INDUCE VOMITING OR SYRUP OF IPECAC Call rapid response team when client is rapidly declining.

Alpha 1 receptors

Activation Causes the skin , mucus membranes and veins to vasoconstrict. Help with: 1) Congestion 2) Superficial bleeding 3) In general help raise blood pressure by constricting the veins. DRUG: Epinephrine:Triggers the Alpha 1 receptors Causing vasoconstriction and increase blood pressure.

Immunizations: Recommended vaccinations for older adult clients

Adults age 50 or older: - Pneumococcal Vaccine (PPSV) - Influenza vaccine - Herpes Zoster Vaccine - Hepatitis A - Hepatitis B - Meningococcal Vaccine

Emergency nursing - Triage

BASED ON ACUITY 1) Emergent- Life threatening situation going on. 2) Urgent - Need to be treated soon but not life threatening. 3) Non urgent- The patient can wait for an extended period of time , without big issues.

fecal occult blood test

Blood in stool

Dopamine

Causes renal blood vessels to dilate. DRUG: Epinephrine: Dopamine receptors and if given a little more Beta I Helps with: 1) Shock 2) Heart failure

Mass casualty event

Class 1 - RED TAG - Immediate threat to life Examples: 1) Breathing issues 2) Chest pain 3) Heart attack coming on 4) Airway problem Class II - YELLOW TAG - Major injuries that require immediate treatment but not life threatening. Examples: 1) Major fracture Class III - GREEN TAG - Minor injury that does not require immediate attention. EXAMPLES: 1) Abrasion 2) Laceration Class IV - BLACK TAG - Expected to die EXAMPLES: 1) Penetrating head wound

A nurse is preparing to administer phytonadione 7 mg subcutaneously to a client who has an INR of 4. Available is phytonadione 10 mg/mL. How many mL should the nurse administer?

Dose ordered / Available X vehicle 7 mg / 10 mg/ML 7 divided by 10 = 0.7 mL

Seizures and Epilepsy: Seizure precautions

During a seizure: 1) Position client on the floor 2)Provide a patent airway 3) Turn client to side 4) Loosen restrictive clothing

What would you do for an ASTHMA emergency management of a bee sting allergies?

Epi Pen

Cardiac Emergencies

If V fib or ventricular tachycardia you would initiate: 1) Basic life support ( BLS) and CPR 2) Establish IV access 3) Epinephrine is used to get the heart up and moving.

Cancer treatment options: Protective Isolation

If WBC drops below 1,000, place the client in a private room and initiate neutropenic precautions. - Have client remain in his room unless he needs to leave for a diagnostic procedure, in that case transport patient and place a mask on him. - Protect from possible sources of infection (plants, change water in equipment daily) - Have client, staff and visitors perform frequent hand hygiene, restrict ill visitors - Avoid invasive procedures (rectal temps, injections) - Administer (neupogen, neulasta) to stimulate WBC production

Dobutamine side effects

Increased heart rate

Epinephrine side effects

Increases blood pressure 1) Hypertensive crisis 2) Dysrhythmia 3) Angina

ALT and AST

Normal is under 40 Something is wrong the liver Cirrosis and hepatitis Greater than 40 abnormal

Amylase and lipase

Problem with the pancreas Under 100 normal

What would you do for wound Evisceration ( removal of internal organs) , Emergency management?

Saline cover wound

Infection control: Appropriate room assignment

Standard Precautions: 1. applies to all patients 2. Hand washing a. alcohol based preferred unless hands visually soiled ( then soap and water ) 3. Gloves - when touching anything that has the potential to contaminate. 4. Masks, eye protection & face shields when care may cause splashing or spraying of body fluids Droplet: 1. private room or with someone with same illness 2. masks Airborne: 1. private room 2. masks or respiratory protection devices a. use an N95 respirator for tuberculosis 3. Negative pressure airflow 4. full face protection if splashing or spraying is possible Contact: 1. private room or room with same illness 2. gloves & gowns 3. disposal of infections dressing materials into a single, nonporous bag without touching the outside of the bag

Billrubin

Under 1 normal Altered liver function over 1

Amonia

Under 100 normal Over 100 liver disease