Medical Surgical HESI

A Among the findings characteristic of a small bowel obstruction is the presence of severe fluid and electrolyte imbalances.

Small bowel obstruction is a condition characterized by which finding? A. Severe fluid and electrolyte imbalances. B. Metabolic acidosis. C. Ribbon-like stools. D. Intermittent lower abdominal cramping.

A The nurse should immediately report the presence of clear, watery drainage from the ear in a client after a high fall. This type of fluid can indicate leakage of cerebrospinal fluid, a sign associated with a basal skull fracture.

A client is admitted to the emergency department after falling from a high roof. Which finding should the nurse report immediately? A. Clear, watery drainage from the ear. B. Dried blood around the ear and neck. C. Tenderness on palpation of the ear. D. Pearly appearance of the tympanic membrane.

B The nurse advising the client to come in provides the best response because it addresses the client's anxiety most effectively and encourages prompt and immediate action for a potential problem.

A 20-year-old female client calls the nurse to report a lump she found in her breast. Which response is the best for the nurse to provide? A. "Check it again in one month, and if it is still there schedule an appointment." B. "Most lumps are benign, but it is always best to come in for an examination." C. "Try not to worry too much about it, because usually, most lumps are benign." D. "If you are in your menstrual period it is not a good time to check for lumps."

B Clients with basilar skull fractures are at high risk for infection of the brain, as indicated by an increased oral temperature, because the fracture leaves the meninges open to bacterial invasion. Clients may experience options C and D, but these findings do not pose as great a life-threatening risk as infection. Jugular distention is not a typical complication of basal skull fractures.

A 25-year-old client was admitted yesterday after a motor vehicle collision. Neurodiagnostic studies have shown a basal skull fracture in the middle fossa. Assessment on admission revealed both halo and Battle signs. Which new symptom indicates that the client is likely to be experiencing a common life-threatening complication associated with a basal skull fracture? A. Bilateral jugular venous distention B. Oral temperature of 102°F C. Intermittent focal motor seizures D. Intractable pain in the cervical region

B Dysmenorrhea, dyspareunia, and difficulty or painful defecation are common symptoms of endometriosis, which is the abnormal displacement of endometrial tissue in the dependent areas of the pelvic peritoneum. A history of infertility is another common finding associated with endometriosis.

A 32-year-old female client complains of severe abdominal pain each month before her menstrual period, painful intercourse, and painful defecation. Which additional history should the nurse obtain that is consistent with the client's complaints? A. Frequent urinary tract infections. B. Inability to get pregnant. C. Premenstrual syndrome. D. Chronic use of laxatives.

B The client with chronic alcoholism is likely to have hypomagnesemia. Option B is the recommended drug for torsades de pointes, which is a form of polymorphic ventricular tachycardia (VT) usually associated with a prolonged QT interval that occurs with hypomagnesemia. Options A and D increase the QT interval, which can cause the torsades to worsen. Option C is the antiarrhythmic of choice in most cases of drug-induced monomorphic VT, not torsades.

A 43-year-old homeless, malnourished client with a history of alcoholism is transferred to the ICU. The nurse palpates a heart rate of 160 beats/min, and the client's blood pressure is 90/54 mm Hg. Based on these findings, which IV medication should the nurse administer? A. Amiodarone (Cordarone) B. Magnesium sulfate C. Lidocaine (Xylocaine) D. Procainamide (Pronestyl)

A Creatinine is a product of muscle metabolism that is filtered by the glomerulus, and blood levels of this substance are not affected by dietary or fluid intake. An elevated creatinine strongly indicates nephron loss, reducing filtration.

A 46-year-old female client is admitted for acute renal failure secondary to diabetes and hypertension. Which test is the best indicator of adequate glomerular filtration? A. Serum creatinine. B. Blood Urea Nitrogen (BUN). C. Sedimentation rate. D. Urine specific gravity.

B The perimenopausal period begins about 10 years before menopause with the cessation of menstruation at the average ages of 52 to 54. Lower estrogen levels causes FSH and LH secretion in bursts (surges), which triggers vasomotor instability, night sweats, and hot flashes, so discussions about the perimenopausal body's changes, comfort measures, and treatment options should be provided.

A 49-year-old female client arrives at the clinic for an annual exam and asks the nurse why she becomes excessively diaphoretic and feels warm during nighttime. What is the nurse's best response? A. Explain the effect of the follicle-stimulating and luteinizing hormones. B. Discuss perimenopause and related comfort measures. C. Assess lung fields and for a cough productive of blood-tinged mucous. D. Ask if a fever above 101 F (38.3 C) has occurred in the last 24 hours.

A Smoking has been associated with ulcer formation, and stopping or decreasing the number of cigarettes smoked per day is an important aspect of ulcer management.

A 51-year-old truck driver who smokes two packs of cigarettes a day and is 30 pounds overweight is diagnosed with having a gastric ulcer. Which content is most important for the nurse to include in the discharge teaching for this client? A. Information about smoking cessation. B. Diet instructions for a low-residue diet. C. Instructions on a weight-loss program. D. The importance of increasing milk in the diet.

D Medication can be administered via a central line without additional IV fluids. The line should first be flushed with a normal saline solution to ensure patency. Insufficient evidence exists on the effectiveness of flushing catheters with heparin. Option A will not affect the decision to administer the medication and is not a priority. Administration of the medication STAT is of greater priority than option B.

A central venous catheter has been inserted via a jugular vein, and a radiograph has confirmed placement of the catheter. A prescription has been received for a medication STAT, but IV fluids have not yet been started. Which action should the nurse take prior to administering the prescribed medication? A. Assess for signs of jugular venous distention. B. Obtain the needed intravenous solution. C. Flush the line with heparinized solution. D. Flush the line with normal saline.

C Smoking, considered to be a modifiable risk factor, is the most significant risk factor for the development of COPD. The exact mechanism of genetic and hereditary implications for the development of COPD is still under investigation, although exposure to similar predisposing factors (e.g., smoking or inhaling secondhand smoke) may increase the likelihood of COPD incidence among family members. Options B and D do not exceed the risks associated with cigarette smoking in the development of COPD.

A 55-year-old male client has been admitted to the hospital with a medical diagnosis of chronic obstructive pulmonary disease (COPD). Which risk factor is the most significant in the development of this client's COPD? A. The client's father was diagnosed with COPD in his 50s. B. A close family member contracted tuberculosis last year. C. The client smokes one to two packs of cigarettes per day. D. The client has been 40 pounds overweight for 15 years.

D Being direct and explaining to the client that the test requires him to be NPO, is the most therapeutic statement because the nurse is responding to the client's question and providing him the reason why.

A 57-year-old male client is scheduled to have a stress-thallium test the following morning and is NPO after midnight. At 0130, he is agitated because he cannot eat and is demanding food. Which response is best for the nurse to provide to this client? A. "I'm sorry sir, you have a prescription for nothing by mouth from midnight tonight." B. "I will let you have one cracker, but that is all you can have for the rest of tonight." C. "What did the healthcare provider tell you about the test you are having tomorrow?" D. "The test you are having tomorrow requires that you have nothing by mouth tonight."

B Post-menopausal females are at risk for osteoporosis due to the cessation of estrogen secretion, but a regimen including calcium, vitamin D, and weight-bearing exercise can help prevent further bone loss.

A 58-year-old client who has been post-menopausal for five years is concerned about the risk for osteoporosis because her mother has the condition. Which information should the nurse offer? A. Osteoporosis is a progressive genetic disease with no effective treatment. B. Calcium loss from bones can be slowed by increasing calcium intake and exercise. C. Estrogen replacement therapy should be started to prevent the progression osteoporosis. D. Low-dose corticosteroid treatment effectively halts the course of osteoporosis.

B It is recommended by the CDC (Dec 2016) that persons over 65 years of age and those with a history of chronic illness receive the vaccine once in a lifetime.

A 58-year-old client, who has no health problems, asks the nurse about the Pneumovax vaccine. The nurse's response to the client should be based on which information? A. The vaccine is given annually before the flu season to those over 50 years of age. B. The immunization is administered once to older adults or persons with a history of chronic illness. C. The vaccine is for all ages and is given primarily to those persons traveling overseas to areas of infection. D. The vaccine will prevent the occurrence of pneumococcal pneumonia for up to five years.

C The most common cause of a fractured hip in elderly women is osteoporosis, resulting from reduced calcium in the bones as a result of hormonal changes in later life.

A 67-year-old woman who lives alone tripped on a rug in her home and fractured her hip. Which predisposing factor probably led to the fracture in the proximal end of her femur? A. Failing eyesight resulting in an unsafe environment. B. Renal osteodystrophy resulting from chronic renal failure. C. Osteoporosis resulting from hormonal changes. D. Cardiovascular changes resulting in small strokes which impair mental acuity.

D Adding PEEP helps improve oxygenation while reducing FiO2 to a less toxic level. Options A, B, and C will not result in improved oxygenation and could cause further complications for this client, who is experiencing respiratory failure.

A 74-year-old male client is admitted to the intensive care unit (ICU) with a diagnosis of respiratory failure secondary to pneumonia. Currently, the client is ventilator-dependent, with settings of tidal volume (VT) of 750 mL and an intermittent mandatory ventilation (IMV) rate of 10 breaths/min. Arterial blood gas (ABG) results are as follows: pH, 7.48; PaCO2, 30 mm Hg; PaO2, 64 mm Hg; HCO3, 25 mEq/L; and FiO2, 0.80. Which action should the nurse take first? A. Increase the ventilator VT to 850 mL. B. Decrease the ventilator IMV to a rate of 8 breaths/min. C. Reduce the FiO2 to 0.70 and redraw ABGs. D. Add 5 cm positive end-expiratory pressure (PEEP).

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

A 77-year-old client is admitted to the hospital with confusion and anorexia of several days' duration. Additional symptoms reported are nausea and vomiting, and current complaints of a headache. The client's pulse rate is 43 beats/min. The nurse is most concerned about the client's history related to which medication? A. Warfarin B. Ibuprofen C. Nitroglycerin D. Digoxin

D Although it is important to obtain a complete medication history, the symptoms described are classic for digitalis toxicity, and assessment of this problem should be made promptly. Elderly persons are particularly susceptible to digitalis intoxication which manifests itself in such symptoms as anorexia, nausea, vomiting, diarrhea, headache, and fatigue.

A 77-year-old female client is admitted to the hospital. She is confused, has no appetite, is nauseated and vomiting, and is complaining of a headache. Her pulse rate is 43 beats per minute. It is most important for the nurse to assess for which finding? A. Wearing dentures. B. Use of aspirin prior to admit. C. Prescribed nitroglycerin for chest pain. D. Takes digitalis.

A The nurse should safely assist the client to a resting position and then perform options C and D. The client must cease all activity immediately, which will decrease the oxygen requirement of the myocardial muscle. After these interventions are implemented, the client can be escorted back to the room via wheelchair or stretcher.

A client diagnosed with angina pectoris complains of chest pain while ambulating in the hallway. Which action should the nurse take first? A. Support the client to a sitting position. B. Ask the client to walk slowly back to the room. C. Administer a sublingual nitroglycerin tablet. D. Provide oxygen via nasal cannula.

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

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

D Digoxin is administered for uncontrolled, symptomatic atrial fibrillation resulting in a decreased cardiac output. Digoxin slows the rate of conduction by prolonging the refractory period of the AV node, thus slowing the ventricular response, decreasing the heart rate, and effecting cardiac output.

A client experiencing uncontrolled atrial fibrillation is admitted to the telemetry unit. Which initial medication should the nurse anticipate administering to the client? A. Xylocaine. B. Procainamide. C. Phenytoin. D. Digoxin.

D Inflammatory breast cancer onset is very rapid and a very rare form of breast cancer and is considered the most aggressive form of breast malignancies. It is often mistaken for a breast infection because it has a thickened appearance like an orange peel (peau d'orange), causing the breast to become swollen and tender.

A client has a staging procedure for cancer of the breast and ask the nurse which type of breast cancer has the poorest prognosis. Which information should the nurse offer the client? A. Stage II. B. Invasive infiltrating ductal carcinoma. C. T1N0M0. D. Inflammatory with peau d'orange.

A Left lower quadrant pain occurs with diverticulitis because the sigmoid colon is the most common area for diverticula, and the inflammation of diverticula causes a low-grade fever.

A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which assessment finding should the nurse expect this client to exhibit? A. Lower left quadrant pain and a low-grade fever. B. Severe pain at McBurney's point and nausea. C. Abdominal pain and intermittent tenesmus. D. Exacerbations of severe diarrhea.

A The use of traction for long bone fractures reduces the potential for damage to the surrounding tissues. Reports of increased pain may indicate circulatory compromise or tissue damage (compartment syndrome). Assessing the client's neurovascular status is the nurse's highest priority.

A client has been hospitalized with a femur fracture and is being treated with traction. Which action by the nurse is the priority when caring for this client? A. Assess neurovascular status. B. Change the client's position. C. Inspect the traction equipment. D. Review pain medication orders.

C Steroids cause immunosuppression, and purulent sputum is an indication of infection, so this symptom is of greatest concern.

A client has been taking oral corticosteroids for the past five days because of seasonal allergies. Which assessment finding is of most concern to the nurse? A. White blood count of 10,000 mm3. B. Serum glucose of 115 mg/dl. C. Purulent sputum. D. Excessive hunger.

B

A client has taken steroids for 12 years to help manage chronic obstructive pulmonary disease (COPD). When making a home visit, which nursing assessment is of greatest importance to this client? A. pulse rate, both apically and radially. B. blood pressure, both standing and sitting. C. temperature. D. skin color and turgor.

D Feelings of dizziness may occur as the result of a decreased heart rate, leading to a decreased cardiac output which may be an indication of pacemaker failure.

A client has undergone insertion of a permanent pacemaker. When developing a discharge teaching plan, the nurse writes a goal of, "The client will verbalize symptoms of pacemaker failure." Which symptoms are most important to teach the client? A. Facial flushing. B. Fever C. Pounding headache D. Feeling of dizziness

A Sarcoidosis is an inflammatory condition that is characterized by the formation of widespread granulomatous lesions involving a pulmonary primary site. Although chest radiography identifies sarcoidosis, lung tissue biopsy obtained by bronchoscopy or bronchoalveolar lavage provides definitive confirmation.

A client is admitted for further testing to confirm sarcoidosis. Which diagnostic test provides definitive information that the nurse should report to the healthcare provider? A. Lung tissue biopsy. B. Positive blood cultures. C. Magnetic resonance imaging (MRI). D. Computerized tomography (CT) of the thorax.

B Gram-negative organisms are very resistant to drug therapy which makes recovery difficult. Antibiotic resistance has become a world-wide concern and the World Health Organization is keeping a very close surveillance on these occurrences.

A client is admitted to the hospital with a medical diagnosis of pneumococcal pneumonia. The nurse knows that the prognosis for gram-negative pneumonias (such as E. coli, Klebsiella, Pseudomonas, and Proteus) is very poor. Which information relates most directly to the prognosis for gram-negative pneumonias? A. The gram-negative infections occur in the lower lobe alveoli which are more sensitive to infection. B. Gram-negative organisms are more resistant to antibiotic therapy. C. Usually occur in healthy young adults who have recently been debilitated by an upper respiratory infection. D. Gram-negative pneumonias usually affect infants and small children.

C The cardiac isoenzyme CK-MB (C) is the one of the cardiac markers to indicate myocardial damage in the presence of MI symptoms and after a positive troponin. The troponin levels will elevate within 2-3 hours indicating myocardial ischemia, followed by the CK-MB cardiac markers within 6-9 hours, peaking within 12 to 20 hours after myocardial infarction (MI).

A client is admitted to the medical intensive care unit with a diagnosis of myocardial infarction. The client's history indicates the infarction occurred ten hours ago. Which laboratory test result would the nurse expect this client to exhibit? A. Elevated LDH. B. Elevated serum amylase. C. Elevated CK-MB. D. Elevated hematocrit.

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

A client is being discharged following radioactive seed implantation for prostate cancer. What is the most important information that the nurse should provide to this client's family? A. Follow exposure precautions. B. Encourage regular meals. C. Collect all urine. D. Avoid touching the client.

A, B, C, D The client is showing signs of peritonitis with the sudden spike in temperature. Low urine output and cool clammy skin are not seen with peritonitis. Peritonitis is a medical emergency and the health care provider must be notified immediately.

A client is diagnosed with an acute small bowel obstruction and suddenly spikes a temperature of 102°F/38.9°C. What other assessments should the nurse include in the client's focused assessment? (Select all that apply.) A. Nausea and vomiting B. Loss of appetite C. Abdominal cramping D. Guarding with abdominal palpation E. Low urine output F. Cool, clammy skin

D A client who has chronic constipation often strains to pass constipated stool which increases intestinal pressure that weakens the intestinal walls and causes out-pouching sacs, called diverticula which commonly occur in the sigmoid.

A client is newly diagnosed with diverticulosis. The registered nurse (RN) is assessing the client's basic knowledge about the disease process. Which statement by the client conveys an understanding of the etiology of diverticula? A. Over use of laxatives for bowel regularity result in loss of peristaltic tone. B. Inflammation of the colon mucosa cause growths that protrude into the colon lumen. C. Diverticulosis is the result of high fiber diet and sedentary life style. D. Chronic constipation causes weakening of colon wall which result in out-pouching sacs.

A To increase the client's tolerance of endotracheal intubation and/or mechanical ventilation, a skeletal-muscle relaxant, such as vecuronium, is usually prescribed. Impaired communication is a serious outcome because the client cannot communicate his/her needs due to intubation and diaphragmatic paralysis caused by the drug.

A client is placed on a mechanical ventilator following a cerebral hemorrhage, and vecuronium bromide 0.04 mg/kg q12 hours IV is prescribed. Which is the priority nursing diagnosis for this client? A. Impaired communication related to paralysis of skeletal muscles. B. High risk for infection related to increased intracranial pressure. C. Potential for injury related to impaired lung expansion. D. Social isolation related to inability to communicate.

A, B, C, D, F The outcome of the client is too early to relay to the family. The nurse must not offer false reassurance. The remaining actions are correct for a client on a ventilator.

A client is placed on a mechanical ventilator following a cerebral hemorrhage. What are the priority nursing actions for this client? (Select all that apply.) A. Assess lung sounds. B. Look for equal and bilateral expansion of the chest. C. Monitor skin color. D. Evaluate the need for suctioning. E. Tell the family the client is expected to fully recover. F. Make sure the ventilator alarms are set.

C A seal must be maintained to prevent leakage of irritating liquid stool onto the skin. Option A is excessive and can cause skin irritation and breakdown. Ileostomies produce liquid fecal drainage, so option B is not necessary. Option D is not needed.

A client is ready for discharge following the creation of an ileostomy. Which instruction should the nurse include in discharge teaching? A. Replace the stoma appliance every day. B. Use warm tap water to irrigate the ileostomy. C. Change the bag when the seal is broken. D. Measure and record the ileostomy output.

B With uncontrolled atrial fibrillation, the treatment of choice is synchronized cardioversion to convert the cardiac rhythm back to normal sinus rhythm. Option A is a medication used for ventricular dysrhythmias. Option C is not for a client with atrial fibrillation; it is reserved for clients with life-threatening dysrhythmias, such as ventricular fibrillation and unstable ventricular tachycardia. Option D is the drug of choice in symptomatic sinus bradycardia, not atrial fibrillation.

A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid ventricular response. Based on this finding, the nurse anticipates assisting the physician with which treatment? A. Administer lidocaine, 75 mg intravenous push. B. Perform synchronized cardioversion. C. Defibrillate the client as soon as possible. D. Administer atropine, 0.4 mg intravenous push.

C Clients who suffer from chronic venous insufficiency often develop stasis dermatitis in the lower extremities. Stasis dermatitis appear as brownish-red discoloration on the lower extremities at the ankles which can develop into stasis ulcers due to the pooling of the venous blood flow back to the heart.

A client presents with chronic venous insufficiency. Which assessment finding should the nurse anticipate? A. Bilateral lower leg stasis dermatitis. B. Clubbing of fingers and toes. C. Intermittent claudication. D. Peripheral cyanosis.

A Cholestyramine is administered to help lower the triglycerides levels. Side effects: clients should be monitored for include increased prothrombin time and prolonged bleeding times which would alert the nurse to a vitamin K deficiency. These drugs reduce absorption of the fat soluble (lipid) vitamins A, D, E, and K.

A client receiving cholestyramine for hyperlipidemia should be evaluated for which vitamin deficiency? A. K B. B12 C. B6 D. C

C A potassium level of 3 is considered low (normal is 3.5 to 5). Taking a thiazide diuretic often results in a loss of potassium, so a potassium supplement needs to be prescribed to restore a normal serum potassium level.

A client taking a thiazide diuretic for the past six months has a serum potassium level of 3. The nurse anticipates which change in prescription for the client? A. The dosage of the diuretic will be decreased. B. The diuretic will be discontinued. C. A potassium supplement will be prescribed. D. The dosage of the diuretic will be increased.

D For a client taking a loop diuretic who complains of sleep issues, the nurse needs to first determine at what time of day the client takes the medication. Because of the diuretic effect of furosemide, clients should take the medication in the morning to prevent nocturia which may be the reason for the sleep difficulties.

A client taking furosemide, reports difficulty sleeping. Which question is important for the nurse to ask the client? A. "What dose of medication are you taking?" B. "Are you eating foods rich in potassium?" C. "Have you lost weight recently?" D. "At what time do you take your medication?"

B Hypokalemia (normal 3.5 to 5 mEq/L [3.5 to 5 mmol/L]) causes changes in myocardial irritability and ECG waveform, so it is most important for the nurse to initiate continuous cardiac monitoring to identify ventricular ectopy or other life-threatening dysrhythmias. After cardiac monitoring is initiated, then the potassium chloride should be given so that the effects of potassium replacement on the cardiac rhythm can be monitored.

A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L (2.9 mmol/L). Which action is most important for the nurse to implement? A. Give 20 mEq of potassium chloride. B. Initiate continuous cardiac monitoring. C. Arrange a consultation with the dietician. D. Teach about the side effects of diuretics.

D AIDS is diagnosed when one of several processes defined by the CDC is present in an individual who is not otherwise immunosuppressed (PCP, candidacies, cryptococcus, cryptosporidiosis, Kaposi's sarcoma, CNS lymphomas) and/or a CD4+ T cell count less than 200 (normal count 1,000).

A client who is HIV positive asks the nurse, "How will I know when I have AIDS?" Which response is best for the nurse to provide? A. "Diagnosis of AIDS is made when you have 2 positive ELISA test results." B. "Diagnosis is made when both the ELISA and the Western Blot tests are positive." C. "I can tell that you are afraid of being diagnosed with AIDS. Would you like for me to call your minister?" D. "AIDS is diagnosed when a specific opportunistic infection is found in an otherwise healthy individual."

D Following gastroscopy, a client should remain nothing by mouth until the effects of local anesthesia have dissipated and the airway's protective gag and swallow reflexes have returned.

A client who is fully awake after a gastroscopy asks the nurse for something to drink. After confirming that liquids are allowed, which assessment action should the nurse consider a priority? A. Listen to bilateral lung and bowel sounds. B. Obtain the client's pulse and blood pressure. C. Assist the client to the bathroom to void. D. Check the client's gag and swallow reflexes.

A The common adverse effects of chemotherapy (nausea, vomiting, alopecia, bone marrow depression) are due to chemotherapy's effect on the rapidly reproducing cells, both normal and malignant.

A client who is receiving chemotherapy asks the nurse, "Why is so much of my hair falling out each day?" Which response by the nurse best explains the reason for alopecia? A. "Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant." B. "Alopecia is a common side effect you will experience during long-term steroid therapy." C. "Your hair will grow back completely after your course of chemotherapy is completed." D. "The chemotherapy causes permanent alterations in your hair follicles that lead to hair loss."

A The use of an intrauterine device (IUD) provides the client with no protection from sexually transmitted diseases (STD).

A client who is sexually active with several partners requests an intrauterine device (IUD) as a contraceptive method. Which information should the nurse provide? A. Using an IUD offers no protection against sexually transmitted diseases (STD), which increase the risk for pelvic inflammatory disease (PID). B. Getting pregnant while using an IUD is common and is not the best contraceptive choice. C. Relying on an IUD may be a safer choice for monogamous partners, but a barrier method provides a better option in preventing STD transmission. D. Selecting a contraceptive device should consider choosing a successful method used in the past.

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

A client who received a nephrotoxic drug is admitted with acute renal failure and asks the nurse if dialysis will always be needed. Which pathophysiologic consequence should the nurse explain that supports the need for temporary dialysis until acute tubular necrosis subsides? A. Azotemia B. Oliguria C. Hyperkalemia D. Nephron obstruction

C Maintaining skin integrity and providing back care is difficult when a client is in traction, but must be performed and is the correct intervention to maintain the client's skin integrity.

A client who was in a motor vehicle collision was admitted to the hospital and the right knee was placed in skeletal traction. The nurse has documented this nursing diagnosis in the client's medical record: "Potential for impairment of skin integrity related to immobility from traction." Which nursing intervention is indicated based on this diagnosis statement? A. Release the traction q4h to provide skin care. B. Turn the client for back care while suspending traction. C. Provide back and skin care while maintaining the traction. D. Give back care after the client is released from traction.

B As the glomerular filtration rate decreases in early renal insufficiency, metabolic waste products, including urea, creatinine, and other substances, such as phenols, hormones, and electrolytes, accumulate in the blood. In the early stage of renal insufficiency, polyuria results from the inability of the kidneys to concentrate urine and contributes to nocturia.

A client with a 16-year history of diabetes mellitus is having renal function tests because of recent fatigue, weakness, elevated blood urea nitrogen, and serum creatinine levels. Which finding should the nurse conclude as an early symptom of renal insufficiency? A. Dyspnea. B. Nocturia. C. Confusion. D. Stomatitis.

D Most ischemic strokes occur during sleep when baseline blood pressure declines or blood viscosity increases due to minimal fluid intake. Completed strokes usually produce neurologic deficits within an hour, and the client's current elevated blood pressure requires antihypertensive medication.

A client with a completed ischemic stroke has a blood pressure of 180/90 mmHg. Which action should the nurse implement? A. Position the head of the bed (HOB) flat. B. Withhold intravenous fluids. C. Administer a bolus of IV fluids. D. Give an antihypertensive medication.

B The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention, repositioning the client, should be attempted first, followed by options A and C, unless either of these interventions is contraindicated. If these measures are unsuccessful, the client may require option D.

A client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last 2 hours. Which action should the nurse take first? A. Irrigate the nasogastric tube with sterile normal saline. B. Reposition the client on her side. C. Advance the nasogastric tube 5 cm. D. Administer an intravenous antiemetic as prescribed.

D Sedatives such as pentobarbital are contraindicated for clients with liver damage and can have dangerous consequences. Option A is often prescribed because the normal clotting mechanism is damaged. Option B is needed to help restore energy to the debilitated client. Sodium is often restricted because of edema. Fluids are restricted to decrease ascites, which often accompanies cirrhosis, particularly in the later stages of the disease.

A client with alcohol-related liver disease is admitted to the unit. Which prescription should the nurse call the health care provider about for reverification for this client? A. Vitamin K1, 5 mg IM daily B. High-calorie, low-sodium diet C. Fluid restriction to 1500 mL/day D. Nembutal sodium at bedtime for rest

B The nurse should call the provider for a different medication because morphine is a histamine-releasing opioid and should be avoided when the client has asthma. Option A is unsafe because it puts the client at risk for an asthma exacerbation. Even if the drug were safe for the client, options C and D both disregard the prescription and the client's need for pain relief in the immediate postoperative period.

A client with chronic asthma is admitted to the PACU complaining of pain at a level of 8 on a 1 to 10 scale, with a blood pressure of 124/78 mm Hg, pulse of 88 beats/min, and respirations of 20 breaths/min. The PACU recovery prescription is "Morphine, 2 to 4 mg IV push, while in recovery for pain level over 5." Which action should the nurse take first? A. Give the medication as prescribed to decrease the client's pain. B. Call the anesthesia provider for a different medication for pain. C. Use nonpharmacologic techniques before giving the medication. D. Reassess the pain level in 30 minutes and medicate if it remains elevated.

D Salt and fluid restrictions are the first dietary modifications for a client who is retaining fluid as manifested by edema and ascites.

A client with cirrhosis develops increasing pedal edema and ascites. Which dietary modification is most important for the nurse to teach this client? A. Avoid high carbohydrate foods. B. Decrease intake of fat soluble vitamins. C. Decrease caloric intake. D. Restrict salt and fluid intake.

D Diabetes mellitus Type 1 is characterized by hyperglycemia that precipitates glucosuria and polyuria (frequent urination), polydipsia (excessive thirst), and polyphagia (excessive hunger). Polyphagia is a consequence of cellular malnourishment when insulin deficiency prevents utilization of glucose into the cell for energy, so the outcome statement should include stabilization of adequate cellular nutrition which is done by providing the insulin supplement the client needs.

A client with diabetes mellitus is experiencing polyphagia. Which outcome statement is the priority for this client? A. Fluid and electrolyte balance. B. Prevention of water toxicity. C. Reduced glucose in the urine. D. Adequate cellular nourishment.

C Treatment decisions and prediction of prognosis are related to the tumor's receptor status, such as estrogen and progesterone receptor status which commonly are well-differentiated, have a lower chance of recurrence, and are receptive to hormonal therapy. Tumor staging designates tumor size and spread of breast cancer cells into axillary lymph nodes, which is one of the most important prognostic factors in early-stage breast cancer.

A client with early breast cancer receives the results of a breast biopsy and asks the nurse to explain the meaning of staging and the type of receptors found on the cancer cells. Which explanation should the nurse provide? A. Lymph node involvement is not significant. B. Small tumors are aggressive and indicate poor prognosis. C. The tumor's estrogen receptor guides treatment options. D. Stage I indicates metastasis.

D Raising the head of the bed on blocks (reverse Trendelenburg position) to reduce reflux and subsequent aspiration is the most non-pharmacological effective recommendation for a client experiencing severe gastroesophageal reflux during sleep.

A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep. Which recommendation by the nurse is most effective to assist the client? A. Losing weight. B. Decreasing caffeine intake C. Avoiding large meals. D. Raising the head of the bed on blocks.

A Propanolol is a beta adrenergic blocking agent, which causes decreased heart rate and decreased contractility.

A client with heart disease is on a continuous telemetry monitor and has developed sinus bradycardia. In determining the possible cause of the bradycardia, the nurse assesses the client's medication record. Which medication is most likely the cause of the bradycardia? A. Propanolol. B. Captopril. C. Furosemide. D. Dobutamine.

A The client's blood pressure is within normal limits, indicating that the ramipril, an antihypertensive, is having the desired effect and should be administered. Options B and C would be appropriate if the client's blood pressure was excessively low (<100 mm Hg systolic) or if the client were exhibiting signs of hypotension such as dizziness. This prescribed dose is within the normal dosage range, as defined by the manufacturer; therefore, option D is not necessary.

A client with hypertension has been receiving ramipril, 5 mg PO, daily for 2 weeks and is scheduled to receive a dose at 0900. At 0830, the client's blood pressure is 120/70 mm Hg. Which action should the nurse take? A. Administer the prescribed dose at the scheduled time. B. Hold the dose and contact the health care provider. C. Hold the dose and recheck the blood pressure in 1 hour. D. Check the health care provider's prescription to clarify the dose.

C Exacerbations of the symptoms of MS occur most commonly as the result of fatigue and stress. The client should be encouraged to schedule extra rest periods to help reduce the symptoms.

A client with multiple sclerosis has experienced an exacerbation of symptoms, including paresthesias, diplopia, and nystagmus. Which instruction should the nurse provide? A. Stay out of direct sunlight. B. Restrict intake of high protein foods. C. Schedule extra rest periods. D. Go to the emergency room immediately.

D Regular insulin dosing based on the client's blood glucose levels (sliding scale) is the best method to achieve control of the client's blood glucose while the client is NPO and coping with the major stress of surgery. Option A increases the risk of vomiting and aspiration. Options B and C provide less precise control of the blood glucose level.

A client with type 2 diabetes takes metformin daily. The client is scheduled for major surgery requiring general anesthesia the next day. The nurse anticipates which approach to manage the client's diabetes best while the client is NPO during the perioperative period? A. NPO except for metformin and regular snacks B. NPO except for oral antidiabetic agent C. Novolin N insulin subcutaneously twice daily D. Regular insulin subcutaneously per sliding scale

A Ulcerative colitis is 4 to 5 times more common among individuals of Jewish European or Ashkenazi ancestry.

A client's susceptibility to ulcerative colitis is most likely due to which aspect in the client's history? A. Jewish European ancestry. B. H. pylori bowel infection. C. Family history of irritable bowel syndrome. D. Age between 25 and 55 years.

B Option B indicates correct technique for performing suctioning. Suction pressure should be between 80 and 120 mm Hg, not 190 mm Hg. The catheter should be withdrawn 1 to 2 cm at a time with intermittent, not continuous, suction. Option D introduces pathogens unnecessarily into the tracheobronchial tree.

A family member was taught to suction a client's tracheostomy prior to the client's discharge from the hospital. Which observation by the nurse indicates that the family member is capable of correctly performing the suctioning technique? A. Turns on the continuous wall suction to 190 mm Hg B. Inserts the catheter until resistance or coughing occurs C. Withdraws the catheter while maintaining suctioning D. Reclears the tracheostomy after suctioning the mouth

A Vasopressin is used to promote vasoconstriction, thereby reducing bleeding from the esophageal varice. Vasoconstriction of the coronary arteries can lead to angina and myocardial infarction, and should be counteracted by IV nitroglycerin per prescribed protocol.

A female client receiving IV vasopressin for esophageal varice rupture reports to the nurse that she feels substernal tightness and pressure across her chest. Which PRN protocol should the nurse initiate? A. Start an IV nitroglycerin infusion B. Nasogastric lavage with cool saline. C. Increase the vasopressin infusion. D. Prepare for endotracheal intubation.

B The fertile period, which occurs 2 weeks prior to the onset of menses, is determined using an accurate record of the number of days of the menstrual cycles for the past 6 months, so it is most important to emphasize to the client that accuracy and being compliant in recording the menstrual diary is the basis of the calendar method.

A female client requests information about using the calendar method of contraception. Which assessment is most important for the nurse to obtain? A. Amount of weight gain or weight loss during the previous year. B. An accurate menstrual cycle diary for the past 6 to 12 months. C. Skin pigmentation and hair texture for evidence of hormonal changes. D. Previous birth-control methods and beliefs about the calendar method.

C Calf pain is indicative of thrombophlebitis, a serious, life-threatening complication associated with the use of oral contraceptives which requires further assessment and possibly immediate medical intervention.

A female client taking oral contraceptives reports to the nurse that she is experiencing calf pain. Which action should the nurse implement? A. Determine if the client has also experienced breast tenderness and weight gain. B. Encourage the client to begin a regular, daily program of walking and exercise. C. Advise the client to notify the healthcare provider for immediate medical attention. D. Tell the client to stop taking the medication for a week to see if symptoms subside.

C Thin nonelastic skin is an important factor in pressure formation. The proportion of body fat to lean mass increases with age and might help decrease ulcer tendency. Option B causes gray hair. Option D can contribute to broken bones, but it is probably not a factor in pressure ulcer formation.

A home health nurse is assessing a 70-year-old male client who is convalescing at home following a hip replacement. The nurse is concerned that the client may develop pressure ulcers. Which physical characteristic of aging puts the client at risk? A. 16% increase in overall body fat B. Reduced melanin production C. Thinning of the skin, with loss of elasticity D. Calcium loss in the bones

B A productive cough may indicate that the feeding has been aspirated. The nurse should first stop the feeding to prevent further aspiration. Options A, C, and D should all be performed before restarting the tube feeding if no evidence of aspiration is present and the tube is in place.

A hospitalized client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. The client begins to cough and produces a moderate amount of white sputum. Which action should the nurse take first? A. Auscultate the client's breath sounds. B. Turn off the continuous feeding pump. C. Check placement of the nasogastric tube. D. Measure the amount of residual feeding.

B The cuff should be inflated before the feeding to block the trachea and prevent food from entering if oral feedings are started while a cuffed tracheostomy tube is in place. It should remain inflated throughout the feeding to prevent aspiration of food into the respiratory system. Options A and D place the client at risk for aspiration. Option C places the client at risk for tracheal wall necrosis.

A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place. When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff? A. Immediately after feeding B. Just prior to tube feeding C. Continuous inflation is required D. Inflation is not required

B Slurred speech in the post-operative client who received a local anesthetic is an atypical finding and may indicate neurological deficits that require further assessment, so obtaining the client's vital signs will provide information about possible cardiovascular complications, such as stroke.

A male client receives a local anesthetic during surgery. During the post-operative assessment, the nurse notices the client is slurring his speech. Which action should the nurse take? A. Determine the client is anxious and allow him to sleep. B. Evaluate his blood pressure, pulse, and respiratory status. C. Review the client's pre-operative history for alcohol abuse. D. Continue to monitor the client for reactivity to anesthesia.

B, C, D Use of tobacco, alcohol, and marijuana may affect sperm counts. Sperm count is also negatively affected by low testosterone levels and obesity.

A male client who smokes two packs of cigarettes a day states he understands that smoking cigarettes is contributing to the difficulty that he and his wife are having in getting pregnant and wants to know if other factors could be contributing to their difficulty. What information is best for the nurse to provide? (Select all that apply.) A. Marijuana cigarettes do not affect sperm count. B. Alcohol consumption can cause erectile dysfunction. C. Low testosterone levels affect sperm production. D. Cessation of smoking improves general health and fertility. E. Obesity has no effect on sperm production.

A The loss of a limb due to diabetes by a family member should be the strongest event or "cue to action" and is most likely to increase the client's perceived seriousness of the disease.

A middle-aged male client with diabetes continues to eat an abundance of foods that are high in sugar and fat. According to the Health Belief Model, which event is most likely to increase the client's willingness to become compliant with the prescribed diet? A. He visits his diabetic brother who just had surgery to amputate an infected foot. B. He is provided with the most current information about the dangers of untreated diabetes. C. He comments on the community service announcements about preventing complications associated with diabetes. D. His wife expresses a sincere willingness to prepare meals that are within his prescribed diet.

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

A nurse is assisting an 82-year-old client with ambulation and is concerned that the client may fall. Which area contains the older person's center of gravity? A. Head and neck B. Upper torso C. Bilateral arms D. Feet and legs

A Estrogen deprivation decreases the moisture-secreting capacity of vaginal cells, so vaginal tissues tend to become thinner, drier, and the rugae become smoother which reduces vaginal stretching that contributes to dyspareunia. The discomfort during intercourse, primary cause can be contributed to the decrease in estrogen hormone levels.

A postmenopausal client asks the nurse why she is experiencing discomfort during intercourse. Which response is best for the nurse to provide? A. Estrogen deficiency causes the vaginal tissues to become dry and thinner. B. Infrequent intercourse results in the vaginal tissues losing their elasticity. C. Dehydration from inadequate fluid intake causes vulva tissue dryness. D. Lack of adequate stimulation is the most common reason for dyspareunia.

A Hepatitis B vaccine should be administered to all health care providers. Hepatitis A (not hepatitis B) can be transmitted by fecal-oral contamination. There is a chance that staff could contract hepatitis B if exposed to the client's blood and/or body fluids; therefore, option C is incorrect. There is no need to wear gloves and gowns except with blood or body fluid contact.

A resident in a long-term care facility is diagnosed with hepatitis B. Which action should the nurse take with the staff caring for this client? A. Determine if all employees have had the hepatitis B vaccine series. B. Explain that this type of hepatitis can be transmitted when feeding the client. C. Assure the employees that they cannot contract hepatitis B when providing direct care. D. Tell the employees that wearing gloves and a gown are required when providing all care.

A Splints may be used at night by clients with rheumatoid arthritis to prevent deformities caused by muscle spasms and contractures.

A splint is prescribed for nighttime use by a client with rheumatoid arthritis. Which statement by the nurse provides the most accurate explanation for use of the splints? A. Prevention of deformities. B. Avoidance of joint trauma. C. Relief of joint inflammation. D. Improvement in joint strength.

B In the event of a tornado, all persons should be moved into the hallways, away from windows, to prevent flying debris from causing injury. Although option A may help decrease the amount of flying debris, it is not safe to leave clients in rooms with closed blinds; option B is a higher priority at this time. Hospital staff should stay away from windows to avoid injury and should focus on client evacuation into hallways rather than option C. Option D is not the first action that should be taken.

A tornado warning alarm has been activated at the local hospital. Which action should the charge nurse working on a surgical unit take first? A. Instruct the nursing staff to close all window blinds and curtains in clients' rooms. B. Move clients and visitors into the hallways and close all doors to clients' rooms. C. Visually confirm the location of the tornado by checking the windows on the unit. D. Assist all visitors with evacuation down the stairs in a calm and orderly manner.

A Radiation at high doses kills the stem cells that produce sperm. While infertility after radiotherapy often occurs, the nurse should be supportive and offer alternatives that address the client's concerns and treatment decisions. Suggesting sperm banking is the most sensitive and supportive response.

A young adult male is diagnosed with Stage 4 Hodgkin's lymphoma in the abdominopelvic region and is scheduled for radiation therapy (RT). The client expresses concern about becoming infertile. How should the nurse respond? A. Propose sperm banking before RT then artificial insemination is an option. B. Suggest adoption when the client is in remission or ready for parenting. C. Tell the client that infertility is a non-reversible side effect of radiotherapy. D. Explain that sperm production will be suppressed after radiotherapy is over.

A After surgery, an adult who weighs 132 pounds (60 kg) should produce about 60 mL of urine hourly (1 mL/kg/hour). Dark, concentrated, and low volume of urine output should be reported to the surgeon.

After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated urinary output of 54 mL for the last 2 hours. Which priority nursing action should be implemented? A. Report the findings to the surgeon. B. Irrigate the indwelling urinary catheter. C. Apply manual pressure to the bladder. D. Increase the IV flow rate for 15 minutes.

A The nurse should suggest creative methods to increase the intake of fluids, such as having disposable fruit juices readily available. Clients with COPD should be encouraged to have at least three liters of fluids a day to help keep their mucus thin. As the disease progresses, these clients often reduce fluid intake because of shortness of breath experienced while drinking and due to the fact, that they may be on diuretics related to heart involvement with the disease and may purposely limit their fluid intake to decrease the need for elimination.

An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that his tongue is somewhat cracked and his eyeballs are sunken into his head. Which nursing intervention is indicated? A. Help the client to determine ways to increase his fluid intake. B. Obtain an appointment for the client to see an ear, nose, and throat specialist. C. Schedule an appointment with an allergist to determine if the client is allergic to the cat. D. Encourage the client to slightly increase his use of oxygen at night and to always use humidified oxygen.

A Full-thickness burns destroy the entire dermal layer. Included in this destruction is the regenerative tissue. For this reason, tissue regeneration does not occur, and skin grafting is necessary.

An adult client is admitted to the hospital burn unit with partial-thickness and full-thickness burns over 40% of the body surface area. In assessing the potential for skin regeneration, which should the nurse remember about full-thickness burns? A. Regenerative function of the skin is absent because the dermal layer has been destroyed. B. Tissue regeneration will begin several days following return of normal circulation. C. Debridement of eschar will delay the body's ability to regenerate normal tissue. D. Normal tissue formation will be preceded by scar formation for the first year.

A Post-surgical clients are at an increased risk for deep vein thrombosis (DVT), which may result in pulmonary embolism if the clot breaks off and travels to the lungs. Signs and symptoms of pulmonary embolism include chest pain, dyspnea, anxiety, restlessness, and - in severe cases - cyanosis.

An adult client who is hospitalized after surgery reports sudden onset of chest pain and dyspnea. The client appears anxious, restless, and mildly cyanotic. The nurse should further assess the client for which condition? A. Pulmonary embolism. B. Heart failure. C. Tuberculosis. D. Bronchitis.

D The onset of pneumonia in the elderly may be signaled by general deterioration, confusion, increased heart rate or increased respiratory rate due to the decreased oxygen- carbon dioxide exchange at the alveoli, known as the V-Q mismatch. Cyanosis is a very late sign.

An elderly client is admitted with a diagnosis of bacterial pneumonia. When observing the client for the first signs of decreasing oxygenation, the nurse should assess for which clinical cues? A. Abdominal distention. B. Undue fatigue. C. Cyanosis of the lips. D. Confusion and tachycardia.

A This client is exhibiting classic symptoms of tuberculosis (TB), and the client is from a high-risk population for TB. Therefore, airborne infection precautions, which are indicated for TB, should be used with this client. Option B is used with droplet precautions. There is no evidence that option C or D would be warranted at this time.

An emaciated homeless client presents to the emergency department complaining of a productive cough, with blood-tinged sputum and night sweats. Which action is most important for the emergency department triage nurse to take for this client? A. Initiate airborne infection precautions. B. Place a surgical mask on the client. C. Don an isolation gown and latex gloves. D. Start protective (reverse) isolation precautions.

D Changes in weight and hygiene may be indicators of self-neglect or neglect by family members. Further assessment is needed before notifying social services or discussing a need for counseling.

An older adult female client is brought to the clinic by her daughter for a flu shot. She has lost significant weight since the last visit. She has poor personal hygiene and inadequate clothing for the weather. The client states that she lives alone and denies problems or concerns. Which action should the nurse implement? A. Notify social services immediately of suspected elderly abuse. B. Discuss the need for mental health counseling with the daughter. C. Explain to the client that she needs to take better care of herself. D. Collect further data to determine whether self-neglect is occurring.

C Thrombophlebitis pain is relieved by rest and elevation of the extremity. It typically occurs with exercise at the site of the thrombus, and is aggravated by placing the extremity in a dependent position, such as standing in one place.

An older adult male client comes to the geriatric screening clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg which is warm to the touch and suspects it might be thrombophlebitis. Which type of pain would further confirm this suspicion? A. Pain in the calf awakening him from a sound sleep. B. Calf pain on exertion which stops when standing in one place. C. Pain in the calf upon exertion which is relieved by rest and elevating the extremity. D. Pain upon arising in the morning which is relieved after some stretching and exercise.

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

An older client comes to the outpatient clinic complaining of left calf pain. The nurse notices a reddened area on the calf of the right leg that is warm to the touch, and the nurse suspects that the client may have thrombophlebitis. Which additional assessment is most important for the nurse to perform? A. Measure the client's calf circumference. B. Auscultate the client's breath sounds. C. Observe for ecchymosis and petechiae. D. Obtain the client's blood pressure.

D The onset of pneumonia in the older client may be signaled by general deterioration, confusion, increased heart rate, and/or increased respiratory rate. Options A, B, and C are often absent in the older client with bacterial pneumonia.

An older client is admitted with a diagnosis of bacterial pneumonia. Which symptom should the nurse report to the health care provider after assessing the client? A. Leukocytosis and febrile B. Polycythemia and crackles C. Pharyngitis and sputum production D. Confusion and tachycardia

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

Client census is often used to determine staffing needs. Which method of obtaining census determination for a particular unit provides the best formula for determining long-range staffing patterns? A. Midnight census B. Oncoming shift census C. Average daily census D. Hourly census

D The color yellow is the easiest for a person with failing vision to see.

Despite several eye surgeries, a 78-year-old client who lives alone has persistent vision problems. The visiting nurse is discussing home safety hazards with the client. The nurse suggests that the edges of the steps be painted which color? A. Black. B. White. C. Light green. D. Medium yellow.

B The most frequent cause of inadequate aeration of the client's lungs during CPR is the improper positioning of the head resulting in occlusion of the airway. The nurse should reposition the client's head and attempt to ventilate again, looking for the rise and fall of the chest.

During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving. Which action should the nurse take first? A. Use a laryngoscope to check for a foreign body lodged in the esophagus. B. Reposition the head to validate that the head is in the proper position to open the airway. C. Turn the client to the side and administer three back blows. D. Perform a finger sweep of the mouth to remove any vomitus.

D Chronic bronchitis, one of the diseases comprising the diagnosis of chronic obstructive pulmonary disease (COPD), is characterized by a productive cough with grayish-white sputum.

During a health fair, a 72-year-old male client tells the nurse that he is experiencing shortness of breath. Auscultation reveals crackles and wheezing in both lungs. Suspecting that the client might have chronic bronchitis, which classic symptom would the nurse expect this client to have? A. Racing pulse with exertion. B. Clubbing of the fingers. C. An increased chest diameter. D. Productive cough with grayish-white sputum.

C The financial implication of selecting a provider from outside of the network is the feature most relevant to the average consumer. The nurse must have knowledge about preferred provider organizations (PPOs), which provides the option for the consumer to select a Healthcare Provider (HCP) from within the PPO network (in-network) at a reduced cost versus a higher cost for selecting an out-of-network HCP.

During an interview with a client planning elective surgery, the client asks the nurse, "What is the advantage of having a preferred provider organization insurance plan?" Which response is best for the nurse to provide? A. Neither plan allows selections of healthcare providers or hospitals. B. There are fewer healthcare providers to choose from than in an HMO plan. C. An individual may select healthcare providers from outside of the PPO network. D. An individual can become a member of a PPO without belonging to a group.

A The client is exhibiting symptoms of cardiac tamponade, a collection of fluid in the pericardial sac that results in a reduction in cardiac output, which is a potentially fatal complication of pericarditis. Treatment for tamponade is a pericardial tap. Lasix IV is not indicated for treatment of pericarditis. Because the client's breath sounds are clear, option C is not a priority. Fluids are frequently increased in the initial treatment of tamponade to compensate for the decrease in cardiac output, but this is not the same priority as option A.

During assessment of a client in the intensive care unit, the nurse notes that the client's breath sounds are clear on auscultation, but jugular vein distention and muffled heart sounds are present. Which action should the nurse take first? A. Prepare the client for a pericardial tap. B. Administer intravenous furosemide. C. Assist the client to cough and breathe deeply. D. Instruct the client to restrict oral fluid intake.

A Amyotrophic lateral sclerosis (ALS) is characterized by a degeneration of motor neurons in the brainstem and spinal cord and is manifested by muscle weakness and wasting.

During assessment of a client with amyotrophic lateral sclerosis (ALS), which finding should the nurse identify when planning care for this client? A. Muscle weakness. B. Urinary frequency. C. Abnormal involuntary movements. D. A decline in cognitive function.

C This test (whispered pectoriloquy) demonstrates hyperresonance and helps determine the clarity with which spoken words are heard upon auscultation. Normally, the spoken word is not well transmitted through lung tissue, and is heard as a muffled or unclear transmission of the spoken word. Increased clarity of a spoken word is indicative of some sort of consolidation process (e. g., tumor, pneumonia), and is not a normal finding.

During lung assessment, the nurse places a stethoscope on a client's chest and instructs him/her to say "99" each time the chest is touched with the stethoscope. Which would be the correct interpretation if the nurse hears the spoken words "99" very clearly through the stethoscope? A. This is a normal auscultatory finding. B. May indicate pneumothorax. C. May indicate pneumonia. D. May indicate severe emphysema.

C Clients with tumor lysis syndrome may experience hyperkalemia, requiring the addition of insulin to the IV solution to reduce the serum potassium level. It is most important for the nurse to monitor the client's serum potassium and blood glucose levels to ensure that they are not at dangerous levels. Options A, B, and D provide valuable assessment data but are of less priority than option C.

During report, the nurse learns that a client with tumor lysis syndrome is receiving an IV infusion containing insulin. Which action should the nurse complete first? A. Review the client's history for diabetes mellitus. B. Observe the extremity distal to the IV site. C. Monitor the client's serum potassium and blood glucose levels. D. Evaluate the client's oxygen saturation and breath sounds.

B The nurse should attempt to reinsert the tracheostomy tube by using a hemostat to open the tracheostomy or by grasping the retention sutures (if present) to spread the opening and insert a replacement tube (with its obturator) into the stoma. Once in place, the obturator should immediately be removed.

During suctioning, a client with an uncuffed tracheostomy tube begins to cough violently and dislodges the tracheostomy tube. Which action should the nurse implement first? A. Notify the healthcare provider for reinsertion. B. Attempt to reinsert the tracheostomy tube. C. Position the client in a lateral position with the neck extended. D. Ventilate client's tracheostomy stoma with a manual bag-mask.

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

During the change of shift report, the charge nurse reviews the infusions being received by clients on the oncology unit. The client receiving which infusion should be assessed first? A. Continuous IV infusion of magnesium B. One-time infusion of albumin C. Continuous epidural infusion of morphine D. Intermittent infusion of IV vancomycin

A Continuing with the shift report is the best immediate action because it allows the nurse who was floated some cooling off time. At a later time (after the nurse has cooled off) the charge nurse should discuss the conduct of the nurse in private. Option B encourages the nurse to shirk the float assignment. Option C is disruptive. Reprimanding the nurse in front of the staff would increase the nurse's hostility, so the nurse should be counseled in private.

During the shift report, the charge nurse informs a nurse of a reassignment to another unit for the day. The nurse begins to sigh deeply and tosses about her belongings when preparing to leave. What is the best immediate action for the charge nurse to take? A. Continue with the shift report and talk to the nurse about the incident at a later time. B. Ask the nurse to call the house supervisor to see if she must be reassigned. C. Stop the shift report and remind the nurse that all staff are floated equally. D. Inform the nurse that her behavior is disruptive to the rest of the staff.

B Other than taking a chest x-ray before initiating every enteral feeding, checking the pH of the stomach contents is another way of determining if the NG tube is still in the stomach. As long as the aspirate is less than 5.5 and the tube has remained secure, the reasonable assumption is the tube is in the stomach. Procedures to start the feeding can begin. Calling for a chest x-ray is appropriate if the nurse suspects the NG tube has been dislodged. There is no need to delay the feeding. Injecting air into a NG tube only determines patency, not placement.

For the client with a prescription for enteral feeding after surgery, the nurse checks the gastric aspirate and notes the pH is 5.2. What is the next nurse's action? A. Call for a chest x-ray. B. Initiate the procedures for the feeding. C. Tell the client the feeding will be delayed. D. Inject 10 mL of air down the NG tube.

B The CDC guidelines recommend that healthcare workers use gloves when coming in contact with blood or body fluids from any client since HIV is infectious before the client becomes aware of their exposure and/or symptomatic.

Healthcare workers must protect themselves against becoming infected with HIV. The Center for Disease Control has issued guidelines for healthcare workers in relation to protection from HIV. These guidelines include which recommendation? A. Place HIV positive clients in strict isolation and limit visitors. B. Wear gloves when coming in contact with the blood or body fluids of any client. C. Conduct mandatory HIV testing of those who work with AIDS clients. D. Freeze HIV blood specimens at -70 F to kill the virus.

A In MCL I monitoring, the positive electrode is placed on the client's mid-chest to the right of the sternum, and the negative electrode is placed on the upper left part of the chest. The ground may be placed anywhere, but is usually placed on the lower left portion of the chest.

How should the nurse position the electrodes for modified chest lead one (MCL I) telemetry monitoring? A. Positive polarity right shoulder, negative polarity left shoulder, ground left chest nipple line. B. Positive polarity left shoulder, negative polarity right chest nipple line, ground left chest nipple line. C. Positive polarity right chest nipple line, negative polarity left chest nipple line, ground left shoulder. D. Negative polarity left shoulder, positive polarity right chest nipple line, ground left chest nipple line.

C Clients with primary hyperaldosteronism exhibit a profound decline in the serum levels of potassium (hypokalemia). Hypertension, along with the hypokalemia are the most prominent and universal signs for this condition. If both of these findings are present, there is a 50% likelihood the client will be diagnosed with hyperaldosteronism.

In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the laboratory test results to indicate a decreased serum level of which substance? A. Sodium. B. Antidiuretic hormone. C. Potassium. D. Glucose.

C Absence of a thrill or bruit indicates that the shunt may be obstructed. The nurse should notify the health care provider so that intervention can be initiated to restore function of the shunt. Option A is incorrect. Option B will not resolve the obstruction. An AV shunt is internal and cannot be flushed without access using special needles.

In assessing a client with an arteriovenous (AV) shunt who is scheduled for dialysis today, the nurse notes the absence of a thrill or bruit at the shunt site. What action should the nurse take? A. Advise the client that the shunt is intact and ready for dialysis as scheduled. B. Encourage the client to keep the shunt site elevated above the level of the heart. C. Notify the health care provider of the findings immediately. D. Flush the site at least once with a heparinized saline solution.

B The most predictive risk factors for development of breast cancer are over 40 years of age and a positive family history (occurrence in the immediate family, i.e., mother or sister). Other risk factors include nulliparity, no history of breastfeeding, early menarche and late menopause, but are not considered as predictive as a positive history of an immediate family member and over 40 years old.

In assessing cancer risk, the nurse identifies which woman as being at greatest risk of developing breast cancer? A. A 35-year-old multipara who never breastfed. B. A 50-year-old whose mother had unilateral breast cancer. C. A 55-year-old whose mother-in-law had bilateral breast cancer. D. A 20-year-old whose menarche occurred at age 9.

D Buerger's disease is strongly related to smoking or the use of some other form of tobacco which affects the circulation in the arms and legs leading to infection and gangrene and sometimes amputation of the affected area. The most effective means of controlling symptoms and disease progression is through smoking cessation. The cause of Buerger's disease is unknown; a genetic predisposition is possible, but unproven.

In preparing a discharge plan for a 22-year-old male client diagnosed with Buerger's disease (thromboangiitis obliterans), which referral is most important? A. Genetic counseling. B. Twelve-step recovery program. C. Clinical nutritionist. D. Smoking cessation program.

A, D, E, F Albumin should be infused within four hours because it does not contain any preservatives. Any fluid remaining after four hours should be discarded. A large gauge catheter allows for fast infusion rate, which may be necessary. Hemodilution may decrease hemoglobin (HgB) and hematocrit (HCT) levels, so the HgB and HCT levels should be monitored while monitoring for bleeding because of the increased blood volume and blood pressure.

In preparing to administer intravenous albumin to a client following surgery, which are the priority nursing interventions? (Select all that apply.) A. Set the infusion pump to infuse the albumin within four hours. B. Compare the client's blood type with the label on the albumin. C. Assign a UAP to monitor blood pressure q15 minutes. D. Administer through a large gauge catheter. E. Monitor hemoglobin and hematocrit levels. F. Assess for increased bleeding after administration.

D Pulmonary embolism and pneumothorax are risks associated with major abdominal surgery. The nurse should immediately provide oxygen while performing further assessment. A rapid respiratory rate should not be treated as hyperventilation. Option B should not be administered until more ominous causes are ruled out or treated. There is no evidence that the client is hypoglycemic.

One day after a Billroth II surgery, the client suddenly grabs his right chest and becomes pale and diaphoretic. Vital signs are assessed as blood pressure 100/80 mm Hg, pulse 110 beats/min, and respirations 36 breaths/min. Which action is most important for the nurse to take? A. Provide a paper bag for his hyperventilation. B. Administer a prescribed PRN analgesic. C. Have the client drink a glass of sweetened fruit juice. D. Apply oxygen at 2 L via nasal cannula.

A, C, E The left leg needs to be elevated above the level of the heart, not the right leg. Massaging the area of tenderness could dislodge the clot and cause a pulmonary embolism. Avoid the use of the knee gatch or a pillow under the knee as that could cause stasis in the lower leg. The remaining are recommendations for the client with a deep vein thrombosis.

The client is admitted to an inpatient unit from the Emergency Department with a swollen, reddened area to the left calf which is warm and painful to the touch. The results of the remaining tests are pending. What admission prescriptions does the nurse anticipate from the healthcare provider? (Select all that apply.) A. Bed rest B. Elevate the right leg. C. Anticoagulant therapy D. Massage the area of calf tenderness tid. E. Warm moist compress to the area of calf tenderness tid F. Place a pillow under the left knee.

A The waist is the anchor point for the bandage for an above the knee amputation.

The client is return demonstrating wrapping of the left limb amputated above the knee. The nurse evaluates the client is starting the wrapping method correctly when the client places the end of the bandage at which point? A. Around the waist B. At the inner aspect of the left stump C. At the outer aspect of the left stump D. At the left groin area

C Hypokalemia can precipitate digitalis toxicity in persons receiving digoxin which will increase the chance of dangerous dysrhythmias (normal potassium level is 3.5 to 5.5 mEq/L).

The client is taking digoxin for congestive heart failure. The nurse would be correct in withholding a dose of digoxin based on which assessment? A. serum digoxin level is 1.5. B. blood pressure is 104/68. C. serum potassium level is 3. D. apical pulse is 68/min.

B By circling the existing stain upon admission to the unit, the nurse can then assess any increase, though subtle, in the amount of drainage over time. The size of the stain will need to be noted in the chart, but it is not the first action. The nurse removes the dressing under the prescription of the health care provider or in an emergency. Neither of those conditions exist in the question. The dressing in place is an absorbent dressing. There is no need for a further dressing until the existing dressing becomes saturated.

The client returns to the unit after abdominal surgery with a 5″ × 9″ absorbent dressing in place to the mid abdomen. The nurse notes a spot of red staining centrally on the dressing. What is the nurse's next action? A. Note the size of the stain in the chart. B. Circle the stain with an ink pen. C. Remove the dressing to assess the source of the bleeding. D. Place a pressure dressing on the existing dressing.

B The iodine dye from the catheterization and metformin can cause the client to develop lactic acidosis. Metformin is held 24 hours before the procedure and up to 48 hours after the procedure. There are no risks for those who have glaucoma. Having an advance directive in place is the standard of care. History of heart disease helps establish risk factors. Since the client is preparing for a heart catheterization, the client has the disease.

The clinic nurse is preparing to teach a client about having a cardiac catheterization. What assessment must the nurse include in the teaching plan? A. "Do you have glaucoma?" B. "Do you take any medication for Type II diabetes?" C. "Is your advance directive in order?" D. "Do any of your family members have heart disease?"

B, C, D The client must keep the ear bandage clean and dry until the packing is removed. Showering and hair washing is discouraged. As with all prescriptions for antibiotics, the client must take the full course of treatment. The remaining client statements do indicate effective teaching.

The clinic nurse is providing post-operative teaching for a client scheduled for a myringoplasty. Which client statements indicate to the nurse that the teaching has been effective? (Select all that apply.) A. "I can wash my hair in the shower when I get home." B. "I will avoid forceful and deep coughing until my post-op checkup." C. "I must lay flat on my non-operative side for the first 12 hours after surgery." D. "My hearing may be less or muffled until the packing comes out." E. "I need to only take the first two doses of antibiotics and save the rest for another time."

A, B, E, F The maximum daily dose of acetaminophen is 4 g, the instruction includes up to 6 g/per day. The best type of exercise does not place additional stress on the knee joints, such as biking or swimming. Apply heat to increase circulation and ice packs to decrease swelling. Support to the knees can take the strain off of the joint. Getting rest will help with coping with the pain of the disease. Eating a balanced diet may help with weight loss; additional weight places strain on the joint.

The clinic nurse is teaching a client with osteoarthritis to the knees bilaterally about self-care. Which teaching points will the nurse include in the client's plan of care? (Select all that apply.) A. Apply heat packs to your knees as needed for pain. B. Support your knees while you are in bed with a pillow or a rolled towel. C. Take 1000 mg of acetaminophen every 4 hours, as needed for pain. D. Walk no less than 3 miles every day. E. Get 7 to 8 hours of sleep every night. F. Eat a balanced diet, including fish with Omega-3 fatty acids.

D Magnesium agents are not usually used for clients with CKD due to the risk of hypermagnesemia, so this prescription should be questioned by the nurse.

The healthcare provider prescribes aluminum and magnesium hydroxide, 1 tablet PO PRN, for a client with chronic kidney disease (CKD) who is complaining of indigestion. Which intervention should the nurse implement? A. Administer 30 minutes before eating. B. Evaluate the effectiveness 1 hour after administration. C. Instruct the client to swallow the tablet whole. D. Question the healthcare provider's prescription.

C A masklike expression and infrequent blinking are common clinical features of parkinsonism. The nurse should document these expected findings. Options A and D are not necessary. Signs of toxicity of levodopa-carbidopa include dyskinesia, hallucinations, and psychosis.

The home health nurse is assessing a male client being treated for Parkinson disease with carbidopa-levodopa. The nurse observes that he does not demonstrate any apparent emotion when speaking and rarely blinks. Which action should the nurse take first? A. Perform a complete cranial nerve assessment. B. Instruct the client that he may be experiencing medication toxicity. C. Document the presence of these assessment findings. D. Advise the client to seek immediate medical evaluation.

D A U wave is a positive deflection following the T wave and is often present with hypokalemia (low potassium level). Options A, B, and C are all signs of hyperkalemia.

The nurse assesses a client who has been prescribed furosemide for cardiac disease. Which electrocardiographic change would be a concern for a client taking a diuretic? A. Tall, spiked T waves B. A prolonged QT interval C. A widening QRS complex D. Presence of a U wave

D A daily record in handwriting may provide evidence of progression of hepatic encephalopathy leading to coma.

The nurse assesses a client with advanced cirrhosis of the liver for signs of hepatic encephalopathy. Which finding would the nurse consider an indication of progressive hepatic encephalopathy? A. An increase in abdominal girth. B. Hypertension and a bounding pulse. C. Decreased bowel sounds. D. Difficulty in handwriting.

B The client is at risk for hypovolemic shock because of the postoperative status and is exhibiting early signs of shock. A priority intervention is the initiation of IV fluids to restore tissue perfusion. Options A, C, and D are all important interventions but are of lower priority than option B.

The nurse assesses a postoperative client whose skin is cool, pale, and moist. The client is very restless and has scant urine output. Oxygen is being administered at 2 L/min, and a saline lock is in place. Which action should the nurse take first? A. Measure the urine specific gravity. B. Obtain IV fluids for infusion per protocol. C. Prepare for insertion of a central venous catheter. D. Auscultate the client's breath sounds.

A Bladder control is a common problem for clients diagnosed with multiple sclerosis. A client with urinary retention should receive instructions about self-catheterization to prevent bladder distention.

The nurse formulates the nursing problem of urinary retention related to sensorimotor deficit for a client with multiple sclerosis. Which nursing intervention should the nurse implement? A. Teach the client techniques of intermittent self-catheterization. B. Decrease fluid intake to prevent over distention of the bladder. C. Use incontinence briefs to maintain hygiene with urinary dribbling. D. Explain that anticholinergic drugs will decrease muscle spasticity.

A, B, E, F The suction catheter does need to be lubricated, but with a water-based product, not a petroleum-based product. The suction catheter needs to be inserted with the suction off, not on. Suction should be applied intermittently while withdrawing the catheter. The remainder are steps in the suction process.

The nurse hears the presence of secretions in the lungs and determines the client, post thoracotomy, needs to be suctioned. What steps will the nurse include in the suctioning procedure? (Select all that apply.) A. Perform hand hygiene. B. Position in no less than a semi-Fowler's position. C. Lubricate the suction catheter with a petroleum-based product. D. Insert the catheter with the suction on. E. Listen for breath sounds. F. Hyperoxygenate the client.

B, C, E The client should be at least sitting at a 45 degree angle to avoid aspiration and increased intracranial pressure. Provide frequent mouth care as the client is unable to do so at this time. The remaining actions are appropriate for the client with a GCS score of 5.

The nurse in the emergency room assesses a client with a head trauma and notes a Glasgow Coma Scale (GCS) score of 5. What actions will the nurse take to ensure the client's safety? (Select all that apply.) A. Place the client in the supine position. B. Assess airway and suction secretions as needed. C. Change the client's position every 2 hours. D. Avoid mouth care, to avoid stimulating a seizure. E. Monitor for drainage from the ears.

A A decrease or change in the level of consciousness is usually the first indication of neurologic deterioration. Options B and C may also occur but are much less likely to be the first sign of neurologic compromise. Option D is often a sign of meningitis.

The nurse initiates neurologic checks for a client who is at risk for neurologic compromise. Which manifestation typically provides the first indication of altered neurologic function? A. Change in level of consciousness B. Increasing muscular weakness C. Changes in pupil size bilaterally D. Progressive nuchal rigidity

A Nystatin suspension is prescribed for fungal infections of the mouth. The client should swish the medication in the mouth for 2 minutes and then swallow. Option B does not affect administration of this medication. The medication should not be diluted because this will reduce its effectiveness. Option D is not necessary.

The nurse is administering a nystatin suspension for stomatitis. Which instruction will the nurse provide to the client when administering this medication? A. "Hold the medication in your mouth for a few minutes before swallowing it." B. "Do not drink or eat milk products for 1 hour prior to taking this medication." C. "Dilute the medication with juice to reduce the unpleasant taste and odor." D. "Take the medication before meals to promote increased absorption."

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

The nurse is assessing a 75-year-old client for symptoms of hyperglycemia. Which symptom of hyperglycemia is an older adult most likely to exhibit? A. Polyuria B. Polydipsia C. Weight loss D. Infection

B Parkinson's Disease is one of the most common neurologic progressive disorders of the older client. Shuffling gait, masklike facial expression, and tremors of the head and hands are common clinical features of Parkinsonism.

The nurse is assessing a client who has a history of Parkinson's disease for the past 5 years. Which symptoms would this client most likely exhibit? A. Loss of short-term memory, facial tics and grimaces, and constant writhing movements. B. Shuffling gait, masklike facial expression, and tremors of the head. C. Extreme muscular weakness, easy fatigability, and ptosis. D. Numbness of the extremities, loss of balance, and visual disturbances.

D Obstructive cholelithiasis and alcoholism are the two major causes of pancreatitis, and elevated serum amylase and lipase levels indicate pancreatic injury. Option A is a normal finding. Options B and C are expected findings related to jaundice.

The nurse is assessing a client who presents with jaundice. Which assessment finding is most important for the nurse to follow up? A. Urine specific gravity of 1.03 B. Frothy, tea-colored urine C. Clay-colored stools D. Elevated serum amylase and lipase levels

A The differentiation between the "pink puffer" and the "blue bloater" is a well-known method of differentiating clients exhibiting symptoms of emphysema (normal color but puffing respirations) from those exhibiting symptoms of chronic bronchitis (edematous, cyanotic, shallow respirations).

The nurse is assessing a client who smokes cigarettes and has been diagnosed with emphysema. Which finding would the nurse expect this client to exhibit? A. A decreased total lung capacity. B. Normal arterial blood gases. C. Normal skin coloring. D. An absence of sputum.

B A positive Trousseau sign indicates hypocalcemia and always requires further assessment and intervention, regardless of the cause (40% to 75% of those with acute pancreatitis experience hypocalcemia, which can have serious, systemic effects). A key diagnostic finding of pancreatitis is serum amylase and lipase levels that are two to five times higher than the normal value. Severe boring pain is an expected symptom for this diagnosis, but dealing with the hypocalcemia is a priority over administering an analgesic. Long-term planning and teaching do not have the same immediate importance as a positive Trousseau sign.

The nurse is assessing a client with acute pancreatitis. Which finding requires the most immediate intervention by the nurse? A. The client's amylase level is three times higher than the normal level. B. The client has a carpal spasm when taking a blood pressure. C. On a 1 to 10 scale, the client tells the nurse that her epigastric pain is at 7. D. The client states that she will continue to drink alcohol after going home.

A Septic emboli secondary to meningitis commonly lodge in the small arterioles of the extremities, causing a decrease in circulation to the hands which may lead to gangrene.

The nurse is assessing a client with bacterial meningitis. Which assessment finding indicates the client may have developed septic emboli? A. Cyanosis of the fingertips. B. Bradycardia and bradypnea. C. Presence of S3 and S4 heart sounds. D. 3+ pitting edema of the lower extremities.

A When assessing a client with chronic kidney disease (CKD), hyperkalemia (normal serum level, 3.5 to 5.5 mEq) is a serious electrolyte disorder that can cause fatal arrhythmias, so the elevation of the potassium level is a nursing priority.

The nurse is assessing a client with chronic kidney disease (CKD). Which finding is most important for the nurse to respond to first? A. Potassium 6.0 mEq. B. Daily urine output of 400 ml. C. Peripheral neuropathy. D. Uremic fetor

B Tumor lysis symdrome (TLS) results in hyperkalemia, hypocalcemia, hyperuricemia, and hyperphosphatemia. A serum calcium level of 5, which is low, is an indicator of possible tumor lysis syndrome.

The nurse is assessing a client's laboratory values following administration of chemotherapy. Which lab value leads the nurse to suspect that the client is experiencing tumor lysis syndrome (TLS)? A. Serum PTT of 10 seconds. B. Serum calcium of 5 mg/dL. C. Oxygen saturation of 90%. D. Hemoglobin of 10 g/dL.

D The first step in assisting a client out of bed for the first time after surgery is to raise the head of the bed to a high Fowler's position, which allows venous return to compensate from lying flat and the vasodilation effects of perioperative drugs. This helps prevent the client from becoming light-headed and decreases the chance of a client fall.

The nurse is assisting a client out of bed for the first time after surgery. Which action should the nurse do first? A. Place a chair at a right angle to the bedside. B. Encourage deep breathing prior to standing. C. Help the client to sit and dangle legs on the side of the bed. D. Allow the client to sit with the bed in a high Fowler's position.

A Clients with primary aldosteronism exhibit an increase in serum sodium levels (hypernatremia) and have profound decline in the serum levels of potassium (hypokalemia)--hypertension is the most prominent and universal sign. Antidiuretic hormone is decreased with diabetes insipidus. Glucose is not affected by primary aldosteronism.

The nurse is caring for a client who has been diagnosed with primary hyperaldosteronism. Which laboratory test result should the nurse expect an increase in the serum level? A. Sodium B. Antidiuretic hormone C. Potassium D. Glucose

B Increasing the oxygen flow rate provides more oxygen to the client's myocardium and may decrease myocardial irritability as manifested by the frequent PVCs. Option A can be delegated and is a lower priority action than option B. Defibrillation may eventually be necessary, but option C is not the immediate treatment for frequent PVCs. Option D may become necessary if the client stops breathing but is not indicated at this time.

The nurse is caring for a client who is one day post-acute myocardial infarction. The client is receiving oxygen at 2 L/min via nasal cannula and has a peripheral saline lock. The nurse notes that the client is having eight premature ventricular contractions (PVCs) per minute. Which action should the nurse take first? A. Obtain an IV pump for antiarrhythmic infusion. B. Increase the client's oxygen flow rate. C. Prepare for immediate countershock. D. Gather equipment for endotracheal intubation.

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

The nurse is caring for a client with a chest tube to water seal drainage that was inserted 10 days ago because of a ruptured bullae and pneumothorax. Which finding should the nurse report to the health care provider before the chest tube is removed? A. Tidaling of water in water seal chamber B. Bilateral muffled breath sounds at bases C. Temperature of 101°F D. Absence of chest tube drainage for 2 days

B Percutaneous endoscopic gastrostomy (PEG) tube placement and residual volume should be checked every four hours for clients on continuous feeding. If the gastric residual is more than 200mL for an adult client; stop the feeding and re-check the gastric residual one hour later. If the residual still remains more than 200mL; continue to keep the feeding on hold and contact the client's health care provider.

The nurse is caring for a client with a continuous feeding through a percutaneous endoscopic gastrostomy (PEG) tube. Which intervention should the nurse include in the plan of care? A. Flush the tube with 50 ml of water q 8 hours. B. Check for tube placement and residual volume q4 hours C. Obtain a daily x- ray to verify tube placement. D. Position on left side with head of bed elevated 45 degrees.

B Compartment syndrome is a condition involving increased pressure and constriction of the nerves and vessels within an anatomic compartment, causing pain uncontrolled by opioids and neurovascular compromise. Option A is an expected finding. Option C related to compartment syndrome cannot be seen, and any visible edema is an expected finding related to the injury. Option D is an expected finding.

The nurse is caring for a client with a fractured right elbow. Which assessment finding has the highest priority and requires immediate intervention? A. Ecchymosis over the right elbow area B. Deep unrelenting pain in the right arm C. An edematous right elbow D. The presence of crepitus in the right elbow

B A stroke affects the whole family and in this case the spouse probably thinks that she is helping and needs to feel that she is contributing to the client's care. Her help is noted as being incongruent with attempts of self-care by the client thereby disabling family coping.

The nurse is caring for a client with a stroke resulting in right-sided paresis and aphasia. The client attempts to use the left hand for feeding and other self-care activities. The spouse becomes frustrated and insists on doing everything for the client. Based on this data, which nursing problem should the nurse document for this client? A. Situational low self-esteem related to functional impairment and change in role function. B. Disabled family coping related to dissonant coping style of significant person. C. Interrupted family processes related to shift in health status of family member. D. Risk for ineffective therapeutic regimen management related to complexity of care.

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

The nurse is caring for a critically ill client with cirrhosis of the liver who has a nasogastric tube draining bright red blood. The nurse notes that the client's serum hemoglobin and hematocrit levels are decreased. Which additional change in laboratory data should the nurse expect? A. Increased serum albumin level B. Decreased serum creatinine C. Decreased serum ammonia level D. Increased liver function test results

C Clients with Parkinson's disease frequently experience difficulty in initiating, maintaining, and performing motor activities. They may even experience being rooted to a spot and unable to move, referrerd to as being "frozen" in one spot.

The nurse is completing an admission interview and assessment on a client with a history of Parkinson's disease. Which question provides information relevant to the client's plan of care? A. "Have you ever experienced any paralysis of your arms or legs?" B. "Have you ever sustained a severe head injury?" C. "Have you ever been 'frozen' in one spot, unable to move?" D. "Do you have headaches, especially ones with throbbing pain?"

A, B, C One hour post op is too soon to ambulate for this client. Visitors help support the patient and are encouraged to visit. Oral care is necessary as the client will be NPO. To decrease the risk of infection post operatively, implement routine pulmonary exercises. The client will have an NG tube in place, likely to intermittent suction, to decompress the stomach post surgery.

The nurse is concerned about infection for a client after an esophagogastrostomy for esophageal cancer. Which actions should the nurse include in the client's plan of care? (Select all that apply.) A. Frequent oral care every 2 hours while awake. B. Use incentive spirometer every 2 hours. C. Empty contents from NG tube every 8 hours. D. Ambulate within 1 hour of return from the PACU. E. Limit visitors until postoperative day 2.

A, C, D Options A, C, and D are factors that decrease the risk for developing osteoporosis. Vitamin D and calcium are important supplements to aid in the decrease of bone loss. Regular sleep patterns are important to overall health but are not identified with a decreasing risk for osteoporosis.

The nurse is conducting an osteoporosis screening clinic at a health fair. What information should the nurse provide to individuals who are at risk for osteoporosis? (Select all that apply.) A. Encourage alcohol and smoking cessation. B. Suggest supplementing diet with vitamin E. C. Promote regular weight-bearing exercises. D. Implement a home safety plan to prevent falls. E. Propose a regular sleep pattern of 8 hours nightly.

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

The nurse is counseling a healthy 30-year-old female client regarding osteoporosis prevention. Which activity would be most beneficial in achieving the client's goal of osteoporosis prevention? A. Cross-country skiing B. Scuba diving C. Horseback riding D. Kayaking

C Peak drug serum levels are achieved 30 minutes after the completion of the IV infusion of gentamicin sulfate. The best time to draw a trough is the closest time to the next prior administration.

The nurse is initiating the client's fourth dose of gentamycin sulfate IV. The health care provider (HCP) has prescribed peak and trough levels. Which is the most important action for the nurse to implement next? A. Draw the peak 15 minutes before and the trough 15 minutes after the next dose. B. Draw the peak one hour before and one hour after the next dose. C. Draw the trough 5 minutes before and the peak 30 minutes after the next dose. D. Draw the trough 30 minutes before and 30 minutes after the next dose.

A According to the National Stroke Association (2013), history of diabetes mellitus poses the greatest risk for developing a CVA, 2-4Xs more than those who do not have diabetes mellitus. The reason for this occurrence is related to the excess glucose circulating throughout the body not being utilized by the cells, leading to increased fatty deposits or clots inside the blood vessels in the brain or neck, eventually causing a stroke.

The nurse is interviewing a male client with hypertension. Which additional medical diagnosis in the client's history presents the greatest risk for developing a cerebral vascular accident (CVA)? A. Diabetes mellitus. B. Hypothyroidism. C. Parkinson's disease. D. Recurring pneumonia.

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

The nurse is observing an unlicensed assistive personnel (UAP) performing care for a bedridden client with advanced Huntington disease. Which care measures are most important for the nurse to supervise? (Select all that apply.) A. Oral care B. Bathing C. Foot care D. Catheter care E. Enteral feeding

A The nurse must document any pressure wounds upon admission to establish the client's baseline and for insurance purposes. Insurance will not reimburse from hospital-acquired pressure ulcers. Massaging is not recommended as it may dislodge the existing tissue. A call is not a good use of the nurse's time as the pressure ulcers exist upon transfer, and the baseline is determined upon admission. The health care provider will order cultures, if needed.

The nurse is performing a skin assessment on a client who is transferred from a long-term care facility to an in-patient hospital unit. The client is unable to move independently while in bed. The nurse observes reddened areas to the sacrum and on the heals bilaterally. What is the next nursing action? A. Document the size and shape of the reddened areas. B. Massage the reddened areas with a hospital-approved lotion. C. Call the nurse from the transferring facility to determine the client's baseline. D. Culture the wounds.

C Examination of the blood vessels of the retina reveal any damage to the retinal vessels. This is a significant indication about how much damage the client's high blood pressure has done to vessels throughout the body. Retinal damage indicates that hypertension is moderate to severe.

The nurse is performing an ophthalmoscopic examination on a hypertensive client. When assessing the client, which finding indicates the severity of hypertension? A. Opague color of the sclera. B. Transparency of the cornea. C. Amount of retinal vessel damage that has occurred. D. Constriction and dilatation of the pupils.

A Any change in pupil size and reactivity is an indication of increasing intracranial pressure and should be reported to the health care provider immediately. Option B is a normal response to being awakened. Options C and D are common manifestations of head injury and are of less immediacy than option A.

The nurse is performing hourly neurologic checks for a client with a head injury. Which new assessment finding warrants immediate action by the nurse? A. A unilateral pupil that is dilated and nonreactive to light B. Client cries out when awakened by a verbal stimulus. C. Client demonstrates a loss of memory of the events leading up to the injury. D. Onset of nausea, headache, and vertigo

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

The nurse is planning care for a client with diabetes mellitus who has gangrene of the toes to the midfoot. Which goal should be included in this client's plan of care? A. Restore skin integrity. B. Prevent infection. C. Promote healing. D. Improve nutrition.

C If a client is incapable or does not want to learn, it is unlikely that learning will occur, so motivation is the first factor the nurse should assess before teaching.

The nurse is planning care for a client with newly diagnosed diabetes mellitus that requires insulin. Which assessment should the nurse identify before beginning the teaching session? A. Present knowledge related to the skill of injection. B. Intelligence and developmental level of the client. C. Willingness of the client to learn the injection sites. D. Financial resources available for the equipment.

C Multiple myeloma is a malignancy of plasma cells that infiltrate bone causing demineralization and hypercalcemia, so maintaining a urinary output of 1.5 to 2 L per day requires an intake of 3 to 4 L to promote excretion of serum calcium.

The nurse is planning care to prevent complications for a client with multiple myeloma. Which intervention is most important for the nurse to include? A. Safety precautions during activity. B. Assess for changes in size of lymph nodes. C. Maintain a fluid intake of 3 to 4 L per day. D. Administer narcotic analgesic around the clock.

D An older person's level of activity is a determining factor in adjustment to aging as described by the Activity Theory of Aging. The most useful information initially would be an assessment of each individual's adjustment to the aging process.

The nurse is planning to initiate a socialization group for older residents of a long-term facility. Which information would be most useful to the nurse when planning activities for the group? A. The length of time each group member has resided at the nursing home. B. A brief description of each resident's family life. C. The age of each group member. D. The usual activity patterns of each member of the group.

A Sweating, dizziness, and trembling are signs of hypoglycemic reactions related to the release of epinephrine as a compensatory response to the low blood sugar.

The nurse is preparing a teaching plan for a client who is newly diagnosed with Type 1 diabetes mellitus. Which clinical cues should the nurse describe when teaching the client about hypoglycemia? A. Sweating, trembling, tachycardia. B. Polyuria, polydipsia, polyphagia. C. Nausea, vomiting, anorexia. D. Fruity breath, tachypnea, chest pain.

A, C, D, E The current recommendation is those who are allergic to eggs can receive the flu vaccine if it is administered in a healthcare environment that can quickly deliver treatment for anaphylaxis. Infants over 6 months van receive the flu shot, but not under 6 months. The remaining options are recommended to receive the flu vaccine.

The nurse is preparing teaching for nursing students who are participating in a flu vaccine clinic at a local school. Who should receive the vaccine? (Select all that apply.) A. Health care personnel B. Those who are allergic to eggs C. Individuals who are over 50 years old D. Individuals with chronic health conditions E. Those who live in nursing homes F. Infants under 6 months of age

A, B Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock, in the area innervated by one or more branches of the trigeminal nerve (cranial V). The remaining symptoms are not related to trigeminal neuralgia.

The nurse is providing care for a client diagnosed with trigeminal neuralgia (tic douloureux). Which symptoms will the nurse be looking for in the focused assessment related to this condition? (Select all that apply.) A. Facial muscle spasms B. Sudden facial pain C. Unilateral facial weakness D. Difficulty in chewing E. Tinnitus F. Hearing difficulties

C, D, E, F Oral carbohydrates, such as sugar and honey, should never be given to the semiconscious or unconscious clients with low blood sugar levels, for concern for aspiration. Glucagon can be administered immediately, followed by starting an IV. Await the orders for the 50% dextrose solution. Place the client in a side lying position as there is a risk for vomiting and aspiration with these clients.

The nurse is providing care to a client admitted to the emergency room with a blood glucose level of 40 mg/dL and is semiconscious. What are the nurse's next actions? (Select all that apply.) A. Place 4 sugar cubes under the tongue. B. Place 1 tablespoon of honey in the client's cheek. C. Start an IV of Normal Saline. D. Obtain a 50% dextrose solution. E. Administer glucagon as per the standing order. F. Turn the client to the side.

B, C, E Theophylline toxicity occurs when the blood level exceeds 20 mcg/mL. Signs of toxicity include restlessness, nervousness, tremors, palpitations, and tachycardia. A low pulse rate and blue nail beds are not associated with theophylline toxicity.

The nurse is providing care to a client admitted with asthma whose theophylline level is 25 mcg/mL. What findings will the nurse be looking for in the client's assessment? (Select all that apply.) A. Pulse of 54 bpm B. Restlessness C. Tremors D. Blue nail beds E. Palpitations

A, B, D, F The client's incisional leg needs to stay straight for 6 to 8 hours to decrease the risk of hemorrhage from the incision site. Pulses must be assessed bilaterally for a point of comparison. The remaining actions are included in the care plan for the client after a PTCA.

The nurse is providing care to a client after a percutaneous transluminal coronary angioplasty (PTCA). What actions will the nurse include in the client's plan of care? (Select all that apply.) A. Frequent vital signs. B. Determine if the client is allergic to aspirin. C. Assist out of bed 2 hours after return from the procedure. D. Offer fluids of choice. E. Assess distal pulses on the side of the procedure. F. Monitor infusion of IV nitroglycerine.

A, C, D, E The amount of normal saline flush solution is incorrect. Two milliliters is too small an amount. The minimum amount is 5 mL, or according to the policies of the institution. The remaining steps are correct.

The nurse is providing care to a client with a central venous catheter. The health care provider orders multiple labs. Using the discard method, what steps will the nurse use to draw the blood samples? (Select all that apply.) A. Prepare the catheter hub with an antiseptic solution according to facility protocol. B. Attach a syringe to the hub containing 2 mL of normal saline and flush the line. C. Attach the vacutainer sleeve or 20 mL syringe to the catheter hub. D. Withdraw waste blood and discard it in an appropriate container. E. Draw the amount of blood needed for the laboratory samples. F. Flush the line with no more than 2 mL of normal saline to flush the line.

B To reduce risk factors associated with coronary heart disease, the daily intake of soluble fiber should be increased to between 10 and 25 grams per day. According to the American Heart Association, soluble fibers helps reduce LDL cholesterol levels.

The nurse is providing dietary instructions to a 68-year-old client who is at high risk for development of coronary heart disease (CHD). Which information should the nurse include? A. Limit dietary selection of cholesterol to 300 mg per day. B. Increase intake of soluble fiber to 10 to 25 grams per day. C. Decrease plant stanols and sterols to less than 2 grams/day. D. Ensure saturated fat is less than 30% of total caloric intake.

D Penrose drains provide a sinus tract or opening and are often used to provide drainage of an abscess. The fact that the client has a penrose drain should alert the nurse to the possibility that the client is infected. To avoid contamination of another postoperative client, it is most for the nurse to verify the condition of the wound and if infected, important to place client in a private room.

The nurse is receiving report from surgery about a client with a penrose drain who is to be admitted to the postoperative unit. Before choosing a room for this client, which information is most important for the nurse to obtain? A. If suctioning will be needed for drainage of the wound. B. If the family would prefer a private or semi-private room. C. Prescription for removal of the drain. D. If the client's wound is infected.

B Clients with angle-closure glaucoma should not take medications that dilate the pupil because this can precipitate acute and severely increased intraocular pressure. Options A, C, and D do not cause increased intracranial pressure, which is the primary concern with angle-closure glaucoma.

The nurse is reviewing routine medications taken by a client with chronic angle-closure glaucoma. Which medication prescription should the nurse question? A. Antianginal with a therapeutic effect of vasodilation B. Anticholinergic with a side effect of pupillary dilation C. Antihistamine with a side effect of sedation D. Corticosteroid with a side effect of hyperglycemia

B An allergy to sulfa drugs may make the client unable to use some of the most common antihyperglycemic agents (sulfonylureas). The nurse needs to highlight this allergy for the healthcare provider.

The nurse is taking a history of a newly diagnosed Type 2 diabetic who is beginning treatment. Which subjective information is most important for the nurse to note? A. A history of obesity. B. An allergy to sulfa drugs. C. Cessation of smoking three years ago. D. Numbness in the soles of the feet.

A Ovulation typically occurs 14 days before menstruation begins during a typical 28 day cycle. Sexual intercourse should occur within 24 hours of ovulation for an increased chance of conception to occur. High estrogen levels occur during ovulation and increase the vaginal mucous membrane characteristics to become more "slippery" and stretchy, along with a rise in basal temperature. The timing during the day is not as significant in determining conception as the day before and after ovulation.

The nurse is teaching a female client about the best time to plan sexual intercourse in order to conceive. Which information should the nurse provide? A. Two weeks before menstruation. B. Vaginal mucous discharge is thick. C. Low basal temperature. D. First thing in the morning.

D, E The diaphragm needs to remain against the cervix for 6 to 8 hours to prevent pregnancy but should not remain for longer than 8 hours to avoid the risk of toxic shock syndrome. The diaphragm should be replaced every 3 months to maintain integrity.

The nurse is teaching a female client who uses a contraceptive diaphragm about reducing the risk for toxic shock syndrome (TSS). Which information should the nurse include? (Select all that apply.) A. Remove the diaphragm immediately after intercourse. B. Wash the diaphragm with an alcohol solution. C. Use the diaphragm to prevent conception during the menstrual cycle. D. Do not leave the diaphragm in place longer than 8 hours after intercourse. E. Replace the old diaphragm every 3 months.

C Achieving a healthy weight is critical to protect the joints of clients with osteoarthritis (OA). Weight loss for obese clients will take off the excess pressure that weight bearing joints such as the hips and knees are exposed to and reduce the wear and tear of the joints.

The nurse is working with a 71-year-old obese client with bilateral osteoarthritis (OA) of the hips. Which recommendation should the nurse make that is most beneficial in protecting the client's joints? A. Increase the amount of calcium intake in the diet. B. Apply alternating heat and cold therapies. C. Initiate a weight-reduction diet to achieve a healthy body weight. D. Use a walker for ambulation to lessen weight-bearing on the hips.

C As older adults age, the protein found in urine slightly rises as a result of kidney changes, and the serum glucose increases slightly, also due to changes in the kidney.

The nurse knows that lab values sometimes vary for the older client. Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old male? A. Increased WBC, decreased RBC. B. Increased serum bilirubin, slightly increased liver enzymes. C. Increased protein in the urine, slightly increased serum glucose levels. D. Decreased serum sodium, an increased urine specific gravity.

D The outflow should match the inflow. With repositioning fluid trapped within the peritoneum may be repositioned to the proximity of the abdominal catheter. While the vital signs and the weight may support the additional fluid, they do not address the cause of the reduced outflow. At this time, there is no medical emergency to notify the HCP.

The nurse notes for the client undergoing peritoneal dialysis during the outflow phase the draining dialysate suddenly stops. The outflow is one liter less than the inflow at this time. What is the next nursing action? A. Take the client's blood pressure. B. Take the client's weight. C. Call the health care provider (HCP). D. Have the client change positions.

B The blood urea nitrogen (BUN) level indicates the effectiveness of the kidneys in filtering waste from the blood. Dehydration, which could be caused by vomiting, would cause an increased BUN level. Option A would affect serum enzyme levels, not the BUN level. Option C would primarily affect the blood glucose level; renal failure that could increase the BUN level would be unlikely in a client newly diagnosed with type 2 diabetes. Effects of option D might affect the complete blood count (CBC) but would not directly increase the BUN level.

The nurse notes that a client who is scheduled for surgery the next morning has an elevated blood urea nitrogen (BUN) level. Which condition is most likely to have contributed to this finding? A. Myocardial infarction 2 months ago B. Anorexia and vomiting for the past 2 days C. Recently diagnosed type 2 diabetes mellitus D. Skeletal traction for a right hip fracture

D The least invasive nursing action should be performed first to determine why the drainage has diminished. Option A is completed after assessing for any problems causing the decrease in drainage. Option B is no longer considered standard protocol because the increase in pressure may be harmful to the client. Option C is an appropriate nursing action after the tube has been assessed for kinks or dependent loops.

The nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12 hours after chest tube insertion for hemothorax. What is the best initial action for the nurse to take? A. Document this expected decrease in drainage. B. Clamp the chest tube while assessing for air leaks. C. Milk the tube to remove any excessive blood clot buildup. D. Assess for kinks or dependent loops in the tubing.

B According to the hospital policy, clients over the age of 50 and/or with a history of cardiovascular disease, should receive ECG evaluation prior to surgery, generally 24 hours to two weeks before. The nurse needs to first arrange for an ECG to be performed immediately prior to surgery.

The nurse notes that the only ECG for a 55-year-old male client scheduled for surgery in two hours is dated two years ago. The client reports that he has a history of "heart trouble," but has no problems at present. Hospital protocol requires that those over 50 years of age have a recent ECG prior to surgery. Which nursing action is best for the nurse to implement? A. Ask the client what he means by "heart trouble." B. Call for an ECG to be performed immediately. C. Notify surgery that the ECG is over two years old. D. Notify the client's surgeon immediately.

D Besides supplemental oxygen, a client with acute respiratory distress syndrome (ARDS) needs medications to widen air passages, increase air space, and reduce alveolar membrane inflammation, such as bronchodilators and steroids.

What types of medications should the nurse expect to administer to a client during an acute respiratory distress episode? A. Vasodilators and hormones. B. Analgesics and sedatives. C. Anticoagulants and expectorants. D. Bronchodilators and steroids.

D Only regular insulin is administered by the IV route, so the TPN solution containing NPH insulin should be returned to the pharmacy. Options A, B, and C are not indicated because the solution should not be administered.

The nurse receives the client's next scheduled bag of TPN labeled with the additive NPH insulin. Which action should the nurse implement? A. Hang the solution at the current rate. B. Refrigerate the solution until needed. C. Prepare the solution with new tubing. D. Return the solution to the pharmacy.

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

The nurse teaches a client with type 2 diabetes nutritional strategies to decrease obesity. Which food items chosen by the client indicate understanding of the teaching? (Select all that apply.) A. White bread B. Salmon C. Broccoli D. Whole milk E. Banana

A A radical mastectomy interrupts lymph flow, and the increased lymph flow that occurs in response to the insect bite increases the risk for the occurrence of lymphedema.

The nurse working in a postoperative surgical clinic is assessing a woman who had a left radical mastectomy for breast cancer. Which factor puts this client at greatest risk for developing lymphedema? A. She sustained an insect bite to her left arm yesterday. B. She has lost twenty pounds since the surgery. C. Her healthcare provider now prescribes a calcium channel blocker for hypertension. D. Her hobby is playing classical music on the piano.

B A client with an automatic defibrillator who is experiencing pulseless ventricular tachycardia (VT) must be externally shocked with 200 joules per hospital policy to restore an effective cardiac rhythm. The automatic defibrillator is obviously malfunctioning.

The nurse working on a telemetry unit finds a client unconscious and in pulseless ventricular tachycardia (VT). The client has an implanted automatic defibrillator. Which action should the nurse implement? A. Prepare the client for transcutaneous pacemaker. B. Shock the client with 200 joules per hospital policy. C. Use a magnet to deactivate the implanted pacemaker. D. Observe the monitor until the onset of ventricular fibrillation.

D The purpose of the intermittent compression stockings is to decrease the risk of blood clots forming in the legs. By assessing the client's knowledge about the devise, the nurse can determine if the client is aware of the potential for blood clots and the sequela that clots have. By answering "They are for your own good," the nurse dismisses the client's concerns. Having no choice about treatment does not acknowledge client autonomy. The "Do you want that to happen to you" is a statement using coercion by fear.

The post-operative client states to the nurse, "I hate the feeling of those compression stockings as they inflate and deflate all the time. It keeps me awake." What is the nurse's best response? A. "They are for your own good." B. "Your health care provider ordered them. You have no choice but to wear them." C. "They are to help prevent blood clots. Do don't want that to happen, do you?" D. "Tell me what you know about the intermittent compression stockings."

A Normal ABG ranges are pH 7.35 to 7.45; pCO2 35 to 45 mmHg; HCO3 21 to 28 mEq/L, and pO2 80 to 100 mmHg. An ABG of pH 7.32, pCO2 46 mmHg, HCO3 24 MEq/L represents a client with respiratory acidosis which is characterized by: low pH, pCO2 higher than normal, and HCO3 within normal limits.

The registered nurse (RN) assesses arterial blood gas results of a client that has emphysema. Which finding is consistent with respiratory acidosis? A. pH 7.32, pCO 2 46 mmHg, HCO 3 24 MEq/L. B. pH 7.45 , pCO 2 37 mmHg, HCO 3 24 mEq/L. C. pH 7.34, pCO 2 36 mmHg, HCO 3 21 mEq/L. D. pH 7.46, pCO 2 35 mmHg, HCO 3 28 mEq/L.

B Self-awareness is the best way for a client to manage chronic hypertension, so the client should obtain a sphygmomanometer and learn how to monitor blood pressure daily and maintain a record.

The registered nurse (RN) is assessing a client who was discharged home after management of chronic hypertension. Which equipment should the RN instruct the client to use at home? A. Exercise bicycle. B. Sphygmomanometer. C. Blood glucose monitor. D. Weekly medication box.

D The RN should ask the client if he has a history of ulcerative colitis, which is characterized by severe abdominal cramping, pain, tenesmus, and dehydration.

The registered nurse (RN) is assessing a male client who arrives at the clinic with severe abdominal cramping, pain, tenesmus, and dehydration. The RN discovers that the client has had 14 to 20 loose stools with rectal bleeding. When taking the client's medical history, which information is most for the nurse to obtain? A. Irritable bowel syndrome. B. Diverticulitis. C. Crohn's disease. D. Ulcerative colitis.

A, B, C Shallow breaths do not promote adequate oxygenation. The client should splint the area and breathe as normally as possible to maintain adequate oxygenation. Shortness of breath should not occur with a rib fracture and is a sign of a pneumothorax. The client will not be sent home with O2 by nasal cannula if the only health issue is a fractured rib.

The x-ray for the client in the emergency department (ED) reveals a right-sided rib fracture. What information will the nurse include in the client's discharge instructions? (Select all that apply.) A. Splint your right side with your right arm. B. You may have to sleep sitting up for a while. C. Return to the ED if you develop difficulty in breathing. D. Use shallow breaths until the pain subsides. E. Use 2 L of oxygen by nasal cannula when you have shortness of breath.

C One of the early signs of hypovolemic shock is changes in the client's level of consciousness due to the decrease perfusion to the brain which can manifests as lethargy or confusion.

Twenty four hours after a client returns from surgical gastric bypass, the registered nurse (RN) observes large amounts of blood in the nasogastric tube (NGT) cannister. Which assessment finding should the RN report as early signs of hypovolemic shock? A. Faint pedal pulses. B. Decrease in blood pressure. C. Lethargy. D. Slow breathing.

D For a client exhibiting symptoms of deep vein thrombosis (DVT), a complication of immobility, the initial care includes bedrest and elevation of the extremity.

Two days postoperative, a male client reports aching pain in his left leg. The nurse assesses redness and warmth on the lower left calf. Which intervention would be most helpful to this client? A. Apply sequential compression devices (SCDs) bilaterally. B. Assess for a positive Homan's sign in each leg. C. Pad all bony prominences on the affected leg. D. Advise the client to remain in bed with the leg elevated.

D Fibrocystic changes in the breast are related to excess fibrous tissue, proliferation of mammary ducts and cyst formation that cause edema and nerve irritation. These changes obscure typical diagnostic tests, such as mammography, due to an increased breast density. Women with fibrocystic breasts should be instructed to carefully perform monthly BSE and consider changes in any previous "lumpiness." Fibrocystic disease does not increase the risk of breast cancer. Cyst size fluctuates with the menstrual cycle, and typically lessens after menopause, and responds with a heightened sensitivity to circulating estrogen.

What instruction should the nurse give a client who is diagnosed with fibrocystic changes of the breast? A. Observe cyst size fluctuations as a sign of malignancy. B. Use estrogen supplements to reduce breast discomfort. C. Notify the healthcare provider if whitish nipple discharge occurs. D. Perform a breast self-exam (BSE) procedure monthly.

C The correct placement of the hands for chest compressions in CPR is just above the notch where the ribs meet the sternum on the lower part of the sternum. Option A is too high. Option B would not compress the heart. Option D would likely cause damage to both structures, possibly causing a puncture of the heart, and would not render effective compressions.

What is the correct location for placement of the hands for manual chest compressions during cardiopulmonary resuscitation (CPR) on the adult client? A. Just above the xiphoid process, on the upper third of the sternum B. Below the xiphoid process, midway between the sternum and the umbilicus C. Just above the xiphoid process, on the lower third of the sternum D. Below the xiphoid process, midway between the sternum and the first rib

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

What is the most important nursing priority for a client who has been admitted for a possible kidney stone? A. Reducing dairy products in the diet B. Straining all urine C. Measuring intake and output D. Increasing fluid intake

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

When a nurse assesses a client receiving total parenteral nutrition (TPN), which laboratory value is most important for the nurse to monitor regularly? A. Albumin B. Calcium C. Glucose D. Alkaline phosphatase

B The most stable client is option B. Options A, C, and D are all at high risk for increased intracranial pressure and require the expertise of the RN for assessment and management of care.

When assigning clients on a medical-surgical floor to an RN and a PN, it is best for the charge nurse to assign which client to the PN? A. A young adult with bacterial meningitis with recent seizures B. An older adult client with pneumonia and viral meningitis C. A female client in isolation with meningococcal meningitis D. A male client 1 day postoperative after drainage of a brain abscess

C Neck breathers carry a medical alert card that notifies health care personnel of the need to use mouth to stoma breathing in the event of a cardiac arrest in this client. Mouth-to-mouth resuscitation will not establish a patent airway. Options A and D are not necessary. There are many alternative means of communication for clients who have had a laryngectomy; dependence on writing messages is probably the least effective.

When educating a client after a total laryngectomy, which instruction would be most important for the nurse to include in the discharge teaching? A. Recommend that the client carry suction equipment at all times. B. Instruct the client to carry writing materials at all times. C. Tell the client to carry a medical alert card that explains the condition. D. Caution the client not to travel outside the United States alone.

C It is imperative that total neck breathers carry a medic alert notice so, that if they have a cardiac arrest, mouth-to-neck breathing can be done.

When preparing a client who has had a total laryngectomy for discharge, which instruction is most important for the nurse to include in the discharge teaching? A. Recommend that the client carry suction equipment at all times. B. Instruct the client to have writing materials with him at all times. C. Tell the client to carry a medic alert card stating that he is a total neck breather. D. Tell the client not to travel alone.

D Discussion about fall prevention strategies is imperative for the discharged client with osteoporosis. Advice about safety measures in the home should be provided such as the elimination of throw rugs and proper lighting to minimize trip hazards and falls.

When providing discharge teaching for a client with osteoporosis, the nurse should reinforce which home care activity? A. A diet low in phosphates. B. Skin inspection for bruising. C. Exercise regimen, including swimming. D. Elimination of hazards to home safety.

A Diaphragmatic or abdominal breathing uses the diaphragm instead of accessory muscles to achieve maximum inhalation and to slow the respiratory rate. The client should protrude the abdomen on inhalation and contract it with exhalation, so placing a book or magazine, helps the client visualize the rise and fall of the abdomen.

When teaching diaphragmatic breathing to a client with chronic obstructive pulmonary disease (COPD), which information should the nurse provide? A. Place a small book or magazine on the abdomen and make it rise while inhaling deeply. B. Purse the lips while inhaling as deeply as possible and then exhale through the nose. C. Wrap a towel around the abdomen and push against the towel while forcefully exhaling. D. Place one hand on the chest, one hand the abdomen and make both hands move outward.

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

Which abnormal laboratory finding indicates that a client with diabetes needs further evaluation for diabetic nephropathy? A. Hypokalemia B. Microalbuminuria C. Elevated serum lipid levels D. Ketonuria

A A newly retracted nipple, compared to a life-long finding, may be an indication of breast cancer and requires additional follow-up.

Which assessment finding by the nurse during a client's clinical breast examination requires follow-up? A. Newly retracted nipple. B. A thickened area where the skin folds under the breast. C. Whitish nipple discharge. D. Tender lumpiness noted bilaterally throughout the breasts.

B Methotrexate is an immunosuppressant. A common side effect is bone marrow depression, which would be reflected by a decrease in the hemoglobin level. Option A indicates disease progression but is not a side effect of the medication. Option C is not related to methotrexate. Option D indicates that inflammation associated with the disease has diminished.

Which change in laboratory values indicates to the nurse that a client with rheumatoid arthritis may be experiencing an adverse effect of methotrexate therapy? A. Increase in rheumatoid factor B. Decrease in hemoglobin level C. Increase in blood glucose level D. Decrease in erythrocyte sedimentation rate (ESR; sed rate)

B Sleep apnea is characterized by lack of respirations for 10 seconds or more during sleep and is due to the loss of pharyngeal tone which allows the pharynx to collapse during inspiration and obstructs air flow through the nose and mouth. Risk factors which increase the condition of sleep apnea include: excessive weight, increases the risk 4 times more than normal weighing individuals; neck circumference, thicker necks have narrower airways; individuals with inherited narrower airways; males in general are more prone to sleep apnea; females risk increase with being overweight and post-menopausal; increased age (geriatrics); family history; use of alcohol, sedatives or tranquilizers; smokers and those who suffer from nasal allergies.

Which client should the nurse recognize as most likely to experience sleep apnea? A. Middle-aged female who takes a diuretic nightly. B. Obese older male client with a short, thick neck. C. Adolescent female with a history of tonsillectomy. D. School-aged male with a history of hyperactivity disorder.

C Urinary tract infections (UTI) for a client with polycystic kidney disease (PKD) require prompt antibiotic therapy to prevent renal damage and scarring which may cause further progression of the disease so bacteria in the urine would be significant finding.

Which finding should the nurse identify as most significant for a client diagnosed with polycystic kidney disease (PKD)? A. Hematuria. B. 2 pounds weight gain. C. 3+ bacteria in urine. D. Steady, dull flank pain.

B Infection is the major complication resulting from stasis of urine and subsequent catheterization. Option A is the involuntary loss of urine through an intact urethra as a result of a sudden increase in intra-abdominal pressure. Option C is the most common symptom of bladder cancer. Option D is the most common and serious complication of peritoneal dialysis.

Which condition should the nurse anticipate as a potential problem in a female client with a neurogenic bladder? A. Stress incontinence B. Infection C. Painless gross hematuria D. Peritonitis

A Bartholin's glands are located posteriorly on each side of the vaginal opening; they secrete lubrication fluid during sexual excitement. The nurse should suspect obstructed Bartholin's glands when a client reports vaginal dryness during intercourse.

Which condition should the nurse suspect when a client reports vaginal dryness during intercourse? A. Obstructed Bartholin's glands. B. Hyperactive sebaceous glands. C. Infected bulbourethral glands. D. Strangulated prostate gland.

A Abnormal blood flow in response to cold (Raynaud phenomenon) is precipitated in clients with scleroderma. Option B is not a significant factor. Stress can also precipitate the severe pain of Raynaud phenomenon, so a quiet environment is preferred to option C, which is often very noisy. Option D is not necessary.

Which consideration is most important when the nurse is assigning a room for a client being admitted with progressive systemic sclerosis (scleroderma)? A. Provide a room that can be kept warm. B. Make sure that the room can be kept dark. C. Keep the client close to the nursing unit. D. Select a room that is visible from the nurses' desk.

A, B, C, D The nurse should include (A, B, C, and D) in the teaching plan of a female client with genital herpes. (E) is specific for Candida infections, and option (F) is used to treat Trichomonas.

Which content about self-care should the nurse include in the teaching plan of a female client who has genital herpes? (Select all that apply.) A. Encourage annual physical and Pap smear. B. Take antiviral medication as prescribed. C. Use condoms to avoid transmission to others. D. Warm sitz baths may relieve itching. E. Use Nystatin suppositories to control itching. F. Use a douche with weak vinegar solution to decrease itching.

C In older adults, the protein found in urine slightly rises, probably as a result of kidney changes or subclinical urinary tract infections, and clients frequently experience asymptomatic bacteriuria and pyuria as a result of incomplete bladder emptying. Laboratory findings in options A, B, and D are not considered to be normal findings in an older adult.

Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old who is in good health overall? A. Complete blood count reveals increased white blood cell (WBC) and decreased red blood cell (RBC) counts. B. Chemistries reveal an increased serum bilirubin level with slightly increased liver enzyme levels. C. Urinalysis reveals slight protein in the urine and bacteriuria, with pyuria. D. Serum electrolytes reveal a decreased sodium level and increased potassium level.

A Rheumatoid arthritis (RA) is an autoimmune disease that causes joint pain and swelling. RA is characterized by pain that is worse when arising and involves symmetric joints.

Which description of pain is consistent with a diagnosis of rheumatoid arthritis? A. Joint pain is worse in the morning and involves symmetric joints. B. Joint pain is better in the morning and worsens throughout the day. C. Joint pain is consistent throughout the day and is relieved by pain medication. D. Joint pain is worse during the day and involves unilateral joints.

B Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock, in the area innervated by one or more branches of the trigeminal nerve (5th cranial). Women are more often afflicted with this condition and generally occurs in clients over the age of 50 years old.

Which description of symptoms is characteristic of a client diagnosed with trigeminal neuralgia (tic douloureux)? A. Tinnitus, vertigo, and hearing difficulties. B. Sudden, stabbing, severe pain over the lip and chin. C. Facial weakness and paralysis. D. Difficulty in chewing, talking, and swallowing.

C After a renal transplantation, acute rejection is a high risk for several months. The organ recipient will have to take immunosuppressive therapy for the rest of their lives, such as corticosteroids and azathioprine, to prevent organ transplant rejection. Discharge instructions include measures such as daily reminders to ensure the client takes these medications regularly to prevent organ rejection from occurring.

Which discharge instruction is most important for a client after a kidney transplant? A. Weigh weekly. B. Report symptoms of secondary Candidiasis. C. Use daily reminders to take immunosuppressants. D. Stop cigarette smoking.

A, B, E, F Apples and bananas are good sources of fiber but are low in protein and iron. The remaining foods are high in iron along with organ meats, all legumes, red meat, pumpkin seeds, quinoa, turkey, broccoli, and tofu.

Which foods will the nurse recommend for the client with tuberculosis being discharged to home? (Select all that apply.) A. Bean soup B. Spinach C. Apples D. Bananas E. Dark chocolate F. Shellfish

C There are different recommendations from different agencies. For a client with no risk factors, the earliest breast screening recommendation is a yearly mammogram at the age 40 and till the age of 54. After that every two years. The American College of OB/GYN still recommend starting mammograms starting at the age of 40 and yearly screenings. The American Cancer Society new guidelines recommend starting at the age of 45 and thereafter till the age of 54 years old, then every two years. The US Preventive Services Task Force Services (USPSTS) recommends starting at the age of 50 years old and screenings every two years thereafter.

Which information about mammograms is most important to provide a post-menopausal female client? A. Breast self-examinations are not needed if annual mammograms are obtained. B. Radiation exposure is minimized by shielding the abdomen with a lead-lined apron. C. Yearly mammograms should be done regardless of previous normal x-rays. D. Women at high risk should have annual routine and ultrasound mammograms.

A, B, C, E Initial assessment of a joint injury is performed to determine the extent of the damage. The nurse's initial assessment of a painful ankle injury should include pain quality, the presence of deformities, evidence of inflammation, and range of motion.

Which information should the nurse obtain when performing an initial assessment of a client who presents to the emergency department with a painful ankle injury? (Select all that apply.) A. Quality of the pain. B. Signs of inflammation. C. Ankle range of motion. D. Muscle strength testing. E. Visible deformities of the joint.

B Certain strains of Staphylococcus aureus produce a toxin that can enter the bloodstream through the vaginal mucosa. Changing the tampon frequently reduces the exposure to these toxins, which are the primary cause of toxic shock syndrome. Option A helps prevent cervical cancer, not toxic shock syndrome. Option C can lessen the incidence of urinary tract infection. Option D can help prevent some individuals from contracting the flu and pneumonia, but no relationship to toxic shock syndrome has been proven.

Which instruction should the nurse teach a female client about the prevention of toxic shock syndrome? A. "Get immunization against human papillomavirus (HPV)." B. "Change your tampon frequently." C. "Empty your bladder after intercourse." D. "Obtain a yearly flu vaccination."

B Pelvic relaxation disorders are structural disorders resulting from weakening support tissues of the pelvis. Kegel exercises help strengthen the surrounding muscles.

Which intervention should the nurse implement for a female client diagnosed with pelvic relaxation disorder? A. Describe proper administration of vaginal suppositories and cream. B. Encourage the client to perform Kegel exercises 10 times daily. C. Explain the importance of using condoms when having sexual intercourse. D. Discuss the importance of keeping a diary of daily temperature and menstrual cycle events.

B A large tourniquet should be placed in plain sight at the client's bedside, in the event severe bleeding occurs. The purpose is to have the tourniquet available to apply to the residual limb to control bleeding if hemorrhaging was to occur.

Which intervention should the nurse plan to implement when caring for a client who has just undergone a right above-the-knee amputation? A. Maintain the residual limb on three pillows at all times. B. Place a large tourniquet at the client's bedside. C. Apply constant, direct pressure to the residual limb. D. Do not allow the client to lie in the prone position.

B Transitioning through young adulthood is characterized by establishing independence as an adult, and includes developmental tasks such as completing education, beginning a career, and becoming self-supporting

Which milestone indicates to the nurse successful achievement of young adulthood? A. Demonstrates a conceptualization of death and dying. B. Completes education and becomes self-supporting. C. Creates a new definition of self and roles with others. D. Develops a strong need for parental support and approval.

A Fingernails and toenails can be affected by chronic kidney disease. This condition may cause horizontal white lines or bands (leukonychia) to appear on the nails.

Which nail color alteration should the nurse expect to observe in a client with chronic kidney disease? A. Horizontal white banding. B. Diffuse blue discoloration. C. Diffuse brown discoloration. D. Thin, dark red vertical lines.

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

Which nursing action would be appropriate for a client who is newly diagnosed with Cushing syndrome? A. Monitor blood glucose levels daily. B. Increase intake of fluids high in potassium. C. Encourage adequate rest between activities. D. Offer the client a sodium-enriched menu.

A Dyspepsia and regurgitation are the main symptoms of gastroesophageal reflux disease (GERD); however, hoarseness is one of the most common long-term symptoms of GERD due to the irritation of the reflux of gastric secretions.

Which physical assessment finding should the nurse anticipate in a client with long-term gastroesophagealreflux disease (GERD)? A. Hoarseness. B. Dry mouth. C. Mouth ulcers. D. Weight loss.

C Postmenopausal vaginal bleeding may be an indication of endometrial cancer, which should be reported to the healthcare provider.

Which postmenopausal client's complaint should the nurse refer to the healthcare provider? A. Breasts feel lumpy when palpated. B. History of white nipple discharge. C. Episodes of vaginal bleeding. D. Excessive diaphoresis occurs at night.

A To prevent exacerbations of chronic pancreatitis, clients should be instructed to avoid nicotine entirely. Additional teaching includes avoiding caffeinated beverages, resting frequently as needed, and eating a bland diet low fat and high in protein.

Which statement made by a client with chronic pancreatitis indicates that further education is needed? A. I will cut back on smoking cigarettes daily. B. I will avoid drinking caffeinated beverages. C. I will rest frequently and avoid vigorous exercise. D. I will eat a bland, low-fat, high-protein diet.

B Pheochromocytoma is a catecholamine secreting non-cancerous tumor of the adrenal medulla, and a headache, profuse sweating and palpitations is the typical triad of symptoms depending upon the relative proportions of epinephrine and norepinephrine secretion. Surgical removal of the tumor is the only treatment.

Which symptoms should the nurse expect a client to exhibit who is diagnosed with a pheochromocytoma? A. Numbness, tingling, and cramps in the extremities. B. Headache, diaphoresis, and palpitations. C. Cyanosis, fever, and classic signs of shock. D. Nausea, vomiting, and muscular weakness.

A, B, E, F CPR is not needed at this time as the child is still moving air. An allergy to bee stings is related to anaphylactic shock, which is not the situation here. The remaining actions are correct for asthma.

While at a home game, the mother of a 6-year-old is heard screaming, "My child is having an asthma attack! Can anyone help?" The nurse arrives and finds the child gasping for breath with circumoral cyanosis. What are the nurse's next actions? (Select all that apply.) A. Yell, "Call 911." B. Ask the mother if she has the child's bronchodilator. C. Start cardiopulmonary respirations. D. Ask the mother if the child is allergic to bee stings. E. Stay with the child and mother until the ambulance arrives. F. Sit the child straight up in Fowler's position.

C A tuberculin skin test is effective 4 to 6 weeks after an exposure, so the individual with a known exposure should wait 4 to 6 weeks before having a tuberculin skin test.

While working in the emergency room, the nurse is exposed to a client with active tuberculosis. When should the nurse plan to obtain a tuberculin skin test? A. Immediately after the exposure. B. Within one week of the exposure. C. Four to six weeks after the exposure. D. Three months after the exposure.