Medical surgical review test

A nurse is caring for a client 8 hr postoperative following a total knee replacement. Which of the following actions should the nurse take? Correct: - Encourage increased fluid intake. Increased fluid intake will prevent dehydration. Dehydration can contribute to the development of deep vein thrombophlebitis.

The nurse should promote early ambulation and leg exercises to prevent deep vein thrombophlebitis. Warm compresses will promote circulation and assist in the prevention of deep vein thrombophlebitis. Placing a pillow under the affected limb could cause a bend in the femoral artery, resulting in reduced circulation to the lower extremity.

A nurse in a provider's office is reviewing the laboratory results of a client who takes furosemide for hypertension. The nurse notes that the client's potassium level is 3.3 mEq/L. The nurse should monitor the client for which of the following complications? Correct: - Cardiac dysrhythmias This client's potassium level is below the expected reference range. Hypokalemia can cause a number of cardiac effects including flattened T waves, prominent U waves, and S-T depression.

A low potassium level can cause weakness and fatigue. Neurogenic shock occurs in response to spinal injury or spinal anesthesia. Hyponatremia places a client at risk for seizures.

A nurse is completing discharge planning for a client who has bacterial endocarditis. The client will need to receive 12 weeks of antibiotic therapy. Which of the following venous access devices should the nurse identify as appropriate for the client? Correct: - Peripherally inserted central catheter A peripherally inserted central catheter (PICC) line is the venous access device commonly used when the client needs extended, but not permanent, intravenous access. The PICC line may remain in place for weeks or months. PICC lines can also be used to draw blood samples without the need for additional venipunctures.

A short peripheral catheter provides IV access that is appropriate for short term therapy. A client who requires 12 weeks of IV antibiotic therapy would require a more permanent type of device. An arteriovenous fistula is used for hemodialysis access. This is not considered a venous access device for the administration of medications. Implanted infusion port. These lines are preferred for clients who need long-term, intermittent intravenous therapy such as chemotherapy.

A nurse is preparing for the admission of client who has suspected active tuberculosis. Which of the following precautions should the nurse plan to implement to safely care for this client? Correct: - Place the client in a private room with a special ventilation system. Clients who have active tuberculosis should be assigned to private rooms with negative-pressure airflow via HEPA filtration systems. In these rooms, the air is not returned to the inside ventilation system but is filtered and exhausted directly to the outside.

Clients who have active or suspected tuberculosis should be assigned to a private room and placed under airborne precautions. Special respiratory protection is required (N95 mask) when interacting with a client who has active tuberculosis. The procedure for donning and removing personal protective equipment is the same for all clients who require isolation precautions. Gloves and gowns are not necessary for airborne precautions but are used for standard precautions protocol when required.

A nurse is teaching a client how to do fecal occult blood testing. Which of the following statements by the client indicates a need for further teaching? Correct: - "I will continue taking my Coumadin as prescribed." The client should discontinue anticoagulants for one week prior to this testing. This statement requires clarification.

Eating red meat interferes with this testing. Eating raw fruits and vegetables interferes with this testing. NSAIDs interfere with this testing.. The client can continue their low-dose aspirin therapy regimen

A nurse is teaching a client who is to start taking warfarin about herbal supplements. The nurse should inform the client that which of the following herbal supplements can interact adversely with warfarin? Correct: - St. John's wort Herbal supplements that interact adversely with warfarin: -St. John's wort. - Garlic. - Feverfew. - Ginkgo biloba. - Ginseng. - Ginger - Green tea. - Turmeric/Curcumin. - Vitamin E. - Fish Oil/Omega 3 Fatty Acids

Echinacea can decrease the effects of immunosuppressant medication. Black cohosh increases the hypotensive effect when using antihypertensive medication and the hypoglycemic effects of insulin and other diabetic medication. Valerian can increase the actions of other CNS depressant medication, such as benzodiazepines, barbiturates, opioids, muscle relaxants, and antihistamines.

A nurse is caring for a client who requires isolation for active pulmonary tuberculosis. Which of the following precautions should the nurse include when creating a sign to post outside of the client's room? (Select all that apply.) Correct: - A protective mask (airborne precautions) - A closed door - A puncture-proof sharps container - Hand hygiene

Gowns are unnecessary for every individual entering the room; however, any staff who anticipate contact with body fluids should wear them.

A nurse is caring for a client who is postoperative following an open reduction internal fixation (ORIF) of a femur fracture. Which of the following parameters should the nurse include in the evaluation of the neurovascular status of the client's affected extremity? (Select all that apply.) Correct: - Color - Temperature - Sensation Clients who have sustained trauma to an extremity, such as a fracture, are at increased risk for neurovascular compromise.

The nurse should check the color of the client's affected extremity as part of this assessment. The nurse should identify pallor or cyanosis of the extremity as an indication of peripheral neurovascular dysfunction The nurse should monitor the temperature of the extremity as a part of this assessment and identify skin that is cool or cold to the touch as having decreased perfusion to the tissues of the extremity, which is an indication of peripheral neurovascular dysfunction. The nurse should assess the client's extremity for numbness or tingling. The nurse should recognize diminished pain or paresthesia as an indication of damage to the nerves or peripheral neurovascular dysfunction and should report it to the provider.

A nurse is caring for a child who has Addison's disease. Which of the following actions should the nurse take? Correct: - Teach the parents about cortisol replacement therapy. The nurse should plan to teach the child's parents about cortisol replacement therapy. Administration of glucocorticoids and mineralocorticoids is necessary because inadequate supplies or a sudden cessation of the medications can cause acute adrenal crisis.

The nurse should discuss the manifestations of hypoglycemia with the child's parents because Addison's disease causes blood glucose levels to decrease as cortisol is no longer available to regulate it. The nurse should monitor the child for fluid volume deficit due to the reduction or absence of cortisol and aldosterone. The nurse should ensure the child consumes salt liberally because Addison's disease causes sodium levels to decrease due to decreased aldosterone production.

A nurse is performing an ECG on a client who is experiencing chest pain. Which of the following statements should the nurse make? Correct: - "I will need to apply electrodes to your chest and extremities." The nurse should inform the client that she will apply small electrodes to the client's chest and extremities before conducting the test. These electrodes transmit electrical current and allow for the recording of the heart's electrical activity.

The nurse should explain that an ECG does not cause pain or discomfort. An ECG does take a few minutes to complete. An ECG does not use radioactive dye.

A nurse is teaching a middle-age client about hypertension. Which of the following information should the nurse include in the teaching? Correct: - "Diuretics are the first type of medication to control hypertension." The nurse should include in the teaching that diuretic medication is the first type of medication to control hypertension, by decreasing blood volume and lowering blood pressure.

The nurse should include in the teaching to have the client lower saturated fats to 5% to 6% of daily calorie intake to help lower cholesterol levels. The nurse should include in the teaching that the client's goal blood pressure should be reached within in a month, and to notify the provider if this does not occur. The nurse should include in the teaching that the client who has hypertension should consume no more than two drinks OF alcohol consumption a day. This is equivalent to one drink that equals 360 mL (12 oz) beer, 150 mL (5 oz_ wine, or 45 mL (1.5 oz) liquor.

A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status? Correct: - Instruct the client to wiggle his toes. The nurse should observe the client's ability to move his toes when collecting data regarding neurovascular status distal to the fracture. Other means of evaluating neurovascular status include assessing skin color and temperature, sensation, pain, and capillary refill.

The nurse should monitor the client's calf for edema, warmth, tenderness, and redness as they are indications of deep-vein thrombosis. The nurse should palpate pulses distal to the fracture to determine whether the blood flow to the extremity has been compromised. However, the femoral pulse is proximal to the injury and does not indicate the neurovascular status of the injured extremity. The nurse should measure the client's thigh and compare it to the unaffected limb to monitor for continued bleeding into the site. The client is at risk for developing shock because of the large amounts of blood loss that can occur with a femur fracture.

A nurse is caring for a client who has a prescription for balanced skeletal traction with a Thomas splint for the treatment of a fractured femur. Which of the following interventions should the nurse implement to prevent pressure points from developing around the edges of the splint? Correct: - The nurse should assist in the prevention of pressure points by keeping the client properly and frequently positioned in bed. Balanced suspension traction with a Thomas splint allows for increased movement.

The nurse should never remove the weights of balanced skeletal traction. The nurse should avoid applying lotion under or around the edges of the splint due to the risk of skin breakdown. Lotion does not address the issue of pressure. The nurse should apply a foot plate to the bed if the client is at risk for foot drop but this will not prevent pressure points from developing.

A nurse is planning care for a client who has hepatitis B. Which of the following interventions should the nurse include in the plan? Correct: - Encourage short periods of ambulation. The nurse should encourage a client who has hepatitis B to alternate between activity and rest.

The nurse should not restrict fluids for a client who has hepatitis B unless other medical conditions warrant fluid restrictions. The nurse should provide a client who has hepatitis B a diet that is high in carbohydrates The nurse should administer antiviral medication to a client who has hepatitis B. Reducing saturated fats (like butter, cream, fatty meats and fried foods) and increasing mono- and polyunsaturated fats (foods like avocados, nuts, eggs and salmon) is the key to a healthier diet. There is no reason for people with hepatitis to avoid dairy foods.

A nurse in the emergency department is caring for a client who has cardiogenic pulmonary edema. The client's assessment findings include anxiousness, dyspnea at rest, crackles, blood pressure 110/79 mm Hg, and apical heart rate 112/min. Which of the following interventions is the nurse's priority? Correct: - Provide the client with supplemental oxygen at 5 L/min via facemask. The first action the nurse should take when using the airway, breathing, and circulation approach to client care is to provide supplemental oxygen at 5 L/min via simple facemask to promote effective gas exchange and tissue perfusion and to prevent rebreathing of exhaled air. The client is exhibiting signs of respiratory distress, such as dyspnea at rest, crackles, and anxiousness. Therefore, this is the nurse's priority intervention because it would helps manage hypoxia related to pulmonary edema.

The nurse should place the client in high-Fowler's position with their legs in a dependent position to decrease venous blood return to the heart. The nurse should administer morphine sulfate IV to decrease the preload and afterload and decrease the client's anxiety. The nurse should give the client sublingual nitroglycerin to decrease the preload and afterload. However, there is another intervention that is the nurse's priority.

A nurse is caring for a client who has a central venous catheter and develops acute shortness of breath. Which of the following actions should the nurse take first? Correct: - Clamp the catheter. The greatest risk to this client is injury from further air entering the central venous catheter; therefore, the first action the nurse should take is to clamp the catheter.

The nurse should position the client in the left lateral Trendelenburg to prevent the air from entering the coronary arteries The nurse should initiate oxygen therapy to treat any hypoxia the client may be experiencing The nurse should auscultate breath sounds to determine if there is air movement within the lungs

A nurse is caring for a client who has Cushing's syndrome. The nurse should recognize that which of the following are manifestations of Cushing's syndrome? (Select all that apply.) Correct: - Hypertension, caused by the presence of excess glucocorticoids. - Moon face, , which is manifested by a round, red, full face - Buffalo hump, which is a collection of fat between the shoulder blades - Purple striations on the skin of the abdomen, thighs, and breasts

- Hypertension - Moon face - Purple striations - Buffalo hump

A nurse is preparing to administer metoclopramide 15 mg PO QID before meals and at bedtime for a client who has GERD. The amount available is metoclopramide 5 mg/5mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) Correct: - 15 mL

15 mL

A nurse is caring for a 1-month-old infant who weighs 3500 g and is prescribed a dose of cephazolin 50 mg/kg by intermittent IV bolus three times daily. How many mg should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) Correct: - 175 mg

175 mg

A nurse is preparing to administer desmopressin 0.2 mg daily to a client. Available is desmopressin 0.1 mg tablets. How many tablets should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) Correct: - 2 tablets

2 tablets

A nurse is caring for an infant who weighs 12 lb and is prescribed cefuroxime sodium 15mg/kg PO every 12 hr. Available is cefuroxime sodium oral solution 125mg/5mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) Correct: - 3.3 mL

3.3 mL

A nurse in a clinic is collecting a history from a client who reports that a member of his family just received a diagnosis of pulmonary tuberculosis. The nurse should expect that the provider will prescribe which of the following diagnostic tests first? Correct: - Nucleic acid amplification test (NAAT) The CDC recommends that the NAAT test replace other diagnostic screening tests for tuberculosis. The test is performed on a client's sputum.

A chest x-ray is used for diagnosis of active pulmonary tuberculosis as well as for the detection of old, healed lesions, but it is not the first diagnostic test the provider will prescribe. A CT scan aids in confirmation of a diagnosis of pulmonary tuberculosis, but it is not the first diagnostic test the provider will prescribe. A sputum culture is used to confirm a diagnosis of tuberculosis, but it is not the first diagnostic test the provider will prescribe.

A nurse is teaching a group of middle adult clients about early detection of colorectal cancer. The nurse should include the American Cancer Society recommendation that men and women beginning at age 50 who are at average risk should have a fecal occult blood test (FOBT) and a colonoscopy at which of the following intervals? Correct: - Ten years Ten years is the recommended interval for colonoscopy screening for clients who have an average risk.

A client who has an average risk for colorectal cancer does not need annual or . biannual testing

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention? Correct: - Airway obstruction When using the airway, breathing, circulation approach to client care, the nurse determines that the priority risk is airway obstruction. Burns of the head, neck, and chest often involve damage to the pulmonary tree due to heat as well as smoke and soot inhalation. This can result in severe respiratory difficulty. Nursing measures to maintain a patent airway should take priority in this client's care.

Adequate fluid replacement is essential throughout the acute phase of burn treatment; however, another risk is the priority. Prevention of infection is essential throughout hospitalization and treatment Paralytic ileus can develop during the acute phase of burn care and might require nasogastric decompression

A nurse is caring for a client who has chronic kidney disease (CKD) and states she has heartburn. The provider prescribes aluminum hydroxide. The client asks, "Why can't I just take the antacid magaldrate my husband has at home?" The nurse explains to the client that aluminum hydroxide is the preferred antacid because it lowers which of the following? Correct: -Serum phosphorus levels Aluminum-based formulas are also a phosphate binder, helping to lower serum phosphorus levels in clients who have CKD.

Aluminum-based formulas elevate serum calcium levels. Magnesium-based antacids may elevate magnesium levels.

A nurse is caring for a female client who has rheumatoid arthritis and asks the nurse if it is safe for her to take aspirin. The nurse should recognize which of the following findings in the client's history is a contraindication to this medication? Correct: -History of gastric ulcers Aspirin is contraindicated for clients who have a history of gastrointestinal bleeding and peptic ulcer disease because it impedes platelet aggregation. An adverse effect of aspirin is gastric bleeding. Contraindications to the use of aspirin. - History of gastric ulcers - Increased intracranial pressure - Nasal polyps - Pregnancy

Amenorrhea is not a contraindication to the use of aspirin. Glaucoma is not a contraindication to the use of aspirin. Migraine headaches are not a contraindication to the use of aspirin.

A nurse is caring for a client who has just returned from the PACU after a traditional cholecystectomy. In which of the following positions should the nurse place the client? Correct: - Semi-Fowler's The nurse should expect a prescription to place the client in semi-Fowler's position following a traditional cholecystectomy to facilitate lung expansion as well as coughing and deep breathing. This position will place minimal stress on the abdomen and increase comfort.

Avoid: Prone, Supported Sims', Dorsal recumbent positions.

A nurse is reviewing the health history for a client who has angina pectoris and a prescription for propranolol hydrochloride PO 40 mg twice daily. Which of the following findings in the history should the nurse report to the provider? Correct: - The client has a history of bronchial asthma. Beta-adrenergic blockers can cause bronchospasm in clients who have bronchial asthma; therefore, this is a contraindication to its use and should be reported to the provider.

Beta-adrenergic blockers, such as propranolol hydrochloride, may be used in combination with other medications for the treatment of hypertension Beta-adrenergic blockers, such as propranolol hydrochloride, may be prescribed for the prevention of migraine headaches Beta-adrenergic blockers may mask the symptoms of hyperthyroidism; therefore, they must be used with caution in clients taking propranolol hydrochloride. Hypothyroidism is not a contraindication for its use.

A nurse is caring for a child who has acute gastroenteritis but is able to tolerate oral fluids. The nurse should anticipate providing which of the following types of fluid? Correct: - Oral rehydration solution Oral rehydration solution is the fluid of choice for infants and children who have dehydration due to diarrhea. Water provides fluid but does not replace other vital elements lost in diarrhea.

Broth provides fluid and sodium but does not replace other vital elements lost in diarrhea. Diluted apple juice Diluted apple juice provides fluid and sugar but does not replace other vital elements lost in diarrhea.

A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the client's lunch tray? Correct: - Cranberry juice Cranberry juice is an acceptable component of a clear liquid diet, along with apple juice and grape juice.

Components of a full liquid diet: - Lemon sherbet - Plain yogurt - Carrot juice

A nurse assessing a client who has multiple fractures in his left leg notes increasing edema. The nurse should recognize this finding as an early manifestation of which of the following complications? Correct: - Acute compartment syndrome Edema is an early manifestation of acute compartment syndrome, which is a complication that involves increased pressure within the fascia that leads to reduced circulation to the affected area.

Confusion is an early manifestation of fat embolism syndrome. Dyspnea, is an early manifestation of pulmonary embolism. Fever and chills, are early manifestations of osteomyelitis.

A nurse is caring for a client who has Cushing's syndrome. Which of the following interventions should the nurse expect to perform? (Select all that apply.) Correct: - Assess blood glucose level - Assess for neck vein distention - Weigh the client daily Cushing's syndrome affects blood glucose levels by causing increased release of glucose from the liver and decreased sensitivity of insulin receptors. This can result in elevated blood glucose levels. May be helpful to monitor daily weight, I&O, maintain low sodium diet, extremities for edema

Cushing syndrome happens when the body makes too much of the hormone cortisol for a long time. Common symptoms of Cushing syndrome: - Weight gain in the trunk, with thin arms and legs. - Weight gain in the face. - fatty lump between the shoulders. - Pink or purple stretch marks on the stomach, hips, thighs, breasts and underarms. - Thin, frail skin that bruises easily. - Slow wound healing. - Acne.

A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make? Correct: - "DIC is caused by abnormal coagulation involving fibrinogen." DIC is caused by abnormal coagulation involving the formation of multiple small clots that consume clotting factors and fibrinogen faster than the body can produce them, increasing the risk for hemorrhage. DIC causes bleeding in part due to a decreased platelet count.

DIC is not controlled with lifelong heparin usage. Heparin is administered to minimize the formation of microthrombi, which improves tissue perfusion. DIC is not a genetic disorder. DIC does not involve vitamin K deficiency. The effect of vitamin K deficiency is to prolong bleeding time. Vitamin K helps to make four of the 13 proteins needed for blood clotting, which stops wounds from continuously bleeding so they can heal.

A nurse is caring for a client. A nurse is reviewing the client's medical record. Which of the following findings places the client at risk for heart disease? Correct: - History of hypertension - History of smoking - Cholesterol level Hypertension is associated with arterial wall thickening and increased peripheral resistance which can lead to heart disease. Nicotine causes vasoconstriction, which can increase blood pressure and heart rate, and lead to heart disease. The client's cholesterol level is greater than the expected reference range which places the client at risk for heart disease. Hyperlipemia can result in restrictive blood flow to cardiac arteries.

Diagnostic Results 1000 Cholesterol 275 mg/dL (<200 mg/dL) Fasting glucose 90 mg/dL (70 to 110 mg/dL) History and Physical 0800: History of hyperlipidemia, rheumatoid arthritis, and hypertension BMI of 28 Exercises for 30 minutes/day Smokes 1 pack of cigarettes/day for the past 5 years

Your patient with history of valvular heart disease is at risk for tricuspid valve disfunction. Which of the following do you know is true about valvular heart disease? Correct: - Teach patient that prophylactive antibiotic therapy is important before any invasisve dental procedure to prevent endocarditis and always perform good oral hygiene. Tricuspid valve dysfunction occurs secondary to endocarditis or IV illicit drug use.

Diuretics are used to treat heart failures by removing excessive extracellular fluid. The nurse should check weight daily for heart failure.

A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications? Correct: Encourage the use of an incentive spirometer Incentive spirometry expands the lungs and promotes gas exchange after surgery which can help prevent pulmonary complications.

Early ambulation is helpful to promote lung expansion and remove secretions. The nurse should encourage the client to cough and deep breathe.

A nurse in a provider's office is assessing a client. The nurse should identify that which of the following findings are manifestations of pulmonary tuberculosis? (Select all that apply) Correct: - Night sweats - Low-grade fever - Blood in the sputum - Weight loss

Flushed cheeks are a manifestation of pneumonia

A nurse is providing teaching about the Mediterranean diet to a client newly who has a new diagnosis of hypertension. Which of the following statements by the client indicates a need for further teaching? Correct: - "I will limit my intake of red meat to twice weekly." This statement by the client indicates a need for further teaching. Following the Mediterranean diet, red meat should be limited to two times monthly.

Following the Mediterranean diet, drinking wine is acceptable in moderation. Following the Mediterranean diet, the intake of fish and seafood is at least two times per week. Following the Mediterranean diet, the client should have dairy in moderate portions daily to weekly.

A nurse is providing discharge teaching for a client who has pulmonary edema and is about to start taking furosemide. Which of the following instructions should the nurse include? Correct: - Eat foods that contain plenty of potassium. Furosemide, a high-ceiling (loop) diuretic, can cause potassium loss. The client should add potassium-rich foods to his diet, such as nuts, dried fruits, bananas, and citrus fruits. The client should take furosemide early in the day so that the diuretic action will not disturb his sleep.

Furosemide should reduce swelling in the hands and feet. Furosemide can increase the effects of aspirin and anticoagulants.

A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate? Correct: - "Large incisions will be made in the eschar to improve circulation." An escharotomy is a surgical incision made to release pressure and improve circulation in a part of the body that has a deep burn and is experiencing excessive swelling. Burn injuries that encircle a body part, such as an arm or the chest, can cause swelling and tightness in the affected area, resulting in reduced circulation. Making surgical incisions into the burned tissue allows the skin to expand, reduces tightness and pressure, and improves circulation.

Hydrotherapy is used to assist in the debridement of dead tissue from the burn wound. The client is placed into a shower and nurses use forceps and scissors to remove tissue. The running water keeps the body temperature consistent and aids in visualization of the wound. Debridement involves the removal of dead tissue in order to restore tissue integrity. It can be done under anesthesia, or non-surgically through mechanical or enzymatic actions.. A surgical procedure in which a piece of skin from one area of the client's body is transplanted to another area is called a skin graft.

A nurse is caring for a client who has uncontrolled type 1 diabetes mellitus. Which of the following findings should the nurse expect? Correct: - Weight loss Weight loss is an expected finding for a client who has uncontrolled diabetes.

Hypotension is an expected finding for a client who has uncontrolled diabetes Tachycardia is an expected finding for a client who has uncontrolled diabetes.

A nurse is caring for a client who has an elevated potassium level and is on a cardiac monitor. The nurse is aware that hyperkalemia may be associated with changes to the T-wave. On the graphic, point and click on the area of the electrocardiogram (ECG) that represents the T-wave.(Selectable areas, or "Hot Spots," can be found by moving your cursor over the artwork until the cursor changes appearance, usually into a hand. Click only on the Hot Spot that corresponds to your answer.) Correct: - BOX ON THE FAR RIGHT. This is the T-wave. The ECG waveform of a client who has hyperkalemia will have a tall, peaked T wave. It is usually seen when the potassium level is 6 mEq/L or higher.

In the client who has hyperkalemia, the QRS waveform becomes widened. In a client who has hyperkalemia the distance between the P wave and the R wave, called the P-R Interval, is increased. In a client who has hyperkalemia the P wave becomes widened and flat and is not present in severe hyperkalemia.

A nurse is reviewing the diagnostic test results of an older adult female client who is preoperative for a knee arthroplasty. The nurse should notify the surgeon of which of the following results? Correct: - WBC count 20,000/mm3 This result exceeds the expected reference range for WBC of 5,000 to 10,000/mm3. The client's elevated WBC count indicates infection. The nurse should notify the surgeon.

Potassium expected reference range of 3.5 to 5.0 mEq/L. Creatinine expected reference range for older adult women of 0.5 to 1.2 mg/dL. Hematocrit expected reference range for women of 37 to 47%.

A nurse is caring for a client who develops an airway obstruction from a foreign body but remains conscious. Which of the following actions should the nurse take first? Correct: - Administer the abdominal thrust maneuver. The nurse should immediately begin applying abdominal thrusts to a conscious client who has an airway obstruction and should continue until the obstruction is clear or the client loses consciousness.

Insertion of an oral airway is appropriate if the client is unconscious and the obstruction is due to the tongue obstructing the airway or from excessive secretions. Inserting an oral airway in a conscious client will cause the client to gag and will not relieve the obstruction. Turning the client to the side is an appropriate intervention if the client is unconscious and breathing to prevent aspiration of any vomitus that occurs. Performing a blind finger sweep creates a risk of worsening the obstruction and is contraindicated.

A nurse is providing teaching to a school-age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates an understanding of the teaching? Correct: - "I should eat a snack half an hour before playing soccer." Exercise lowers blood glucose levels. The child should eat a snack half an hour prior to physical activity. If the exercise is prolonged, the child might require a snack during the activity.

Insulin should be stored at room temperature or in a refrigerator. Freezing insulin causes it to become inactive. The child's fasting blood glucose should be between 80 and 120 mg/dL. A child who has type 1 diabetes mellitus can experience hyperglycemia during illness. The nurse should encourage the child to monitor glucose levels more frequently on sick days than on healthy days and adjust insulin doses as needed.

A nurse is educating a group of clients about the contraindications of warfarin therapy. Which of the following statements should the nurse include in the teaching? Correct: - "Clients who are pregnant should not take warfarin." Warfarin therapy is contraindicated in the pregnant client because it crosses the placenta and places the fetus at risk for bleeding.

Liver disease is a contraindication for warfarin therapy. Thrombocytopenia is a contraindication for warfarin therapy. Peptic ulcer disease is a contraindication for warfarin therapy

A nurse in a provider's office is assessing a client who reports dyspnea and fatigue. Physical assessment reveals tachycardia and weak peripheral pulses. The nurse should recognize these findings as manifestations of which of the following conditions? Correct: - Heart failure Fatigue and tachycardia are early manifestations of heart failure. Other manifestations include dyspnea and weak peripheral pulses.

Manifestations of aortic valve regurgitation include dyspnea, orthopnea, nocturnal angina with diaphoresis. Manifestations of asthma include cough, dyspnea and wheezing. If asthma exacerbations progress, the client might have diaphoresis, tachycardia and widening pulse pressure. Manifestations of aortic stenosis include dyspnea, angina and syncope. As the condition progresses the client might have fatigue and peripheral cyanosis.

A nurse is caring for a client who has acute pancreatitis. After treating the client's pain, which of the following should the nurse address as the priority intervention? Correct: - Withhold oral fluids and food. To rest the pancreas and reduce secretion of pancreatic enzymes, NPO status must be initiated and maintained during the acute phase of pancreatitis. This is the priority intervention to address after the client's pain has been treated.

Monitoring respiratory status is appropriate Encouraging a side-lying position with knees flexed is appropriate Providing oral hygiene is appropriate and should be done frequently

A nurse is reviewing the medication list for a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize which of the following medications can cause glucose intolerance? Correct: - Prednisone Corticosteroids such as prednisone can cause glucose intolerance and hyperglycemia. The client might require increased dosage of a hypoglycemic medication.

Non related information: - Atorvastatin can interfere with alkaline phosphatase and bilirubin levels - Dextromethorphan can cause drowsiness and dizziness - Cimetidine can alter serum creatinine levels

A nurse in the emergency department is caring for a client who reports chest pressure and shortness of breath. Which of the following laboratory tests should the nurse anticipate the provider to prescribe? Correct: - Troponin I The troponins (I and T) are proteins that only exist in cardiac muscle and enter the bloodstream within a few hours of myocardial injury. They are the most specific indicator of myocardial damage.

Other types of tests: Lipase. This test is used identify pancreatic disease. B-type natriuretic peptide (BNP). B-type natriuretic peptide are peptides used to identify heart failure. Aspartate aminotransferase. (AST)AST is an enzyme test that is used to identify liver disease.

A nurse is teaching about self-monitoring to a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? Correct: - "I will check my blood glucose every 4 hours when I am sick." The client should follow specific guidelines when sick. The nurse should instruct the client to monitor blood glucose every 3 to 4 hr and continue to take insulin or oral antidiabetic agents. The client should consume 4 oz of sugar-free, noncaffeinated liquid every 30 min to prevent dehydration and meet carbohydrate needs through soft food if possible. If not, the client should consume liquids equal to usual carbohydrate content. The nurse should also instruct the client to test urine for ketones and report to provider if they are abnormal (the level should be negative to small).

Pre-meal blood glucose level reference range of 70 to 130 mg/dL, Urine testing for ketones is only advised for clients who have type 1 diabetes mellitus and have glycosuria, blood glucose levels greater than 240 mg/dL for two testing periods in a row, and during illness. A client who has manifestations of hypoglycemia, such as hunger, lightheadedness, or shakiness, should treat the manifestations with 15 g of a fast-acting carbohydrate ( a milk cup).

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability? Correct: - Paraplegia Paraplegia, or paralysis of both legs, is seen after a spinal cord injury below T1.

Quadriplegia, or paralysis of all four extremities, is seen with spinal cord injuries in the cervical vertebrae above C7. Hemiplegia, or paralysis of an arm and leg on the same side of the body, is seen after a cerebral vascular accident or stroke. Paresthesia refers to a burning or tingling sensation due to pressure on nerves, circulatory impairment, or peripheral neuropathy. It is not a form of paralysis associated with a transected spinal cord.

An assistive personnel (AP) reports to the nurse that a client who is 3 days postoperative following an abdominal hysterectomy has a dressing that is saturated with blood. Which of the following tasks should the nurse delegate to the AP? Correct: - Obtain vital signs. Obtaining vital signs is a skill within the scope of practice for an AP; therefore, the nurse can delegate this task to the AP.

Requires assessment by the nurse: - Changing the abdominal dressing - Palpating the client's bladder - Observing the incision site

A nurse is assessing a client who has cirrhosis. Which of the following is an expected finding for this client? Correct: - Spider angiomas Other expected finding for a client who has cirrhosis: - Dark colored, foamy urine - Clay colored stools - Dry skin

Spider angiomas are lesions with a red center and numerous extensions that spread out like a spider web.

A nurse is caring for a client who is HIV positive and is one day postoperative following an appendectomy. The nurse should wear a gown as personal protective equipment when taking which of the following actions? Correct: -Completing a dressing change Standard precautions require personal protective equipment when there is a risk of contact with body fluids. A dressing change does present a risk for coming into contact with body fluids.

Standard precautions do not require the nurse to wear personal protective equipment while at the bedside of a client who is HIV positive and postoperative unless there is a risk of contact with body fluids. Administering an intermittent IV bolus does not present a risk of contact with body fluids. Standard precautions require personal protective equipment when there is a risk of contact with body fluids. The nurse should wear gloves when administering an IM injection to this client.

A nurse in a provider's clinic is assessing a client who takes sublingual nitroglycerin for stable angina. The client reports getting a headache each time he takes the medication. Which of the following statements should the nurse make? Correct: - "Try taking a mild analgesic to relieve the headache." Headache is a common side effect of nitroglycerin. The nurse should suggest conservative measures, such as taking aspirin, acetaminophen, or some other mild analgesic, to manage the headache. Generally, headaches that are a side effect of nitroglycerin are transient.

Sublingual nitroglycerin may be taken up to three times, five minutes apart. Reducing the number of doses may not relieve the angina pain. Nitroglycerine is the drug of choice for acute angina attacks. The headaches associated with nitroglycerin use diminish over time. Until then, headaches can be relieved by mild analgesics.

A nurse is providing teaching to a client who is taking warfarin about monitoring its therapeutic effects. Which of the following explanations should the nurse provide about the international normalized ratio (INR) test? Correct: - "The INR is a standardized test that eliminates the variations between laboratories reports in prothrombin times." The INR is a standardized test, which means that the result will be the same, no matter which laboratory performs it.

The INR monitors warfarin therapy. At the start of warfarin therapy, the prescriber should monitor the client's INR daily. Several tests are available for monitoring anticoagulant therapy, including the INR, prothrombin time (PT), and activated partial thromboplastin time (aPTT). The activated partial thromboplastin time (aPTT) monitors heparin therapy.

A nurse is interpreting a client's ECG strip. Which of the following components of the ECG should the nurse examine to determine the time it takes for ventricular depolarization and repolarization? Correct: - QT interval The QT interval reflects the time it takes for ventricular depolarization and repolarization. The nurse should measure the QT interval from the start of the QRS complex to the end of the T wave. The QRS complex reflects the time it takes for ventricular depolarization.

The PR interval reflects the time it takes for atrial depolarization plus the transit of the impulse through the fibers that make up the conduction system. The ST segment reflects the time it takes for early ventricular repolarization.

A nurse is teaching a group of nursing students about the pathophysiology of the spinal cord. Which of the following statements by a nursing student indicates understanding? Correct: - "The descending tracts of the spinal cord deliver the CNS motor information to neurons in the muscle." The descending tracts of the spinal cord carry motor information from the CNS to lower muscle neurons and cause a reaction to occur. Motor neurons are in the muscles.

The ascending tracts of the spinal cord deliver information from the body's sensory receptors to the CNS. Sensory receptors are in the dermal layer of the skin.

A nurse is teaching a client who has pre-dialysis end-stage kidney disease about diet. Which of the following instructions should the nurse include? Correct: - "Reduce intake of foods high in potassium." The client should reduce foods high in potassium because potassium clearance is impaired in the client who has end-stage kidney disease.

The client should reduce foods high in sodium because sodium clearance is impaired in the client who has end-stage kidney disease. The client should restrict protein intake to 0.55 to 0.60 g/kg/day to preserve kidney function. The client should limit phosphorous intake to 700 mg/day.

A nurse is caring for a client following the surgical placement of a colostomy. Which of the following statements indicates the client understands the dietary teaching? Correct: - "Eating yogurt can help decrease the amount of gas that I have." The client who has a colostomy can include yogurt into his diet to help reduce odors and intestinal gas. The client who has a colostomy should avoid carbonated beverages due to the increased production of intestinal gas.

The client who has a colostomy should have his largest meal of the day in the middle of the day to help decrease the amount of stool produced during the hours of sleep. The client who has a colostomy should include pasta and other sources of fiber into his diet to help control loose stools.

A nurse is caring for a client who is postoperative following an open cholecystectomy. Which of the following actions should the nurse take when caring for the client's Jackson-Pratt (JP) drain? Correct: - Expel the air from the JP bulb after emptying to re-establish suction. With the drainage and the air removed and the bulb tightly closed, the system works to exert gentle negative pressure, facilitating the removal of accumulated fluid from the surgical area.

The drain should be secured to the client's gown to avoid tension on the drain site from the weight of the drain bulb when the client is ambulatory and to from accidental dislodgment of the drain when the client is in bed. It is not necessary to empty, measure, and record the drainage hourly. The nurse should monitor the color and measure the amount of drainage every 8 hr and when the JP container becomes full. A surgeon removes a JP drain, usually on the second postoperative day. If the tube is displaced accidentally, the nurse should cover the site with sterile gauze.

A nurse is caring for a client who is postoperative following an inner mandibular fixation for a fractured mandible. Which of the following actions should the nurse take? Correct: - Place wire cutters at the client's bedside. The client should have wire cutters at his bedside in case he vomits, so the nurse can cut the mandibular wires and clear the client's airway.

The nurse should provide the client with a dental liquid diet, because the client's jaw is fixed in a closed position. The nurse should provide the client with an oral irrigating device to clean his teeth, because his jaw is fixed in a closed position. The supraglottic method of swallowing is used for clients who have a laryngectomy to reduce the risk for aspiration.

A nurse is preparing to administer warfarin to a client. Which of the following information should the nurse recognize prior to administering the medication? Correct: - The client should be observed for manifestations of hemorrhage. The nurse should observe for manifestations of hemorrhage because it is an adverse side effect of warfarin, which has anticoagulant and anti-inflammatory actions.

The nurse should recognize that the antidote for warfarin is vitamin K The nurse should closely monitor the prothrombin time (PT) as an indicator of coagulation. The nurse should not administer warfarin with NSAIDS because it can cause an increased risk of bleeding. Protamine is the antidote for heparin.

A nurse is teaching self-management to a client who has hepatitis B. Which of the following Instructions should the nurse include in the teaching? Correct: - Rest frequently throughout the day. Limiting activity is usually recommended until the symptoms of hepatitis have subsided. The nurse should recommend the client rest frequently throughout the day to reduce the metabolic demands upon the liver and decrease energy demands. Clients who contract hepatitis are restricted from donating blood, body organs or tissue for the remainder of their life.

medications that must be metabolized by the liver, such as acetaminophen, are avoided. The nurse should instruct the client to contact his provider before taking any medication, nutritional supplement, vitamin, or herbal preparation intended for pain-relief measures. Protein intake should be moderated when the liver's ability to metabolize protein by-products is impaired. The nurse should recommend a diet high in carbohydrates, and moderate in protein and fat to maintain adequate nutrition.

A nurse is providing teaching about a heart healthy diet to a group of clients with hypertension. Which of the following statements by one of the clients indicates a need for further teaching? Correct: - "I may eat 10 ounces of lean protein each day."

"Fresh fruits make a good snack option." "I will replace table salt with dried herbs." "I may thicken gravies with cornstarch as I cook."

A nurse is assessing a client prior to administering a seasonal influenza vaccine. The client says he read about an influenza vaccine that is given as a nasal spray and wants to receive it. The nurse should recognize that which of the following findings is a contraindication for the client receiving the live attenuated influenza vaccine (LAIV)? Correct: - The client's age is 62. Clients must be between the ages of 2 and 49 to receive the LIAV; therefore, it is contraindicated for this client. Pregnancy and immunocompromised status are also contraindications.

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A nurse is teaching a client who is at risk for osteoporosis. Which of the following instructions should the nurse include? Correct: - Limit calcium intake to 600 mg per dose. The client should limit calcium intake to 600 mg per dose day to promote absorption. The client should take 600 IU of vitamin D per day to promote the absorption of calcium.

.The client should perform weight bearing exercises at least 3 times per week to reduce the risk for osteoporosis. The client should decrease the intake of caffeinated beverages to reduce the risk for osteoporosis.

A nurse is caring for a client who has end-stage kidney disease (ESKD) and reports having shortness of breath and swelling in his lower extremities. Upon assessment, the nurse notes the client has crackles in his lungs and an elevated blood pressure. The nurse should suspect which of the following based on the client's manifestations? Correct: - Hypervolemia A client who has ESKD experiences excess fluid volume. The increase in circulating fluid causes hypertension which, along with the anemia that occurs in ESKD, ultimately causes heart failure. The client's manifestations of dyspnea, crackles, and edema indicate the client is experiencing heart failure.

A client who has ESKD experiences severe disruptions in fluid and electrolyte balance. During the end stages, the kidney is severely limited in its ability to excrete fluids, resulting in fluid overload. A client who has ESKD will have hyperkalemia due to protein catabolism and a decreased ability to excrete excess potassium. However, the nurse should expect manifestations of hyperkalemia to include changes in cardiac rate and rhythm, weakness and paresthesia, and an increase in intestinal motility. A client who has ESKD will have hypernatremia due to an inability of the kidneys to excrete sodium. The nurse should expect manifestations of hypernatremia to include changes in the level of consciousness, muscle weakness, and decreased or absent deep-tendon reflexes.

A nurse is caring for a client who has developed agranulocytosis as a result of taking propylthiouracil to treat hyperthyroidism. The nurse should understand that this client is at increased risk for which of the following conditions? Correct: - Infection Agranulocytosis is a failure of the bone marrow to make enough white blood cells, causing neutropenia and lowering the body defenses against infection. Agranulocytosis is a condition in which the absolute neutrophil count (ANC) is less than 100 neutrophils per microlitre of blood. People with this condition are at a very high risk of severe infection. Broadly, it can be due to hereditary disease due to genetic mutation or acquired disease.

Agranulocytes (also known as nongranulocytes or mononuclear leukocytes) are one of the two types of leukocytes (white blood cells), the other type being granulocytes. Agranular cells are noted by the absence of granules in their cytoplasm, which distinguishes them from granulocytes. Granulocytes, A type of immune cell that has granules (small particles) with enzymes that are released during infections, allergic reactions, and asthma. Neutrophils, eosinophils, and basophils are granulocytes. A granulocyte is a type of white blood cell. Also called granular leukocyte, PMN, and polymorphonuclear leukocyte

A nurse is caring for a client who has Addison's disease and is at risk for Addisonian crisis. Which of the following actions should the nurse take? Correct: - Weigh the client daily. Addison's disease is an endocrine disorder that causes weight loss, muscle weakness, fatigue, low blood pressure, and hyperpigmentation (darkening) of the skin. Obtaining the client's daily weight will alert the nurse that dehydration is developing, which could indicate an impending crisis. An addisonian crisis is a life-threatening situation that results in low blood pressure, low blood levels of sugar and high blood levels of potassium.

Clients who have Addison's disease are prone to hypoglycemia. They should follow a high-protein, high-carbohydrate diet to ensure adequate caloric intake and avoid weight loss, which is common with Addisonian crisis. The nurse should administer IV corticosteroids to manage Addisonian crisis until the client is no longer at risk for dehydration, hypotension, and shock. Due to the risk for dehydration, the nurse should not restrict the client's fluid intake.

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia? Correct: - The client's bladder becomes distended. Autonomic dysreflexia (sometimes called hyperreflexia) can occur in clients with a spinal cord injury at or above the T6 level. Autonomic dysreflexia happens when there is an irritation, pain, or stimulus to the nervous system below the level of injury. There are many kinds of stimulation that can precipitate autonomic dysreflexia. For example, catheter changes, a distended bladder or bowel, enemas, and sudden position changes. Manifestations include elevated blood pressure, severe headache, and flushed face.

Emergency care of the client who experiences autonomic dysreflexia is to place the client into a sitting position and assess and treat the underlying cause. Extremely elevated blood pressure is the most serious manifestation seen in autonomic dysreflexia as it may result in the client experiencing a stroke If the client develops nasal congestion, they may be experiencing the manifestations of autonomic dysreflexia.

A nurse is providing teaching to a client who has a history of pancreatitis. Which of the following food choices should the nurse instruct the client to avoid? Correct: - Cheddar cheese Clients who have pancreatitis should avoid foods high in fat. Cheddar cheese is high in fat content and the client should avoid this food choice.

Low in fat and is therefore an appropriate food choice: - Noodles - Vegetable soup - Baked fish

A nurse is assessing a client who has Cushing's syndrome. Which of the following findings should the nurse expect? Correct: - Hyperpigmentation Hyperpigmentation, bruising, and striae or stretch marks, are manifestations of Cushing's syndrome.

Manifestation of Cushing's syndrome: - Weight gain - Hypertension - Thinning skin and acne

A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse the client is developing this condition? Correct: - Breathlessness Manifestations of left-sided heart failure include crackles or wheezes and breathlessness due to pulmonary congestion.

Manifestation of right-sided heart failure: - Anorexia - Nausea - Weight gain - Distended abdomen

A nurse is assessing a client who has type 1 diabetes mellitus and finds the client lying in bed, sweating, and reporting feeling anxious. Which of the following complications should the nurse suspect? Correct: - Hypoglycemia Manifestations of hypoglycemia include sweating, tachycardia, tremors, palpitations, hunger, and anxiety.

Manifestations of nephropathy include hypertension, microalbuminuria, and elevated uric acid levels. Manifestations of hyperglycemia include warm skin, rapid respirations, and changes in mental status. Manifestations of ketoacidosis include tachycardia, Kussmaul respirations, nausea, and lethargy.

A nurse is teaching a client who has angina about nitroglycerin sublingual tablets. Which of the following statements should the nurse include in the teaching? Correct: - "Nitroglycerin dilates cardiac blood vessels to deliver more oxygen to the heart." Nitroglycerin is a nitrate medication that increases collateral blood flow, redistributes blood flow toward the subendocardium, and dilates the coronary arteries. The client should place one tablet under the tongue every 5 min for 15 min, for 3 total doses, to relieve chest pain.

Nitroglycerin loses its effectiveness after 6 months or after exposure to light or moisture. The client should not store the tablets in the bathroom. Nitroglycerin relaxes the blood vessels, which increases blood and oxygen supply to the heart. Nitroglycerin does not dissolve blood clots.

A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client? Correct: - Packed RBCs Packed RBCs are given to restore blood volume and replace hematocrit and hemoglobin levels in clients who have hypovolemic shock.

Platelets are administered to clients who have thrombocytopenia. Albumin is administered to clients who have hypoproteinemia and burns. Cryoprecipitates are administered to clients who have hemophilia or von Willebrand disease. Hemophilia is usually an inherited bleeding disorder in which the blood does not clot properly. This can lead to spontaneous bleeding as well as bleeding following injuries or surgery. A person with hemophilia has problems when a fibrin clot is needed to stop the bleeding. People with hemophilia do not have enough of either clotting factor 8 or 9. Because of this, the fibrin clot is not made or is so thin that the bleeding goes on.

A nurse is providing dietary teaching for a client who has just learned that she has type 2 diabetes mellitus. The nurse should explain that which of the following sweeteners will add calories to the client's carbohydrate count? Correct: - Sorbitol This nutritive sweetener provides calories just as sucrose does. However, it can have benefits for clients who must restrict caloric intake. This is because it causes less elevation in blood glucose levels than sucrose does.

Sucralose, Aspartame, and Acesulfame potassium are a nonnutritive sweeteners; therefore, they contains no calories and will not add to the carbohydrate count.

A nurse is admitting a client to the surgical unit from the PACU following a cholecystectomy. Which of the following assessments is the nurse's priority? Correct: - Oxygen saturation The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to assess the client's oxygen saturation. The nurse should check the client's airway, listen to the client's breath sounds, and check the client's pulse oximetry to assess for respiratory depression.

The nurse should assess the client's bowel sounds to monitor for a paralytic ileus The nurse should assess the client's surgical dressing to monitor for bleeding The nurse should assess the client's temperature to monitor for hypothermia or hyperthermia

A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first? Correct: - Cover the wound with a moist, sterile gauze dressing. The client's wound has dehisced, or opened along the suture line, and is now draining. The primary clinical objective in managing a dehisced wound is to keep it clean and moist, and manage any exudate. The nurse's priority action therefore is to cover the wound with a moist, sterile, saline-soaked gauze dressing. Dehiscence places the client at risk for shock and is often caused by infection of the incision site.

The nurse should assess the client's level of pain because increased pain levels release catecholamines which cause systemic vasoconstriction The nurse should obtain a culture of the wound drainage because the drainage indicates there may be infection present. It will be important to identify the specific organism causing the infection so that proper antibiotics may be prescribed

A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines the nurse should document burns to which percentage of the client's total body surface area (TBSA)? Correct: - 54 percent Each arm represents 9% of the client's TBSA and each leg represents 18% of the client's TBSA totaling 54%.

The rule of nines allows for an estimation of the extent of the body that has been burned by dividing anatomical regions into multiples of nines. Each arm represents 9% of the client's TBSA. Each leg (anterior and posterior) represents 18% of the client's TBSA. Both legs represent 36% of the client's TBSA.

A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care? Correct: - Encourage fluid intake at and between meals. Increased fluid intake dilutes the urine, reduces stasis, and greatly reduces the urinary bacterial count. Consequently, the risk of nosocomial (hospital-acquired) UTI is reduced, even for a client who has a spinal cord injury.

.The perineum should be cleansed from front to back to limit the spread of bacteria from the perianal region to the urethra in female clients. Indwelling catheters are associated with a greatly increased risk for UTI and should be avoided whenever possible in a client who is at risk. Intermittent catheterization to empty the bladder of residual urine is more effective. The client will be unable to completely empty her bladder by herself.

A nurse is assessing a client who has advanced cirrhosis. Which of the following manifestations should the nurse expect? Correct: - Petechiae A manifestation of advanced cirrhosis is petechiae due to impaired coagulation from a dysfunctional liver.

A client who has advanced cirrhosis will experience hypotension. A client who has advanced cirrhosis will develop osteoporosis, especially with primary biliary cirrhosis. Peripheral ulcers are a manifestation of atherosclerosis, rather than cirrhosis.

A staff nurse is teaching a client who has Addison's disease about the disease process. The client asks the nurse what causes Addison's disease. Which of the following responses should the nurse make? Correct: - "It is caused by the lack of production of aldosterone by the adrenal gland." Addison's disease is caused by a lack of production of the adrenocorticotropic hormones (cortisol and aldosterone) by the adrenal gland.

A client who has hyperparathyroidism produces an excessive amount of parathormone. client who has an overproduction of the growth hormone has acromegaly. A client who does not produce insulin has type 1 diabetes mellitus.

A nurse is caring for a client who has a new diagnosis of essential hypertension. The nurse should monitor the client for which of the following findings that is consistent with this diagnosis? Correct: - The nurse should monitor the client for findings such as vertigo, headache, facial flushing, and fainting. These manifestations are consistent with a new diagnosis of essential hypertension.

A client who has malignant hypertension might manifest: - Uremia. - Blurred vision. - Dyspnea.

A nurse is caring for a client who has type 2 diabetes mellitus and their glucose levels are rising. Which of the following would indicate the client is in a hyperosmolar hyperglycemic state (HHS)? Correct: - Plasma osmolarity of 350 mOsm/L A plasma osmolarity of greater than 320 mOsm/L is an indicator of HHS.

A plasma glucose level above 600 mg/dL indicates HHS. The absence of ketosis would indicate HHS. Hypotension would indicate HHS.

A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.) Correct: - Open the airway using the jaw-thrust maneuver.. - Determine effectiveness of ventilator efforts. -Establish IV access - Perform a Glasgow coma Scale Assessment - Remove clothing for a thorough assessment. A primary survey is an organized system to rapidly identify and manage immediate threats to life. The mnemonic "ABCDE" is a reminder of the steps of the primary survey: airway, breathing, circulation, disability, exposure.

A primary survey is an organized system to rapidly identify and manage immediate threats to life. The mnemonic "ABCDE" is a reminder of the steps of the primary survey. The first step is "airway," during which the nurse should establish a patent airway using the jaw-thrust maneuver. The second is "breathing," during which the nurse should assess the client's ventilator efforts to determine effectiveness of breaths. During the third step, "circulation," the nurse should establish IV access for fluids and blood administration as needed. The fourth step is "disability," during which the nurse should determine a baseline neurologic status by completing a GSC assessment. And the fifth step is "exposure," during which the nurse should remove the client's clothing to complete a thorough assessment of the client's injuries.

A nurse administers desmopressin to a client who has a diagnosis of diabetes insipidus. The nurse recognizes that which the following laboratory findings indicate a therapeutic effect of the medication? Correct: - Urine specific gravity 1.015 A therapeutic effect of the medication would be urine specific gravity within the expected reference range, which is 1.010-1.025. Signs of diabetes insipidus (DI) include polyuria, signs of dehydration, decreased urine specific gravity, and increased serum sodium. Desmopressin, a synthetic ADH, is used to treat DI. This medication is not expected to alter blood glucose levels.

A therapeutic effect of the medication would be decreased serum sodium and increased urine sodium. The expected reference range for serum sodium is 136-145 mEq/dL. This medication is not expected to alter BUN. The expected reference range for BUN is 10-20 mg/dL.

A nurse in a community health center is assessing the results of a tuberculin skin test she performed for a client. Which of the following results indicates exposure to and a possible infection with tuberculosis (TB)? Correct: - 15 mm induration A positive reaction to a tuberculin skin test is an induration (a hardened area) that is 10 mm or greater in diameter. The nurse should measure the area of induration, not any accompanying erythema or swelling.

A wheal should appear when the nurse injects the purified protein derivative into the client's forearm. The nurse can expect erythema around the injection.

A nurse is reviewing the medical record of a client who is to receive the first dose of cefoxitin via intermittent IV bolus. Which of the following findings should the nurse identify as a contraindication for the client to receive cefoxitin and report to the provider? Correct: - A severe allergy to amoxicillin A client who has a suspected or documented history of severe allergy to penicillins may also have an allergy to cephalosporins that could result in anaphylaxis. The nurse should withhold the dose and notify the provider.

Cefoxitin can lead to renal impairment with elevated BUN and serum creatinine. A history of phlebitis is not a contraindication to receiving cefoxitin via intermittent IV bolus because the nurse can insert a new IV catheter at a new site to infuse the cefoxitin. Cephalosporin antibiotics can cause clostridium difficile infection. However, recent diarrhea does not predict the occurrence of this complication of therapy and is not a contraindication to receiving cefoxitin.

A nurse is providing care for a group of clients in the emergency department. Which of the following clients is at risk for developing neurogenic shock? Correct: - The client who has Guillain-Barré syndrome Clients whose autonomic nerves have been affected by Guillain-Barré syndrome are at risk for developing neurogenic shock because both blood pressure and heart rate are controlled by the autonomic nervous system.

Clients who have severe burn injuries are at risk for hypovolemic or septic shock Clients who have asthma are at risk for anaphylactic shock. Clients who have chronic kidney disease are at risk for septic shock.

A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions? Correct: - Elective cardioversion Elective cardioversion is the priority intervention when the client is awake and responsive. Ventricular tachycardia might not be an immediate threat to the client, but it does require intervention to prevent long-term cardiac impairment.

Defibrillation Defibrillation is performed to correct life-threatening cardiac arrhythmias including VT. In cardiac emergencies, defibrillation should be performed immediately after identifying the client is experiencing an arrhythmia. The client in the question is awake and reporting sudden heart palpitations. There is no indication the client is unstable. Radiofrequency catheter ablation is a procedure used to destroy the area of the heart (irritable focus) that causes the VT. It is used to treat clients who have repeated episodes of stable VT, but it is not used in initial treatment. The nurse should assess the client's airway, breathing, circulation, level of consciousness, and oxygenation level prior to beginning CPR. Because this client is awake and in a stable VT rhythm, the nurse should not initiate CPR.

A home health nurse is visiting a client. For each of the client's findings, indicate if the finding is a possible indication of tuberculosis (TB). Select all that apply. Correct: - When recognizing cues, the nurse should understand that clinical manifestations of TB are persistent cough, shortness of breath, fever, weight loss, anorexia, hemoptysis, and night sweats. If symptoms of TB are expected, the client should be screened for TB using a Mantoux test. The results should be read in 48-72 hours. A positive test is induration and redness measuring 10 mm or greater.

Diameter of reddened area Temperature Appearance of right forearm Weight Report of breathing Report of cough Day 1: Client reports unintentional weight loss of 10 pounds and persistent cough. Mantoux test placed on right forearm. Day 3: Client reports persistent cough with shortness of breath. Has been having night sweats. A flat, soft red area noted on the client's right forearm, measuring 8mm in diameter. Day 1: Temperature 98.8°F (37.1°C) Day 3:Temperature 102.4°F (39.1°C)

A nurse is assessing a client who has Cushing's syndrome. Which of the following findings should the nurse expect? Correct: - Hyperpigmentation Manifestations of Cushing's syndrome: - Hyperpigmentation - Bruising - Striae or stretch marks - Thinning skin and acne - Hypertension - Weight gain

Diaphoresis is a manifestation of hyperthyroidism.

A nurse is assessing a client who has infective endocarditis. Which of the following findings should be the priority for the nurse to report to the provider? Correct: - Dyspnea The client who has infective endocarditis and develops dyspnea, tachycardia, or a cough might be developing heart failure or experiencing pulmonary emboli, two complications of the infection.

Fine reddish-brown lines, called splinter hemorrhages to the nails, are an expected finding in the client who has infective endocarditis. Clients who have infective endocarditis might experience intermittent fevers, even after initiating antibiotic therapy. Petechiae are manifestations of infective endocarditis and can appear in clusters over different areas of the body, including the mucous membranes of the mouth, the palms of the hands, and soles of the feet.

A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG? Correct: - Atrial fibrillation Atrial fibrillation causes a disorganized twitching of the atrial muscles. The rate is irregular with no visible P waves. The ventricular response is irregular which results in an irregular pulse and a pulse deficit.

First-degree AV block is a regular rhythm with a prolonged P-R interval. A pulse deficit does not occur. Sinus bradycardia is a slow heart rate with a regular rhythm. Therefore, a pulse deficit does not occur. Sinus tachycardia is a rapid heart rate with a regular rhythm. Therefore, a pulse deficit does not occur.

A nurse is caring for a male client who has peripheral vascular disease (PVD), is taking dietary supplements, and has a new prescription for warfarin. The nurse should instruct the client to stop which of the following supplements prior to starting the warfarin? (Select all that apply.) Correct: - Saw palmetto is used to relieve symptoms associated with benign prostatic hypertrophy and has an antiplatelet effect. It should not be taken with warfarin. - Glucosamine is correct. Glucosamine is used to prevent osteoarthritis and may increase the risk of bleeding. It should not be taken with warfarin. - Gingko biloba is correct. Gingko biloba is used to increase pain-free walking in clients with PVD and may suppress coagulation. It should not be taken with warfarin.

Flaxseed oil is a source of Omega-3 fatty acids used to promote cardiovascular health. No interactions occur with warfarin. Black cohosh is used for sleep disturbances and depression. No interactions occur when taking warfarin.

A nurse is teaching a school-age child who has type 1 diabetes mellitus and his parents about illness management. Which of the following instructions should the nurse include? Correct: - "Test the urine for ketones." The parent or child should test the urine for ketones and report the presence of them in the urine. Ketonuria can indicate that the child does not have enough glucose for energy and is breaking down fats to provide glucose to cells.

Fluid intake is the most important intervention during acute illness in order to prevent dehydration and promote urinary excretion of ketones. The nurse should instruct the school-age child and his parent to notify the provider if his blood glucose levels are greater than 250 mg/dL in order to initiate treatment before injury can occur. The child should never omit usual insulin doses when ill because the stress of acute illness usually results in elevated blood glucose levels.

A nurse is talking with a client who has cholelithiasis and is about to undergo an oral cholangiogram. Which of the following client statements indicates to the nurse understanding of the procedure? Correct: - "They are going to examine my gallbladder and ducts." With oral cholangiography, the client receives an iodide-containing contrast agent 10 to 12 hr before the procedure. Then, the examiner can evaluate the gallbladder for filling, contracting, and emptying and can also see the gallstones on the x-rays.

For a cholangiogram, the client will receive a contrast material to enhance visualization of the gallbladder, not a medication to dissolve the stones. For an endoscopic retrograde cholangiopancreatography the examiner passes a flexible fiberoptic endoscope through the esophagus to visualize gastrointestinal structures. Lithotripsy uses shock waves to break up gallstones.

A nurse is assessing a client who has hyperthyroidism. The nurse should expect the client to report which of the following manifestations? Correct: - Frequent mood changes Hyperthyroidism develops when the thyroid gland produces an excess of the thyroid hormones that regulate the metabolic rate. Clients experience emotional lability that fluctuates between emotional hyperexcitability and irritability. They often cannot sit quietly.

Hyperthyroidism causes an increased rate of body metabolism. The nurse should expect the client to report heat intolerance Hyperthyroidism causes increased peristalsis, which results in diarrhea. Hyperthyroidism causes an increased rate of body metabolism. The nurse should expect the client to report weight loss

A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding? Correct: - Oliguria Oliguria is present in hypovolemic shock as a result of decreased blood flow to the kidneys. Hypovolemic shock occurs when there is a large amount of blood loss or there is massive vasodilation resulting in decreased perfusion and oxygenation

Hypovolemic shock occurs when there is a large amount of blood loss or there is massive vasodilation resulting in decreased perfusion and oxygenation. This client would be hypotensive. Pallor is a sign of hypovolemic shock. The client may also appear cyanotic or mottled. Tachypnea is a sign of hypovolemic shock.

A nurse is admitting an infant who has severe dehydration from acute gastroenteritis. Which of the following findings should the nurse expect? Correct: - 13% weight loss A weight loss greater than 10% is a manifestation of severe dehydration in an infant.

Other manifestations of severe dehydration in an infant: - A sunken anterior fontanel - Hyperpnea - A capillary refill greater than 4 seconds

nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip? Correct: - Pacemaker spikes before each QRS complex The pacemaker fires, showing a spike on the monitor strip, which stimulates the ventricle, and the QRS complex appears, indicating that depolarization has occurred.

Pacemaker spikes after each QRS complex. This indicates improper functioning. Pacemaker spikes with each T wave. This indicates improper functioning. Pacemaker spikes before each P. This is seen with an atrial pacemaker.

A nurse is caring for an older adult client who had a femoral head fracture 24 hr ago and is in skin traction. The client reports shortness of breath and dyspnea. The nurse should suspect that the client has developed which of the following complications? Correct: - Fat embolism The nurse should suspect that the client has fat embolism syndrome. This complication develops within 12 to 48 hr of a fracture and can cause dyspnea, respiratory distress, alterations in mental status, tachycardia, and other manifestations. Older adults who have hip fractures are at greater risk.

Pneumonia can develop with immobility, but generally takes longer than 24 hr.

Please select all that apply. - Provide IV bolus to improve hydration. - Administer oxygen at 2-4 liters/min to improve or maintain oxygenation. - Continuously monitor ECG for dysrythmias.

Provide IV bolus to improve hydration. Administer oxygen at 2-4 liters/min to improve or maintain oxygenation. Monitor hourly urine output. Monitor blood pressure continuously and note sudden increases in readings. Continuously monitor ECG for dysrythmias.

A nurse is providing preoperative teaching for a client who is scheduled for a gastrectomy. Which of the following information regarding prevention of postoperative complications should the nurse include in in the teaching? Correct: - Instruct the client about the use of a sequential compression device. The nurse should instruct the client about the use of a sequential compression device to prevent deep-vein thrombosis, a postoperative complication.

Teach the client how to use the PCA pump. Instruct the client about the use of a sequential compression device. Discuss the visitation policy. Review the pain scale.

A nurse is interpreting the ECG strip of a client who has bradycardia. Which of the following cardiac components should the nurse identify as the role of the P wave? Correct: - Atrial depolarization The P wave reflects atrial depolarization, typically initiated in the sinoatrial node.

The QRS complex reflects ventricular depolarization. A U wave appears when there is slow repolarization of ventricular Purkinje fibers. The ST segment reflects early ventricular repolarization.

A nurse is teaching a client who has a new prescription for transdermal nitroglycerin to treat angina pectoris. Which of the following instructions should the nurse include in the teaching? Correct: - Apply the transdermal patch in the morning. The client should apply the patch every morning and leave it in place for a 12 to 14 hr, then remove it in the evening.

The client should apply a new patch each day The client should rotate the sites used for patch placement to avoid areas of local skin irritation. The transdermal route of nitroglycerin has a delayed onset of action, making it suitable for prophylaxis use but not for immediate relief of chest pain.

A nurse is providing discharge teaching to a client who has pulmonary tuberculosis and a new prescription for rifampin. Which of the following information should the nurse provide? Correct: - "Urine and other secretions might turn orange." Rifampin might turn the urine and other secretions reddish-orange. This includes sputum, tears, and sweat.

The client should take rifampin on an empty stomach, 1 hr before or 2 hr after meals. Rifampin is more likely to cause fatigue and drowsiness. Treatment with rifampin for tuberculosis lasts from 6 to 9 months.

A nurse is teaching a client who has a prosthetic limb due to a right below-the-knee amputation about prosthesis and stump care. Which of the following instructions should the nurse include in the teaching? Correct: - Dry the prosthesis socket completely before applying it to the limb. The client should dry the prosthesis socket thoroughly with a clean cloth. Moisture between the socket and the stump can put the client at risk for fungal or bacterial infection and skin breakdown.

The client should use lotion only if the skin is extremely dry and at risk of cracking. Instead, he should wash the residual limb each day with warm water and a mild soap, rinse it and dry it thoroughly, never using talcum powder. The client must always wear a clean, dry sock on the residual limb to prevent direct contact between the skin and the prosthetic socket. The nurse should instruct the client to inspect the skin of the stump daily. He should temporarily discontinue use of the prosthesis if any skin irritation or breakdown develops and notify the provider.

A nurse is assisting with obtaining an electrocardiogram (ECG) for a client who has atrial fibrillation. Which of the following actions should the nurse take? (Select all that apply.) Correct: - Inspect the electrode pads. - Instruct the client not talk during the test. The gel is necessary to promote electrical conduction between the skin and the electrodes; therefore, the nurse should inspect the electrode pads to check that the gel is present. The nurse should instruct the client to lie quietly and not to talk or move to prevent the recording of artifact.

The client will not receive anesthesia for to the test, so he does not need to follow a food or fluid restriction prior to the test. The nurse should wipe the skin with alcohol where she will place the electrodes to ensure the skin is free of oils. The client does not need to receive an analgesic prior to the test because the test is noninvasive and does cause any discomfort.

A nurse is establishing health promotion goals for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should the nurse include? Correct: - The client will walk for 30 min 5 days a week. CDC recommendations include engaging in a moderate exercise, such as walking, for a total of 150 min each week.

The client's BMI indicates the client is overweight; therefore, the nurse should counsel the client on weight reduction strategies. Female clients are at increased risk for osteoporosis; therefore, the nurse should instruct the client to increase intake of calcium and vitamin D. Smokeless tobacco delivers a higher concentration of nicotine and places the client at risk for cancer. The nurse should discuss nicotine replacement and acupuncture as measures to stop smoking tobacco products.

A nurse is caring for a client who is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? Correct: - Verify that the suction regulator is on and check the tubing for leaks. A lack of bubbling may indicate that either the suction regulator is turned off or that there is a leak in the tubing.

The expected finding would be a gentle bubbling of the water in the suction control chamber. Stripping, or milking, can pull too hard on the chest cavity and may cause a tissue injury to the lung. Stripping is only done when specifically indicated. More water should not be added to the closed system.

A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia? Correct: - Atropine The team administers atropine during CPR if the client has symptomatic bradycardia, or is hemodynamically unstable.

The team administers sodium bicarbonate to correct metabolic acidosis that does not improve with CPR. The team administers magnesium during CPR for clients who have torsade de pointes, which is a specific type of ventricular tachycardia. The team administers epinephrine during cardiopulmonary resuscitation (CPR) to clients who have asystole or pulseless electrical activity.

A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of following values? Correct: - Amylase Amylase is an enzyme that changes complex sugars into simple sugars that can be used by the body. It is produced by the pancreas and salivary glands and released into the mouth, stomach, and intestines to aid in digestion. The amylase level of a client who has acute pancreatitis usually increases within 12 to 24 hr and can remain elevated for 2 to 3 days.

The nurse should expect a decreased calcium level in a client who has acute pancreatitis. The nurse should expect an elevated WBC count in a client who has acute pancreatitis. The nurse should expect a decreased magnesium level in a client who has acute pancreatitis.

A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect? Correct: - Blood pressure 115/68 mmHg The sympathetic nervous system is stimulated, resulting in the release of epinephrine and norepinephrine. These catecholamines help maintain the client's blood pressure within normal limits during the compensatory stage of shock.

The nurse should expect possible hyperkalemia, which is mild during compensatory (nonprogressive) shock, and worsens in later stages. During the compensatory stage of shock, the heart and blood pressure generally remain only slightly altered. A heart rate of 100-150/min with only a slight increase in diastolic blood pressure is seen in this stage. Shock progresses along a continuum beginning with the compensatory stage, in which the body is still able to maintain hemodynamic stability. Vasoconstriction and shunting of blood ensures perfusion to vital organs. However, the skin becomes cool, pale, and diaphoretic. As shock progresses into the progressive stage, the skin begins to mottle.

A nurse is teaching a client who has type 1 diabetes mellitus about foot care. Which of the following statements by the client indicates an understanding of the teaching? Correct: - "I'll check my feet every day for sores and bruises." The client should check his feet daily to monitor for any problems and observe any other changes before they become serious. He can use a hand mirror to examine areas that are difficult for him to see.

The nurse should instruct the client to avoid shoes such as sandals that have an open toe or straps that rest between the toes to decrease the risk of foot injuries. The nurse should instruct the client that lotion is appropriate for dry areas of the feet but not to apply it between the toes, because it creates a moist environment that promotes bacterial growth. The nurse should instruct the client not soak his hands or feet for prolonged periods of time, as this can increase the risk of infection. When cleansing the feet, the client should use warm, soapy water.

A nurse is teaching a client who has type 1 diabetes mellitus about exercise. Which of the following instructions should the nurse include? Correct: - Do not exercise if ketones are present in your urine. The nurse should instruct the client not exercise if ketones are present in her urine because this is an indication of inadequate insulin and increases the risk for hyperglycemia.

The nurse should instruct the client to perform vigorous exercise when blood glucose is between 100 and 250 mg/dL. The nurse should instruct the client to eat a snack if it has been over 1 hr since her last meal. The nurse should instruct the client to examine her feet daily and after exercising to assess for ulcers.

A nurse is teaching a client who has acute kidney disease about fluid restrictions. Which of the following statements by the client should the nurse identify as understanding of the teaching? Correct: - "I will make a list of my favorite beverages." The nurse should work with the client to develop a schedule for fluid restrictions, and should attempt to include the client's favorite beverages when possible to promote satisfaction.

The nurse should instruct the client to plan to consume most fluids during the daytime, when she is more likely to receive medications. The nurse should instruct the client to use small beverage containers to give the appearance of drinking a full cup of liquid. The nurse should tell the client to include foods that become liquid at room temperature, such as fruity ice pops, sherbet, and ice cream.

A nursing is providing dietary teaching for a client who has Cushing's disease. Which of the following recommendations should nurse include in the teaching? Correct: - Restrict sodium intake. The nurse should recommend the client to restrict sodium intake to control fluid volume. This restriction can range from "no-added-salt" to table foods to a restriction of 2 g/day.

The nurse should recommend a low-carbohydrate diet due to the weight gain that occurs in clients who have Cushing's disease. Cushing's disease causes protein catabolism, which results in muscle wasting and osteoporosis. Therefore, the nurse should not recommend a decrease in protein intake.

Your patient with history of valvular heart disease is at risk for tricuspid valve disfunction. Which of the following do you know is true about valvular heart disease? Correct: - Teach patient that prophylactive antibiotic therapy is important before any invasive dental procedure to prevent endocarditis and always perform good oral hygiene

Tricuspid valve dysfunction occurs secondary to endocarditis or IV illicit drug use. Diuretics are used to treat heart failures by removing excessive extracellular fluid. The nurse should check weight daily for heart failure

A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication? Correct: - Hypotension Verapamil, a calcium channel blocker, can be used to control supraventricular tachyarrhythmias. It also decreases blood pressure and acts as a coronary vasodilator and antianginal agent. A major adverse effect of verapamil is hypotension; therefore, blood pressure and pulse must be monitored before and during parenteral administration.

Verapamil is not toxic to the ear. Verapamil does not cause muscle pain. Temperature is not affected by verapamil.

A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first? Correct: - Epinephrine The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to administer epinephrine, a bronchodilator and vasopressor used for allergic reactions to reverse severe manifestations of anaphylactic shock.

he nurse should administer furosemide, a loop diuretic, to improve renal profusion during an anaphylactic crisis The nurse should administer methylprednisolone, a corticosteroid, to decrease itching and severe rash The nurse should administer dobutamine, a cardiac stimulant used when cardiac decompensation occurs due to anaphylactic shock