Monitoring for Health Problems (9) No Rationale

A nurse is reviewing the results of renal function testing in a client with renal calculi. Which finding indicates to the nurse that the client's blood urea nitrogen (BUN) level is within the normal range?

18 mg/dL The normal BUN ranges from 5 to 20 mg/dL.

A client reports for a scheduled electroencephalogram (EEG). Which statement by the client indicates a need for additional preparation for the test?

"I didn't shampoo my hair."

A client who has just undergone bronchoscopy was returned to the nursing unit 1 hour ago. With which assessment finding is the nurse most concerned?

Absence of cough and gag reflexes

A nurse is assessing the status of a client with diabetes mellitus. The nurse concludes that the client is exhibiting adequate diabetic control if the serum level of glycosylated hemoglobin A1C (HbA1C) is less than:

7%

A serum phenytoin determination is prescribed for a client with a seizure disorder who is taking phenytoin (Dilantin). Which result indicates that the prescribed dose of phenytoin is therapeutic?

16 mcg/mL

A young adult asks the nurse about the normal cholesterol level. The nurse tells the client that the total cholesterol level should be maintained at less than:

200 mg/dL

An adult female client has undergone a routine health screening in the clinic. Which of the following values indicates to the nurse who receives the report of the client's laboratory work that the client's hematocrit is normal?

43% The normal hematocrit for an adult female client ranges from 35% to 47%.

A client has just undergone a renal biopsy. Which intervention should the nurse include intervention in the post-procedure plan of care?

A Periodically testing the urine for occult blood

A client who has just undergone a skin biopsy is listening to discharge instructions from the nurse. The nurse determines that the client has misunderstood the directions if the client indicates that as part of aftercare he plans to:

Apply cool compresses to the site twice a day for 20 minutes

A nurse is assessing a client who has a closed chest tube drainage system. The nurse notes constant bubbling in the water seal chamber. What actions should the nurse take? (Select all that apply).

Assessing the system for an external air leak Documenting assessment findings, actions taken, and client response

A nurse is preparing a client for transfer to the operating room. Which of the following actions should the take in the care of this client at this time?

Assuring that the client has voided

A client who experienced the sudden onset of respiratory distress has been intubated with an endotracheal tube. Immediately after the tube is placed in the trachea, the nurse should:

Auscultate both lungs for the presence of breath sounds

A client who has undergone renal biopsy complains of pain, radiating to the front of the abdomen, at the biopsy site. For which of the following findings should the nurse assess the client?

Bleeding

A nurse is helping a client with a closed chest tube drainage system get out of bed and into a chair. During the transfer, the chest tube is caught on the leg of the chair and dislodged from the insertion site. The immediate priority on the part of the nurse is

Covering the insertion site with a sterile occlusive dressing Correct

A client who has undergone abdominal surgery calls the nurse and reports that she just felt "something give way" in the abdominal incision. The nurse checks the incision and notes the presence of wound dehiscence. The nurse immediately:

Covers the abdominal wound with a sterile dressing moistened with sterile saline solution

A nurse is preparing to examine a client's skin using a Wood light. What should the nurse do to facilitate this procedure?

Darken the examining room

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased to more than 2 L/min. The nurse responds that this would be harmful because it could:

Decrease the client's oxygen-based respiratory

A nurse is admitting a client with a diagnosis of hypothermia to the hospital. Which of the following signs does the nurse anticipate that this client will exhibit?

Decreased heart rate and decreased blood pressure

A client is receiving a continuous IV infusion of heparin for the treatment of deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) level is 80 seconds. The client's baseline before the initiation of therapy was 30 seconds. Which action does the nurse anticipate is needed?

Decreasing the rate of the heparin normal aPTT varies between 20 and 36 seconds

A client is scheduled to undergo computerized tomography (CT) with contrast for evaluation of an abdominal mass. The nurse should tell the client that:

Dye is injected and may cause a warm flushing sensation

A nurse has a prescription to apply a Holter monitor to a client for continuous cardiac monitoring for a 24-hour period. What steps should the nurse take to initiate this prescription? Select all that apply.

Giving the client a device holder to wear around the waist Giving the client a diary in which to record all activity and symptoms

A client has been given a diagnosis of multiple myeloma. Which of the following results does the nurse reviewing the client's laboratory findings recognize as being specifically related to this diagnosis?

Increased calcium level

A nurse is caring for a client with diarrhea. For which acid-base disorder does the nurse assess the client?

Metabolic acidosis

A client tells the nurse that he has been experiencing frequent heartburn and has been "living on antacids." For which acid-base disturbance does the nurse recognize a risk?

Metabolic alkalosis

A nurse is preparing a client for colonoscopy. Into which position does the nurse assist the client for the procedure?

Left Sim's position

A nurse is reading the radiology report of a client with a chest tube attached to a closed drainage system who has undergone a chest x-ray. The report states that the client's affected lung is fully reexpanded. The nurse anticipates that the next assessment of the chest tube system will reveal

No fluctuation in the water seal chamber

A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is restless and her pulse rate is increased. As the nurse continues the assessment, the client begins to vomit a copious amount of bright-red blood. The immediate nursing action is to:

Notify the surgeon

A client recovering from surgery has a large abdominal wound. Which of the following foods, high in vitamin C, should the nurse encourage the client to eat as a means of promoting wound healing?

Oranges

A client has been scheduled for magnetic resonance imaging (MRI). For which of the following conditions, a contraindication to MRI, does the nurse check the client's medical history?

Pacemaker insertion

A client has undergone renal angiography by way of the right femoral artery. The nurse determines that the client is experiencing a complication of the procedure on noting:

Pallor and coolness of the right leg

A nurse is teaching a nursing student how to measure a carotid pulse. The nurse should tell the student to measure the pulse on only one side of the client's neck primarily because:

Palpating both carotid pulses simultaneously could cause the heart rate and blood pressure to drop

A client is scheduled for a barium swallow (esophagography) in 2 days. The nurse, providing preprocedure instructions, should tell the client to:

Remove all metal and jewelry before the test

A client with histoplasmosis has the following arterial blood gas (ABG) results: pH 7.30, PCO2 58 mm Hg, PO2 75 mm Hg, HCO3 27 mEq/L. Which of the following acid-base disturbances does the nurse recognize in these results?

Respiratory acidosis

A nurse reviews the blood gas results of a client in respiratory distress. The pH is 7.32 and the PCO2 is 50 mm Hg. Which of the following acid-base imbalances does the nurse recognize in these findings?

Respiratory acidosis

A nurse is caring for a client who has just regained bowel sounds after undergoing surgery. The physician has prescribed a clear liquid diet for the client. Which of the following items does the nurse ensure is available in the client's room before allowing the client to drink?

Suction epuipment

A nurse is conducting an assessment of a client who underwent thoracentesis of the right side of the chest 3 hours ago. Which findings does the nurse report to the physician? Select all that apply.

Unequal chest expansion Diminished breath sounds in the right lung

A nurse is reviewing laboratory results for a client who is at risk for nephrotoxicity because of medications he is taking. Which of the following serum creatinine results does the nurse document as normal?

1.0 mg/dL

A nurse has a prescription to collect a 24-hour urine specimen from a client. Which of the following measures should the nurse take during this procedure?

Asking the client to void, discarding the specimen, and noting the start time

A CD4+ lymphocyte count is performed on a client who is infected with HIV. The results of the test indicate a CD4+ count of 450 cells/L. The nurse interprets this test result as indicating:

The need for antiretroviral The normal CD4+ count is between 500 and 1600 cells/mcL. Antiretroviral therapy is recommended when the CD4+ count is less than 500 cells/mcL or below 25%, or when the client shows symptoms of HIV.

A client has made an appointment to for her annual Papanicolaou test (a.k.a. Pap smear). The nurse who schedules the appointment should tell the client that:

The test cannot be performed while the client is menstruating

A client is tested for HIV with the use of an enzyme-linked immunosorbent assay (ELISA), and the test result is positive. The nurse should tell the client that:

The test will need to be confirmed with the use of a Western blot

A client has a chest drainage system in place. The fluid in the water seal chamber rises and falls during inspiration and expiration. The nurse interprets this finding as an indication that:

The tube is patent

A nurse is providing post-procedure instructions to a client returning home after arthroscopy of the shoulder. The nurse should tell the client:

To report to the physician the development of fever or redness and heat at the site

A nurse reviews a client's urinalysis report. Which finding does the nurse recognize as abnormal?

The presence of ketones

A client's baseline vital signs are temperature 98° F oral, pulse 74 beats/min, respiratory rate 18 breaths/min, and blood pressure 124/76 mm Hg. The client suddenly spikes a fever of 103° F. Which of the following respiratory rates would the nurse anticipate as part of the body's response to the change in client status?

22 breaths/min

Oxygen by way of nasal cannula has been prescribed for a client with emphysema. The nurse checks the physician's prescriptions to ensure that the prescribed flow is not greater than:

3 L/min

A client with cardiovascular disease is scheduled to receive a daily dose of furosemide (Lasix). Which potassium level would cause the nurse, reviewing the client's electrolyte values, to contact the physician before administering the dose?

3.0 mEq/L

A client admitted to the hospital with a diagnosis of acute pancreatitis has blood drawn for several serum laboratory tests. Which of the following serum amylase values, noted by the nurse reviewing the results, would be expected in this client at this time?

395 units/L The normal serum amylase range is 25 to 151 units/L. In acute pancreatitis, the amylase level is greatly increased; starts rising 3 to 6 hours after the onset of pain, peaks at about 24 hours, and returns to normal in 2 to 3 days after the onset of pain.

Blood is drawn from a client with suspected uric acid calculi for a serum uric acid determination. Which value does the nurse recognize as a normal uric acid level?

5.8 mg/dL The normal range for uric acid is 4.5 to 8 mg/dL for males and 2.5 to 6.2 mg/dL for females.

A client without a history of respiratory disease has a pulse oximeter in place after surgery. The nurse monitors the pulse oximeter readings to ensure that oxygen saturation remains above:

95%

A nurse has a prescription to insert a nasogastric tube into the stomach of an assigned client. Which action should the nurse take to insert the tube safely and easily?

Asking the client to swallow as the tube is being advanced Correct

A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets about:

Administering oxygen by way of nasal cannula

A nurse receives a telephone call from a nurse on the post-anesthesia care unit, who reports that a client is being transferred to the surgical unit. What should the nurse plan to do first on arrival of the client?

Assess the patency of the airway

A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse hears a wheeze. The nurse tries to remove the suction catheter from the client's trachea but is unable to do so. The nurse would first:

Disconnect the suction source from the catheter

A client has just returned to the nursing unit after computerized tomography (CT) with contrast medium. Which of the following actions should the nurse plan to take as part of routine after-care for this client?

Encouraging fluid intake

A nurse assesses the closed chest tube drainage system of a client who underwent lobectomy 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. The nurse first:

Check for kinks in the drainage system

A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody secretions. The nurse would first:

Check the degree of suction being applied

A client has just returned to the nursing unit after bronchoscopy. To which intervention should the nurse give priority?

Checking for the return of the gag reflex Correct

A nurse is assessing a postoperative client on an hourly basis. The nurse notes that the client's urine output for the past hour was 25 mL. On the basis of this finding, the nurse first:

Checks the client's overall intake and output record

Blood for arterial blood gas determinations is drawn on a client with pneumonia, and testing reveals a pH of 7.45, PCO2 of 30 mm Hg, and HCO3 of 19 mEq/L. The nurse interprets these results as indicative of:

Compensated respiratory alkalosis

A nurse is monitoring a client who has undergone pleural biopsy. Which of the following findings causes the nurse to suspect that the client is experiencing a complication?

Complains of shortness of breath

A nurse administers scopolamine as prescribed to a client in preparation for surgery. For which side effect of this medication does the nurse monitor the client?

Complaints of dry mouth an anticholinergic medication

signs and symptoms of respiratory acidosis

Disorientation and dyspnea

A client has undergone pericardiocentesis to treat cardiac tamponade. For which signs should the nurse assess the client to determine whether the tamponade is recurring?

Distant muffled heart sounds

Polyethylene glycol-electrolyte solution (GoLYTELY) is prescribed for a hospitalized client scheduled for colonoscopy. The client begins to experience diarrhea after drinking the solution. Which action by the nurse is appropriate?

Documenting the diarrhea in the medical record

A pelvic ultrasound is prescribed to evaluate a client's ovarian mass. What should the nurse giving preprocedure instructions tell the client that it important to do before the procedure?

Drink 6 to 8 glasses of water without voiding

A client who has received sodium bicarbonate in large amounts is at risk for metabolic alkalosis. For which of the following signs and symptoms does the nurse assess this client?

Dysrhythmias and decreased respiratory rate and depth

A client has just undergone lumbar puncture. Into which position does the nurse assist the client after the procedure?

Flat

A client is receiving intermittent bolus feedings by way of a nasogastric tube. In which position should the nurse place the client once the feeding is complete?

Head of the bed elevated 30 to 45 degrees

A client who underwent preadmission testing 1 week before surgery had blood drawn for several serum laboratory studies. Which abnormal laboratory results should the nurse report to the surgeon's office? Select all that apply.

Hematocrit 30% Hemoglobin 8.9 g/dL The normal hemoglobin is 12 to 16.5 g/dL, and the hematocrit ranges from 35% to 52%.

A nurse has a prescription to discontinue a client's nasogastric tube. The nurse auscultates the client's bowel sounds, positions the client properly, and flushes the tube with 15 mL of air to clear secretions. The nurse then instructs the client to take a deep breath and:

Hold the breath during tube removal

A client who is mouth breathing is receiving oxygen by face mask. The nursing assistant asks the nurse why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The nurse responds that the primary purpose of the water is to:

Humidify the oxygen that is bypassing the client's nose

A nurse is monitoring the respiratory status of a client who has just undergone surgery and is wearing a pulse oximeter. Which of the following coexisting problems is cause for the nurse to suspect that the oxygen saturation readings are not entirely accurate?

Low blood pressure

A nurse is getting a client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which of the following actions should the nurse take first?

Lowering the head of the bed slowly until the dizziness is relieved

A client is brought to the emergency department by a neighbor. The client is lethargic and has a fruity odor on the breath. The client's arterial blood gas (ABG) results are pH 7.25, PCO2 34 mm Hg, PO2 86 mm Hg, HCO3 14 mEq/L. Which of the following acid-base disturbances does the nurse recognize in these results?

Metabolic acidosis

A client with type 1 diabetes mellitus has a blood glucose level of 620 mg/dL. After the nurse calls the physician to report the finding and monitors the client closely for:

Metabolic acidosis

A nurse is caring for a client who is vomiting. For which acid-base imbalance does the nurse assess the client?

Metabolic alkalosis

A client in the postanesthesia care unit has an as-needed prescription for ondansetron (Zofran). Which of the following occurrences would prompt the nurse to administer this medication to the client?

Nausea and vomiting

A nurse is preparing for intershift report when a nurse's aide pulls an emergency call light in a client's room. Upon answering the light, the nurse finds a client who returned from surgery earlier in the day experiencing tachycardia and tachypnea. The client's blood pressure is 88/60 mm Hg. Which action should the nurse take first?

Placing the client in a modified Trendelenburg position

A nurse checks the residual volume from a client's nasogastric tube feeding before administering an intermittent tube feeding and finds 35 mL of gastric contents. What should the nurse do before administering the prescribed 100 mL of formula to the client?

Pour the residual volume into the nasogastric tube through a syringe with the plunger removed

A nurse is caring for a client who has lost a significant amount of blood as a result of complications during a surgical procedure. Which parameter does the nurse recognize as the earliest indication of new decreases in fluid volume?

Pulse rate

A nurse is preparing a client for intravenous pyelography (IVP). Which action by the nurse is most important?

Questioning the client about allergies to iodine or shellfish

A client has the following arterial blood gas (ABG) results: pH 7.51, PCO2 31 mm Hg, PO2 94 mm Hg, HCO3 24 mEq/L. Which of the following acid-base disturbances does the nurse recognize in these results?

Respiratory alkalosis

A nurse is caring for a client who has undergone pulmonary angiography with catheter insertion through the right femoral vein. The nurse assesses for allergic reaction to the contrast medium by monitoring for the presence of:

Respiratory distress

A nurse is reviewing the results of serum laboratory studies of a client with suspected hepatitis. Which increased parameter is interpreted by the nurse as the most specific indicator of this disease?

Serum bilirubin

A nurse is watching as a nursing student suctions a client through a tracheostomy tube. Which actions on the part of the student would prompt the nurse to intervene and demonstrate correct procedure? Select all that apply.

Setting the suction pressure to 60 mm Hg Applying suction throughout the procedure Placing the client in a supine position before the procedure

A client who is anxious about an impending surgery is at risk for respiratory alkalosis. For which signs and symptoms of respiratory alkalosis does the nurse assess this client?

Tachypnea, dizziness, and paresthesias

A client who has undergone an esophagogastroduodenoscopy (EGD) returns from the endoscopy department. After checking the client's gag reflex, which action should the nurse take?

Taking the clients vital signs

A client has just undergone insertion of a chest tube that is attached to a closed chest drainage system. Which action should the nurse plan to take in the care of this client?

Taping the connections between the chest tube and the drainage system

A client who has sustained a myocardial infarction is scheduled to have an echocardiogram. Which of the following measures should the nurse take before the procedure?

Telling the client that the procedure is painless and takes 30 to 60 minutes to complete

A woman has been scheduled for a routine mammogram. The nurse should tell the client:

That deodorants, powders, or creams used in the axillary or breast area must be washed off before the test Correct

A client has just been scheduled for endoscopic retrograde cholangiopancreatography (ERCP). What should the nurse tell the client about the procedure? Select all that apply.

That informed consent is required. That food and fluids will be withheld before the procedure. That multiple position changes may be necessary to pass the tube .

A nurse is reading the chest x-ray report of a client who has just been intubated. The report states that the tip of the endotracheal tube lies 1 cm above the carina. The nurse interprets that the tube is positioned above:

The bifurcation of the right and left main stem bronchi

A nurse is assessing the chest tube drainage system of a postoperative client who has undergone a right upper lobectomy. The closed drainage system contains 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour after the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant, and the client appears dyspneic. On the basis of these findings, the nurse should first assess:

The chest tube connections

A nurse is performing nasotracheal suctioning on a client. Which of the following observations should be cause for concern to the nurse? Select all that apply.

The client becomes cyanotic Secretions are becoming bloody.

A nurse provides information to a client who is scheduled for cardiac catheterization to rule out coronary occlusion. The nurse should tell the client that:

The client may have feelings of warmth or flushing during the procedure Correct

A physician is about to perform paracentesis on a client with abdominal ascites. Into which position would the nurse assist the client?

Upright

A nurse is watching as a nursing assistant measures the blood pressure (BP) of a hypertensive client. Which actions on the part of the assistant that would interfere with accurate measurement would prompt the nurse to intervene? Select all that apply.

Used a cuff with a rubber bladder that encircles at least 60% of the limb. Measuring the BP after the client reports that he just drank a cup of coffee. Allowing the client to talk as the blood pressure is being measured.

A client with diabetes mellitus is scheduled to have blood drawn for a fasting blood glucose determination drawn in the morning. What does the nurse tell the client that it is acceptable to consume on the morning of the test?

Water

A nurse in a physician's office has just made an appointment for a client to undergo an exercise stress test. The nurse, in providing pre-procedure teaching, should tell the client to:

Wear comfortable rubber-soled shoes such as sneakers