N322 EXAM 2 Review

8. A client admitted to the hospital states, "Someone asked me to fill out an advance directive when I was admitted, but I was too stressed. What is that for?" How will the nurse respond? -"You will need to see a lawyer to complete advance directives." -"You need to complete that paperwork before admission." -"Advance directives allow a client to convey health care wishes." -"Advance directives are for those individuals who are critically ill."

"Advance directives allow a client to convey health care wishes." The nurse responds by stating that advanced directives allow a client to convey his or her wishes about health care. This best addresses the client's comments. Most advance directives are in place before the client becomes severely ill. Many Americans do not have advance directives in place. Legal assistance is not necessary to complete them. Although completing paperwork pertaining to advance directives before admission would be ideal, any time is a good to do this.

58. Which precaution will the nurse include when providing instructions to the female client with hypothyroidism who is prescribed to take thyroid hormone replacement therapy (HRT)? -"Increase the amount of fiber in your diet to prevent the side effect of constipation." -"Stop this drug immediately if you discover you are pregnant." -"Avoid over-the-counter medications unless prescribed by your primary health care provider." -"If you miss a dose, double your next day's dose."

"Avoid over-the-counter medications unless prescribed by your primary health care provider." The amount of drug in synthetic thyroid hormone tablets is very small and many other foods and drugs interfere with its absorption. The client is instructed to not take over-the-counter medications without approval from the primary health care provider. Fiber greatly interferes with the drug's absorption and is not to be taken with or within 4 hours of HRT. In addition, the drug does not cause constipation. Thyroid HRT must continue during pregnancy. The therapy works best when blood levels are maintained. The client is taught to take the forgotten drug as soon as it is remembered and not to double the next day's dose.

62. A client with chronic kidney disease asks the nurse about the relationship between the disease and high blood pressure. What is the most appropriate nursing response? -"The damaged kidneys no longer release a hormone that prevents high blood pressure." -"The waste products in the blood interfere with mechanisms that control blood pressure." -"There is a compensatory mechanism that increases blood flow through the kidneys in an effort to get rid of some of the waste products." -"Because the kidneys cannot get rid of fluid, blood pressure goes up."

"Because the kidneys cannot get rid of fluid, blood pressure goes up." The nurse's best response to a client with chronic kidney disease and high blood pressure is, "Because the kidneys cannot get rid of fluid, blood pressure goes up." In chronic kidney disease, fluid levels increase in the circulatory system. The statements asserting that damaged kidneys no longer release a hormone to prevent high blood pressure, waste products in the blood interfere with other mechanisms controlling blood pressure, and high blood pressure is a compensatory mechanism that increases blood flow through the kidneys in attempt excrete waste products are not accurate regarding the relationship between chronic kidney disease and high blood pressure.

9. The nurse reviews a routine discharge teaching plan on postoperative care with a client. Which client statement indicates that teaching about wound care has been effective? -"The wound will completely heal in about 2 months." -"I should remove the dressing if the wound is draining." -"I may need to restrict my activities for several months." -"Some bleeding from the incision is normal for several weeks."

"I may need to restrict my activities for several months." To protect the integrity of the wound, activities may need to be restricted. The wound is usually open to air for healing, but draining wounds need to be covered. Bleeding and serosanguineous drainage are not normal after 5 days. The length of time it takes for a wound to heal varies, which can be up to 2 years.

62. A client, who is a mother of two, has autosomal dominant polycystic kidney disease (ADPKD). Which client statement indicates to the nurse that the client needs further education? -"My children have a 50% chance of inheriting the ADPKD gene that causes the disease." -"By maintaining a low-salt diet in our house, I can prevent ADPKD in my children." -"Even though my children don't have symptoms at the same age I did, they can still have ADPKD." -"If my children have the ADPKD gene, they will have cysts by the age of 30."

"By maintaining a low-salt diet in our house, I can prevent ADPKD in my children." Further teaching about ADPKD when a mother of two says, "By maintaining a low-salt diet in our house, I can prevent ADPKD in my children." There is no way to prevent ADPKD, although early detection and management of hypertension may slow the progression of kidney damage. Limiting salt intake can help control blood pressure. Limiting salt intake can help control blood pressure. Presentation of ADPKD can vary by age of onset, manifestations, and illness severity, even in one family. Almost 100% of those who inherit a polycystic kidney disease (PKD) gene will develop kidney cysts by age 30. Children of parents who have the autosomal dominant form of PKD have a 50% chance of inheriting the gene that causes the disease.

56. What is the nurse's best first response when a client with a suspected endocrine disorder says, "I can't, you know, satisfy my wife anymore."? -"Don't worry. It happens to everyone occasionally." -"Do you use any over the counter or recreational drugs?" -"Can you please tell me more?" -"Would you like to speak with a counselor?"

"Can you please tell me more?" An open-ended question such as, "Can you please tell me more?," is a best first response because it allows the nurse to explore the client's feelings more thoroughly. Clients with endocrine disorders may report issues with infertility, impotence, and changes in sexual function. Telling a client not to worry or that something happens to many others is dismissive and therefore incorrect. Referring the client to a counselor is not an appropriate first step. This action does not allow for assessment of the issue nor allow him to express his concerns. Asking about drug use is not a good first question until the nurse or other health care provider knows more about how long the problem has been present and about the client's general health. Sexual difficulties may also be psychological, as well as be caused by a variety of physical changes.

59. Which precaution is most important for the nurse to teach a client who has cardiovascular autonomic neuropathy (CAN) from diabetes to prevent harm? -"Check your hands and feet weekly for chronic excessive sweating." -"Change positions slowly when moving from sitting to standing." -"Avoid drinking caffeine or caffeinated beverages." -"Be sure to take your blood pressure drug daily."

"Change positions slowly when moving from sitting to standing." Cardiovascular autonomic neuropathy (CAN) affects sympathetic and parasympathetic nerves of the heart and blood vessels. This problem contributes to left ventricular dysfunction, painless myocardial infarction, and exercise intolerance. Most often, CAN leads to orthostatic (postural) hypotension and syncope (brief loss of consciousness on standing). These problems are from failure of the heart and arteries to respond to position changes by increasing heart rate and vascular tone. As a result, blood flow to the brain is interrupted briefly. Orthostatic hypotension and syncope increase the risk for falls, especially among older adults. Although taking blood pressure medication daily is important, it does not prevent orthostatic hypotension and in fact, may make orthostatic hypotension worse. Sensation changes are associated with peripheral neuropathy, not cardiovascular autonomic neuropathy. Avoiding caffeine is no longer a recommended action.

61. A male client being treated for bladder cancer has a live virus compound instilled into his bladder as a treatment. What instruction does the nurse provide for post procedure home care? -"Underwear worn during the procedure and for 12 hours afterward should be discarded." -"Please be sure to stand when you are urinating." -"After 12 hours, your toilet should be cleaned with a 10% solution of bleach." -"Do not share your toilet with family members for the next 24 hours."

"Do not share your toilet with family members for the next 24 hours." The nurse tells the client who is being treated for bladder cancer and had a live virus compound instilled into his bladder not to share his toilet with family members for the next 24 hours. The toilet must not be shared for 24 hours following this procedure because others using the toilet could be infected with the live virus that was instilled into the client. If only one toilet is available in the household, teach the client to flush the toilet after use and to follow this by adding 1 cup (236 mL) of undiluted bleach to the bowl water. The bowl is then flushed after 15 minutes, and the seat and flat surfaces of the toilet are wiped with a cloth containing a solution of 10% liquid bleach. The client must sit while urinating for at least 24 hours postprocedure to prevent splashing of the contaminated urine out of the commode, where it could be toxic for anyone who comes in contact with it. Underwear or other clothing that has come into contact with urine during the 24 hours after instillation must be washed separately from other clothing in a solution of 10% liquid bleach. It does not need to be discarded.

60. The nurse is teaching a client who needs a clean-catch urine specimen. What teaching will the nurse include? -"Save all urine for 24 hours." -"Do not touch the inside of the container." -"Use the sponges to cleanse the urethra, and then initiate voiding directly into the cup." -"You will receive an isotope injection, then I will collect your urine."

"Do not touch the inside of the container." Before obtaining a clean-catch urine specimen, the nurse instructs the client not to touch the inside of the container. A clean-catch specimen is used to obtain urine for culture and sensitivity of organisms present. Contamination by any part of the client's anatomy will render the specimen invalid and alter results. Saving urine for 24 hours is not necessary for a midstream clean-catch urine specimen. After cleaning, the client needs to initiate voiding into the commode, then stop and resume voiding into the container. Only 1 ounce (30 mL) is needed. The remainder of the urine may be discarded into the commode. A midstream collection further removes secretions and bacteria because urine flushes the distal portion of the internal urethra. A clean catch specimen for culture does not require injection of an isotope before urine is collected.

57. Which question asked by a 48-year-old client with sleep apnea whose blood glucose level is elevated suggests to the nurse the possibility of a growth hormone excess? -"Do you think if I lost weight my sleep apnea would improve?" -"Why do I feel thirsty all the time?" -"How can I make my skin less itchy?" -"Does everyone's feet get bigger during menopause?"

"Does everyone's feet get bigger during menopause?" Growth hormone is secreted and is needed throughout the life span. When it is secreted in excess in adults, organs can enlarge and bones containing desmoid bone type increase in size, including the facial bones, hands, and feet. The other client questions are reasonable for a client with sleep apnea, hyperglycemia, and menopause to ask.

60. An older adult woman who reports a change in bladder function says, "I feel like a child who sometimes pees her pants." What is the best nursing response? -"Have you tried using the toilet every couple of hours?" -"How does that make you feel?" -"We can fix that." -"That happens when we get older."

"Have you tried using the toilet every couple of hours?" The nurse's best response to a client who states, "I feel like a child who sometimes pees her pants," is to ask the client if she uses the toilet at least every couple of hours. By emptying the bladder on a regular basis, urinary incontinence from overflow may be avoided, which may give the client some sense of control. The client has already stated how she feels. Asking her again does not address her concern, nor does it allow for nursing education. The nurse cannot assert that the problem can be fixed because this may be untrue. Suggesting that the problem occurs as we get older does not address the client's concern and does not provide for any client teaching.

57. Which question is most relevant to ask a male client suspected to have a gonadotropin deficiency? -"Are you experiencing any pain during sexual intercourse?" -"Do you work with or have hobbies that involve exposure to chemicals?" -"Have you gained or lost any weight recently?" -"How often do you need to shave your face?"

"How often do you need to shave your face?" A gonadotropin deficiency reduces the expression of secondary sexual characteristics and leads to decreased libido and fertility in both male and female clients. Male clients lose facial fair and need to shave less frequently. This change may be the first problem noticed by the client. A deficiency does not result in painful intercourse for men although it can in women from vaginal dryness.

58. Which statement made by the client alerts the nurse to the possibility of hypothyroidism? -"I seem to feel the heat more than other people." -"I am always tired, even when I get 10 or 12 hours of sleep." -"Food just doesn't taste good without a lot of salt." -"My grandmother had thyroid problems."

"I am always tired, even when I get 10 or 12 hours of sleep." Clients with hypothyroidism usually feel tired or weak and often report an increase in time spent sleeping, sometimes up to 14 to 16 hours per day. Thyroid problems are very common among women and do not demonstrate a specific pattern of inheritance. Clients with hypothyroidism have a slow metabolism and have difficulty keeping warm. Salt craving is not a symptom of hypothyroidism.

62. The school nurse is counseling a teenage student about how to prevent kidney trauma. Which student statement indicates a need for further teaching? -"I always wear pads when playing football." -"I can't play contact sports since my brother had kidney cancer." -"I will avoid riding motorcycles." -"I always wear a seat belt in the car."

"I can't play contact sports since my brother had kidney cancer." Further teaching about preventing kidney trauma is needed when the teenage student says, "I can't play any type of contact sports because my brother had kidney cancer." Contact sports and high-risk activities must be avoided if a person has only one kidney. A family history of kidney cancer does not prohibit this type of activity. To prevent kidney and genitourinary trauma, caution would be taken when riding bicycles and motorcycles. People need to wear appropriate protective clothing when participating in contact sports. Anyone riding in a car must wear a seat belt.

9. During a preoperative assessment, which statement by a client requires further investigation by the nurse to assess surgical risks? -"I quit smoking 10 years ago." -"I had a heart attack 4 months ago." -"I take a multivitamin daily." -"I drink a glass of wine a night."

"I had a heart attack 4 months ago." The statement by the client that he or she had a heart attack 4 months ago requires further investigation. Cardiac problems increase surgical risks, and the risk for a myocardial infarction during surgery is higher in clients who have heart problems. The nurse will note that the client takes a multivitamin, but this is not of substantial risk. Moderate alcohol consumption is not considered high-risk behavior. A past history of smoking should be noted, but current or more recent smoking is of greater concern.

61. The nurse educates a group of women who have had frequent urinary tract infections (UTIs) about how to avoid recurrences. Which client statement shows understanding of the teaching? -"Trying to get to the bathroom to urinate every 6 hours is important for me." -"Urinating 1000 mL on a daily basis is a good amount for me." -"I need to be drinking at least 1.5 to 2.5 L of fluids every day." -"It is a good idea for me to reduce germs by taking a tub bath daily."

"I need to be drinking at least 1.5 to 2.5 L of fluids every day." The client who shows a correct understanding of avoiding UTIs says, "I need to be drinking at least 1.5 to 2.5 L of fluids every day." To reduce the number of UTIs, clients need to be drinking a minimum of 1.5 to 2.5 L of fluid (mostly water) each day. Showers, rather than tub baths, are recommended for women who have recurrent UTIs. Urinating every 3 to 4 hours is ideal for reducing the occurrence of UTI. This is advisable rather than waiting until the bladder is full to urinate. Urinary output needs to be at least 1.5 L daily. Ensuring this amount "out" is a good indicator that the client is drinking an adequate amount of fluid.

61. The nurse is instructing an older adult female client about interventions to decrease the risk for cystitis. Which client statement indicates that the teaching was effective? -"I need to douche vaginally once a week." -"I will not drink fluids after 8 p.m. each evening." -"I need to drink 2½ L of fluid every day." -"I must avoid drinking carbonated beverages."

"I need to drink 2½ L of fluid every day." Teaching an older female about interventions to decrease the risk for cystitis is effective when the client says, "I need to drink 2½ L of fluid every day." Drinking this much fluid each day flushes out the urinary system and helps reduce the risk for cystitis. Avoiding carbonated beverages is not necessary to reduce the risk for cystitis. Douching is not a healthy behavior because it removes beneficial organisms as well as the harmful ones. Avoiding fluids after 8:00 p.m. would help prevent nocturia but not cystitis. It is recommended that clients with incontinence problems limit their late-night fluid intake to 120 mL.

61. The nurse is questioning a female client with a urinary tract infection (UTI) about her antibiotic drug regimen. Which client statement requires further teaching? -"I try to drink 3 L of fluid a day." -"I take my medication when I have symptoms." -"I don't use bubble baths." -"I wipe front to back."

"I take my medication when I have symptoms." Further teaching is need for a female client with a UTI taking an antibiotic drug regimen when the client says, "I take my medication only when I have symptoms." clients with UTIs must complete all prescribed antibiotic therapy, even when symptoms of infection are absent. Wiping front to back helps prevent UTIs because it prevents infection-causing microorganisms in the stool from getting near the urethra. Limiting bubble baths and drinking 3 L of fluid a day help prevent UTIs.

61. A client is admitted for extracorporeal shock wave lithotripsy (ESWL). What information obtained on admission is most critical for a nurse to report to the primary health care provider before the ESWL procedure begins? -"I have been taking cephalexin for an infection." -"I previously had several ESWL procedures performed." -"Blood in my urine has decreased, so maybe I don't need this procedure." -"I take over-the-counter naproxen twice a day for joint pain."

"I take over-the-counter naproxen twice a day for joint pain." For a client admitted for ESWL, it is most critical for the nurse to report to the primary health care provider that the client takes over-the-counter naproxen twice a day for joint pain. Because a high risk for bleeding during ESWL has been noted, clients would not take nonsteroidal anti-inflammatory drugs before this procedure. The ESWL will have to be rescheduled for this client. Blood in the client's urine would be reported to the primary health care provider but will not require rescheduling of the procedure because blood is frequently present in the client's urine when kidney stones are present. A diminished amount of blood would not eliminate the need for the procedure. The client's taking cephalexin (Keflex) and the fact that the client has had several previous ESWL procedures would be reported, but will not require rescheduling of the procedure.

59. Which statement by a client indicates to the nurse correct understanding of what to do when the sensations of hunger and shakiness occur? -"I will eat three graham crackers." -"I will drink a glass of water." -"I will sit down and rest." -"I will give myself a dose of glucagon."

"I will eat three graham crackers." Feeling hungry and shaky are symptoms of mild hypoglycemia. Correct understanding of what the client needs to do when these symptoms occur is to eat three graham crackers. This is the correct management strategy for mild hypoglycemia. Drinking a glass of water or sitting down and resting does not remedy hypoglycemia. Glucagon is generally administered for episodes of severe not mild hypoglycemia.

61. The nurse is teaching a client who is scheduled for a neobladder and a Kock pouch. Which client statement indicates a correct understanding of these procedures? -"I need to wear loose-fitting pants so the urine can flow into my ostomy bag." -"If I restrict my oral intake of fluids, the adjustment will be -easier." -"I must go to the restroom more often because my urine will be excreted through my anus." -"I will have to drain my pouch with a catheter."

"I will have to drain my pouch with a catheter." The client who is scheduled for a neobladder and Kock pouch correctly understands the procedure when the client says, "I will have to drain my pouch with a catheter." A neobladder is a type of continent reservoir created from an intestinal graft to store urine and replace the surgically removed bladder. A Kock pouch is also a continent reservoir with a Penrose drain and a plastic Medena catheter in the stoma. The drain removes lymphatic fluid or other secretions. The catheter ensures urine drainage so that incisions can heal. For the client with a neobladder and a Kock pouch, urine is collected in a pouch and is drained with the use of a catheter.Urine is not excreted through the anus. Fluids would not be restricted. A neobladder does not require the use of an ostomy bag.

57. Which statement made by the client who is going home after a transsphenoidal hypophysectomy indicates to the nurse correct understanding of actions to prevent complications from this treatment? -"While I am awake, I will be sure to cough and deep breathe at least every 2 hours." -"I will keep the cat food bowl on my counter so that I do not have to bend over." -"Whenever I am out-of-doors in the sunshine, I will wear dark glasses." -"If the dressing gets wet, I will wash the incision line and redress it immediately."

"I will keep the cat food bowl on my counter so that I do not have to bend over." After this surgery, the client must take care to avoid activities that can increase intracranial pressure. They should avoid bending from the waste and should not bear down, cough, or lay flat. Wearing dark glasses while outside is not necessary to prevent complications from the surgery.

61. The nurse is teaching the importance of a low purine diet to a client admitted with urolithiasis consisting of uric acid. Which client statement indicates that teaching was effective? -"I will quit growing rhubarb in my garden since I'm not supposed to eat it anymore." -"I will no longer be able to have red wine with my dinner." -"I am so relieved that I can continue eating my fried fish meals every week." -"My wife will be happy to know that I can keep enjoying her liver and onions recipe."

"I will no longer be able to have red wine with my dinner." Teaching about low purine diets to a client with urolithiasis consisting of uric acid is effective when the client says, "I will no longer be able to have red wine with my dinner." Nutrition therapy depends on the type of stone formed. When stones consist of uric acid (urate), the client needs to decrease intake of purine sources such as organ meats, poultry, fish, gravies, red wines, and sardines. Reduction of urinary purine content may help prevent these stones from forming. Avoiding oxalate sources such as spinach, black tea, and rhubarb is appropriate when the stones consist of calcium oxalate.

56. After instructing a client about the correct procedure for a 24-hour urine test, which client statement indicates to the nurse a need for further teaching? -"I will not eat any fatty foods when I am collecting urine for this test." -"To end the collection, I must empty my bladder and add this urine to the collection." -"I need to keep the urine container cool in a separate refrigerator or cooler." -"I won't save the first urine sample of the day."

"I will not eat any fatty foods when I am collecting urine for this test." A need for further teaching is needed when the client says that he/she will not eat any fatty foods while collecting urine for a 24-hour urine test to evaluate a hormone level. Eating fatty foods does not interfere with collection or testing of the urine sample. The other statements indicate correct understanding of the client's actions for collection of an accurate 24-hour urine specimen.

61. The nurse is teaching a client with a neurogenic bladder to use intermittent self-catheterization for bladder emptying. Which client statement indicates a need for further clarification? -"Proper handwashing before I start the procedure is very important." -"My family members can be taught to help me if I need it." -"A small-lumen catheter will help prevent injury to my urethra." -"I will use a new, sterile catheter each time I do the procedure."

"I will use a new, sterile catheter each time I do the procedure." The client with a neurogenic bladder who needs to self-catheterize for bladder emptying requires further clarification when the client says, "I will use a new, sterile catheter each time I do the procedure." Catheters are cleaned and reused. With proper handwashing and cleaning of the catheter, no increase in bacterial complications has been shown. Catheters are replaced when they show signs of deteriorating. The smallest lumen possible and the use of a lubricant help reduce urethral trauma to this sensitive mucous tissue. Research shows that family members in the home can be taught to perform straight catheterizations using a clean (rather than a sterile) catheter with good outcomes. Proper handwashing is extremely important in reducing the risk for infection in clients who use intermittent self-catheterization and is a principle that must be stressed.

60. The nurse is teaching a client how to provide a clean-catch urine specimen. Which client statement indicates that teaching was effective? -"I will have to drink 2 L of fluid before providing the sample." -"I'll start to urinate in the toilet, stop, and then urinate into the cup." -"It is best to provide the sample while I am bathing." -"I must clean with the wipes and then urinate directly into the cup."

"I'll start to urinate in the toilet, stop, and then urinate into the cup." Teaching is demonstrated to be effective when the client says, "I'll start to urinate in the toilet, stop, and then urinate into the cup." A midstream collection further removes secretions and bacteria because urine flushes the distal portion of the internal urethra. Although cleaning with wipes before providing a clean-catch urine sample is proper procedure, a step is missing. It is not necessary to drink 2 L of fluid before providing a clean-catch urine sample. Providing a clean-catch urine sample does not involve bathing.

58. Which statement made by a client about thyroid hormone replacement therapy (HRT) indicates to the nurse that further teaching is needed? -"If I continue to lose weight, I may need an increased dose." -"I will have more energy with this medication." -"If I often am constipated and feel tired, I may need an increased dose." -"I will take the medication every morning."

"If I continue to lose weight, I may need an increased dose." The statement, "If I continue to lose weight, I may need an increased dose," indicates a need for further teaching. Weight loss indicates a need for a decreased dose, not an increased dose. One of the symptoms of hypothyroidism is lack of energy. Thyroid replacement therapy would cause the client to have more energy. The correct time to take thyroid replacement therapy is in the morning. Frequent constipation and continuing to feel tired are indications that the dose may need to be increased.

59. What is the nurse's best response to a client newly diagnosed with type 1 diabetes who asks why insulin is only given by injection and not as an oral drug? -"Injected insulin works faster than oral drugs to lower blood glucose levels." -"Oral insulin is so weak that it would require very high dosages to be effective." -"Insulin is a small protein that is destroyed in by stomach acids and intestinal enzymes." -"Insulin is a "high alert drug" and could more easily be abused if it were available as an oral agent."

"Insulin is a small protein that is destroyed in by stomach acids and intestinal enzymes." Because insulin is a small protein that is easily destroyed by stomach acids and intestinal enzymes, it cannot be used as an oral drug. Most commonly, it is injected subcutaneously.

63. A client is scheduled to undergo kidney transplant surgery. Which teaching point does the nurse include in the preoperative teaching session? -"It is essential for you to wash your hands and avoid people who are ill." -"The new kidney will be placed directly below one of your old kidneys." -"You will receive dialysis the day before surgery and for about a week after." -"Your diseased kidney will be removed when the transplant is performed."

"It is essential for you to wash your hands and avoid people who are ill." Teaching the client to wash hands and stay away from sick people are important points for the nurse to include in teaching for a client scheduled for a kidney transplant. Antirejection medications increase the risks for infection, sepsis, and death. Strict aseptic technique and handwashing are essential. Unless severely infected, the client's kidneys are left in place and the graft is placed in the iliac fossa. Dialysis is performed the day before surgery. After the surgery, the new kidney should begin to make urine.

58. Which statement made by a client who is undergoing therapy with radioactive iodine (RAI) for Graves disease indicates a lack of understanding about the disorder and its treatment? -"Luckily, I have my own bathroom, so I won't be exposing the rest of my family to radiation. -"If this treatment works, maybe I will stop sweating all the time. -"It will be great to lose my "bug-eyed" appearance. -"I hope I don't gain too much weight when my thyroid function is normal.

"It will be great to lose my "bug-eyed" appearance. Although successful radioactive iodine (RAI) therapy for Graves disease results in reducing most physical symptoms, the exophthalmia does not respond to this therapy. Other measures, such as drug therapy targeted to the exophthalmos and not the hyperthyroidism and surgery to remove tissue from behind the eye, are needed to improve the eye appearance. All other client statements demonstrate accurate understanding of the disorder and its treatment.

5. The family of a client with chronic cancer pain says to the nurse, "Can you please reduce Dad's pain medication so that we can spend more quality time with him?" How does the nurse respond? -"Yes, this is a valuable way for all of you to make needed adjustments." -"Let's ask your father about your request." -"No, his pain relief is more important than your concerns." -"I will ask his oncologist about your question."

"Let's ask your father about your request." The nurse will respond by indicating that the client's desires about analgesia are the most important consideration in this scenario, and so he would be consulted initially about his family's request. This open-ended type of question acknowledges the family, while keeping the client as the major decision maker. Although the health care provider might have an opinion about the family's request, pain is subjective, and the client's desires about analgesia are the most important consideration. Telling the family that the father's pain control is more important than their concerns is a demeaning response, although technically true; it is dismissive of the family and is nontherapeutic. Giving the family control of pain relief for their father is inappropriate in this situation; the subjective nature of pain places decisions about the use of analgesia with the client who is experiencing the pain. The family and the client may need to make adjustments, but reducing pain relief for the client is not an advisable way to accomplish this goal.

59. A client expresses fear and anxiety over the life changes associated with diabetes, stating, "I am scared that I can't do it all and will get so sick that I will be a burden on my family." What is the nurse's best response? -"Let's tackle it piece by piece. What is most scary to you?" -"It is overwhelming, isn't it?" -"Let's see how much you can learn today, so you are less nervous." -"Many people live with diabetes and do it just fine."

"Let's tackle it piece by piece. What is most scary to you?" The nurse's best response is to suggest that the client tackle it piece by piece and ask what is most scary to him or her. This is the best client-centered response, and acknowledges the client's concern, letting the client master survival skills first. Referring to the illness as overwhelming may reflect the client's feelings, but is a closed-ended question and does not encourage the client to express his feelings about the underlying fear. Trying to see how much the client can learn in 1 day may add to his anxiety by overwhelming him with information and the need to "do it all" in 1 day. Suggesting that other people handle the illness just fine criticizes the client and does not recognize his concerns.

59. What action will the nurse advise to prevent harm for a client with diabetes who has a 3-cm callus on the ball of the right foot? -"Make an appointment with your podiatrist as soon as possible." -"Make an appointment with a pedicurist and have them cut or file off the callus." -"Soak your feet nightly in warm water and peel of a little of the callus every day." -"Apply an over-the-counter callus-dissolving pad and follow the package directions."

"Make an appointment with your podiatrist as soon as possible." The client with diabetes is taught to see his or her diabetes health care provider or a podiatrist for calluses, corns, or any other foot lesion and never to self-treat such problems. The risk for development of an ongoing injury with chronic infection is very high could lead to eventual amputation.

58. What is the nurse's best response when family members of a client with hyperthyroidism express concern about the client's frequent mood swings? -"Do the client's mood swings make you feel angry?" -"The medications will make the mood swings disappear completely." -"Your family member is sick. You must be patient." -"Mood swings are common should diminish with treatment."

"Mood swings are common should diminish with treatment." Telling the family that the client's mood swings should diminish over time with treatment provides information to the family, as well as reassurance that this behavior is expected. Asking the family if the client's mood swings make them angry is a closed-ended question and could make the family members feel guilty. The response needs to be client-centered. Any medications or treatment may not completely remove the mood swings associated with hyperthyroidism. The family is aware that the client is sick. Telling them to be patient can also cause feelings of guilt and does not address the family's concerns.

62. The nurse is performing discharge teaching for a client after a nephrectomy for renal cell carcinoma. Which client statement indicates that teaching has been effective? -"Since renal cell carcinoma usually affects both kidneys, I'll need frequent biopsies." -"My remaining kidney will provide normal kidney function in a few days or weeks." -"I need to decrease my fluid intake to prevent stress to my remaining kidney." -"I'll eventually require some type of renal replacement therapy."

"My remaining kidney will provide normal kidney function in a few days or weeks." Effective discharge teaching for a client after a nephrectomy for renal cell carcinoma is indicated when the client says, "my remaining kidney will provide me with normal kidney function in a few days or weeks." After a nephrectomy, the second kidney is expected to provide adequate kidney function, but this may take days or weeks. Renal cell carcinoma typically only affects one kidney. Renal replacement therapy is not the typical treatment for renal cell carcinoma. Fluids would be maintained to flush the remaining kidney.

59. Which specific action is a priority for the nurse to teach a client with diabetes who has peripheral neuropathy to prevent harm? -"Wear a medical alert bracelet." -"Never go barefoot." -"Never reuse insulin syringes." -"Drink at least 3 L of fluids daily."

"Never go barefoot." All the actions are important for the client with diabetes to perform for safety and to prevent a variety of complications. However, the most important action to prevent harm from peripheral neuropathy is to never go barefoot and wear shoes and slippers with firm soles.

5. The charge nurse is working with a new nurse. Which statement by the new nurse requires additional teaching by the charge nurse? -"Older adults usually believe that pain is irrelevant and is to be expected." -"Older adults are at a very high risk for undertreated pain." -"Older adults typically believe that expressing pain is acceptable." -"I always assess older adults for present pain."

"Older adults typically believe that expressing pain is acceptable." The charge nurse will need to provide further education to the new nurse regarding the statement, "Older adults typically believe that expressing pain is acceptable." Older adults typically do not believe that expressing pain is acceptable. Many older adults believe that pain is irrelevant and is "just part of getting older." As a result, many older adults are at great risk for undertreated pain. In addition, some health care providers have outdated beliefs about older adults' pain sensitivity, tolerance, and ability to take opioids.

9. The nurse is educating a client who is about to undergo cardiac surgery with general anesthesia. Which statement by the client indicates the need for further instruction from the nurse? -"I will have a bandage on my chest." -"My family will not be able to see me right away." -"I will wake up with a tube in my throat." -"Pain medication will take away all of my pain."

"Pain medication will take away all of my pain." The client's statement that, "Pain medication will take away all of my pain," indicates the need for further instruction. Pain medication will reduce pain, but will not take it away completely. The client statement about waking up with a tube in the throat is accurate, because the client will be intubated. Following heart surgery, a dressing is placed on the chest. The client will not be able to see family immediately because he or she will go to recovery first.

5. A client who is using patient-controlled analgesia (PCA) is asleep. The nurse observes a family member pushing the PCA button for the sleeping client. What will the nurse say to the visitor? -"Please allow the client to push the button when needed." -"Please don't touch any equipment in the client's room." -"Thank you. I am sure the client appreciated that." -"The client is asleep and is not in pain."

"Please allow the client to push the button when needed." The nurse will request that the visitor allow the client to push the button for medication when needed. The "PC" in "PCA" means "patient-controlled," so having someone else push the button and administer analgesia defeats the purpose. More important, this action could cause oversedation and possible serious safety issues. Telling the family member not to touch any equipment in the client's room is not only nonspecific, but it may also be perceived as disrespectful. Expressing appreciation is inappropriate because the nurse is condoning an unauthorized and potentially unsafe action. The fact that the client is asleep does not mean that the client is pain-free.

63. A client is being treated for kidney failure. Which nursing statement encourages the client to express his or her feelings? -"All of this is new. What can't you do?" -"How are you doing this morning?" -"Are you afraid of dying?" -"What concerns do you have about your kidney disease?"

"What concerns do you have about your kidney disease?" Asking the client about any concerns regarding your disease is an open-ended statement and specific to the client's concerns. Asking the client to explain what he or she can't do implies inadequacy on the client's part. Asking the client if he or she is afraid of dying is too direct and would likely cause the client to be anxious. Asking the client how he or she is doing is too general and does not encourage the client to share thoughts on a specific topic.

62. A client is hesitant to talk to the nurse about genitourinary dysfunction symptoms. What is the best nursing response? -"Why are you hesitant?" -"You need to tell me so we can determine what is wrong." -"Take your time. What is bothering you the most?" -"Don't worry, no one else will know."

"Take your time. What is bothering you the most?" The nurse's best response when a client is hesitant to talk about genitourinary dysfunction is "take your time. What is bothering you the most?" Asking the client what is bothering him or her expresses patience and understanding when trying to identify the client's problem. It is important for the nurse to encourage the client to tell his/her own story in familiar, comfortable language. Telling the client that others will not know is untrue because the client's symptoms will be in the medical record for other health care personnel to see. Asking why the client is hesitant can seem accusatory and threatening to the client. Admonishing the client to disclose his or her symptoms is too demanding; the nurse must be more understanding of the client's embarrassment.

5. A 44-year-old client with osteoarthritis pain tells the nurse, "I take two extra-strength acetaminophen (500 mg) every 8 hours." How does the nurse respond? -"More acetaminophen is needed to provide effective pain relief for you." -"You will need to have routine blood draws to monitor clotting time." -"That is the appropriate dose of acetaminophen for your pain." -"Aspirin would be a better, more effective choice for your pain relief."

"That is the appropriate dose of acetaminophen for your pain." In the healthy adult, a maximum daily dose below 4000 mg is rarely associated with liver toxicity. Many experts recommend reducing the daily dose (e.g., 2500 to 3000 mg daily) when used for long-term treatment in older adults. Acetaminophen does not increase bleeding time and has a low incidence of GI adverse effects, making it the analgesic of choice for many people in pain, especially older adults. The dose is appropriate; more is not indicated or advised. Acetaminophen is a better choice for pain relief than aspirin because it has fewer side effects on the gastrointestinal system, such as bleeding.

61. An older adult woman confides to the nurse, "I am so embarrassed about buying adult diapers for myself." How does the nurse respond? -"That is tough. What do you think might help?" -"Tell everyone that they are for your husband." -"Shop at night, when stores are less crowded." -"Don't worry about it. You need them."

"That is tough. What do you think might help?" When an older women says to the nurse, "I am so embarrassed about buying adult diapers for myself," the nurse says "That is tough. What do you think might help?" Stating that the situation is tough acknowledges the client's concerns, and asking the client to think about what might help assists the client to think of methods to solve her problem. Telling the client not to worry is dismissive of the client's concerns. Telling the client to shop at night does not empower the client, and it reaffirms the client's embarrassment. Suggesting to the client that she tell everyone they are for her husband also does not empower the client. Rather, it suggests to the client that telling untruths is acceptable.

5. A client being discharged after hip replacement says, "I am going to use hypnosis instead of medication to manage my pain. I believe in mind over body." Which nursing response is appropriate? -"I will discuss cancelling your medication order with your health care provider." -"That sounds like a wonderful idea; and I think it will definitely work!" -"That sounds like a great plan; can you tell me more about it?" -"Your plan will not work; people with your type of pain need opioids."

"That sounds like a great plan; can you tell me more about it?" Complementary and integrative therapies are most often used to supplement, not replace, medication management. The nurse needs to obtain more data, and will ask for more information about the client's plan. Contacting the health care provider to cancel the medication order is not appropriate. Telling the client that his idea is wonderful and will definitely work is not appropriate, as alternative strategies alone, may not work to relieve the client's pain. Telling the client that his or her plan will not work is dismissive of the client. In addition, the client may not need to be prescribed opioids for the pain.

59. Which statement made by a client who is learning about self-injection of insulin indicates to the nurse that clarification is needed about injection site selection and rotation? -"The abdominal site is best because it is closest to the pancreas." -"I can reach my thigh best, so I will use different areas of the same thigh." -"If I change my injection site from the thigh to an arm, the inulin absorption may be different." -"By rotating sites within one area, my chance of having skin changes is less."

"The abdominal site is best because it is closest to the pancreas." The abdominal site has the fastest and most consistent rate of absorption because of the blood vessels in the area and not because of its proximity to the pancreas. The other statements demonstrate correct understanding about injection site selection and rotation.

63. Discharge teaching has been provided for a client recovering from kidney transplantation. Which client statement indicates understanding of the teaching? -"I will drink 8 ounces (236 mL) of water with my medications." -"I can stop my medications when my kidney function returns to normal." -"If my urine output is decreased, I should increase my fluids." -"The antirejection medications will be taken for life."

"The antirejection medications will be taken for life." When the client states that antirejection medications must be taken for life, it indicates that the kidney transplant client understands the discharge teaching. Immune-suppressant therapy must be taken for life to prevent organ rejection. Adherence to immunosuppressive drugs is crucial to survival for clients with transplanted kidneys. Lack of adherence can lead to complications such as rejection, graft loss, return to dialysis, and death. Oliguria (decreased urine output) is a symptom of transplant rejection. If this occurs, the transplant team must be contacted immediately. It is not necessary to take antirejection medication with 8 ounces (236 mL) of water.

57. What is the nurse's best response when a client, who has been taking high-dose corticosteroid therapy for a month for a problem that has now resolved, asks you why she needs to continue taking the corticosteroid? -"Corticosteroids are a type of hormone, and once you have been started on a replacement hormone, you must continue the hormone replacement therapy for the rest of your life." -"The drug suppressed your own adrenal gland secretion of corticosteroids. Slowly decreasing the dose over time allows your adrenal glands to start adequate secretion again." -"It is possible for your health problem to recur when corticosteroid therapy is halted suddenly." -"The drug suppressed your immune system while you were taking it. Slowly decreasing the dose over time prevents your immune system from starting up too quickly and causing allergic reactions."

"The drug suppressed your own adrenal gland secretion of corticosteroids. Slowly decreasing the dose over time allows your adrenal glands to start adequate secretion again." One of the most frequent causes of adrenal insufficiency, a life-threatening problem, is the sudden cessation of long-term, high-dose corticosteroid therapy. This therapy suppresses the hypothalamic-pituitary-adrenal axis and must be withdrawn gradually to allow for pituitary production of ACTH and adrenal production of cortisol. None of the other statements are completely accurate.

59. What is the nurse's best response to a client newly diagnosed with diabetes who asks why he is always so thirsty? -"Without insulin, glucose is excreted rather than used in the cells. The loss of glucose directly triggers thirst, especially for sugared drinks." -"The extra glucose in the blood increases the blood sodium level, which increases your sense of thirst." -"Without insulin, glucose combines with blood cholesterol, which damages the kidneys, making you feel thirsty even when no water has been lost." -"The extra glucose in the blood makes the blood thicker, which then triggers thirst so that the water you drink will dilute the blood glucose level."

"The extra glucose in the blood makes the blood thicker, which then triggers thirst so that the water you drink will dilute the blood glucose level." The high blood glucose levels that are present, because movement of glucose into cells is impaired, increase the osmolarity of the blood. The increased osmolarity stimulates the osmoreceptors in the hypothalamus, which triggers the thirst reflex. In response, the person drinks more water (not sugary fluids or hyperosmotic fluids), which helps dilute blood glucose levels and reduces blood osmolarity.

8. The family of a client who is unconscious and dying realizes that their mother will die soon. The client's children are having a difficult time letting go. How will the nurse respond to the needs of this family? -"She will soon be in a better place." -"She would not want you to cry; she needs you to be strong." -"This must be difficult for you." -"Things will be ok, just try to enjoy your time together."

"This must be difficult for you." The nurse responds by stating, "This must be difficult for you." This statement tells the family that the nurse is aware of their needs. The nurse knows that she must accept whatever the grieving person says about the situation, must remain present, be ready to listen attentively, and guide gently. In this way, the nurse can help the bereaved prepare for the necessary reminiscence and integration of the loss. The client's or family member's pain of loss should never be minimized. Trite assurances such as saying, "She would not want you to cry" or "Things will be ok," should be avoided. Such comments can actually be barriers to demonstrating care and concern. Never try to explain a client's death or impending death in philosophic or religious terms because such statements are not helpful when the bereaved person has yet to express feelings of anguish or anger.

62. During discharge teaching for a client with kidney disease, what does the nurse teach the client to do? -"Eat breakfast and go to bed at the same time every day." -"Drink 2 L of fluid and urinate at the same time every day." -"Weigh yourself and take your blood pressure." -"Check your blood sugar and do a urine dipstick test."

"Weigh yourself and take your blood pressure." When discharging the client with kidney disease, the nurse needs to tell the client to "Weigh yourself and take your blood pressure." Regular weight assessment monitors fluid restriction control while blood pressure control is necessary to reduce cardiovascular complications and slow the progression of kidney dysfunction. Fluid intake and urination, and breakfast time and bedtime, do not need to be at the same time each day. The Clients with diabetes, not kidney disease, would regularly check their blood sugar and perform a urine dipstick test.

8. The nurse is performing a spiritual assessment on a dying client. Which question provides the most accurate data on this aspect of the client's life? -"Do you believe in God?" -"Where have you been attending church?" -"Tell me about religion in your life." -"What gives you purpose in life?"

"What gives you purpose in life?" The most accurate data about the client's spirituality would come from the question, "What gives you purpose in your life?" Spirituality arises from whatever or whoever provides the client ultimate purpose and meaning. It is not necessarily God, but it could be. It could be the client's definition of a higher power. The client may not believe in God and may find an inquiry about believing in God offensive and judgmental. Religion is considered by many people to be affiliation or membership in a faith community. Members of such a community may be supportive of the client if the client is a member, but this is not the best way to determine what the client's spirituality is. Church attendance is one way that some individuals express their religion, but it does not necessarily define a person's spirituality; asking about church could place the client on the defensive.

5. The nurse is assessing a client for acute or persistent pain. What nursing question allows the nurse to obtain the most data from the client? -"Is the pain really that bad?" -"Does it feel like sharp pain?" -"When does the pain occur?" -"Did someone do this to you?"

"When does the pain occur?" Asking when the pain occurs helps determine precipitating factors to identify the source of pain. It is an open-ended question that requires a descriptive response and allows the nurse to obtain the most data. Asking if someone hurt the client may be appropriate in rare circumstances, but typically it is not an appropriately focused question; the question does not relate to the severity or character of the pain. Further, this is not an open-ended question. The nurse should ask the client open-ended questions, not questions requiring a "yes-or-no" answer, such as "Does it feel like sharp pain?" Asking "Is the pain really that bad?" minimizes the client's perception of pain; it is also a closed-ended question requiring a "yes-or-no" answer.

61. The nurse is teaching a client about pelvic muscle exercises. What information does the nurse include? -"For the best effect, perform all of your exercises while you are seated on the toilet." -"You are exercising correct muscles if you can stop urine flow in midstream." -"Limit your exercises to 5 minutes twice a day, or you may injure yourself." -"Results should be visible to you within 72 hours."

"You are exercising correct muscles if you can stop urine flow in midstream." The nurse is telling the client about pelvic muscle exercises and says, "You are exercising correct muscles if you can stop urine flow in midstream." When the client can start and stop the urine stream, the pelvic muscles are being used. Pelvic muscle exercises can be performed anywhere and would be performed at least 10 times daily to improve and maintain pelvic muscle strength. Noticeable results in pelvic muscle strength take several weeks.

59. How will the nurse reply when a client with type 2 diabetes tells the nurse that he would like to have a 12-ounce glass of beer with supper but believes that is now impossible? -"You can have a beer with a meal if you test yourself for hypoglycemia an hour later." -"You can have a beer with a meal if you test yourself for hyperglycemia an hour later." -"There are nonalcoholic beers available that you can substitute for a regular beer." -"If you gave up dessert, you can still have one beer."

"You can have a beer with a meal if you test yourself for hypoglycemia an hour later." Alcohol consumption contributes to hypoglycemia. This risk is reduced if the alcohol is consumed with or shortly after a meal. The client is instructed to check blood glucose levels about an hour after alcohol is consumed to determine if either more food is needed or if insulin dosage needs to be adjusted.

9. The nurse is instructing a client about the postoperative use of antiembolism stockings. Which statement by the client indicates the need for further teaching? (Select all that apply.) Select all that apply. -"I will take off my stockings one to three times a day for 30 minutes." -"It is up to me to determine how long I wear the stockings at each interval." -"My stockings are loose so they do not hurt my legs." -"These stockings help promote blood flow." -"I feel like these stockings are compressing my legs just a bit."

-"It is up to me to determine how long I wear the stockings at each interval." -"My stockings are loose so they do not hurt my legs." Stockings that are too loose are ineffective. Stockings that are too tight will impede blood flow. The client should wear the stockings as prescribed; not at their own discretion.Frequent removal of the stockings is appropriate to allow for hygiene and a break from their wear. Antiembolism stockings may be used during and after surgery to promote venous return. Antiembolism stockings should fit properly by providing gentle compression to achieve the desired result.

57. What is the nurse's best response when a client with Cushing syndrome screams at her husband, bursts into tears, throws her water pitcher against the wall, and then says "I feel like I am going crazy"? -"You must learn to control your behavior. Because you are disturbing others, I am going to keep the door to your room closed and restrict your visitors." -"You feel this way because of your high hormone levels. Your health care provider can prescribe an antianxiety drug for you." -"I will tell your primary health care provider order a psychiatric consult for you." -"You are probably feeling this way because you are frightened about having a chronic disease. Would you like some information about a support group?"

"You feel this way because of your high hormone levels. Your health care provider can prescribe an antianxiety drug for you." Changes in blood cortisol levels can cause the client to show neurotic or psychotic behaviors. The client's need to know that these behavior changes do not reflect a true psychiatric disorder and will resolve when therapy results in lower and more steady blood cortisol levels. Drug therapy to reduce these feelings and behaviors may be appropriate. A psychiatric consult is not likely to be needed. A support group may be indicated depending on why the client has hypercortisolism but the nurse should not make assumptions about the client's feelings and possible fears. Punishing the client for her behavior does not solve the problem or help the client understand her feelings.

59. What is the nurse's best response to a client with type 2 diabetes controlled with metformin who asks why now that he is recovering from surgery, is he prescribed to receive insulin therapy for a few days? -"Your insurance doesn't permit metformin to be used during hospitalization." -"Your presurgical testing indicates that you now have type 1 diabetes and require daily insulin." -"You just need insulin temporarily because the stress of surgery causes increased blood glucose levels for a day or two." -"You must take insulin from now on because the surgery has aggravated the intensity of your diabetes."

"You just need insulin temporarily because the stress of surgery causes increased blood glucose levels for a day or two." The nurse's best response is that due to the stress of surgery and NPO status, short-term insulin therapy may be needed perioperatively for clients with diabetes who use oral antidiabetic agents. For those receiving insulin, dosage adjustments may be required until the stress of surgery subsides. No evidence suggests that the client's diabetes has worsened. However, surgery is stressful and may increase insulin requirements. Metformin may be taken in the hospital, but not on days when the client is NPO for surgery. When the client returns to his or her previous health state, oral agents will be resumed.

8. The daughter of a client who is dying states, "I don't want my father to be uncomfortable." How will the nurse respond? -"Your father will be closely monitored and cared for." -"Do you want to talk to the bereavement nurse?" -"Your father will be sedated and comfortable." -"We will send him to hospice when the time comes."

"Your father will be closely monitored and cared for." The nurse responds by telling the daughter that her father will be closely monitored and cared for. This would reassure the daughter as well as providing support and comfort. The daughter's comment does not require the expertise of a bereavement nurse. Also, asking if the daughter wants to talk to a bereavement nurse is a "yes-or-no" question, it is a nontherapeutic response and may shut off the dialog. The client who is dying is not typically kept sedated; clients are kept comfortable with as little or as much pain medication as needed. A goal is to keep the client alert and able to communicate. Telling the daughter that her father will be sent to hospice when the time comes does not address the daughter's concern about her father's comfort and it closes the dialog.

5. The nurse is teaching the client about the use of medical marijuana. What teaching will the nurse include? (Select all that apply.) Select all that apply. -"Medical cannabis is a controlled substance in the United States". -"Federal and state law often vary in the legality of medical cannabis use." -"The psychoactive component of medical cannabis is removed." -"Your health care provider can prescribe cannabis for you." -"Side effects of cannabis can include dizziness and increased appetite."

-"Medical cannabis is a controlled substance in the United States". -"Your health care provider can prescribe cannabis for you." -"Side effects of cannabis can include dizziness and increased appetite." Cannabis is a schedule I controlled substance and has been since 1970. Federal and state law often vary in the legality of cannabis use. A health care provider cannot prescribe cannabis in any state; however, they may assess and determine whether a client has a qualifying condition in accordance with state law. Side effects of cannabis include: increased heart rate, increased appetite, dizziness, decreased blood pressure, dry mouth, hallucinations, paranoia, altered psychomotor function, and impaired attention. The psychoactive component, THC, is not removed from medical cannabis.

61. A client with a urinary tract infection is prescribed trimethoprim/sulfamethoxazole (Bactrim). What information does the nurse provide to this client about taking this drug? (Select all that apply.) Select all that apply. -"You will need to take all of these drugs to get the benefits." -"Drink at least 3 L of fluids every day." -"Be certain to wear sunscreen and protective clothing." -"Take this drug with 8 ounces (236 mL) of water." -"Try to urinate frequently to keep your bladder empty."

-"You will need to take all of these drugs to get the benefits." -"Drink at least 3 L of fluids every day." -"Be certain to wear sunscreen and protective clothing." -"Take this drug with 8 ounces (236 mL) of water." The nurse tells the client with a UTI who is taking trimethoprim/sulfamethoxazole to be certain to wear sunscreen protection clothing, drink at least 3 L of fluid every day, take the drug with 8 ounces (236 mL) of water, and take all of these drugs to get the benefits. Wearing sunscreen and protective clothing is important while taking trimethoprim/sulfamethoxazole, because increased sensitivity to the sun can lead to severe sunburn. Sulfamethoxazole can form crystals that precipitate in the kidney tubules, so fluid intake prevents this complication. Clients must be cautioned to take all of the drug that is prescribed for them, even if their symptoms improve or disappear soon, to prevent bacterial resistance and infection recurrence.Emptying the bladder is important, but not keeping it empty. The client would be advised to urinate every 3 to 4 hours or more often if he or she feels the urge.

8. The nurse is teaching a class on advance directives. What will the nurse include? (Select all that apply.) Select all that apply. -A durable power of attorney for health care is the same as a durable power of attorney for one's health care. -A living will identifies health care wishes regarding end of life treatment. -A health care proxy can only make decisions once a person no longer has their own ability to make decisions. -In order to make a health care decision, a person much be totally oriented. -A living will contains funeral directives as well as last wishes for family. -Advance directive are the same from state to state.

-A living will identifies health care wishes regarding end of life treatment. -A health care proxy can only make decisions once a person no longer has their own ability to make decisions. Advance directive vary from state to state. While all have similarities, each state is unique. A durable power of attorney for health care is not the same as the durable power of attorney for finances. This can be the same person—but must be defined specifically for both roles. A living will identifies would an individual would (or would not) want when he or she is near death. A living will contains information specific to artificial ventilation, and nutrition or hydration as well as resuscitation directives. It does not contain funeral directives or last wishes for family. In order to make a health care decisions, a person does not need to be totally oriented. However, he or she must be able to receive information and then evaluate, deliberate, and manipulate the information as well as communicate a treatment preference.

57. Which primary health care provider order will the nurse perform first for a client with syndrome of inappropriate antidiuretic hormone (SIADH) who has a serum sodium level of 105 mEq/L (105 mmol/L)? -Administering an infusion of 150 mL hypertonic saline over the next 3 hours -Drawing blood for hemoglobin and hematocrit levels -Measuring serial weights at the same daily with the client wearing the same amount of clothing -Inserting an indwelling catheter and monitoring urine output

-Administering an infusion of 150 mL hypertonic saline over the next 3 hours The first intervention the nurse performs is to administer an infusion of 150 mL hypertonic saline over 3 hours. When the serum sodium level is below 115 mEq/L (115 mmol/L), the client is at increased risk for seizures and coma. Drawing blood for hematocrit and hemoglobin levels, inserting an indwelling catheter for urine monitoring, and weighing the admitted client are not top priority actions.

60. The nurse is using a bladder scanner on a female client to estimate bladder volume. Which action will the nurse take? (Select all that apply.) Select all that apply. -Aim the scanner toward the client's coccyx to visualize the bladder. -Select the female icon since the client has had a hysterectomy. -Two readings should be completed for best accuracy. -Gently insert the scanner probe into the vagina. -Place a gel pad over the client's pubic area.

-Aim the scanner toward the client's coccyx to visualize the bladder. -Two readings should be completed for best accuracy. -Place a gel pad over the client's pubic area. A bladder scan is a noninvasive method to estimate the bladder volume. The nurse will not insert the scanner probe into the vagina. A gel pad is applied over the pubic area and the scanner probe is placed over the abdomen and aimed toward the bladder which is typically toward the client's coccyx. Two readings are suggested for increased accuracy. The nurse will select the male icon since the client has had a hysterectomy as the uterus affects the estimate of bladder volume.

57. Which action immediately after a hypophysectomy will the nurse instruct a client to avoid to prevent harm? (Select all that apply.) Select all that apply. Bending at the waist Talking Deep breathing Coughing Wearing makeup Using dental floss

-Bending at the waist -Coughing Coughing early after surgery both increases intracranial pressure (ICP) and also increases pressure in the incision area and may lead to a leak of cerebrospinal fluid. Bending at the waist also increases ICP.The actions of talking and wearing makeup have no harmful effects. In place of coughing, clients are instructed to take deep breaths to promote gas exchange. To prevent harm, clients are taught to avoid toothbrushing (which could injure the incision line) and are encouraged to floss instead.

62. The nurse is caring for a client who has just returned to the surgical unit after a radical nephrectomy. Which assessment data requires further nursing action? (Select all that apply.) Select all that apply. -Blood pressure is 98/56 mm Hg. -Urine output over the past hour was 80 mL. -Heart rate is 118 beats/min. -Dressing has a 1-cm area of bleeding. -Abdominal distention. -Pain is at a level 4 (on a 0--10 scale).

-Blood pressure is 98/56 mm Hg. -Heart rate is 118 beats/min. -Abdominal distention. -Pain is at a level 4 (on a 0--10 scale). A blood pressure of 98/56 mm Hg, and a heart rate of 118 beats/min in a client who just returned to the unit after a radical nephrectomy, alarms the nurse and requires immediate nursing action in the form of additional assessment. Bleeding is a complication of radical nephrectomy. Tachycardia and hypotension may indicate impending hypovolemic or hemorrhagic shock. The surgeon must be notified immediately and fluids must be administered, complete blood count needs to be checked, and blood administered, if necessary. The nurse will also address the client's pain level after addressing the potential for hemorrhage. Abdominal distention requires additional assessment as this can also be a sign of hemorrhage.A urine output of 80 mL can be considered normal. Administering pain medication to a client who has developed shock will exacerbate hypotension. A dressing with a 1-cm area of bleeding is expected postoperatively.

5. The nursing is using the pain assessment in advanced dementia pain scale to assess a client. What categories of pain indicators will the nurse assess? (Select all that apply.) Select all that apply. -Body language -Facial expression -Breathing pattern -Ability to calm the client -Ability to distract the client -Picking at skin or clothing -Vocalizations

-Body language -Facial expression -Breathing pattern -Ability to calm the client -Vocalizations Pain Assessment in Advanced Dementia (PAINAD) scale has been tested in patients with severe dementia (Herr et al., 2011). The tool groups behavioral indicators into five categories for scoring using a graduated scale of 0 (least intense behaviors) to 2 (most intense behaviors) per category for a maximum behavioral score of 10:· Breathing (independent of vocalization)· Negative vocalization· Facial expression· Body language· Consolability (ability to calm the patient)Picking at the skin or clothing as well as ability to distract the client are not portions of the PAINAD scale.

58. Which items are most important for the nurse to ensure are in the room when a client returns from having a thyroidectomy? (Select all that apply.) Select all that apply. -Hypertonic saline -Furosemide -Calcium gluconate -Oxygen -Suction -Emergency tracheotomy kit

-Calcium gluconate -Oxygen -Suction -Emergency tracheotomy kit Calcium gluconate needs to be available at the bedside to treat hypocalcemia and tetany that might occur if the parathyroid glands have been injured during the surgery. Equipment for an emergency tracheotomy must be kept at the bedside in the event that hemorrhage or edema occludes the airway. Oxygen always needs to be at the bedside and especially for the thyroidectomy client who may experience respiratory distress from swelling or damage to the laryngeal nerve leading to spasm. It is also important to have suction available at the client's bedside because of the risk for increased secretions.Furosemide is a diuretic used to treat hypercalcemia associated with hyperparathyroidism. However, hypocalcemia from inadvertent parathyroid removal during thyroidectomy is the greater concern. Hypertonic saline is not necessary for this client. This client is not expected to have hyponatremia after surgery.

63. Which client will the nurse assess as at risk for acute kidney injury (AKI)? (Select all that apply.) Select all that apply. -Client in the intensive care unit on high doses of antibiotics -Football player in preseason practice -Accident victim recovering from a severe hemorrhage -Accountant with poorly controlled diabetes mellitus -Client who underwent contrast dye radiology -Client recovering from gastrointestinal influenza

-Client in the intensive care unit on high doses of antibiotics -Football player in preseason practice -Accident victim recovering from a severe hemorrhage -Accountant with poorly controlled diabetes mellitus -Client recovering from gastrointestinal influenza To prevent AKI, all people must be urged to avoid dehydration by drinking at least 2 to 3 L of fluids daily, especially during strenuous exercise or work associated with diaphoresis, or when recovering from an illness that reduces kidney blood flow, such as influenza. Contrast media may cause acute renal failure, especially in older clients with reduced kidney function. Recent surgery or trauma, transfusions, or other factors that might lead to reduced kidney blood flow may cause AKI. Certain antibiotics may cause nephrotoxicity. Poorly controlled diabetes mellitus is a risk factor for chronic kidney disease.

60. The nurse is caring for the following clients who are scheduled for a computed tomography (CT) scan with contrast. For which clients will the nurse communicate safety concerns to the health care provider (HCP)? (Select all that apply.) Select all that apply. -Client who took metformin 4 hours ago -Client with an allergy to shrimp -Client who requests morphine sulfate every 3 hours -Client with a history of asthma -Client with a blood urea nitrogen of 62 mg/dL (22.1 mmol/L) and a creatinine of 2.0 mg/dL (177 umol/L)

-Client who took metformin 4 hours ago -Client with an allergy to shrimp -Client with a history of asthma -Client with a blood urea nitrogen of 62 mg/dL (22.1 mmol/L) and a creatinine of 2.0 mg/dL (177 umol/L) The nurse would communicate to the HCP CT scan contrast safety concerns about a client with an allergy to shrimp, a client with an asthma history, a client with an elevated BUN and creatinine, and a client who took Metformin 4 hours ago. All clients undergoing a CT scan with contrast would be asked about known hay fever or food or drug allergies, especially to seafood, eggs, milk, or chocolate. Contrast reactions have been reported to be as high as 15% in these clients. Clients with asthma have been shown to be at greater risk for contrast reactions than the general public. When reactions do occur, they are more likely to be severe. The risk for contrast-induced nephropathy is also increased in clients who have pre-existing renal insufficiency (e.g., serum creatinine levels greater than 1.5 mg/dL (133 umol/L) or estimated glomerular filtration rate less than 45 mL/min). Metformin must be discontinued at least 24 hours before and for at least 48 hours after any study using contrast media because the life-threatening complication of lactic acidosis, although rare, could occur. There are no contraindications to undergo CT scan with contrast while taking morphine sulfate. CT with contrast may help to identify the underlying cause of pain.

63. The nurse is caring for a client following a kidney transplant. Which assessment data indicate to the nurse possible rejection of the kidney? (Select all that apply.) Select all that apply. -Crackles in the lung fields -Temperature of 98.8° F (37.1° C) -Blood pressure of 164/98 mm Hg -Blood urea nitrogen (BUN) 21 mg/dL (7.5 mmol/L), creatinine 0.9 mg/dL (80 mcmol/L) -3+ edema of the lower extremities

-Crackles in the lung fields -Blood pressure of 164/98 mm Hg -3+ edema of the lower extremities Signs and symptoms indicating rejection of a transplanted kidney include: crackles in the lung fields, blood pressure of 164/78 mm Hg, and 3+ edema of lower extremities. These are assessment findings related to fluid retention and transplant rejection. Increasing BUN and creatinine are symptoms of rejection; however, a BUN of 21 mg/dL (7.5 mmol/L) and a creatinine of 0.9 mg/dL (80 mcmol/L) reflect normal values. Fever, not normothermia, is symptomatic of transplant rejection.

57. For which symptoms will the nurse instruct the family and client who is being treated for diabetes insipidus (DI) to call 911 or go to the nearest emergency department? (Select all that apply.) Select all that apply. -Decreased urine output -Hypotension -Weigh gain of more than 2.2 lb (1 kg) in 24 hours -Persistent headache -Hyperglycemia -Acute confusion

-Decreased urine output -Weigh gain of more than 2.2 lb (1 kg) in 24 hours -Persistent headache -Acute confusion Drug therapy for DI can cause a greatly increased kidney reabsorption of water and lead to life-threatening water toxicity. Indications of water toxicity are a relatively rapid onset of acute confusion, rapid weight gain, decreased urine output, persistent headache, and nausea and vomiting.Clients become hypertensive (not hypotensive). Usually blood glucose levels are unaffected but can be diluted below normal levels.

8. The nurse is caring for a client who is actively dying. What nursing action is appropriate? (Select all that apply.) Select all that apply. -Do not encourage the client to stay awake. -Offer to insert a Foley catheter for comfort. -Place warm blankets on the client to keep them warm. -Use moist swabs to keep the mouth and lips moist. -Encourage the client to eat ice chips and drink as much as possible. -Make sure the room is well-lit.

-Do not encourage the client to stay awake. -Offer to insert a Foley catheter for comfort. -Use moist swabs to keep the mouth and lips moist. When caring for a client who is actively dying, the skin may become cold and mottled. Do not apply heating blankets. Using moist swabs will help to keep the client's mouth and lips more comfortable. The room should be dimly lit, with minimal noise and stimulation. The client should be offered ice chips or drink but do not force to drink as much as possible. Allow the client to rest, do not force them to stay awake. The nurse can offer a Foley catheter for comfort.

63. While managing care for a client with chronic kidney disease, which action does the registered nurse (RN) plan to delegate to assistive personnel (AP)? (Select all that apply.) Select all that apply. -Explain the components of a low-sodium diet. -Document the amount the client drinks throughout the shift. -Auscultate the client's lung sounds every 4 hours. -Check the arteriovenous (AV) fistula for a thrill and bruit. -Obtain the client's prehemodialysis weight.

-Document the amount the client drinks throughout the shift. -Obtain the client's prehemodialysis weight. Actions the RN delegates to the UAP include: obtaining the client's weight and documenting oral fluid intake. These are routine tasks that can be performed by a UAP. Assessment skills (checking the AV fistula and auscultating lung sounds) and client education (explaining special diet) require more education and are in the legal scope of practice of the RN.

61. The nurse is teaching a group of older adult women about the signs and symptoms of urinary tract infection (UTI). What teaching will the nurse include? (Select all that apply.) Select all that apply. -Dysuria -Enuresis -Frequency -Polyuria -Urgency -Nocturia

-Dysuria -Frequency -Urgency -Nocturia The signs and symptoms of UTI include: dysuria (pain or burning with urination), frequency, nocturia (frequent urinating at night), and urgency (having the urge to urinate quickly).Enuresis (bed-wetting) and polyuria (increased amounts of urine production) are not signs of a UTI.

58. Which signs and symptoms in a client who has hyperthyroidism indicate to the nurse possible progression to a thyroid storm? (Select all that apply.) Select all that apply. -Elevated temperature -Tachycardia -Somnolence -Elevated systolic blood pressure -Abdominal pain and nausea -Slow respiratory rate

-Elevated temperature -Tachycardia -Elevated systolic blood pressure -Abdominal pain and nausea Symptoms of thyroid storm are caused by excessive thyroid hormone release, which dramatically increases metabolic rate. Key symptoms include fever, tachycardia, and systolic hypertension. Additional symptoms include abdominal pain, nausea, vomiting, diarrhea, tremors, and anxiety. The increased metabolic rate causes the respiratory rate to increase. Clients are agitated, not somnolent.

63. When caring for a client with a left forearm arteriovenous fistula created for hemodialysis, which nursing actions are required? (Select all that apply.) Select all that apply. -Ensure that no blood pressures are taken in that arm. -Teach the client to palpate for a thrill over the site. -Elevate the arm above heart level. -Auscultate for a bruit every 8 hours. -Check brachial pulses daily.

-Ensure that no blood pressures are taken in that arm. -Teach the client to palpate for a thrill over the site. -Auscultate for a bruit every 8 hours. A bruit or swishing sound and a thrill or buzzing sensation upon palpation would be present in this client, indicating patency of the fistula. No blood pressure, venipuncture, or compression, such as lying on the fistula, would occur.Distal pulses and capillary refill would be checked daily. For a forearm fistula, the radial pulse is checked instead of the brachial pulse which is proximal. Elevating the arm increases venous return, possibly collapsing the fistula.

60. The nurse is teaching a class about kidney and urinary changes that occur with age. What teaching will the nurse include? (Select all that apply.) Select all that apply. -Drug clearance is often increased which produces more drug reactions. -Glomerular filtration rate decreases which increases the risk for fluid overload. -Urinary sphincters lose tone and weaken with age. -Blood flow to the kidneys increases promoting nocturia. -The ability to concentrate urine decreases which creates urgency.

-Glomerular filtration rate decreases which increases the risk for fluid overload. -Urinary sphincters lose tone and weaken with age. -The ability to concentrate urine decreases which creates urgency. Blood flow to the kidneys decreases (not increases) with age. Nocturnal polyuria is associated with tubular changes that cause a decrease in the concentration of urine. Drug clearance is often decreased which is what leads to more drug reactions.

56. Which changes in laboratory values will the nurse expect to see in a client who has tumor causing excess secretion of aldosterone? (Select all that apply.) Select all that apply. -Hypoglycemia -Hyponatremia -Hypokalemia -Hypernatremia -Hyperglycemia -Hyperkalemia

-Hypokalemia -Hypernatremia Aldosterone is the mineralocorticoid that maintains extracellular fluid volume and electrolyte composition. It promotes sodium and water reabsorption and potassium excretion in the kidney. Excessive amounts of this hormone result in hypernatremia and hypokalemia.Increased aldosterone levels do not affect blood glucose levels.

61. An older adult client diagnosed with urge incontinence is prescribed oxybutynin. Which side effects will the nurse tell the client to expect? (Select all that apply.) Select all that apply. -Increased intraocular pressure -Dry mouth -Reddish-orange urine color -Constipation -Increased blood pressure

-Increased intraocular pressure -Dry mouth -Constipation Urge incontinence is the loss of urine for no apparent reason after suddenly feeling the need or urge to urinate. Side effects of oxybutynin prescribed for urge incontinence include: dry mouth, constipation, and increased intraocular pressure with the potential to make glaucoma worse. Oxybutynin is an anticholinergic/antispasmodic medication.Alpha-adrenergic agonists and beta blockers, which may be prescribed for urinary incontinence, may cause an increase in blood pressure. Phenazopyridine, a bladder analgesic used to decrease urinary pain, causes the urine to be a reddish-orange color.

62. Which assessment findings does the nurse expect in a client with kidney cancer? (Select all that apply.) Select all that apply. -Increased sedimentation rate -Hepatic dysfunction -Erythrocytosis -Hypercalcemia -Hypokalemia

-Increased sedimentation rate -Hepatic dysfunction -Erythrocytosis -Hypercalcemia Assessment findings the nurse expects to assess in a client with kidney cancer include: erythrocytosis, hypercalcemia, hepatic dysfunction, and increased sedimentation rate. Erythrocytosis alternating with anemia and hepatic dysfunction with elevated liver enzymes may occur with kidney cancer. Parathyroid hormone produced by tumor cells can cause hypercalcemia. An elevation in sedimentation rate may occur in paraneoplastic syndromes. Potassium levels (hypokalemia) are not altered in kidney cancer.

58. Which statements regarding hyperthyroidism are accurate? (Select all that apply.) Select all that apply. -Has a sudden onset of symptoms. -Is much more common among women than among men. -Produces symptoms of a hypermetabolic state. -Most common form is Graves disease. -Can be diagnosed by the presence of a goiter. -Often occurs weeks after exposure to ionizing radiation.

-Is much more common among women than among men. -Produces symptoms of a hypermetabolic state. -Most common form is Graves disease. Hyperthyroidism increases the metabolism and function of all systems. The most common cause of hyperthyroidism is Graves disease, which is an autoimmune disorder, often occurring after an episode of thyroid inflammation leading to the production of autoantibodies (thyroid-stimulating immunoglobulins [TSIs]) that attach to the thyroid-stimulating hormone (TSH) receptors on the thyroid gland. The increased stimulation of TSH receptors greatly increases thyroid hormone production. All thyroid problems are from five to ten more common among women than men.The onset is so slow and insidious that clients may not even notice them until severe changes are present. A goiter only indicates a thyroid problem and can occur with both hypothyroidism and hyperthyroidism. Exposure to ionizing radiation can induce hypothyroidism, not hyperthyroidism.

5. The nurse is documenting a pain assessment. Which pain descriptions document location of pain? (Select all that apply.) Select all that apply. -Localized pain -Sharp pain -Negative vocalization -Radiating pain -Referred pain -Pain rated as a 4 on a scale of 0-10.

-Localized pain -Radiating pain -Referred pain Pain can be described as belonging to one of four categories related to its location: localized, projected, referred, and radiating. Localized pain is confined to the site of origin. Projected pain is diffuse around the site of origin and is not well localized. Referred pain is felt in an area distant from the site of painful stimuli. Radiating pain is felt along a specific nerve or nerves.Pain rated as a 4 on a scale of 0-10 describes the intensity of the pain, not the location. Sharp pain describes the quality of the pain, not the location. Negative vocalization is an indicator of the presence of and quality of pain in adults with dementia.

59. Which new-onset symptoms will the nurse instruct a client with diabetes who is prescribed to take the sodium-glucose cotransport inhibitor, empagliflozin, to report to the diabetes health care provider to prevent harm? (Select all that apply.) Select all that apply. -Muscle weakness and dizziness on standing -Redness and tenderness at the injection site -Rapid weight gain and shortness of breath -Redness and tenderness of the perineum -Sensations of hunger, tremors, sweating, and confusion -Pain and burning on urination

-Muscle weakness and dizziness on standing -Redness and tenderness of the perineum -Sensations of hunger, tremors, sweating, and confusion -Pain and burning on urination Drugs from the lower blood glucose levels by preventing kidney reabsorption of glucose and sodium that was filtered from the blood into the urine. This filtered glucose is excreted in the urine rather than moved back into the blood. Hypoglycemia (symptoms of hunger, tremors, sweating, confusion) is possible as is dehydration with excessive sodium loss (muscle weakness and orthostatic hypotension with dizziness on standing). The excess glucose in the urine increases the risk for urinary tract infections with pain and burning on urination. These drugs increase the risk for Fournier gangrene with perineal fasciitis, which has early symptoms of redness and tenderness of the perineal skin.The drug is taken orally and not by injection. It is not associated with heart failure that may manifest with symptoms of rapid weight gain and shortness of breath.

5. A client reports increasing pain during dressing changes to the nurse. Which interventions are recommended for the client? (Select all that apply.) Select all that apply. -Music therapy -Assistance by the client with the dressing change -Epidural analgesic -Transcutaneous electrical nerve stimulation (TENS) -Distraction -Premedication

-Music therapy -Distraction -Premedication Interventions recommended for the client include distraction, music therapy, and premedication. Distraction stimulates efferent nerve fibers and reduces the client's perception of painful experiences. Music therapy provides a distraction and can reduce the client's pain perception; efferent nerve fibers are stimulated. Premedication before painful treatments is a good method of controlling pain during treatment. Involving the client in an uncomfortable dressing change would tend to increase the client's perception of pain; it is a better tactic to distract the client. Although epidural analgesia is effective, it is a method of providing pain relief that requires an epidural catheter to be in place; the use of such an invasive procedure would not be indicated for pain relief during a dressing change. Use of a TENS unit is effective in controlling certain types of pain, such as incisional pain, but its use during a dressing change would not be feasible.

58. Which signs, symptoms, or behaviors will the nurse expect to find when assessing a client who has just been diagnosed with hypothyroidism? (Select all that apply.) Select all that apply. -Goiter -Nonpitting edema of hands and feet -Warm, moist skin -Decreased deep tendon reflexes -Agitation and inability to sleep -Pulse rate below 60 beats/min

-Nonpitting edema of hands and feet -Decreased deep tendon reflexes -Pulse rate below 60 beats/min Hypothyroidism slows the metabolism and function of all systems and the ones that are usually first noticed and can lead to life-threatening complications are the cardiac and central nervous systems. Thus, the heart rate is usually slower than 60 beats/min, and the deep tendon reflexes are decreased. Metabolites that are compounds of proteins and sugars called glycosaminoglycans (GAGs) build up inside cells, which increase the mucus and water, forming cellular edema that is nonpitting.The onset is so slow and insidious that clients may not even notice them until severe changes are present. A goiter only indicates a thyroid problem and can occur with both hypothyroidism and hyperthyroidism. The skin reflects the client's overall decreased metabolism and is cool and dry.

63. The nurse is teaching dietary modification to a client with acute kidney injury (AKI). What dietary teaching will the nurse include? (Select all that apply.) Select all that apply. -Liberal sodium -Low fat -Restricted fluids -Restricted protein -Low potassium

-Restricted fluids -Restricted protein -Low potassium A client with acute kidney injury needs to modify the diet to include restricted protein, restricted fluids, and low potassium. Breakdown of protein leads to azotemia and increased blood urea nitrogen. For the client who does not require dialysis, 0.6 g/kg of body weight or 40 g/day of protein is usually prescribed. For clients who do require dialysis, the protein level needed will range from 1 to 1.5 g/kg. Fluid is restricted during the oliguric stage. The daily amount of fluid permitted is calculated to be equal to the urine volume plus 500 mL. Potassium intoxication may occur, so dietary potassium is also restricted. Dietary potassium is restricted to 60 to 70 mEq/kg (70 mmol/kg).Sodium is restricted during AKI because oliguria causes fluid retention. Dietary sodium recommendations range from 60 to 90 mEq/kg (60 to 90 mmol/kg). Fats may be used for needed calories when proteins are restricted.

61. The nurse is teaching a class about cancer prevention. Which interventions will the nurse include that can prevent bladder cancer? (Select all that apply.) Select all that apply. -Using pelvic floor muscle exercises -Drinking 2½ L of fluid a day -Stopping the use of tobacco -Wearing a lead apron when working with chemicals -Wearing gloves and a mask when working around chemicals and fumes -Showering after working with or around chemicals

-Stopping the use of tobacco -Wearing gloves and a mask when working around chemicals and fumes -Showering after working with or around chemicals The interventions that are helpful in preventing bladder cancer are: showering after working with or around chemicals, stopping the use of tobacco, and wearing gloves and a mask when working around chemical and fumes. Certain chemicals (e.g., those used by professional hairdressers) are known to be carcinogenic in evaluating the risk for bladder cancer. Protective gear is advised. Bathing after exposure to them is advisable. Tobacco use is one of the highest, if not the highest, risk factor in the development of bladder cancer. Increasing fluid intake is helpful for some urinary problems such as urinary tract infection, but no correlation has been noted between fluid intake and bladder cancer risk. Using pelvic floor muscle strengthening (Kegel) exercises is helpful with certain types of incontinence, but no data show that these exercises prevent bladder cancer. Precautions must be taken when working with chemicals. However, lead aprons are used to protect from radiation.

9. The nurse completes the preoperative checklist for a client scheduled for general surgery. Which factor does the nurse identify that places the client at high risk for the planned procedure? (Select all that apply.) Select all that apply. -Ten pounds (4.5 kg) over ideal body weight -Takes saw palmetto for benign prostatic hyperplasia (BPH) -Anesthesia complications experienced by partner -Currently prescribed methylprednisolone therapy -Age 59 years -History of diabetes mellitus

-Takes saw palmetto for benign prostatic hyperplasia (BPH) -Currently prescribed methylprednisolone therapy -History of diabetes mellitus The client's risk factors include diabetes mellitus, being on methylprednisolone therapy, and taking an herbal preparation (saw palmetto). Diabetes contributes an increased risk for surgery or postsurgical complications. Methylprednisolone use can decrease the body's ability to fight infection. Any type of herbal preparation has the potential to interfere with anesthesia or recovery.Older adults are at greater risk for surgical procedures, but this client is not classified as an older adult. Family medical history and problems with anesthetics may indicate possible reactions to anesthesia, but not anesthesia complications experienced by a partner. Obesity increases the risk for poor wound healing, but being 10 lb (4.5 kg) overweight does not categorize this client as obese.

8. In which newly admitted client situations does the nurse initiate a conversation about advance directives? (Select all that apply.) Select all that apply. -The laboring mother expecting her first child -A client with a non-life-threatening illness -A person who currently has advance directives -The comatose client who was injured in an automobile crash -The client with end-stage kidney disease

-The laboring mother expecting her first child -A client with a non-life-threatening illness -A person who currently has advance directives -The client with end-stage kidney disease All clients who are hospitalized need to be asked about advance directives by the nurse when they are admitted to a hospital. This is a requirement of the Patient Self-Determination Act. Many nurses feel uncomfortable discussing advance directives with "healthy" clients, but the circumstances of admission do not relieve the nurse of this responsibility. The client with preexisting advance directives still needs to be questioned; it is possible that the client's wishes have changed since the documents were established. Clients who have potentially life-threatening diseases or conditions should establish advance directives while they are able to do so. The comatose client is not considered capable of making decisions about his or her wishes concerning advance directives.

NCLEX Examination Challenge 60-4 Which assessment finding would require the nurse to take immediate action in a client who is one hour post kidney biopsy? Select all that apply. A. Pink-tinged urine B. Nausea and vomiting C. Increased bowel sounds D. Reports of flank pain E. The patient is ambulating to the bathroom

A Hemorrhage is a major complication of renal biopsy. The biopsy site and urine need to be closely monitored in addition to the hemoglobin. A fall in hemoglobin may indicate internal bleeding. Pain lasting more than 12 hours may indicate a ureteral obstruction.

61. A client diagnosed with urge incontinence is started on tolterodine. What interventions will the nurse suggest to alleviate the side effects of this drug? (Select all that apply.) Select all that apply. -Limit the intake of dairy products. -Use hard candy for dry mouth. -Encourage increased fluids. -Increase fiber intake. -Take the drug at bedtime.

-Use hard candy for dry mouth. -Encourage increased fluids. -Increase fiber intake. Interventions the nurse suggests to alleviate the side effects of tolterodine include: encouraging increased fluids, increasing fiber intake, and using hard candy for dry mouth. Anticholinergics cause constipation. Increasing fluids and fiber intake will help with this problem. Anticholinergics also cause extreme dry mouth, which can be alleviated with using hard candy to moisten the mouth. Taking the drug at night and limiting dairy products will not have an effect on the complications encountered with propantheline.

62. When assessing a client with acute pyelonephritis, which finding does the nurse anticipate? (Select all that apply.) Select all that apply. -Oliguria -Vomiting -Dysuria -Chills -Suprapubic pain

-Vomiting -Dysuria -Chills The findings the nurse expects to find in a client with acute pyelonephritis include: vomiting, chills, and dysuria. Nausea and vomiting and chills along with fever may occur. Dysuria (burning), urgency, and frequency can also occur.Suprapubic pain is indicative of cystitis, not kidney infection (pyelonephritis). Flank, back, or loin pain are symptoms of acute pyelonephritis. Oliguria is related to kidney impairment from severe or long-standing pyelonephritis.

59. A client newly diagnosed with type 1 diabetes says she is not ready to learn everything about diabetes control right now. Which information has the greatest priority for the nurse to teach this client and her family for now to prevent harm? (Select all that apply.) Select all that apply. -Causes of type 1 diabetes -What to do when ill? -Symptoms and treatment of hypoglycemia -Insulin administration -Dietary control of blood glucose -Importance of regular exercise

-What to do when ill? -Symptoms and treatment of hypoglycemia -Insulin administration The priority information for safety and preventing harm that the nurse needs to teach the client and family about diabetes are: Symptoms and management of hypoglycemia because it is a life-threatening condition. Proper insulin administration is essential for the management of type 1 diabetes and to prevent death. Knowing what to do when ill is critical information because illness will require changes in the client's day-to-day use of insulin and may need contact with the client's diabetes health care provider to prevent harm. The causes of diabetes, dietary control, and exercise are less important for immediate safety and can be taught at another time.

59. When (at which time) will the nurse plan to monitor for hypoglycemia in a client with type 1 diabetes received regular insulin at 7:00 a.m.? -7:30 a.m. -7:30 p.m. -11:00 a.m. -2:00 p.m.

11:00 a.m. Regular insulin is a short-acting type of insulin. Onset of action to regular insulin is ½ to 1 hour. The peak effect time is when hypoglycemia may start to occur. Peak time for regular insulin is 2 to 4 hours. Therefore, 11:00 a.m. is the anticipated peak time for regular insulin received at 7:00 a.m. The other options for peak times for regular insulin are incorrect.

62. What is the appropriate range of urine output for the client who has just undergone a nephrectomy? -30 to 50 mL/hr -50 to 70 mL/hr -23 to 30 mL/hr -41 to 60 mL/hr

30 to 50 mL/hr A urine output of 30 to 50 mL/hr or 0.5 to 1 mL/kg/hr is considered within acceptable range for the client who is post nephrectomy. Output of less than 25 to 30 mL/hr suggests decreased blood flow to the remaining kidney and the onset or worsening of acute kidney injury. A large urine output, followed by hypotension and oliguria, is a sign of adrenal insufficiency.

5. The nurse is planning a dressing change on a postoperative mastectomy client. The client is receiving acetaminophen and oxycodone orally for pain every 4 hours and is due to receive them at 4:00 p.m. When will the nurse change the dressing? -3:30 p.m. -4:30 p.m. -4:00 p.m. -7:00 p.m.

4:30 p.m. The nurse will change the dressing at 4:30 p.m. About 30 minutes after administration of an analgesic is an optimal time to perform a procedure on a client. At 4:30 p.m., the opioid has had time to take effect and provide relief for the client. It would be inappropriate to perform a painful procedure, such as a dressing change, just before a scheduled analgesic is received (i.e., 3:30 p.m.), because the pain medication will be at its lowest concentrations in the client's system. At 4:00 p.m., the analgesic has not had time to enter the client's system, so it is too soon to perform the dressing change. If the client received the analgesic at 4:00 PM, it is not at the highest or best concentration at 7:00 p.m. to facilitate a dressing change with minimal discomfort.

60. Mastery Question Which client being managed for dehydration does the nurse consider at greatest risk for possible reduced kidney function? A. An 80-year-old man who has benign prostatic hyperplasia B. A 62-year-old woman with a known allergy to contrast media C. A 48-year-old woman with established urinary incontinence D. A 45-year-old man receiving oral and intravenous fluid therapy

A Older adults have fewer nephrons and about half of the glomerular filtration rate of younger adults. This change increases their risk for kidney dysfunction more profoundly and persistently after dehydration of other conditions that can impair the renal system. Although an allergy to contrast media can cause problems, the adult must be exposed to it first. Tests requiring contrast media are not used to diagnose or manage dehydration. Urinary incontinence can lead to poor quality of life and skin problems but does not reduce kidney function. The client receiving hydration therapy with both oral and intravenous fluids is at risk for overhydration (fluid overload), not dehydration-induced kidney damage.

NCLEX Examination Challenge 61-1 For which client would the nurse expect to teach intermittent catheterization? A. 35-year-old woman who has multiple sclerosis and incontinence B. 48-year-old man who is admitted for pneumonia and is on complete bedrest C. 61-year-old woman who is admitted following a fall at home and has new-onset dysrhythmia D. 74-year-old man who has lung cancer with brain metastasis and has advanced dementia.

A Rationale: Intermittent self-catheterization remains the preferred method of bladder emptying in patients who have incontinence as a result of a neurogenic bladder (Beauchemin et al., 2018). Multiple sclerosis can cause neurogenic bladder.

8. The nurse working on an inpatient hospice unit has received the change-of-shift report. Which client does the nurse assess first? -A 62 year old with lung cancer who has cool, clammy, dusky skin, and blood pressure of 64/20 mm Hg. -A 26 year old with metastatic breast cancer who is experiencing pain rated at 8 (0-10 scale) and anxiety. -A 70 year old with cancer of the colon who has a respiratory rate of 8 with loud, wet-sounding respirations. -A 30 year old with AIDS-associated dementia and agitation who is asking for assistance with calling family members.

A 26 year old with metastatic breast cancer who is experiencing pain rated at 8 (0-10 scale) and anxiety. Management of pain is the priority goal for hospice care, so decreasing this client's pain and anxiety should be the first action. The client with AIDS needs rapid assistance, but is the second priority for the nurse in this scenario. The client with lung cancer and the client with colon cancer are exhibiting normal signs and symptoms associated with dying.

59. The nurse has just received report on a group of clients. Which client is the nurse's first priority? -A 26 year old with type 1 diabetes whose insulin pump is beeping "occlusion." -A 30 year old with type 1 diabetes who is reporting thirst. -A 40 year old with type 2 diabetes who has a blood glucose of 150 mg/dL (8.3 mmol/L). -A 50 year old with type 2 diabetes with a blood pressure of 150/90 mm Hg.

A 26 year old with type 1 diabetes whose insulin pump is beeping "occlusion." The client the nurse sees first is the client with type 1 diabetes whose insulin pump is beeping "occlusion." Because glucose levels will increase quickly in clients whose continuous insulin pumps malfunction, the nurse must assess this client and the insulin pump first to avoid hyperglycemia or diabetic ketoacidosis. Thirst is an expected symptom of hyperglycemia and, although important, is not a priority. The nurse could delegate fingerstick blood glucose to unlicensed assistive personnel while assessing the client whose insulin pump is beeping. Although a blood glucose reading of 150 mg/dL (8.3 mmol/L) is mildly elevated, this does not require immediate action. Mild hypertension does not require immediate action. The nurse can later assess if this is within the client's usual range or represents a change before taking action.

57. The nurse has just received report on a group of clients. Which client is the nurse's first priority? -A 42 year old with diabetes insipidus who has a dose of desmopressin due. -A 35 year old with hyperaldosteronism who has a serum potassium of 3.0 mEq/L (3.0 mmol/L). -A 50 year old with pituitary adenoma who is reporting a severe headache. -A 28 year old with acute adrenal insufficiency who has a blood glucose of 36 mg/dL (2.0 mmol/L).

A 28 year old with acute adrenal insufficiency who has a blood glucose of 36 mg/dL (2.0 mmol/L). The nurse first attends to the client with adrenal insufficiency who has a blood glucose level of 36 mg/dL (2.0 mmol/L). The client's condition is considered a medical emergency and must be assessed and treated immediately. Although it is important to maintain prescribed drugs on schedule, especially when a client is demonstrating a need for the next dose, the client requiring a dose of desmopressin cannot take priority over treatment of severe hypoglycemia. A serum potassium of 3.0 mEq/L (3.0 mmol/L) in the client with hyperaldosteronism may be considered normal (or slightly hypokalemic) and does not require immediate attention. The client reporting a severe headache needs to be evaluated as soon as possible after the client with acute adrenal insufficiency.

61. The nurse receives the change-of-shift report on four clients. Which client does the nurse decide to assess first? -A 26 year old admitted 2 days ago with urosepsis with an oral temperature of 99.4° F (37.4° C). -A 32 year old admitted with hematuria and possible bladder cancer who is scheduled for cystoscopy. -A 40 year old with noninfectious urethritis who is reporting "burning" and has estrogen cream prescribed. -A 28 year old with urolithiasis who has been receiving morphine sulfate and has not voided for 8 hours.

A 28 year old with urolithiasis who has been receiving morphine sulfate and has not voided for 8 hours. After change-of-shift report, the nurse decides to first assess a 28 year old with urolithiasis who has been receiving morphine sulfate and has not voided for 8 hours. Anuria may indicate urinary obstruction at the bladder neck or urethra and is an emergency because obstruction can cause acute kidney failure. The client who has been receiving morphine sulfate may be oversedated and may not be aware of any discomfort caused by bladder distention. The 26 year old admitted with urosepsis and slight fever, the 32 year old scheduled for cystoscopy, and the 40 year old with noninfectious urethritis are not at immediate risk for complications or deterioration.

58. With which client will the nurse be aware of an increased risk for hypoparathyroidism? -A 28-year-old woman with pregnancy-induced hypertension -A 35-year-old woman who had radiation therapy for Graves disease -A 50-year-old man starting on insulin therapy for type 2 diabetes mellitus -A 55-year-old man with moderate heart failure after myocardial infarction

A 35-year-old woman who had radiation therapy for Graves disease Hypoparathyroidism is a relatively rare disorder. It is most often caused by treatment for hyperthyroidism that resulted in injury to the parathyroid glands. None of the other client health problems increase the risk for development of hypoparathyroidism.

59. The nurse has just received report on a group of clients. Which client is the nurse's first priority? -A 50 year old taking repaglinide who has nausea and back pain. -A 55 year old taking pioglitazone who has bilateral ankle swelling. -A 45 year old taking metformin who has abdominal cramps. -A 40 year old taking glyburide who is dizzy and sweaty.

A 40 year old taking glyburide who is dizzy and sweaty. The nurse needs to first assess the client taking glyburide who is dizzy and sweaty and has symptoms consistent with hypoglycemia. Because hypoglycemia is the most serious adverse effect of antidiabetic medications, this client must be assessed as soon as possible. Nausea is a documented side effect of repaglinide. Checking the client's back pain requires assessment, which can be performed after the nurse assesses the client displaying signs and symptoms of hypoglycemia. Metformin may cause abdominal cramping and diarrhea, but the client taking it does not require immediate assessment. Ankle swelling is an expected side effect of pioglitazone.

9. Which client does the nurse identify at greatest risk for slow wound healing? -A 47-year-old man with obesity and diabetes -A 58-year-old woman who smokes 2 packs of cigarettes daily -A 78-year-old man with controlled hypertension -A 21-year-old woman with an STI

A 47-year-old man with obesity and diabetes Obesity and diabetes significantly place a client at greatest risk for slow wound healing. The other clients may encounter slower wound healing, yet they are not at the highest risk like the client with obesity and diabetes.

57. For which client will the nurse question the prescription for long-term androgen therapy? -A 40 year old who also has syndrome of inappropriate antidiuretic hormone (SIADH). -A 52 year old with a history of prostate cancer treatment. -A 30 year old who is taking antiviral therapy for HIV disease. -A 66 year old with impotence that is resistant to standard erectile dysfunction therapy.

A 52 year old with a history of prostate cancer treatment. Androgen therapy can make any residual prostate cancer cells proliferate and cause a recurrence of the disease. This therapy is often prescribed for impotence. SIADH is not a contraindication for the therapy and neither is HIV disease or its treatment.

61. Which client does the nurse manager on the medical unit assign to an experienced LPN/LVN? -A 46 year old scheduled for cystectomy who needs help in selecting a stoma site. -A 48 year old receiving intravesical chemotherapy for bladder cancer. -A 55 year old with incontinence who has intermittent catheterization prescribed. -A 42 year old with painless hematuria who needs an admission assessment.

A 55 year old with incontinence who has intermittent catheterization prescribed. The nurse manager assigns a 55-year-old client with incontinence who has intermittent catheterization prescribed to the experienced LPN/LVN. Admission assessments and intravesical chemotherapy would be done by an RN. Preoperative preparation for cystectomy and stoma site selection would be done by an RN and either a Certified Wound, Ostomy, and Continence Nurse or an enterostomal therapy nurse.

59. Which client does the nurse caution to avoid self-monitoring of blood glucose (SMBG) at alternate sites? -A 55-year-old client who has hypoglycemic unawareness -An 80-year-old client with type 2 diabetes mellitus -A 45-year-old client with type 1 diabetes mellitus -A 75-year-old client whose blood glucose levels show little variation

A 55-year-old client who has hypoglycemic unawareness Comparison studies have shown wide variation between fingertip and alternate sites, and variation is most evident during times when blood glucose levels are rapidly changing. Clients are taught that there is a lag time for blood glucose levels between the fingertip and other sites when blood glucose levels are changing rapidly and that the fingertip reading is the only safe choice at those times. Because of this lag time, clients who have hypoglycemic unawareness are warned to not ever use alternate sites for SMBG.

63. The nurse is caring for client who is receiving erythropoietin. Which assessment finding indicates a positive response to the medication? -A decrease in fatigue -Potassium within normal range -Absence of spontaneous fractures -Hematocrit of 26.7%

A decrease in fatigue The assessment finding of less fatigue is considered a positive response to erythropoietin. Treatment of anemia with erythropoietin will result in increased hemoglobin and hematocrit (H&H) and decreased shortness of breath and fatigue.A hematocrit value of 26.7% is low. Erythropoietin would restore the hematocrit to at least 36% to be effective. Erythropoietin stimulates the bone marrow to increase red blood cell production and maturation, increasing H&H, not potassium. Calcium supplements and phosphate binders prevent renal osteodystrophy and do not treat anemia.

NCLEX Examination Challenge 60-1 When obtaining a health history and physical assessment from a 68 year-old male client who has a history of an enlarged prostate, which finding does the nurse consider significant? Select all that apply A. Distended bladder B. Absence of a bruit C. Frequency of urination D. Dribbling urine after voiding E. Chemical exposure in the workplace

A, C, D A distended bladder, urinary frequency, and dribbling urine after voiding are significant findings for a client with an enlarged prostate. The nurse would expect the absence of bruit- as a bruit is considered an abnormal finding. Although chemical exposure in the workplace may cause kidney damage, it is not associated with an enlarged prostate.

61. Answer Key - Mastery Questions 1. Which adverse drug effects will the nurse assess for in a hospitalized client who is prescribed an anticholinergic drug to manage incontinence? (Select all that apply.) a. Insomnia b. Blurred vision c. Constipation d. Dry mouth e. Loss of sphincter control f. Increased sweating g. Worsening mental function

ANS: B, C, D, G Rationale: Anticholinergic drugs tend to block the parasympathetic nervous system and mimic the sympathetic nervous system responses. In addition to reducing urinary output, side effects commonly include dry mouth, reduced gastric motility, constipation, blurred vision, hypertension, increasing confusion, dizziness, and sleepiness.

61. Answer Key - Mastery Questions 1. A 28-year-old female client states, "I don't know why I get cystitis every year, I don't drink much at work so I can avoid using the public toilet." Which teaching by the nurse is most likely to reduce her risk for cystitis? Select all that apply. a. Reinforce her choice to avoid using a public toilet b. Teach her to shower immediately after having sexual intercourse c. Suggest that she drink at least 2-3 L of fluid throughout the day d. Urge her to change her method of birth control from oral contraceptives to a barrier method e. Instruct her to always wipe her perineum from front to back after each toilet use f. Reinforce that she should complete the entire course of antibiotics as prescribed g. Instruct her to empty her bladder immediately before intercourse

ANS: C, E, F, G Rationale: A is incorrect because using a public toilet, even sitting on the seat, does not lead to cystitis or a UTI. Showering after intercourse does not affect the development of UTIs. Showering BEFORE intercourse can reduce the number of perineal organisms and reduce the risk for UTI. Oral contraceptives do not increase the risk for UTI; however, some barrier methods (especially a cervical cap or diaphragm) can increase because of the increased manipulation of tissues in the area. Drinking more fluids throughout the day dilute the urine and increase the frequency of urination, and both responses help reduce the number of organisms in the bladder.

61. Answer Key - Mastery Questions 1. For which hospitalized client does the nurse recommend the ongoing use of a urinary catheter? a. A 35-year-old woman who was admitted with a splenic laceration and femur fracture (closed repair completed) following a car crash b. A 48-year-old man who has established paraplegia and is admitted for pneumonia c. A 61-year-old woman who is admitted following a fall at home and has new-onset dysrhythmia d. A 74-year-old man who has lung cancer with brain metastasis and is bring transitioned to hospice

ANS: D Rationale: The man with advanced lung cancer and brain metastasis is dying and likely to be incontinent, in a lot of pain, and confused. An indwelling catheter can help provide comfort at this time by reducing the amount of manipulation needed to keep him and his bed dry. The other clients have no conditions for which use of a bedpan or intermittent catheterization would be contraindicated.

5. The nurse is caring for a client who reports pain. As an advocate for the client, what will the nurse do first for this client? -Assess the level of pain. -Administer pain medication. -Accept the client's report of pain. -Call the health care provider for a medication order.

Accept the client's report of pain. The nurse's primary role in pain management is to advocate for the client by accepting reports of pain, as such, this is the nurse's first action. This has become the clinical definition of pain worldwide and reflects an understanding that the client is the authority and the only one who can describe the pain experience. In other words, self-report is always the most reliable indication of pain. Administering pain medication, assessing the pain level, and calling the provider are responses to the first response which is accepting that the client is in pain.

5. A postoperative client reports, "I have pain from a mild headache." Which PRN medication will the nurse administer? -Oxycodone -Hydromorphone -Midazolam -Acetaminophen

Acetaminophen The nurse will administer acetaminophen as prescribed. Nonopioid analgesics such as acetaminophen are the first line of therapy for mild to moderate pain. Hydromorphone is appropriate for acute pain, such as pain from surgery, but it is inappropriate to give it for headache pain, especially for a mild headache. Midazolam is not appropriate for routine postoperative pain or headache; it is often used as a preoperative sedative. Oxycodone is an opioid and is not needed for a mild headache.

5. The nurse is caring for a client who had a fractured ankle repaired. Twenty minutes after receiving 1.5 mg of hydromorphone IV push, the client is slow to respond and has constricted pupils and a respiratory rate of 6 breaths/min. What is the priority nursing action? -Perform a cognitive assessment on the client. -Call the care provider for a change in the medication order. -Administer a dose of naloxone 0.4 mg slow IV push. -Change the order to every 6 hours rather than every 4 hours.

Administer a dose of naloxone 0.4 mg slow IV push. The priority nursing action is to administer a dose of naxalone 0.4 mg IV. For an unresponsive client, the nurse would administer naloxone 0.4 mg over a 2-minute time period to reverse the action of the opioid analgesic. The order may need to be altered or changed, but calling for a medication order change is not the first action that the nurse would take in an unresponsive client. Nurses do not change orders in terms of dosage or frequency; the health care provider changes the order. A sedated client will not be able to complete a cognitive assessment, and this action would waste time that should be spent on reversing the effects of hydromorphone.

61. A client who is admitted with urolithiasis reports "spasms of intense flank pain, nausea, and severe dizziness." Which intervention does the nurse implement first? -Administer morphine sulfate as prescribed. -Infuse 0.9% normal saline at 100 mL/hr as prescribed -Obtain a urine specimen for urinalysis as prescribed. -Begin an infusion of metoclopramide as prescribed.

Administer morphine sulfate as prescribed. The intervention the nurse implements first for a client admitted with urolithiasis who reports "spasms of intense flank pain, nausea, and severe dizziness" is to administer morphine sulfate 4 mg IV. Morphine administered intravenously will decrease the pain and the associated sympathetic nervous system reactions of nausea and hypotension. An infusion of metoclopramide (Reglan) 10 mg IV would be begun after the client's pain is controlled. A urine specimen for urinalysis would be obtained and an infusion of 0.9% normal saline at 100 mL/hr would be started after the client's pain is controlled.

8. A client with terminal lung cancer is receiving hospice care at home. Which nursing action will the RN manager ask the LPN/LVN to do? -Administer prescribed medications to relieve the client's pain, shortness of breath, and nausea. -Teach the family to recognize signs of client discomfort such as restlessness or grimacing. -Clarify family members' feelings about the meaning of client behaviors and symptoms. -Develop a plan for care after assessing the needs and feelings of both the client and the family.

Administer prescribed medications to relieve the client's pain, shortness of breath, and nausea. LPN/LVNs are educated to administer medications and monitor clients for therapeutic and adverse medication effects; the administration of prescribed medications to the client for pain, shortness of breath, and nausea is appropriate to delegate to the LPN/LVN. Clarifying family members' feelings, developing a plan of care, and teaching the family to recognize signs of discomfort all require broader education and are appropriate for the RN practice level.

5. A client with cancer who is taking pain medication states, "I am still having pain." During the assessment, the client does not exhibit any physical signs of pain. What will the nurse do next? -Administer the pain medication as requested. -Withhold the pain medication. -Decrease the client's standard pain medication dose. -Give the client a placebo and monitors the outcome.

Administer the pain medication as requested. The nurse will administer the pain medication as requested. Both types of persistent (chronic) pain (chronic cancer pain and chronic noncancer pain) do not cause sympathetic reactions. Therefore, some clients do not appear to be in pain, even when they are. Clients with cancer tend to know what medication works for them. The nurse needs to follow the protocol for the client regardless of the client's objective symptoms when managing chronic cancer pain. The nurse would not decrease pain medication under the assumption that, because the client does not exhibit signs of pain, the client must not have any pain. Unless the client is involved in a clinical research trial, giving a placebo in place of medication is never appropriate. It is never appropriate to withhold prescribed pain medication unless the client is medically unstable and the nurse would contact the health care provider.

57. Clients who have deficiencies of which hormones will the nurse assess for increased risk of life-threatening consequences? -Prolactin and prolactin inhibiting hormone (PIH) -Adrenocorticotrophicn hormone (ACTH) and thyroid-stimulating hormone (TSH) -Growth hormone (GH) and melanocyte-stimulating hormone (MSH) -Follicle-stimulating hormone (FSH) and luteinizing hormone (LH)

Adrenocorticotrophicn hormone (ACTH) and thyroid-stimulating hormone (TSH) Deficiencies of (ACTH) or TSH are the most life threatening because they cause a decrease in the secretion of vital hormones from the adrenal and thyroid glands. Deficiencies of the other hormones result in significant changes but these deficiencies are not incompatible with life.

8. The nurse manager for home health and hospice is scheduling daily client visits. Which client is appropriate for the assistive personnel to visit? -Aggressive brain tumor and needs daily assistance with ambulation and bathing -Advanced cirrhosis of the liver and just called the hospice agency reporting nausea -Inoperable lung cancer and considering whether to have radiation and chemotherapy -Prostate cancer with bone metastases and has new-onset leg weakness and tingling

Aggressive brain tumor and needs daily assistance with ambulation and bathing Assisting clients with activities of daily living such as ambulation and bathing is a common role for assistive personnel working in home health or hospice agencies. Assessing and acting upon a new symptom (nausea), helping clients make decisions, and evaluating a new-onset symptom all require more complex assessment skills and interventions, which are within the RN scope of practice.

NCLEX Examination Challenge 62-1 Which assessment data would the nurse anticipate in a client with acute pyelonephritis? Select all that apply. A. Urinary frequency B. Dysuria C. Oliguria D. Heart rate 120 E. Uremia F. Costovertebral angle tenderness

Answer(s): A, B, D, F Acute pyelonephritis is an active bacterial infection. The client will likely experience urinary frequency (increased in urination) and dysuria (Painful urination). The client will likely have a fever, chills and exhibit tachycardia and/or tachypnea. A heart rate of 120 indicates tachycardia. Costovertebral angle tenderness is anticipated. Uremia (build up or urea in the blood) is not anticipated with acute pyelonephritis.

NCLEX Examination Challenge 5-3 A client has a one-time prescription for morphine 2 mg IV push for breakthrough pain. The drug is available as 5 mg/mL. The nurse administers _____ mL of morphine for one dose.

Answer: 0.4 mL The nurse administers 0.4mL of morphine for one dose.

NCLEX Examination Challenge 8-2 The family of a client who is near death is concerned about a loud rattling that occurs with the client's breathing. What nursing intervention is appropriate? Select all that apply. 1) Administer hyoscyamine as prescribed to dry up secretions. 2) Turn the client onto one side to help decrease the gurgling with respirations. 3) Suction the client regularly to remove secretions in the bronchi and oropharynx. 4) Assess the client for signs of dyspnea or respiratory distress. 5) Administer diuretics as prescribed to help decrease the wet respirations. 6) Teach the family about the buildup of secretions that occur when a client is near death.

Answer: 1, 2, 4, 6 Rationale: The client is experiencing loud or wet respirations, commonly referred to as a death rattle, as it happens in the end of life. Appropriate nursing interventions include administering hyoscyamine as prescribed to dry up oral secretions, turning the client to one side to help the secretions drain from the bronchi and oropharynx, assessing for signs of dyspnea, and teaching the family about the buildup of secretions that occur when a client is near death. It is not appropriate to suction the client as this is generally ineffective and can be uncomfortable for the dying patient. Administering diuretics is also not appropriate as the secretion are in the respiratory tract and oropharynx and diuretics will not affect these secretions.

NCLEX Examination Challenge 62-3 The nurse is caring for a male client 8 hours after a nephrectomy. Which assessment data requires immediate nursing intervention? A. Abdominal distension B. Urine output 38 ml in the last hour C. Blood pressure 108/64 mmHg D. Hemoglobin 14 g/dL

Answer: A Rationale: Abdominal distension can indicate bleeding which is a significant risk following nephrectomy. The nurse will need to assess the client's vital signs, check under the bed linens to see if the client is bleeding outwardly. Then the nurse will notify the surgeon with the vital sign data and abdominal distension assessment. Urine output of 38ml in the last hour is within the acceptable range. The blood pressure is low normal and the hemoglobin is low normal for a male client (normal hgb is 14-18 g/dL).

NCLEX Examination Challenge 5-1 The nurse is teaching a class on pain management strategies. Which client statement requires additional teaching? A. "Persistent pain is a warning in my body that alerts the sympathetic nervous system." B. "Acute pain has a quick onset and is usually isolated to one area of my body." C. "My frozen-shoulder causes musculoskeletal or somatic pain." D. "Nociceptive pain follows a normal and predictable pattern."

Answer: A Rationale: Acute pain, not persistent (chronic) pain serves as a warning signal to alert the sympathetic nervous system. Persistent or chronic pain serves no biologic purpose. The other answer options are all correct and do not require additional teaching.

NCLEX Examination Challenge 61-3 A client with diabetes has the following assessment changes after a percutaneous nephrolithotomy procedure. Which change requires immediate nursing intervention? A. Difficulty breathing and an oxygen saturation of 88% on 2 L of oxygen by nasal cannula B. A point-of-care blood glucose of 150 mg/dL and client report of thirst C. A decreased hematocrit by 1% (compared with preoperative values and hematuria) D. An oral temperature of 38° C (101° F) and cloudiness of urine draining from the nephrostomy tube after IV administration of a broad-spectrum antibiotic

Answer: A Rationale: All changes are somewhat abnormal but the only one that raises the level of concern to a point at which it should be immediately is the difficulty breathing and drop in oxygen saturation. This is NOT an expected problem associated with the procedure and is potentially life-threatening. The blood glucose elevation, thirst, temperature elevation, cloudiness of the urine, and slight decrease in hematocrit are expected and do not pose an immediate threat.

5-1. A client taking newly prescribed gabapentin for persistent neuropathic pain reports dizziness. What is the best nursing response? A. "This is common side effect of gabapentin and will decrease with use." B. "Stop taking the medication and contact the healthcare provider." C. "The dizziness is caused by the neuropathic pain, not the medication." D. "The dizziness is likely from another medication, not the gabapentin."

Answer: A Rationale: Gabapentin is commonly used for neuropathic pain. The most common side effect is dizziness which will generally decrease with use. It is not appropriate to tell the client to stop taking the medication and it is unlikely that the neuropathic pain or another medication is causing the dizziness.

NCLEX Examination Challenge 5-2 Which documentation will the nurse record for a client who had a total knee replacement 2 days ago and reports sharp pain at the surgical site? A. Reports acute pain at the surgical site. B. Persistent pain reported around the surgical site. C. Experiences neuropathic pain near the surgical site. D. Discomfort has progressed to chronification of pain.

Answer: A Rationale: The nurse will document that the client reports acute pain at the surgical site. Acute pain is commonly associated with surgical procedures and lasts for a short duration. The client does not demonstrate persistent or chronic pain, nor is the pain neuropathic in nature. Acute pain that is poorly controlled and lasts longer than it should can lead to chronification of pain.

56-1. Which action best exemplifies the expected outcome of appropriate negative feedback control over endocrine gland hormone secretion? A. Decreased secretion of glucagon when blood glucose approaches normal levels B. Increased secretion of parathyroid hormone in response to a calcium-containing intravenous infusion C. Increased secretion of thyroid stimulating hormone in response to long-term exogenous thyroid hormone replacement therapy D. Decreased secretion of cortisol in response to a pituitary tumor stimulating the increased secretion of adrenocorticotropic hormone

Answer: A Rationale: A negative feedback mechanism signals an endocrine gland to secrete a hormone in response to a body change to cause a reaction that will result in actions to oppose the action of the initial condition change and restore homeostasis. Serum calcium levels determine when and to what degree parathyroid hormone PTH is released. PTH secretion decreases when serum calcium levels are high, and it increases when serum calcium levels are low. If thyroid hormone levels are high, as would be the case if a client was taking exogenous thyroid hormone replacement therapy, release of both thyrotropin-releasing hormone (TRH) and thyroid stimulating hormone TSH is inhibited. Adrenocorticotropic hormone (ACTH) triggers the release of cortisol from the adrenal cortex, not suppression of its release.

NCLEX Examination Challenge 63-4 The nurse is caring for a 38 year old male with hypertension and Stage 1 CKD. The client reports lifestyle changes and feeling "better" and has stopped taking a prescribed diuretic. What is the appropriate nursing response? A. "The diuretic will reduce your blood pressure which may slow or prevent progression of your chronic kidney disease." B. "Your primary health care provider prescribed the diuretic because it will reverse the damage caused by kidney disease." C. "Taking medications is a personal decision, and you have the right to decline this prescription." D. "Since you have implemented lifestyle changes the diuretic is likely not needed."

Answer: A Rationale: Blood pressure control is critical in the treatment of patients with CKD - lowering the blood pressure reduces the risk of stroke, MI, and progression of CKD. Stage 1 CKD already indicates some irreversible damage. Management of blood pressure at this stage of CKD can greatly slow its progression. A diuretic does not improve kidney function or reverse CKD damage. It does not alter the course of CKD progression. It does improve elimination of fluid, and fluid overload can contribute to hypertension. While personal values and preferences are essential decision points in determining a plan of care for each adult, it is also important that the client be well informed. While this client has had lifestyle changes, they may not be enough to control hypertension. The control of hypertension can slow progression of CKD. Drug therapy reduces vessel damage.

NCLEX Examination Challenge 58-2 Which assessment finding of a client 8 hours after a subtotal thyroidectomy does the nurse consider most relevant as an indication of a possible complication? A. The client's hand spasms during blood pressure measurement. B. The respiratory rate has dropped from 18 to 14 breaths per minute. C. The dressing has a moderate amount of serosanguinous drainage. D. The client responds to questions correctly but does not open the eyes while talking.

Answer: A Rationale: Hand spasms in the presence of decreased oxygen (as would happen while a blood pressure cuff was inflated above systolic pressure) is an indication of hypocalcemia, a possible complication of reduced parathyroid function that can result from thyroid surgery. The respiratory rate is within normal limits for a healthy adult. A moderate amount of drainage may be more than expected but is not an indication of obstruction. After general anesthesia, most clients are sleepy. Not opening his or her eyes during a response to a question is not an indication of a complication.

NCLEX Examination Challenge 59-3 Which precaution is a priority for the nurse to teach a client prescribed semaglutide to prevent harm? A. Only take this drug once weekly. B. Report any vision changes immediately. C. Do not mix in the same syringe with insulin. D. This drug can only be given by a health care professional.

Answer: A Rationale: Semaglutide is a long-acting GLP-1 agonist given only once weekly and comes only as a self-injection pen. It does not have to be administered by a health care professional. It is not associated with any vision changes.

63. Answer Key - Mastery Questions 1. A client with a recently created vascular access for hemodialysis is being discharged. Which discharge teaching will the nurse include? A. Do not allow blood pressure measurements in the affected arm. B. Elevate the affected arm allowing for total rest of the extremity. C. Assess for a bruit in the affected arm on a daily basis. D. Sleep on the affected side to protect the access device.

Answer: A Rationale: The nurse must teach the client to avoid blood pressure measures in the arm that contains the newly created vascular access device. Compression of vascular access causes decreased blood flow and may cause occlusion. If this occurs, dialysis will not be possible. The arm with the access device must be exercised to encourage venous dilation, not rested. The client can palpate for a thrill, but a stethoscope is needed to auscultate the bruit at home. The nurse will teach the patient to sleep on the opposite side- to avoid compressing the affected extremity.

Answer Key - Mastery Questions 58-1. Performance of which assessment is a priority for the nurse before giving a client the first oral dose of hormone replacement for hypothyroidism? A. Measuring heart rate and rhythm B. Checking core body temperature C. Asking about previous allergic drug reactions D. Listening to bowel sounds in all four abdominal quadrants

Answer: A Rationale: The side effects and adverse effects of thyroid hormone replacement drugs increase metabolic rate and cardiac activity. Checking heart rate and rhythm before giving the drug provides a baseline to determine whether or not the drug is working correctly or is causing an overdose effect. Although changes in core body temperature and bowel sounds will eventually indicate responses to the prescribed therapy, the most critical to assess are those related to cardiac function. Thyroid replacement hormone has not been taken by this client before and is not associated with any other types of drug allergies.

Answer Key - Mastery Questions 57-2 57-2. Which assessment has the highest priority for the nurse to perform for a client with syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24 hours? A. Evaluating serum sodium levels B. Evaluating serum potassium levels C. Examining the skin and sclera for jaundice D. Examining the IV site for indications of phlebitis

Answer: A Rationale: Tolvaptan carries a black box warning of increased risk for developing hypernatremia within 12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not directly affected by this drug. Although the drug is associated with an increased risk for jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral one.

62. 3. When providing care to a client who has undergone a nephrostomy for hydronephrosis, which observation alerts the nurse to a possible complication? (Select all that apply.) A. Urine output of 15 mL for the first hour and then diminishes B. Tenderness at the surgical site C. Pink-tinged urine draining from the nephrostomy D. A hematocrit value 3% lower than the preoperative value E. Sudden onset of abdominal pain that worsens after abdominal palpation F. Blood pressure of 180/90 that persists despite administration of pain medication

Answer: A, D, E, F Rationale: Low output is concerning immediately after nephrostomy placement; most clients have a diuresis. After nephrostomy placement, most clients have bloody urine (red- or pink-tinged) for several hours. There is pain and tenderness at the surgical site but bleeding at the site is not common. New onset of abdominal pain with rebound tenderness may indicate a perforation, an uncommon but potentially life-threatening complication of manipulating the needles during nephrostomy placement. Similarly, blood loss either through the nephrostomy or surgical site can be related to a clinical important decrease in hematocrit; diuresis means that the change in hematocrit is unlikely to be from hemodilution. Inform the provider whenever this change occurs post-operatively. Hypertension can contribute to bleeding risk and occurrence; generally, as will most post-operative or post-interventional procedures, a reasonable blood pressure goal is 120-140/80-90.

NCLEX Examination Challenge 62-2 The nurse is reviewing the client's laboratory data prior to a nephrostomy tube insertion. Which data requires the nurse to take action? A. White blood cells in the urine B. INR of 2.1 C. Hematocrit 44% D. Creatinine 0.8 mg/dL

Answer: B Rationale: The INR is high and could lead to bleeding during insertion of the nephrostomy tube. This laboratory data requires the nurse to take action by notifying the provider. The INR (part of the client's clotting factors) will need to be corrected prior to the procedure. White blood cells would be anticipated as this may be the cause (recurrent infection) for the tube placement. The hematocrit and creatinine values are within normal limits.

62. 1. Which question will the nurse ask the client who has a urinary tract infection to assess the risk for pyelonephritis? A. What drugs do you take for asthma? B. How long have you had diabetes? C. How much fluid do you drink daily? D. Do you take your antihypertensive drugs at night or in the morning?

Answer: B Pyelonephritis risk is increased in the client with diabetes and a urinary tract infection (UTI). While it is important to know all the drugs that a client takes, neither asthma drugs nor asthma itself increases the risk for pyelonephritis. Although insufficient fluid intake may make a UTI worse, it does not increase the risk for pyelonephritis. Antihypertensives are not a risk factor for pyelonephritis.

56-2. Which assessment finding in a 40-year-old client is most relevant for the nurse to assess further for a possible endocrine problem? A. He has lost 10 lbs in the past month following a low carbohydrate eating plan. B. The client reports now only needed to shave once weekly instead of daily. C. His new prescription for eye glasses is for a higher strength. D. The client's father died of a stroke at age 70 years.

Answer: B Rationale: A change in degree of facial hair is could indicate an endocrine problem, particularly of the pathway for testicular function. An intentional weight loss of 10 lb over a month's time is within the normal range for gender and age. Although the need for a stronger prescription for eye glasses at this age could potentially be related to an endocrine problem, many other factors are more likely to be related to this problem. The same is true of his father's stroke.

Answer Key - Mastery Questions 8- 1. A client receiving palliative care for a terminal cancer diagnosis asks the nurse, "Why is this happening to me?" What is the nurse's best response? A. "I don't know. God knows when your time is up on this earth." B. "I'm sorry. I know that this is a very difficult time for you." C. "It's going to be OK; at least you aren't leaving any family behind." D. "We'll make sure that all of your needs are met, so don't worry."

Answer: B Rationale: Acknowledging that a terminal diagnosis is difficult is the most appropriate nursing response. Inferring that God knows when time is up implies a belief in God that may not exist. False reassurance by saying it's okay is not therapeutic and implies that since they are not leaving family there is no reason to be upset. Telling a client not to worry does not allow him or her to express themselves regarding their feelings.

56-2. Which instruction/precaution does the nurse teach a client to prevent harm during a 24-hour urine specimen collection? A. Be sure to keep the specimen cool for the entire collection period. B. Avoid splashing urine in the container when a preservative is present. C. Add the preservative to the collection container before adding any urine. D. Discard the first specimen that marks the beginning of the 24-hour test period.

Answer: B Rationale: All instructions/precautions are needed for correct collection of a 24-hour urine collection. The only precaution that will prevent harm is the one for avoiding the splashing of any urine in the container with the preservative.

NCLEX Examination Challenge 63-1 A 62-year-old client was admitted 2 days ago with traumatic injuries and hypovolemic shock. Which lab result is most important for the nurse to report to the health care provider immediately? A. Serum sodium 132 mEq/L (mmol/L) B. Serum potassium 6.9 mEq/L (mmol/L) C. Blood urea nitrogen 24 mg/dL (mmol/L) D. Hematocrit 32% (0.32 volume fraction); hemoglobin 9.2 g/dL (92 g/L)

Answer: B Rationale: All listed laboratory values are out of the normal range. However, the only value that has reached or is approaching a critical level is the serum potassium, which shows hyperkalemia. The recent trauma combined with shock is likely affecting perfusion to the kidneys. This problem (both in terms of kidney perfusion and critical potassium levels) must be addressed immediately.

5-2. A client has been receiving the same dose of an intravenous opioid for two days to manage post-surgical pain. The client reports that the drug is no longer controlling the pain. What does the nurse suspect? A. There is likely a history of addiction. B. Tolerance to the opioid is developing. C. Physical dependence is developing. D. The client is opioid-naïve.

Answer: B. Rationale: A client who has been receiving the same dose of an opioid for several days and now reports that the drug is not controlling the pain is likely developing tolerance. This is not the same thing as addiction or physical dependence. Physical dependence is manifested when a drug is stopped and the client shows withdrawal symptoms. Tolerance means the body has adapted to the drug and the client may require an increased dose or switching to a different drug for pain control. An opioid-naïve person has not recently taken enough opioid on a regular basis to become tolerant to the effects of an opioid. Tolerance does not indicate addiction or a history of addiction.

62. 2. When assessing a client with acute glomerulonephritis, which question will the nurse ask to determine whether the client is following best practices to slow progression of kidney damage? A. "Do you avoid contact sports while you are taking cyclosporine?" B. "How are you evaluating the amount of daily fluid you drink?" C. "Have you contacted anyone from our dialysis support services?" D. "Have you increased your protein intake to promote healing of the damaged nephrons?"

Answer: B Rationale: Protein intake may be increased early in Chronic Kidney Disease (CKD) and reduced late in CKD. Since you do not have information about the extent of CKF (stage), this question may be incorrect. Cyclosporine is a cytotoxic agent that reduces immune responses, which would require the client to avoid sick contacts. Because the client needs to find a balance between too much and too little fluid intake (both are harmful), this is a good question to see how the individual ensures adequate kidney blood flow (perhaps with systemic blood pressure assessment) while providing sufficient intake to eliminate waste (perhaps through urine volume or color or via staying within a target of fluid intake. A target fluid intake is generally 1.5 to 2 L daily if not receiving dialysis). The client may not progress to needing dialysis; this intervention is usually reserved until the last stage of CKD before dialysis occurs; there is no indication that CKD has been staged at this point.

NCLEX Examination Challenge 59-4 How will the nurse modify insulin injection technique for a client who is 5 feet 10 inches tall and weighs 106 lb (48.1 kg) A. Use a 6 mm needle and inject at a 90-degree angle. B. Use a 6 mm needle and inject at a 45-degree angle. C. Use a 12 mm needle and inject at a 90-degree angle. D. Use a 12 mm needle and inject at a 45-degree angle.

Answer: B Rationale: The client is very thin. Using either a longer needle or injecting the insulin at a 90-degree angle increases the likelihood of performing an intramuscular injection instead of a subcutaneous one, which would affect insulin absorption. Selecting a shorter needle and injecting at a 45-degree angle prevents an intramuscular injection into this client.

59-5. While making rounds the nurse finds a client with type 1 diabetes mellitus pale, sweaty, slightly confused, and can still swallow. The client's blood glucose level check is 48 mg/dL (2.7 mmol/L). What is the nurse's best first action to prevent harm? A. Call the pharmacy and order a STAT does of glucagon B. Immediately give the client 30 grams of glucose orally C. Start an IV and administer 50 mL of a 50% dextrose solution D. Recheck the blood glucose level and call the rapid response team

Answer: B Rationale: The client's blood glucose level is seriously low and will get even lower quickly. Because the client can still swallow, giving 30 grams of glucose (following the 15-15 rule) is the best course of action. Obtaining a dose of glucagon from the pharmacy or starting an IV are too slow to prevent severe hypoglycemia. Just rechecking the blood glucose level without giving glucose is very dangerous when the client already has symptoms of hypoglycemia.

NCLEX Examination Challenge 59-5 A client with diabetes who now has chronic albuminuria asks the nurse how this change will affect his health. How will the nurse answer this question? A. "You will need to limit your intake of dietary albumin and other proteins to reduce the albuminuria." B. "This change indicates beginning kidney problems and requires good blood glucose control to prevent more damage." C. "Your risk for developing urinary tract infections is greatly increased, requiring the need to take daily antibiotics for prevention." D. "From now on you will need to keep your fluid intake to just 1 L daily and completely avoid caffeine to protect your kidneys."

Answer: B Rationale: The microvascular complications of diabetes reduce kidney perfusion and damage the glomeruli, leading to chronic kidney disease. The first indication of this problem is chronic albuminuria from increased filtration of proteins through damage glomeruli. Although this problem cannot be reversed, the rate of progression can be slowed with tight glycemic control. With albuminuria, proteins are lost from the body and do need to be replaced, not restricted, at this stage. The risk for urinary tract infections is increased with glucose in the urine, not albumin or other protein. Reducing fluid intake has the potential to damage the kidneys further and is not helpful.

NCLEX Examination Challenge 63-3 The nurse is preparing a client with stage 3 CKD for discharge. Which client statement indicates the need for further teaching? A. "I will be sure to attend my follow up appointment with my nephrologist." B. "I will increase my protein intake so my body can heal." C. "I will weigh myself daily and call the doctor if my weight increases by 2 pounds or more. D. "I will take my blood pressure each day and keep a daily log."

Answer: B Rationale: While it is common to think of protein as necessary to heal, the client with CKD will often have protein restrictions. Protein restriction early in the course of the disease prevents some of the problems of CKD and may preserve kidney function. Protein is restricted on the basis of the degree of kidney and waste elimination impairment (reduced glomerular filtration rate [GFR]) and the severity of the symptoms.

NCLEX Examination Challenge 57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively to this drug therapy? A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L) B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L) C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L) D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)

Answer: B Rationale: With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium levels below normal (hyponatremia) and increase serum potassium levels above normal (hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and hyperkalemia.

Answer Key - Mastery Questions 8-2. The family of a client experiencing terminal dehydration requests that intravenous fluids be started. What is the nurse's best response? A. "We can start fluids to help ease the dehydration." B. "Intravenous fluids can increase discomfort for the client." C. "Intravenous fluids will likely prolong life." D. "Terminal dehydration can be managed better with pain medication."

Answer: B Rationale: With terminal dehydration, administering intravenous fluids can increase discomfort. At this stage, there is multisystem slow down and the body is unable to process the fluids, and this can cause ascites, vomiting, edema, and respiratory distress. Intravenous fluids will not prolong life, but they will make the client less comfortable in this stage. Terminal dehydration does not usually cause discomfort and is managed by keeping the client's oral cavity moist.

NCLEX Examination Challenge 61-4 A 68-year-old male client is seeing the primary care provider for an annual examination. Which assessment finding alerts the nurse to an increased risk for bladder cancer? A. A five-pack year history of smoking 45 years ago B. Difficulty starting and stopping the urine stream C. A 30-year occupation as a long-distance truck driver D. A recent colon cancer diagnosis in his 72-year-old brother

Answer: C Rationale: Although cigarette smoking is a risk factor for bladder cancer, a 5-pack year history more than 45 years ago is not significant as a potential cause of cancer. Bladder cancer does not appear to have a familial or genetic predisposition. Difficulty starting or stopping urination is a symptom, usually of prostate issues, not a harbinger of bladder cancer. The latest research indicates exposure to gasoline and diesel fuel is a major risk factor for bladder cancer.

Answer Key - Mastery Questions 57-1 57-1. Which precaution is most important for the nurse to teach a female client to prevent harm while undergoing drug therapy with estrogen and progesterone for hypopituitarism? A. "Use a barrier method of contraception to prevent an unplanned pregnancy." B. "Wear a hat with a brim and use sunscreen when outdoors." C. "Do not smoke or use nicotine in any form." D. "Avoid drinking caffeinated beverages."

Answer: C Rationale: Both estrogen therapy and progesterone therapy increase the risk for thromboembolism formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is unlikely to occur without further medical intervention. These hormones do not increase photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no recommendations for avoiding caffeine while taking these drugs.

NCLEX Examination Challenge 57-2. Which urine characteristics indicate to the nurse that the client being managed for diabetes insipidus is responding appropriately to interventions? A. Urine output volume increased; urine specific gravity increased B. Urine output volume increased; urine specific gravity decreased C. Urine output volume decreased; urine specific gravity increased D. Urine output volume decreased; urine specific gravity decreased

Answer: C Rationale: Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a result, water is excessively excreted, causing a decrease in blood volume and an increase in urine volume. Blood is concentration indicating dehydration and urine is very dilute, as measured by specific gravity, is very low. When interventions to counter act DI are effective, the adult increases water reabsorption so that urine output volume decreases at the same time that urine concentration increases, seen as an increased urine specific gravity.

59-2. Which precaution is a priority for the nurse to teach a client prescribed pramlintide to prevent harm? A. Only take this drug once weekly. B. Do not drink alcohol when taking this drug. C. Do not mix in the same syringe with insulin. D. Report any genital itching to your primary health care provider.

Answer: C Rationale: Pramlintide is an amylin analog injected subcutaneously several times daily with or right before any meal. It has a pH that is different from and incompatible with insulin and is not to be mixed in the same syringe. It does not increase the risk for genital yeast infections. It does not increase the risk for lactic acidosis when alcohol is comsumed.

NCLEX Examination Challenge 63-5 A client who performs home continuous ambulatory peritoneal dialysis reports that the drainage (effluent) has become cloudy in the past 24 hours. What is the priority nursing action? A. Remove the peritoneal catheter. B. Notify the nephrology health care provider. C. Obtain a sample of effluent for culture and sensitivity. D. Teach the client that effluent should be clear or slightly yellow.

Answer: C Rationale: The client most likely has beginning peritonitis. This problem needs to be confirmed and interventions started quickly. A culture is needed to identify that an infection is indeed present. Although the health care provider does need to be notified, obtaining a sample as soon as the effluent is observed is important. The peritoneal catheter should not be removed at this time because it may be needed to instill intraperitoneal antibiotics. Also, removal of this catheter in not within the scope of practice for registered nurses in most states. While teaching the client is important, the priority at this time is to address the potential infection by securing a sample for culture.

NCLEX Examination Challenge 58-3 A client at continuing risk for hyperparathyroidism is prescribed to take furosemide 40 mg and to drink at least 3 to 4 L of fluid daily. He tells the nurse he believes taking a "water pill" and then drinking so much seems wrong. How will the nurse respond? A. "This combination of a water pill and drinking more ensures protects you from buildup of excess sodium in the kidney." B. "The furosemide makes you lose water and you need to increase your intake to keep from becoming dehydrated." C. "The drug helps you to get rid of calcium and drinking more helps dilute your blood calcium so the level doesn't get too high." D. "You are correct. I will check with your primary health care provider to determine whether you should restrict your fluid intake."

Answer: C Rationale: The purpose of the furosemide and hydration therapy is to lower the blood calcium levels to manage the hypercalcemia associated with hyperparathyroidism. Although it is true that increasing fluid intake while on furosemide can help prevent dehydration and also helps excrete sodium, that is not the desired outcome in hyperparathyroidism.

58-3. The nurse reviewing the laboratory values of a client with hypoparathyroidism finds a serum calcium level of 7.9 mg/dL (1.76 mmol/L). Which parameter is most important for the nurse to assess to prevent harm? A. Temperature B. Heart rate and rhythm C. Deep tendon reflexes D. Level of consciousness

Answer: C Rationale: The serum calcium is low, placing the client in danger of increased muscle contractions and tetany. The client's deep tendon reflexes should be evaluated for hyperreflexia, which is an indicator of impending tetany. The other parameters are much less affected by hypocalcemia.

NCLEX Examination Challenge 57-4. A nurse caring for a client with Cushing's syndrome who must remain on continued corticosteroid therapy for another health problem will use which of the following actions to prevent harm? A. Urging the client to salt his or her food. B. Testing voided urine for the present of glucose. C. Using non-adhesive methods to secure an IV access. D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach.

Answer: C Rationale: The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured. The client also is a increased risk for infection and an open skin site increases that risk. Using nonadhesive methods to secure an IV access protects the skin from injury. Usually the client on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach lining and can cause GI bleeding for many reasons. They are recommended to be taken with food to prevent GI irritation.

56-1. Which statement regarding trophic (tropic) hormones is true? A. All are categorized as catecholamines. B. Responses are independent of target tissue receptors. C. Their target tissues are always another endocrine gland. D. They represent the final hormone secreted in a complex negative feedback pathway.

Answer: C Rationale: Trophic (tropic) hormones stimulate the secretion of other hormones from another endocrine gland. Just like any other hormone, a receptor is required for action (receptor can be on the receptor or somewhere else inside the responsive target tissue. Only epinephrine, norepinephrine, and dopamine are catecholamines. None of them are trophic hormones. Trophic hormones represent the initiating hormone or an intermediate hormone in a more complex negative feedback pathway, not the final hormone.

63. Answer Key - Mastery Questions The nurse is providing discharge teaching to a client recovering from kidney transplantation. Which client statement indicates understanding? A. "I can stop my medications when my kidney function returns to normal." B. "If my urine output decreases I will increase my fluids." C. "The antirejection medications will be taken for life." D. "I will drink 8 ounces (236 ml) of water with my medications."

Answer: C Rationale: When the client states that antirejection medications must be taken for life, it indicates that the kidney transplant client understands the discharge teaching. Immune-suppressant therapy must be taken for life to prevent organ rejection. Adherence to immunosuppressive drugs is crucial to survival for clients with transplanted kidneys. Lack of adherence can lead to complications such as rejection, graft loss, return to dialysis, and death. Oliguria (decreased urine output) is a symptom of transplant rejection. If this occurs, the transplant team must be contacted immediately. It is not necessary to take antirejection medication with 8 ounces (236 mL) of water.

NCLEX Examination Challenge 61-2 The nurse is caring for an 80-year-old female client with recurrent cystitis. Which teaching will the nurse include in the plan of care? Select all that apply. A. Drink citrus juices daily. B. Douche regularly; a minimum of two times weekly. C. Encourage fluid intake of 2-3 L of fluid throughout the day. D. Instruct her to always wipe the perineum from front to back after each toilet use. E. Reinforce that she should complete the entire course of antibiotics as prescribed. F. Instruct her to empty her bladder immediately before and after having intercourse.

Answer: C, D, E Rationale: When teaching a female patient about preventing cystitis, the nurse will include increasing fluids every day to help flush out the bladder, wiping from front to back after toileting to prevent fecal matter and microorganisms from entering the urethral meatus, taking the full course of antibiotics to prevent risk of organism resistance, and to empty her bladder before and after intercourse due to possible irritation of the urethral meatus and exposure to another individual's microorganisms.

61. Answer Key - Mastery Questions 1. A client is diagnosed with renal colic. What would the nurse do first? a. Prepare the client for lithotripsy. b. Encourage oral intake of fluids. c. Strain the urine and send for urinalysis. d. Administer opioids as prescribed.

Answer: D Rationale: Renal colic is severe flank pain caused from kidney stones. The pain can be most severe when the stone is moving or the ureter is obstructed. The first nursing action is to provide pain relief by administering opioids as prescribed. The client may require lithotripsy, if the stone is too large to pass on its own, however, pain relief should occur first. Renal colic is usually very severe and the client will likely be diaphoretic and nauseated. Encouraging oral fluids is not suggested until the pain is controlled. The urine should be strained and sent for urinalysis, however, this can occur after the client has received pain medication.

59-4. When preparing to administer a prescribed subcutaneous dose of NPH insulin from an open vial taken from a medication drawer to a client with diabetes, the nurse notes the solution is cloudy. What action will the nurse perform to ensure client safety? A. Warm the vial in a bowl of warm water until it reaches normal body temperature. B. Return the vial to the pharmacy and open a fresh vial of NPH insulin. C. Roll the vial between the hands until the insulin is clear. D. Check the expiration date and draw up the insulin dose.

Answer: D Rationale: The character of NPH insulin is uniformly cloudy. If the expiration date has not passed it can be safely used. Insulin should never be warmed by placing the vial in water.

NCLEX Examination Challenge 8-1 A client receiving palliative care, who has advanced dementia, is non-verbal, restless and moans when the family attempts to touch or comfort the client. Which nursing intervention is appropriate for this client? A. Administer acetaminophen 650 mg by rectally for pain. B. Instruct the family to avoid touching the client to prevent pain. C. Provide passive range of motion to increase mobility once a shift. D. Obtain a prescription for transdermal fentanyl for pain.

Answer: D Rationale: The client is likely experiencing severe pain and needs to be treated with a strong analgesic rather than a mild one like acetaminophen. Further, rectal administration is likely to cause unnecessary discomfort. The purpose of palliative care is to promote comfort. Instructing the family to avoid touching the client is not appropriate, as the family and the client can benefit from supportive touch.

Answer Key - Mastery Questions 57-4 57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland asks the nurse whether the physical changes from the excessive cortisol will go away as a result of the surgery so she can look like herself again. What is the nurse's best response? A. "The surgery is to remove the tumor, not reconstructive surgery." B. "You will notice a great difference in your appearance starting within a week after surgery." C. "All the changes will resolve but may take a year or longer to completely disappear." D. "The fatty changes and and acne will resolve with time but the stretch marks only fade."

Answer: D Rationale: The good news is that the changes that are not related to tissue structure, such as the moon face, buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a year or longer to do so. Her muscles can become stronger and larger again as well. However, the stretch marks will only fade and become less noticeable. Although she did not ask about bone changes and osteoporosis, this may never completely resolve.

NCLEX Examination Challenge 59-2 The nurse reviewing the preadmission testing laboratory values for a 62-year-old client scheduled for a total knee replacement finds an A1C value of 6.2%. How will the nurse interpret this finding? A. The client's A1C is completely normal B. The client has type 1 diabetes mellitus C. The client has type 2 diabetes mellitus D. The client has prediabetes mellitus

Answer: D Rationale: The normal range for A1C (glycosylated hemoglobin A1c) is between 4% and 6%, with diabetes defined as a consistent level above 6.5%. However, clients whose AIC range between 5.7% and 6.4% are considered to have prediabetes with a greatly increased risk for development of actual diabetes mellitus within the next 5 years. Thus this value is not completely normal and is of concern. A1C levels do not distinguish between type 1 and type 2 diabetes.

Answer Key - Mastery Questions 57-3 57-3. Which of the following are the priority precautions the nurse will teach the client who remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy to prevent harm related to the disorder? Select all that apply. A. Avoid crowds and people who are ill B. Check your heart rate for irregular or skipped beats twice daily C. Do not choose low sodium versions of prepared foods D. Get up slowly from sitting or lying positions E. Keep a source of glucose, such as candy, with you at all times F. Never skip your hormone replacement drugs

Answers: A, B, C, D, E, F Rationale: All precautions are a priority. The hormone replacement therapy reduces inflammation and Immunity, increasing the risk for infection. A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum potassium levels that cause cardiac dysrhythmias. Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate intake of this mineral. The disorder is associated with hypotension and postural hypotension. Another common problem is hypoglycemia. The client should always have a concentrated oral glucose source on hand and eat it whenever symptoms of hypoglycemia are present. Skipping hormone replacement therapy increases the likelihood that serious and potentially life-threatening complications can occur quickly. Blood hormone levels need to be relatively constant.

NCLEX Examination Challenge 57-1 57-1 A 30-year-old male client having an annual health physical reports that all of the following changes have developed during the past year. Which ones alert the nurse to possible pituitary hyperfunction? Select all that apply. A. 15 lb weight gain B. Decreased libido C. Four sinus infections D. Frequent constipation E. Increased foot callus formation F. Occasional dripping of clear fluid from both breasts G. Severely sprained ankle from a volley ball injury

Answers: A, B, F Rationale: Several hormones secreted in excess can cause weight gain, although so can increased caloric intake and decreased energy output. However in this instance it is occurring along with other indicators of pituitary hyperfunction. Decreased libido is associated with increased prolactin production, as well as decreased gonadotropins. Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin. Increased sinus infections are not associated with changing pituitary hormone levels. Constipation could be associated with decreased thyroid stimulating hormone but not pituitary hyperfunction. Callus formation and a sprained ankle are physical responses not related to endocrine function.

Answer Key - Mastery Questions 59-1. Which physiological processes directly prevent severe hypoglycemia in a healthy adult without diabetes who is NPO for 12 hours? Select all that apply. A. Gluconeogenesis B. Glycogenesis C. Glycogenolysis D. Ketogenesis E. Lypogenesis F. Lypolysis

Answers: A, C Rationale: Gluconeogenesis is the conversion of protein into glucose. This process increases blood glucose levels and prevents hypoglycemia during fasting. Glycogenolysis is the breakdown of stored glycogen in the liver and skeletal muscle and conversion to glucose. It is the main process that prevents hypoglycemia during fasting. Glycogenesis is the conversion by the liver of excess circulating glucose into glycogen. This process reduces blood glucose levels and does not directly prevent hypoglycemia. Ketogenesis is the breakdown of fats (lipids) into ketone bodies that can be used for fuel by some cells. It does not raise blood glucose levels and does not directly prevent hypoglycemia. Lypogenesis is the conversion of glucose (and other substances) into body fats, usually as free fatty acids. This process does not prevent hypoglycemia during fasting. Lypolysis is the breakdown of fatty acids but does not convert them to glucose and does not directly prevent hypoglycemia during fasting.

58. Which action is most important for the nurse to take first after finding a client who has severe hypothyroidism to be unresponsive to attempts to waken her and have a heart rate of 46 beats/min? -Increasing the IV infusion rate -Initiating the Rapid Response Team -Assessing temperature -Applying oxygen by mask

Applying oxygen by mask The most common cause of death with severe hypothyroidism is respiratory failure with decreased gas exchange. The nurse would apply oxygen first and then initiate the Rapid Response Team. Although a decreased body temperature would support the findings that a client with severe hypothyroidism is worsening, assessing it would not be helpful in this situation. Increasing the IV flow rate may not even improve cardiac output because the slow heart rate is not related to a volume deficit but to reduced myocardial contractility.

59-3. Which health promotion activity(ies) will the nurse recommend to prevent harm in a client with type 2 diabetes? Select all that apply. A. "Avoid all dietary carbohydrate and fat." B. "Have your eyes and vision assessed by an ophthalmologist every year." C. "Reduce your intake of animal fat and increase your intake of plant sterols." D. "Be sure to take your antidiabetes drug right before you engage in any type of exercise." E. "Keep your feet warm in cold weather by using either a hot water bottle or a heating pad." F. "Avoid foot damage from shoe-rubbing by going barefoot or wearing "flip-flops" when you are at home."

Answers: B, C Rationale: Regardless of whether diabetes is type 1 or type 2, the long-term complications are the same as are most prevention activities. The microvascular complications of diabetes increase the risk for eye and vision problems for all who have the disorder. Annual examinations by an ophthalmologist are critical to preventing or delaying reduced vision. Hypercholesterolemia is common in diabetes and contributes to hypertension, as well as microvascular and macrovascular complications, especially cardiovascular problems. Reducing animal-sourced fats and using plant-based sterols is recommended for everyone. Controlling carbohydrate and fat intake is important but they cannot be avoided or eliminated from the diet. Exercising increases the risk for hypoglycemia. Taking antidiabetes drugs immediately before exercising increases this risk and should not be done. Most patients with diabetes, even type 2 diabetes, have some degree of peripheral neuropathy and an increased risk for development of foot ulcers and the need for amputation. Using hot water bottles and heating pads on the feet should never be done because the reduced sensory perception does not allow the client to know when feet are being damaged by the heat. Adults with diabetes should never walk bare-foot or just use "flip-flops" even in the home. They need to wear properly fitting shoes with sturdy soles to prevent any foot injury.

NCLEX Examination Challenge 59-1 Which hormones help prevent hypoglycemia? Select all that apply. A. Aldosterone B. Cortisol C. Epinephrine D. Growth hormone E. Glucagon F. Insulin G. Norepinephrine H. Proinsulin

Answers: B, C, D, E, G Rationale: Cortisol decreases glucose uptake by cells and increases liver production and release of glucose. Epinephrine and norepinephrine rapidly increase liver glycogen breakdown and release of glucose into circulation. Growth hormone also rapidly increases liver glycogen breakdown and increases release of glucose into circulation. Glucagon is the major hormone preventing hypoglycemia. It is produced and secreted by alpha cells of the pancreatic islets as soon as blood glucose levels begin to drop below normal. Aldosterone is an adrenal hormone that affects water and mineral metabolism, not glucose metabolism. Insulin decreases blood glucose levels and can cause hypoglycemia. Proinsulin is an inactive compound that does not directly affect blood glucose levels until it is metabolized into insulin.

NCLEX Examination Challenge 63-2 The nurse is caring for a 74 year old client scheduled for a cardiac catheterization with contrast dye. What nursing action is appropriate? Select all that apply. A. Assess creatinine clearance using a 24 hour urine collection test. B. Assess for co-existing conditions of diabetes, heart failure, and kidney disease. C. Collaborate with the provider about whether IV fluids should be infused before the test D. Notify the provider regarding changes in serum creatinine from 0.2 to 0.4 mg/dL in 24 hours. E. Alert the provider to a glomerular filtration rate (GFR) < 60 mL/min/1.73 m2

Answers: B, C, E Rationale: Assessment of risk factors, such as co-existing conditions that can increase the risk of AKI is an important part of preventing contrast induced nephropathy. Pre-existing conditions that are associated with impaired kidney function include diabetes, heart failure, and advanced age. Clients with a history of kidney disease may not tolerate the contrast dye without subsequent harm. IV fluids are commonly used prior to procedures with contrast dye to ensure adequate intravascular volume and reduce kidney hypoperfusion. This also dilutes the contrast and promotes faster elimination of the contrast. A GRF less than 60mL/min/1.73 m2 requires the nurse to alert the provider as this is indicative of existing kidney disease and significant impairment in kidney function. Creatinine can be assessed using a serum test, a 24-hour collection is not warranted. The serum creatinine is normal and does not require nursing action.

63. Answer Key - Mastery Questions 1. Which client will the nurse identify at risk for acute kidney injury? Select all that apply. A. 68 year old male with diabetes mellitus. B. 16 year old male football player in preseason practice. C. 27 year old female recovering from shock following a car accident. D. 52 year old male with newly diagnosed hypertension. E. 30 year old female in intensive care receiving multiple intravenous antibiotics

Answers: B, C, E Rationale: To prevent AKI, all people must be urged to avoid dehydration by drinking at least 2 to 3 liters of fluids daily, especially during strenuous exercise or work associated with diaphoresis, or when recovering from an illness that reduces kidney blood flow, such as influenza. Recent surgery or trauma, transfusions, or other factors that might lead to reduced kidney blood flow may cause AKI. Certain antibiotics may cause nephrotoxicity. Diabetes and hypertension may cause chronic kidney injury (not acute).

58-2. Which assessment findings in a client with hyperthyroidism indicates to the nurse that the client is in danger of thyroid storm? Select all that apply. A. Increased salivation B. Client report of increased palmar sweating C. Decreased pulse pressure from 40 mm Hg to 36 mm Hg D. Diminished bowel sounds in all four abdominal quadrants E. An increase in temperature from 99.5o F (37.5o C) to 101.3o F (38.5o C) F. Serum sodium level increase from 136 mEq/L (mmol/L) to 139 mEq/L (mmol/L) G. Increase in premature ventricular heart contractions from 4 per minute to 28 per minute

Answers: B, E, G Rationale: The changes most associated with impending thyroid storm (thyroid crisis) are the increase in sweating, body temperature, and irregular heartbeats. This client requires immediate attention. Increased salivation and diminished bowel sounds are not associated with thyroid storm. The changes in pulse pressure and serum sodium values are still within normal limits and not insignificant.

NCLEX Examination Challenge 58-1 An assistive personnel reports that a nursing home client who has hypothyroidism has a pulse of 48 beats per minute this morning. Which assessments have the highest priority for the nurse to perform immediately? Select all that apply. A. Checking body temperature B. Testing deep tendon reflex responses C. Measuring oxygen saturation by pulse oximetry D. Checking blood pressure, heart rate, and rhythm E. Determining level of consciousness and cognition F. Identifying presence or absence of the swallowing reflex G. Examining feet and ankles for indications of peripheral edema

Answers: C, D Rationale: All changes in any of these parameters are important and would be expected to be abnormal in a client with hypothyroidism whose metabolism is decreasing. However, the most common cause of death for a client with severe hypothyroidism is respiratory failure with reduced gas exchange and perfusion. Thus, measuring oxygen saturation should be performed first followed by assessment of cardiac function in order to implement the most effective interventions as soon as possible.

8. A client who is dying is having difficulty swallowing oral medications. Which intervention will the nurse implement for this client? -Ask the provider if the medications can be discontinued or substituted. -Do not administer the medications and document: "Unable to swallow." -Ask the pharmacy to substitute intramuscular (IM) equivalents for the medications. -Crush the pills, open the sustained-release capsules, and mix them with a spoonful of applesauce.

Ask the provider if the medications can be discontinued or substituted. The nurse will contact the provider to ask if the medications can be discontinued or substituted. Since the client is in the dying process, he or she may no longer require some of the medications prescribed, and other routes may be available for medications that will promote comfort. The IM route is almost never used for clients at the end of life because this method is invasive and painful, and can cause infection. Although some pills may be crushed, sustained-release capsules should not be taken apart and their contents administered directly. The client may still need the medications prescribed for comfort; withholding them could cause discomfort throughout the dying process.

8. A client has died after a long hospital stay. The family was present at the time of the client's death. Which postmortem nursing action is appropriate? -Removing dentures and any prosthetics -Raising the head of the bed and opens the client's eyes -Asking the family if they wish to help wash the client -Asking the family to leave during post-death care

Asking the family if they wish to help wash the client The nurse may ask the family if they wish to be involved in washing the client after the client's death. The family should be allowed to grieve at the bedside of the client. The head of the bed should be flat and the client's eyes closed. The client's dentures and prosthetics should be replaced, not removed.

60. Mastery Question Which client assessment data is essential for the nurse to report to the healthcare provider before a renal scan is performed? A. Pink-tinged urine B. Reports pregnancy C. Reports claustrophobia D. History of an aneurysm clip

B A renal scan uses radioisotopes which may be unsafe to the fetus. A renal scan may be done to evaluate pink-tinged urine and is not conducted in an enclosed or magnetic environment.

59. Which action has the highest priority for the nurse to take when a client with type 1 diabetes arrives in the emergency department breathing deeply and stating, "I can't catch my breath." and has vital signs of: T 98.4° F (36.9° C), P 112 beats/min, R 38 breaths/min, BP 91/54 mm Hg, and O2 saturation 99% on room air? -Administering oxygen -Connecting a cardiac monitor -Assessing arterial blood gas (ABG) values -Assessing blood glucose level

Assessing blood glucose level The nurse would first obtain the client's glucose level. Breathing deeply and stating, "I can't catch my breath" is indicative of Kussmaul respirations which is a sign of diabetic ketoacidosis (DKA).Based on the oxygen saturation, oxygen administration is not indicated. The diagnosis of DKA does not require ABGs. Cardiac monitoring may be implemented, but the first action would be to obtain the glucose level.

58. The nurse reviews the vital signs of a client diagnosed with Graves disease and notes that the client's temperature is 99.6° F (37.6° C). After notifying the primary health care provider, what is the nurse's best next action? -Administering acetaminophen -Observing for the presence of chills -Initiating the Rapid Response Team -Assessing cardiac status

Assessing cardiac status Graves disease is manifested by symptoms of hyperthyroidism and increased metabolic rate, including fever. The nurse must next assess the client's cardiac status as atrial fibrillation or other dysrhythmias may have developed. If the client has a cardiac monitor, the nurse needs to check for any dysrhythmias. Administering a nonsalicylate antipyretic such as acetaminophen is appropriate, but is not a priority action for this client. Alerting the Rapid Response Team is not needed at this time as no instability has been noted. Unlike with infection, temperature elevations in a client with hyperthyroidism are not associated with chills.

62. The RN is working with assistive personnel (AP) in caring for a group of clients. Which action is best for the RN to delegate to AP? -Assessing the vital signs of a client who was just admitted with blunt flank trauma and hematuria -Assisting a client who had a radical nephrectomy 2 days ago to turn in bed -Palpating for bladder distention on a client recently admitted with a ureteral stricture -Helping the primary health care provider with a kidney biopsy for a client admitted with acute glomerulonephritis

Assisting a client who had a radical nephrectomy 2 days ago to turn in bed The best action for the RN is to have the AP assist a client who had a radical nephrectomy 2 days ago to turn in bed. The AP would be working within legal guidelines when assisting a client to turn in bed. Although assessment of vital signs is within the scope of practice for AP, the trauma victim would be assessed by the RN because interpretation of the vital signs is needed. Assisting with procedures such as kidney biopsy and assessment for bladder distention are responsibilities of the professional nurse that would not be delegated to staff members with a limited scope of education.

63. A client with chronic kidney disease reports chest pain. The nurse notes tachycardia and low-grade fever. Which additional assessment is warranted? -Monitor for decreased peripheral pulses. -Determine if the client is able to ambulate. -Auscultate for pericardial friction rub. -Assess for crackles.

Auscultate for pericardial friction rub. The additional assessment needed for the client with uremia is to auscultate the pericardium for friction rub. Clients with CKD are prone to pericarditis. Signs/symptoms of pericarditis include inspiratory chest pain, tachycardia, narrow pulse pressure, low-grade fever, and pericardial friction rub. Crackles and tachycardia are symptomatic of fluid overload. Fever is not present with fluid overload. Although the nurse will monitor pulses, and ambulation is important to prevent weakness and deep vein thrombosis, these are not pertinent to the constellation of signs/symptoms of pericarditis that the client presents with.

63. Which instruction by the nurse will help a client with chronic kidney disease prevent renal osteodystrophy? -Increasing dairy products enriched with vitamin D -Drinking cola beverages only once daily -Consuming a low-calcium diet -Avoiding peas, nuts, and legumes

Avoiding peas, nuts, and legumes To prevent renal osteodystrophy in a chronic kidney disease client, the nurse needs to instruct the client to avoid peas, nuts, and legumes. Kidney failure causes hyperphosphatemia, so phosphorus-containing foods such as beans, peas, nuts (peanut butter), and legumes must be restricted. Calcium would not be restricted. Hyperphosphatemia results in a decrease in serum calcium and demineralization of the bone. Cola beverages and dairy products are high in phosphorus, contributing to hypocalcemia and bone breakdown.

63. A client with a recently created vascular access for hemodialysis is being discharged. Which teaching will the nurse include in the discharge instructions? -How to practice proper nutrition? -Avoiding venipuncture and blood pressure measurements in the affected arm -How to assess for a bruit in the affected arm? -Modifications to allow for complete rest of the affected arm

Avoiding venipuncture and blood pressure measurements in the affected arm The nurse must teach the client to avoid venipunctures and blood pressure measures in the arm that contains the newly created vascular access device. Compression of vascular access causes decreased blood flow and may cause occlusion. If this occurs, lifesaving dialysis will not be possible. The arm with the access device must be exercised to encourage venous dilation, not rested. The client can palpate for a thrill, but a stethoscope is needed to auscultate the bruit at home. The nurse needs to take every opportunity to discuss nutrition, even as it relates to wound healing, but loss of the venous access device must take priority.

NCLEX Examination Challenge 60-3 The nurse is admitting a client undergoing a CT scan with contrast. Which finding does the nurse report as a possible immediate hypersensitivity reaction? Select all that apply. A. Nausea B. Pruritis C. Urticaria D. Laryngeal stridor E. Flushing of the skin

B, C, D, E Signs and symptoms of a hypersensitivity (allergic) reaction include: itching (pruritis), urticaria (hives or wheals), erythema (redness), stridor, hoarseness, bronchospasm and anaphylactic shock (hypotension, tachycardia).

NCLEX Examination Challenge 60-2 A client is on a 24-hour urine collection. At midpoint during the collection, the client tells the nurse that some of the urine was discarded. What action will the nurse take? Select all that apply. A. No action is required. B. Reinforce client education C. Notify the laboratory staff D. Restart the urine collection E. Document the discarded urine F. Notify the healthcare provider

B, C, E, F Reinforcing patient education is important to ensure all urine is collected for the 24-hour urine test. Notifying the laboratory staff is essential in determining next steps and whether the urine collection must be restarted. Document the discarded urine as part of the 24-hour urine collection and notify the healthcare provider of the discarded urine for further instructions.

60. Mastery Question Which lab finding is indicative of renal function alterations and not dehydration? Select all that apply. A. BUN 20 ml/dL B. Creatinine 2.3 ml/dL C. Hemoglobin 14 g/dL D. Cystatin-c 105 mg/mL E. BUN - creatinine ratio 10 F. Creatinine clearance 175 ml/min

B, D, F · BUN is within normal limits. · Creatinine is a test used to determine renal function and a level 2.3ml/dL is high. · Hemoglobin is within normal limits. · Cystatin-c is an indicator of glomerular filtration rate and a level of 1.5mg/L is higher than normal indicating renal disease. · BUN/creatinine ratio is within normal limits · Creatinine clearance is a test to measure renal function. A level of 175ml/min is higher than normal.

58. Which trends in serum electrolyte values will the nurse expect to find in a client who has untreated hypoparathyroidism? -Below normal calcium levels; above normal phosphorus levels -Below normal calcium levels; below normal phosphorus levels -Above normal calcium levels; above normal phosphorus levels -Above normal calcium levels; below normal phosphorus levels

Below normal calcium levels; above normal phosphorus levels With hypoparathyroidism, the lack of parathyroid hormone (PTH) decreases serum calcium levels by increasing kidney calcium excretion and inhibiting calcium absorption from the GI tract. Low levels of calcium cause a corresponding increase in serum phosphorus levels because calcium and phosphorus exist in a balanced reciprocal relationship in which a decrease in one always causes an increase in the other.

58. Which assessment finding in a client who had a parathyroidectomy yesterday indicates to the nurse that immediate action is needed? -Hypoactive bowel sounds -Apical pulse of 92 beats/min -Bilateral leg muscle twitching -Dry mouth

Bilateral leg muscle twitching Clients are at risk for hypocalcemia and seizures after removal of the parathyroid glands. Muscle twitching is an indication of hypocalcemia and requires assessment and intervention. The other findings are abnormal but not associated with complications from the surgery.

62. The nurse receives report on a client with hydronephrosis. Which laboratory study does the nurse monitor? -Lipid levels -Blood urea nitrogen (BUN) and creatinine -White blood cell (WBC) count -Hemoglobin and hematocrit (H&H)

Blood urea nitrogen (BUN) and creatinine In the client with hydronephrosis, the nurse monitors the client's BUN and creatinine. BUN and creatinine are kidney function tests. With back-pressure on the kidney, glomerular filtration is reduced or absent, resulting in permanent kidney damage. Hydronephrosis results from the backup of urine secondary to obstruction. H&H monitors for anemia and blood loss, while WBC count indicates infection. Elevated lipid levels are associated with nephrotic syndrome, not with obstruction and hydronephrosis.

62. When caring for a client 24 hours after a nephrectomy, the nurse assesses abdominal distention. Which action will the nurse perform next? -Insert a nasogastric (NG) tube. -Notify the surgeon. -Check vital signs. -Continue to monitor.

Check vital signs. After noting a distended abdomen in a client who had a nephrectomy 24 hours ago, the nurse next needs to check the client's vital signs. The client's abdomen may be distended from bleeding. Hemorrhage or adrenal insufficiency causes hypotension, so vital signs must be taken to see if a change in blood pressure has occurred. The surgeon would be notified after vital signs are assessed. Just continuing to monitor is not appropriate. An NG tube is not indicated for this client.

56. Which action in the plan of care for a client who is hospitalized for pituitary function testing would be most appropriate for the nurse to delegate to an experienced assistive personnel (AP)? -Checking the client's blood glucose levels every 4 hours -Monitoring the client's response to the IV insulin given during a stimulation test -Teaching the client about a hormone suppression test -Assessing the client for symptoms of hypopituitarism

Checking the client's blood glucose levels every 4 hours Monitoring blood glucose is within the nursing assistant's scope of practice if the nursing assistant has received education and evaluation in the skill. Assessing and teaching are actions that are within only the nurse's scope of practice. When IV insulin is given for a stimulation test, adverse reactions, especially hypoglycemia, are common and the client needs monitoring by a health care worker who knows exactly what the signs and symptoms are. Such a person must be either a registered nurse or an LPN/LVN.

57. For which change reported by a client taking bromocriptine therapy to manage hyperpituitarism will the nurse notify the primary health care provider immediately to prevent harm? -Chest pain -Constipation -Headache -Increased sleepiness

Chest pain Bromocriptine can cause serious cardiac dysrhythmias and coronary artery spasms. Constipation, increased sleepiness, and headaches are possible side effects of the drug and their degree of discomfort to the client always should be considered; however, their presence does not constitute harm or require immediate attention.

60. The nurse is preparing to obtain a sterile urine specimen from a client with a Foley catheter. What technique will the nurse use? -Disconnect the Foley catheter from the drainage tube and collect urine directly from the Foley. -Use a sterile syringe to withdraw urine from the urine collection bag. -Clamp the tubing, attach a syringe to the specimen, and withdraw at least 5 mL of urine. -Remove the existing catheter and obtain a sample during the process of inserting a new Foley.

Clamp the tubing, attach a syringe to the specimen, and withdraw at least 5 mL of urine. The nurse will employ the technique of clamping the tubing, attaching a syringe to the specimen, and withdrawing at least 5 mL of urine when obtaining a sterile urine specimen from a client with a Foley catheter. Disconnecting the Foley catheter from the drainage tube and collecting urine directly from the Foley increases the risk for microbe exposure. A Foley catheter would not be removed to get a urine sample. Microbes may be in the urine collection bag from standing urine, so using a sterile syringe to withdraw urine from the urine collection bag is not the proper technique to obtain a sterile urine specimen.

57. For which assessment finding in a client who had a transsphenoidal hypophysectomy yesterday will the nurse notify the primary health care provider immediately? -Dry lips and oral mucosa on examination -Nasal drainage that tests negative for glucose -Urine specific gravity of 1.016 -Client report of a headache and stiff neck

Client report of a headache and stiff neck Headache and stiff neck (nuchal rigidity) are symptoms of meningitis that have immediate implications for the client's care. The finding requires the nurse to immediately notify the primary health care provider. Dry lips and mouth are not unusual after surgery. Nasal drainage that tests negative for glucose is normal, expected, and not significant. A urine specific gravity of 1.016 is within normal limits.

57. Which assessment finding in a client with hyperaldosteronism indicates to the nurse that the condition is becoming more severe? -Urine output for the past 24 hours has increased. -Client reports numbness and tingling around the mouth. -Temperature is now elevated. -pH is now 7.43.

Client reports numbness and tingling around the mouth. Hyperaldosteronism causes potassium to be excreted excessively. As hypokalemia becomes more severe, paresthesias occur with numbness and tingling around the mouth and of the fingers and toes. Alkalosis is possible, but the pH shown is normal. Temperature elevation and increased urine output are not associated with a worsening of hyperaldosteronism.

62. After receiving change-of-shift report on the urology unit, which client will the nurse assess first? -Client who was involved in a motor vehicle collision and has hematuria. -Client with nephrotic syndrome who has gained 2 kg since yesterday. -Client with glomerulonephritis who has cola-colored urine. -Client postradical nephrectomy whose temperature is 99.8° F (37.6° C).

Client who was involved in a motor vehicle collision and has hematuria. After the change-of-shift report, the nurse first needs to assess the client who was involved in a motor vehicle collision. The nurse would be aware of the risk for kidney trauma after a motor vehicle crash. This client needs further assessment and evaluation to determine the extent of blood loss and the reason for the hematuria because hemorrhage can be life threatening. Although slightly elevated, the low-grade fever of the client who is postradical nephrectomy is not life threatening in the same way as a trauma victim with bleeding. Cola-colored urine is an expected finding in glomerulonephritis. Because of loss of albumin, fluid shifts and weight gain can be anticipated in a client with nephrotic syndrome.

63. The RN has just received change-of-shift report. Which client will the nurse assess first? -Client with azotemia whose blood urea nitrogen and creatinine are increasing. -Client with kidney insufficiency who is scheduled to have an arteriovenous fistula inserted. -Client receiving peritoneal dialysis who needs help changing the dialysate bag. -Client with chronic kidney failure who was just admitted with shortness of breath.

Client with chronic kidney failure who was just admitted with shortness of breath. After the change-of-shift report, the nurse must first assess the newly admitted client with chronic kidney failure and shortness of breath, the dyspnea of the client with chronic kidney failure may indicate pulmonary edema and must be assessed immediately. The client with kidney insufficiency is stable and assessment can be performed later. The client with azotemia requires assessment and possible interventions but is not at immediate risk for life-threatening problems. The client receiving peritoneal dialysis can be seen last because it is a slow process and the client has no urgent needs.

60. Which client will the nurse encourage to consume 2 to 3 L of fluid each day? -Client with heart failure -Client with chronic kidney disease -Client with complete bowel obstruction -Client with hyperparathyroidism

Client with hyperparathyroidism The nurse encourages the client with hyperparathyroidism to drink 2 to 3 L of fluid each day. A major feature of hyperparathyroidism is hypercalcemia, which predisposes a client to kidney stones. This client must remain hydrated. A client with chronic kidney disease would not consume 2 to 3 L of water because the kidneys are not functioning properly. Consuming that much fluid could lead to fluid retention. People with heart failure typically have fluid volume excess. A client with complete bowel obstruction may experience vomiting and would be NPO.

60. The charge nurse is making client assignments for the day shift. Which client is best to assign to an LPN/LVN? -Client with polycystic kidney disease who is having a kidney ultrasound. -Client with glomerulonephritis who is having a kidney biopsy. -Client who is going for a cystoscopy and cystourethroscopy. -Client who has just returned from having a kidney artery angioplasty.

Client with polycystic kidney disease who is having a kidney ultrasound. The best client to assign to an LPN/LVN is the client with polycystic kidney disease who is having a kidney ultrasound. Kidney ultrasounds are noninvasive procedures without complications, and the LPN/LVN can provide this care. A kidney artery angioplasty is an invasive procedure that requires postprocedure monitoring for complications, especially hemorrhage. A registered nurse is needed for this client. Cystoscopy and cystourethroscopy are procedures that are associated with potentially serious complications such as bleeding and infection. These clients must be assigned to RN staff members. Kidney biopsy is associated with potentially serious complications such as bleeding, and this client would also be assigned to RN staff members.

56. Which factor or condition does the nurse expect to result in an increase in a client's production of thyroid hormones (TH)? -Getting 8 hours of sleep nightly -Chronic constipation -Protein-calorie malnutrition -Cold environmental temperatures

Cold environmental temperatures Cold and stress are two factors that cause the hypothalamus to secrete thyrotropin-releasing hormone (TRH), which then stimulates the anterior pituitary to secrete thyroid-stimulating hormone (TSH) to increase production of the two major thyroid hormones. Constipation does not affect thyroid hormone production. Stress from inadequate sleep could increase TH production but adequate sleep does not. Protein-calorie malnutrition would decrease production of many hormones, including TH.

5. Which activity does the RN team leader on a large medical-surgical unit assign to the LPN/LVN? -Complex dressing changes for a sacral wound for a client with type 2 diabetes who was given prescriptions for pain medication before wound care -Instructions to a postoperative hip replacement client who has just been placed on patient-controlled analgesia for pain relief -Assessment of a client scheduled for surgery who is crying and expressing fear that the pain will be intolerable -Assessment of a client using a transcutaneous electrical nerve stimulation unit to relieve chronic pain

Complex dressing changes for a sacral wound for a client with type 2 diabetes who was given prescriptions for pain medication before wound care Complex dressing changes for a sacral wound for a client with type 2 diabetes who was given prescriptions for pain medication before wound care would be assigned to the LPN/LVN. LPN/LVN education and scope of practice include working within practice parameters to administer pain medication and to perform dressing changes. Assessments and client education are not within the LPN/LVN scope of practice.

63. To prevent prerenal acute kidney injury, which person will the nurse -encourage to increase fluid consumption? -Office secretary -Construction worker -School teacher -Taxicab driver

Construction worker Construction workers perform physical labor and work outdoors, especially in warm weather. Working in this type of atmosphere causes diaphoresis and places this worker at risk for dehydration and prerenal azotemia. The office secretary and schoolteacher work indoors and, even without air conditioning, will not lose as much fluid to diaphoresis as someone performing physical labor. The taxicab driver, even without air conditioning, will not experience diaphoresis and fluid loss like the construction worker.

9. As the nurse gives a client the informed consent form to sign, the client asks, "Now what exactly are they going to do to me?" What is the appropriate nursing action? -Have the client sign the form. -Contact the anesthesiologist. -Contact the surgeon. -Explain the procedure.

Contact the surgeon. The nurse will contact the surgeon to convey the client's question. The nurse is not responsible for explaining or providing detailed information about the surgical procedure. Rather, the nurse's role is to clarify facts that have been presented by the health care provider and dispel myths that the client or family may have heard about the surgical experience. The anesthesiologist is responsible for the anesthesia, not the surgical details. Although the nurse is only witnessing the signature, it is the nurse's role to ensure that the facts are clarified before the consent form is signed. It is not appropriate to have the client sign the form until the surgeon has clarified the procedure with the client.

NCLEX Examination Challenge 9-4 The nurse has prepared a client for transport from the medical-surgical unit to surgery. Which client statement will the nurse respond to as the priority? A. "When I eat shrimp, my tongue swells and I have trouble breathing." B. "I'm feeling more anxious about my surgery than I thought I would be." C. "I'm not sure what I will do if insurance doesn't cover this expensive hip replacement." D. "My sister had anesthesia a few months ago and she said she did not like the way she felt."

Correct Answer: A Rationale: Clients have often heard historically that an allergy to iodine or shellfish indicates a risk for a reaction to the agents used to clean the surgical area. Shellfish allergies are usually associated with a reaction to tropomyosin - not iodine. Still, the nurse will respond to this statement as the priority to ascertain whether the reported reaction is only to shellfish consumption, or if there has ever been a similar reaction when exposed to other substances, and then provide teaching as needed. All other client statements can then be addressed.

NCLEX Examination Challenge 9-1 The surgery for a client scheduled for an 8:00 AM procedure is delayed until 11:00 AM. What is the appropriate nursing action regarding administration of preoperative prophylactic antibiotic? A. Administer at 8:00 AM as originally prescribed. B. Request an order for the administration time to be changed to 10:00 AM. C. Do not administer, as preoperative prophylactic antibiotics are optional. D. Hold the antibiotic until immediately following surgery, and then administer.

Correct Answer: B Rationale: According to the Surgical Care Improvement Project (SCIP) guidelines, prophylactic antibiotics should be given within one hour before the surgical incision.

9. NCLEX Mastery Question #2 The nurse is caring for a postoperative patient who has asked for pain medicine an hour before it is due. What is the priority nursing response? A. "You cannot have more pain medicine until an hour from now." B. "Can you describe the pain you are having, and rate it on a 1-10 scale?" C. "I can help you begin a pain diary so we can see trends when your pain worsens." D. "Let's try some relaxation exercises to help address the discomfort you are feeling."

Correct Answer: B Rationale: The nurse will assess the client's level of pain to determine whether it is increasing, unmanaged, or able to be managed until the next dose of medication is due. Telling the client they cannot have medication for another hour, without conducting an assessment, is inappropriate, as cues to a changing health status could be missed. Starting a pain diary may be an appropriate intervention at a later time, but does not address the client's immediate concern. Providing relaxation exercises may be appropriate, but only after an assessment is conducted to determine the cause of the client's pain.

NCLEX Examination Challenge 9-5 The nurse is caring for a client who has been readmitted to the medical-surgical unit following surgery for a hernia repair completed under general anesthesia. What is the priority nursing assessment? A. Perform thorough auscultation of the lungs B. Assess response to pin-prick stimulation from feet to mid-chest level C. Determine level of consciousness and response to environmental stimuli D. Compare blood pressure findings from preoperative assessment to the present

Correct Answer: C Rationale: After general anesthesia, which affects the entire body, the priority assessment is to determine that the client's level of consciousness has returned. All other assessment can be performed subsequently, including lung auscultation, as there is no indication that the client is experiencing any type of respiratory distress.

NCLEX Examination Challenge 9-6 In the early postoperative period, which assessment finding in a client who had an epidural during surgery requires immediate nursing intervention? A. Blood pressure of 142/90 B. Headache of 4 on a 1-10 scale C. Gradual return of motor function D. Increase in back pain when coughing

Correct Answer: D Rationale: An increase in back pain can be indicative of an epidural hematoma; therefore, the nurse will immediately address this finding. Blood pressure can be compared to baseline after addressing the back pain, as can the headache. The nurse can continue to monitor the expected, gradual return of motor function.

NCLEX Examination Challenge 9-3 The nurse is teaching a client about postoperative leg exercises. What teaching will the nurse include? Select all that apply. A. Begin practicing leg exercises prior to surgery. B. Repeat leg exercises several times daily for each leg. C. Push the ball of the foot into the bed until the calf and thigh muscles contract.* D. If pain or warmth in the calf is present, discontinue exercises and contact the surgeon. E. Point toes of one foot toward bed bottom; then point toes of same leg toward face. Switch.

Correct Answers: A, B, C, D, E Rationale: Teaching regarding postoperative leg exercises should include having the client begin practicing the exercises before surgery; repeating the exercises several times daily for each leg; pushing the ball of the foot into the bed until the calf and thigh muscles contract; discontinuing exercises and contacting the surgeon if pain of warmth in the calf is present; and pointing toes of one foot towards the bottom of the bed, then towards the face, and switching.

9. NCLEX Mastery Question #1 The nurse is completing a preoperative physical assessment for a client who will have surgery this afternoon. Which assessment finding will the nurse report to the operative team? Select all that apply. A. Left arm prosthesis B. Skin turgor < 3 seconds C. Blood pressure 160/100 D. Presence of chest rigidity E. Has been NPO since midnight F. Expressed concern about surgery payment

Correct Answers: A, C, D Rationale: The nurse will report assessment findings of a left arm prosthesis (as this must be addressed prior to surgery); blood pressure of 160/100 (as this is high, which may delay surgery); and the presence of chest rigidity (which is an abnormal finding that may indicate respiratory compromise which could affect whether surgery takes place) to the operative team. The findings of skin turgor of < 3 seconds, adherence to the NPO plan, and a natural concern about payment for surgery do not require reporting to the operative team.

NCLEX Examination Challenge 9-2 The nurse is caring for a client who is to undergo surgery at 6:00 AM today. Which assessment data will the nurse communicate immediately to the surgeon and anesthesia provider? Select all that apply. A. Blood pressure 130/72 B. Serum potassium 3.5 mEq/L C. Diffuse rash on upper torso D. Took 650 mg of aspirin yesterday E. Has not had food nor water since 9:00 PM last night

Correct Answers: C, D Rationale: A diffuse rash could be an indication of a health deviation that must be assessed before surgery. Taking aspirin (or any other medication that anti-coagulates) is generally not permitted for a certain period of time before surgery. Therefore, the nurse will notify the surgeon and anesthesia provide of both of these assessment findings. A blood pressure of 130/72 and a serum potassium of 3.5 mEq/L are normal findings, as is the adherence of the client who has not had food nor water for the recommended time before surgery.

NCLEX Examination Challenge 9-7 The nurse is caring for a client who reports being fearful of becoming dependent on opioid pain medication after surgery. What is the appropriate nursing response? Select all that apply. A. "Why do you think you're going to get hooked?" B. "Don't worry, I won't give you any opioid medications." C. "Have you had concerns with drug dependence in the past?" D. "Tell me what makes you most fearful about taking opioid medication." E. "There are proper ways of taking opioids so you will not become dependent."

Correct Answers: C, D, E Rationale: The nurse will use therapeutic communication to determine the client's underlying concerns. This is accomplished by asking the client if there has been a past history of drug dependence (which may explain the reluctance), what seems most fearful about taking opioids (which gives the nurse the chance to dispel myths), and teaching that there are proper ways of taking opioids (as directed and for a short period of time) that is meant to keep the client from becoming dependent. Asking "why" is nontherapeutic and can shut down the line of communication between the client and nurse, as this approach demands a response. The nurse will not promise to avoid give the patient opioids at this time, as further investigation of the client's concerns are warranted first.

9. Which action does the nurse implement for a client with wound evisceration? -Irrigate the wound with warm, sterile saline. -Cover the wound with a sterile, warm, moist dressing. -Replace tissue protruding into the opening. -Apply direct pressure to the wound.

Cover the wound with a sterile, warm, moist dressing. Covering the wound with a sterile, warm, moist dressing protects the organs until the surgeon can repair the wound. Evisceration occurs when a wound opens up and body organs are exposed. Applying direct pressure to a wound traumatizes the organs. Irrigating the wound is not necessary. Replacing protruding tissue could induce infection.

62. When assessing a client with acute glomerulonephritis, which assessment finding causes the nurse to notify the primary health care provider? -Purulent wound on the leg -Crackles throughout the lung fields -Cola-colored urine -History of diabetes

Crackles throughout the lung fields The nurse notifies the primary health care provider if crackles throughout the lung fields are heard in a client with acute glomerulonephritis. Crackles indicate fluid overload resulting from kidney damage. Shortness of breath and dyspnea are typically associated. The primary health care provider must be notified of this finding. Glomerulonephritis may result from infection (e.g., purulent wound); it is not an emergency about which to notify the primary health care provider. The history of diabetes would have been obtained on admission. Dark urine is expected in glomerulonephritis.

60. Which laboratory test will the nurse assess as the best indicator of kidney function? -Creatinine -Blood urea nitrogen (BUN) -Aspartate aminotransferase (AST) -Alkaline phosphatase

Creatinine The laboratory test that is the best indicator of kidney function is creatinine excretion. Creatinine excretion, the end product of muscle metabolism, remains relatively steady and therefore is the best laboratory marker of renal function. BUN may be affected by protein, fluid intake, rapid cell destruction, cancer treatment, steroid therapy, and hepatic damage. AST and alkaline phosphatase are measures of hepatic function.

9. Which electrolyte laboratory result for a presurgical client will the nurse report to the anesthesiologist? (Select all that apply.) -White blood cell count 14,000 mm3 -Potassium, 3.9 mEq/L (3.9 mmol/L) -Creatinine, 1.9 mg/dL (168 mcmol/L) -Fasting glucose, 80 mg/dL (4.4 mmol/L) -Sodium, 140 mEq/L (140 mmol/L)

Creatinine, 1.9 mg/dL (168 mcmol/L) The nurse will report a creatinine of 1.9 mg/dL (168 mcmol/L) and a white blood cell count of 14,000 mm3 to the anesthesiologist. These values are outside of the expected normal ranges and may indicate renal problems (creatinine) and infection (white blood cell count).A fasting glucose of 80 mg/dL (4.4 mmol/L), a potassium level of 3.9 mEq/L (3.9 mmol/L), and sodium level of 140 mEq/L (140 mmol/L) are normal laboratory values.

60. Mastery Question Which symptom(s) in a client during the first 12 hours after a kidney biopsy indicates to the nurse a possible complication from the procedure? A. The client experiences nausea and vomiting after drinking juice. B. The biopsy site is tender to light palpation. C. The abdomen is distended and the client reports abdominal discomfort. D. The heart rate is 118, blood pressure is 108/50, and peripheral pulses are thready.

D The most serious complication after a kidney biopsy is excessive bleeding. Nausea and vomiting are not signs of bleeding. Some discomfort at the biopsy site is expected and not considered a complication unless there is swelling and a large amount of bruising/discoloration in the flank area. The kidneys are not in the abdomen. Bleeding from the kidney would cause flank pain and swelling, not abdominal pain and swelling. The elevated pulse rate, thready peripheral pulses, and low diastolic blood pressure are consistent with excessive bleeding.

63. A client is receiving immune-suppressive therapy after kidney transplantation. Which measure for infection control is important for the nurse to implement? -Adherence to therapy -Handwashing -Monitoring for low-grade fever -Strict clean technique

Handwashing Handwashing is the most important infection control measure for the client receiving immune-suppressive therapy to perform. Adherence to therapy and monitoring for low-grade fever are important but are not infection control measures. The nurse must practice aseptic technique for this client, not simply clean technique.

59. Which client assessment finding indicates to the nurse the possible presence of diabetic autonomic neuropathy? -Loss of sensation in both feet -Hyperglycemia -Intermittent constipation -Increased thirst

Intermittent constipation Autonomic neuropathy can affect the entire GI system. The most common GI problem from diabetic automonic neuropathy is sluggish intestinal movement and chronic intermittent constipation.Loss of sensation in the feet is peripheral neuropathy, not autonomic neuropathy. Hyperglycemia is not related to any type of neuropathy. Increased thirst is related to hyperglycemia and increased blood osmolarity, not neuropathy.

63. A client with end-stage kidney disease has been placed on fluid restrictions. Which assessment data indicates to the nurse that the fluid restriction has not been followed? -Dyspnea and anxiety at rest -Blood pressure of 118/78 mm Hg -Central venous pressure (CVP) of 6 mm Hg -Weight loss of 3 lb (1.4 kg) during hospitalization

Dyspnea and anxiety at rest The assessment finding that shows that the client has not adhered to fluid restriction is dyspnea and anxiety at rest. Dyspnea is a sign of fluid overload and possible pulmonary edema. The nurse needs to assist the client in correlating symptoms of fluid overload with nonadherence to fluid restriction. Nonadherence to fluid restriction results in fluid volume excess and higher blood pressures. 118/78 mm Hg is a normal blood pressure. Excess fluid intake and fluid retention are manifested by an elevated CVP (>8 mm Hg) and weight gain, not weight loss.

59. Which factor is most important for the nurse to assess before providing instruction to a client newly diagnosed with diabetes about the disease and its management? -Current energy level and rest patterns -Sexual orientation -Current lifestyle for diet and exercise -Education and literacy levels

Education and literacy levels The most important factor for the nurse to determine before providing instruction to the newly diagnosed client with diabetes is the client's educational level and literacy level. A large amount of information must be synthesized. Written instructions are typically given. The client's ability to learn and read is essential to provide the client with instructions and information about diabetes.Although lifestyle would be taken into account, it is not the priority. Sexual orientation will have no bearing on the ability of the client to provide self-care. Although energy level will influence the ability to exercise, it is not essential.

63. When assisting with dietary protein needs for a client on peritoneal dialysis, the nurse recommends which food selection? -Eggs -Ham -Eggplant -Macaroni

Eggs The nurse recommends eggs as a dietary protein need for a client on peritoneal dialysis. Other suggested protein-containing foods for this client are milk and meat. Although a protein, ham is high in sodium and needs to be avoided. Vegetables and pasta contain mostly carbohydrates. Peritoneal dialysis clients are allowed 1.2 to 1.5 g of protein/kg/day because protein is lost with each exchange.

56. Which action is most important for the nurse to perform when caring for an older client decreased antidiuretic hormone (ADH) production? -Inspecting feet and legs for ulcers -Planning for weight-bearing activities -Stressing the important of fiber in the diet -Encouraging fluids every 2 hours

Encouraging fluids every 2 hours A decrease in ADH production in the older adult causes urine to be more dilute. In this instance, urine might not concentrate when fluid intake is low, allowing for excess water loss. Encouraging fluid intake every 2 hours, even during the night, is important to prevent dehydration. Weight-bearing activities are appropriate for older adults to prevent bone loss, not fluid loss. Development of foot or leg ulcers is not associated with changes in ADH production. Although a client with dehydration may be constipated, the problem is not the priority when ADH production is low.

57. What is the nurse's best action when noticing that the phlebotomist, who plans to draw blood from the client with severe hypercortisolism, displays symptoms of a cold? -Ensuring the phlebotomist wears a facemask while in the client's room -Asking the phlebotomist to delay the blood draw -Monitoring the client closely for cold-like symptoms -Placing a facemask on the client

Ensuring the phlebotomist wears a facemask while in the client's room The nurse needs to make sure the phlebotomist wears a facemask because the client is immunosuppressed and at higher risk for respiratory infection. Anyone with a suspected upper respiratory infection who must enter the client's room needs to wear a mask to prevent the spread of infection. Asking the phlebotomist to delay the blood draw could lead to harm by not providing sufficient information about the client's condition. The phlebotomist, not the client, is exhibiting cold-like symptoms, so monitoring the client for these symptoms is not appropriate. Having the client wear a mask during the blood draw does not protect him or her from any airborne microorganisms that remain in the atmosphere of the room or droplets that may reside on surfaces.

59. What is the nurse's best action when finding that a client who has had diabetes for 15 years has decreased sensory perception in both feet? -Testing the sensory perception of the client's hands -Examining both feet for indications of injury -Explaining to the client that peripheral neuropathy is now present -Documenting the finding as the only action

Examining both feet for indications of injury When reduced peripheral sensory perception is present, the likelihood of injury is high. Any open area or other problem on the foot of a person with diabetes is at great risk for infection and must be managed carefully and quickly. Checking for sensory perception on the hands and other areas is important but can come after a thorough foot examination.

8. The nurse is coordinating interprofessional palliative care interventions for the client who is dying. Which goal is the nurse seeking to meet? -Facilitating a peaceful death for the client -Ensuring an expedited death -Meeting all of the client's needs -Avoiding symptoms of client distress

Facilitating a peaceful death for the client Facilitating a peaceful death for the client is one of the goals of palliative care. Symptoms of distress cannot be avoided but can be controlled. Expedited death is not a goal of palliative care. Identifying client needs is a goal of palliative care, but it is not always possible to meet all of the client's needs (e.g., to prevent death or lengthen life).

58. Which type of drug therapy will the nurse prepare to teach about to a client who has mild hyperparathyroidism? -Antipyretics -Opioid analgesics -Furosemide diuretics -Calcium supplements

Furosemide diuretics High ceiling or loop diuretics, such as furosemide increase calcium excretion and are used to manage calcium levels in clients who have mild hyperparathyroidism. Antipyretics are not routinely prescribed because fever is not associated with the disorder. Opioid analgesics are used only when a problem causing acute pain is present and not for typical management of mild hyperparathyroidism. Calcium supplements are contraindicated because hyperparathyroidism results in chronic hypercalcemia.

56. Which laboratory findings will the nurse use to validate the statement of a client with diabetes that therapy instructions for glucose control "have been followed to the letter" for the past 2 months? -Random blood glucose level -Glycosylated hemoglobin (HbA1c) -Fasting blood insulin level -Fasting blood glucose level

Glycosylated hemoglobin (HbA1c) The glycosylated hemoglobin (HbA1c) evaluates the average blood glucose level for 2 to 3 months; this is the best indicator of overall blood glucose control. Although fasting blood glucose can be used to monitor daily glucose control, it is not the best method to evaluate blood glucose over a period of time. A random blood glucose level reflects what the client has eaten within the last few hours and provides no real indication of long-term control. Fasting insulin levels are not used to evaluate anything.

61. A client with cognitive impairment has urge incontinence. Which method for achieving continence does the nurse include in the client's care plan? -Kegel exercises -Habit training -Credé method -Bladder training

Habit training Habit training (scheduled toileting) will be most effective in reducing incontinence for a cognitively impaired client because the caregiver is responsible for helping the client to a toilet on a scheduled basis. Bladder training, the Credé method, and learning Kegel exercises require that the client be alert, cooperative, and able to assist with his or her own training.

58. For which new-onset symptom or behavior will the nurse teach a client taking thyroid hormone replacement therapy (HRT) to report immediately to the primary health care provider? -Calf muscle cramping -Runny nose -Anorexia -Hand tremors

Hand tremors Hand tremors are an indication of HRT toxicity with increased central nervous system stimulation. The dose must be decreased to prevent more serious neurologic and cardiac toxicities. Anorexia, runny nose, and muscle cramping are neither side effects of the drug nor indications of toxicity.

60. When performing bladder scanning to detect residual urine in a female client, the nurse must first assess which factor? -History of hysterectomy -Abdominal girth -Hematuria -Presence of urinary infection

History of hysterectomy Before performing bladder scanning to detect residual urine in a female client, the nurse must first determine if the client has had a hysterectomy. The scanner must be in the scan mode for female clients in order to ensure the scanner subtracts the volume of the uterus from the measurement. If the client has had a hysterectomy, the scanner should remain in the scan mode for males. The nurse performs this procedure in response to distention or pressure in the bladder; girth is not a factor. This procedure detects urine retained in the bladder, not infection. The presence of retained urine in the bladder is assessed, regardless of hematuria.

60. The nurse is reviewing the medical record for a client with polycystic kidney disease who is scheduled for computed tomographic angiography with contrast: H&P: Polycystic kidney disease; Diabetes; Hysterectomy; Abdomen distended; Negative edema Medications: Glyburide; Metformin; Synthroid Diagnostic Findings: -BUN 26 mg/dL (9.2 mmol/L) -Creatinine 1.0 mg/dL (77 umol/L) -HbA1c 6.9% -Glucose 132 mg/dL (7.3 mmol/L) Which nursing intervention is essential? -Hold the metformin 24 hours before and on the day of the procedure. -Notify the provider regarding blood glucose and glycosylated hemoglobin (HbA1c) values. -Report the blood urea nitrogen (BUN) and creatinine. -Obtain a thyroid-stimulating hormone (TSH) level.

Hold the metformin 24 hours before and on the day of the procedure. The essential intervention for the nurse to perform is to withhold metformin at least 24 hours before the time of a contrast media study and for at least 48 hours after the procedure because metformin may cause lactic acidosis. The focus of this scenario is the client with polycystic kidneys. A TSH level is not essential at this time. BUN and creatinine are normal. The glucose is only mildly elevated (if fasting), and the HgbA1C is in an appropriate range.

59. What is the nurse's best response when a client with diabetes who is being treated for hypoglycemic asks why people without diabetes don't become severely hypoglycemic even after fasting for 8 hours? -In a person without diabetes, fasting for 8 hours converts proteins into glycose (gluconeogenesis) so that hypergycemia develops rather than hypoglycemia. -In a person without diabetes, the secretion of glucagon prevents hypoglycemia by promoting glucose release from liver storage sites (glycogenolysis). -Normal metabolism is so slow when a person without diabetes fasts that blood glucose does not enter cells to be used for energy. As a result, hypoglycemia does not occur. -Lipolysis (fat breakdown) in fat stores occurs faster in the nondiabetic person, which converts fatty acids into glucose to maintain blood glucose levels.

In a person without diabetes, the secretion of glucagon prevents hypoglycemia by promoting glucose release from liver storage sites (glycogenolysis). Glucagon is a counter-regulatory hormone secreted by pancreatic alpha cells when blood glucose levels are low, as they would be during an 8 hour fast. The body's metabolic rate does decrease during sleep (which is not stated in this question) but not sufficiently to prevent hypoglycemia. Glucagon works on the glycogen stored in the liver, breaking it down to glucose (glycogenolysis) molecules that are then released into the blood to maintain blood glucose levels and prevent hypoglycemia. Although proteins can be broken down and converted to glucose, they are not converted to glycogen. Fat break down through lipolysis can provide fatty acids for fuel but this is not glucose and lipolysis does not occur until all stored glycogen is used.

60. Which client assessment data indicates to the nurse that the client has a potential need for fluids? -Increased blood urea nitrogen -Increased creatinine -Decreased sodium -Pale-colored urine

Increased blood urea nitrogen Potential for increased fluids are needed for a client with increased blood urea nitrogen. Increased blood urea nitrogen can indicate dehydration. Increased creatinine indicates kidney impairment. Pale-colored urine signifies diluted urine, which indicates adequate fluid intake. Increased, not decreased, sodium indicates dehydration.

63. The nurse is caring for a client with kidney failure. Which assessment data indicates the need for increased fluids? -Decreased sodium level -Pale-colored urine -Increased blood urea nitrogen (BUN) -Increased creatinine level

Increased blood urea nitrogen (BUN) An increase in BUN can be an indication of dehydration, and a needed increase in fluids. Increased creatinine indicates kidney impairment. Urine that is pale in color is diluted and does not indicate that an increase in fluids is necessary. Sodium is increased, not decreased, with dehydration.

56. Which client assessment finding indicates to the nurse the need to assess further for a possible endocrine problem? -Increased facial hair and absent menses in a 28-year-old nonpregnant woman -Increased appetite in a 40-year-old man who started an aerobic exercise program 1 week ago -Male-pattern baldness in a 32-year-old man -Dry skin on the shins of a 70-year-old woman

Increased facial hair and absent menses in a 28-year-old nonpregnant woman Absence of menses when pregnancy is not present is considered abnormal, especially when accompanied by hirsutism. Possible endocrine problems associated with these changes include ovarian, adrenal gland, hypothalamic, or anterior pituitary dysfunction. Male-pattern baldness in a man is usually associated with a genetic predisposition. Dry skin is a normal finding in older women. An increased appetite when physical activity increases is also considered normal.

56. What effect on circulating levels of sodium and glucose does the nurse expect in a client who has been taking an oral cortisol preparation for 2 years because of a respiratory problem? -Decreased sodium; decreased glucose -Increased sodium; increased glucose -Increased sodium; decreased glucose -Decreased sodium; increased glucose

Increased sodium; increased glucose Any of the glucocorticoids have some mineralocorticoid activity and increase the reabsorption of sodium from the kidney tubules, thus increasing the serum sodium level. Cortisol also increases liver production of glucose (gluconeogenesis) and inhibits peripheral glucose uptake by the cells. Both these actions increase blood glucose levels.

60. When a client with diabetes returns to the medical unit after a computed tomography (CT) scan with contrast dye, all of these interventions are prescribed. Which intervention will the nurse implement first? -Administer captopril. -Request a breakfast tray for the client. -Administer lispro (Humalog) insulin, 10 units subcutaneously. -Infuse 0.45% normal saline at 125 mL/hr.

Infuse 0.45% normal saline at 125 mL/hr. After a diabetic client returns to the unit after a CT scan, the first intervention implemented by the nurse is to infuse 0.45% normal saline at 125 mL/hr. Fluids are needed because the iodinated dye used in a CT scan with contrast has an osmotic effect, causing dehydration and potential kidney failure. Lispro is not administered until the breakfast tray arrives. A breakfast tray will be requested, but preventing complications of the procedure is done first. Because the client may be hypovolemic, the nurse needs to monitor blood pressure and administer IV fluids before deciding whether administration of captopril is appropriate.

5. A postoperative client is vomiting and states, "I am having a lot of pain—a 7 on a scale of 0-10." Which route of administration will the nurse choose to administer an analgesic to the client? -Oral -Rectal -Intravenous -Transdermal

Intravenous The intravenous route is the best choice for fast relief of nausea and pain. Oral pain medication may exacerbate the client's nausea and is not the best choice. The rectal route and the transdermal route are not the routes of choice for short-term pain control because their effect is not as rapid or controlled as that of other routes.

57. In collaboration with the registered dietitian nutritionist, which dietary alterations will the nurse instruct a client with Cushing disease to make? -High carbohydrate, low potassium, and fluid restriction -Low carbohydrate, high calorie, and low sodium -Low protein, high carbohydrate, and low calcium -High protein, high carbohydrate, and low potassium

Low carbohydrate, high calorie, and low sodium The client with Cushing disease has weight gain, muscle loss, hyperglycemia, and sodium retention. Dietary modifications need to include reduction of total calories and carbohydrates to prevent or reduce the degree of hyperglycemia. The sodium retention causes water retention and hypertension. Clients are encouraged to moderately restrict sodium intake.

8. Which condition, when assessed in a client who is dying requires the nurse to take action? -Alternating apnea and rapid breathing -Cool extremities -Moaning -Anorexia

Moaning Moaning indicates pain and requires pain medication. Alternating apnea and rapid breathing, anorexia, and cool extremities are normal assessment findings in the client who is dying.

58. Which action does the postanesthesia care unit (PACU) nurse perform first when caring for a client who has just arrived after a total thyroidectomy? -Administering morphine for pain -Assessing the wound dressing for bleeding -Hyperextending the neck -Monitoring oxygen saturation

Monitoring oxygen saturation Airway assessment and management is always the first priority with every client, especially for a client who has had surgery that involves potential bleeding and edema near the trachea. Assessing the wound dressing for bleeding is a high priority, which is performed next after assessing airway and breathing. Pain control is important, but can be addressed after airway assessment. The neck should not be extended or hyperextended because this position puts too much tension on the incision.

8. A client with terminal pancreatic cancer is near death and reports increasing shortness of breath with associated anxiety. Which hospice protocol order will the nurse implement first? -Morphine sulfate sublingually as needed -Albuterol solution per nebulizer -Prednisone elixir 10 mg orally -Oxygen 2 to 6 L/min per nasal cannula

Morphine sulfate sublingually as needed Morphine sulfate is the standard treatment for the dyspneic client who is near death. Albuterol, oxygen, and steroids may be useful, but should be used as adjuncts to therapy with morphine.

60. The nurse is caring for a client with uremia. What assessment data will the nurse anticipate? -Nausea and vomiting -Insomnia -Cyanosis of the skin -Tenderness at the costovertebral angle (CVA)

Nausea and vomiting The signs and symptoms the nurse needs to assess for are nausea and vomiting. Other manifestations of uremia include anorexia, nausea, vomiting, muscle cramps, pruritus, fatigue, and lethargy. CVA tenderness is a sign of inflammation or infection in the renal pelvis. Cyanosis is related to poor tissue perfusion. Insomnia is nonspecific and may be caused by psychoemotional factors, medications, or other problems.

Which client symptom appearing after a head injury suffered in a car crash is most relevant for the nurse to consider the possibility of diabetes insipidus (DI)? -New-onset hypertension. -The client reports extreme salt craving. -No change in urine output with minimal fluid intake. -The client's headache is gradually increasing in intensity.

No change in urine output with minimal fluid intake. DI results from absent or insufficient secretion of antidiuretic hormone (ADH, vasopressin) from the posterior pituitary and can result from a head injury that damages this endocrine gland. With less or absent ADH, the client is unable to reabsorb water even when fluid intake is low. Although headache is usually present with a head injury, it is not associated with DI. The dehydration associated with DI would cause hypotension and an increased serum sodium concentration.

63. The nurse teaches a client who is recovering from acute kidney injury to avoid which type of medication? -Opioids -Nonsteroidal anti-inflammatory drugs (NSAIDs) -Calcium channel blockers -Angiotensin-converting enzyme (ACE) inhibitors

Nonsteroidal anti-inflammatory drugs (NSAIDs) Clients recovering from acute kidney disease need to be taught to avoid NSAIDs. NSAIDs may be nephrotoxic to a client with acute kidney disease and must be avoided. ACE inhibitors are used for treatment of hypertension and to protect the kidneys, especially in the diabetic client, from progression of kidney disease. Opioids may be used by clients with kidney disease if severe pain is present. Excretion, however, may be delayed. Calcium channel blockers can improve the glomerular filtration rate and blood flow within the kidney.

62. The nurse is caring for a client with hemorrhage secondary to kidney trauma. Which element does the nurse anticipate will be used for volume expansion? -Platelet infusions -5% dextrose in water -Normal saline solution -Fresh-frozen plasma

Normal saline solution To provide volume expansion to a client with hemorrhage secondary to kidney trauma, the nurse expects that normal saline solution will be used. Isotonic solutions and crystalloid solutions are administered for volume expansion. 0.9% sodium chloride (NS) and 5% dextrose in 0.45% sodium chloride may also be given. Lactated Ringer's solution may be used if the client has no liver damage. Clotting factors, contained in fresh-frozen plasma, are given for bleeding, not for volume expansion. Platelet infusions are administered for deficiency of platelets. A solution hypotonic to the client's blood, 5% dextrose, is administered for nutrition or hypernatremia, not for volume expansion.

60. A client is scheduled for a cystoscopy later this morning. The consent form is not signed, and the client has not had any preoperative medication. The nurse notes that the health care provider (HCP) visited the client the day before. What action will the nurse take? -Notifies the department and the HCP. -Asks the client's spouse to sign the form. -Cancels the procedure. -Asks the client to sign the informed consent.

Notifies the department and the HCP. The nurse notifies both the HCP and the department to ensure effective communication across the continuum of care. This nursing action makes it less likely that essential information will be omitted. The client may be asked to sign the consent form in the department. The HCP gives the client a complete description of and reasons for the procedure and explains complications. The nurse reinforces this information. The procedure would not be cancelled without an attempt to correct the situation. The client has not received sedation, so nothing suggests that the client is not competent to consent and that the spouse needs to sign the form.

60. The nurse assesses blood clots in a client's urinary catheter after a cystoscopy. What initial nursing intervention is appropriate? -Administer heparin intravenously. -Remove the urinary catheter. -Irrigate the catheter with sterile saline. -Notify the health care provider (HCP).

Notify the health care provider (HCP). The nurse first notifies the HCP after visualizing a blood clot in a postoperative cystoscopy client's urinary catheter. Bleeding and/or blood clots are potential complications of cystoscopy and may obstruct the catheter and decrease urine output. In addition, the nurse must monitor urine output and notify the HCP of obvious blood clots or a decreased or absent urine output. Heparin would not be administered due to bleeding. The urinary catheter is allowing close monitoring of the urinary system and would not be removed at this time. The Foley catheter may be irrigated with sterile saline if prescribed by the HCP.

8. A dying client becomes increasingly withdrawn and begins to refuse to eat and drink. What intervention will the nurse implement? -Administer intravenous hydration. -Call the family to come in right away. -Offer ice chips. -Bring in the client's favorite food.

Offer ice chips. The client who is dying should not be forced to eat or drink, but small sips of liquids or ice chips at frequent intervals can be offered if the client is alert and able to swallow. This helps the client with problems of dehydration and "dry mouth." The client's metabolic needs have decreased, so the client will not want any food or drink. Calling the family is not yet necessary in this client's case. Because the dying client's metabolic needs have decreased, invasive procedures are not currently necessary.

9. A client is scheduled to have an ileostomy placed. How does the nurse document this type of surgery? -Diagnostic -Cosmetic -Curative -Palliative

Palliative Colostomy surgery is categorized as palliative. Palliative surgery is performed to increase the quality of life (and often to reduce pain) while reducing stressors on the body. It is noncurative in nature. Cosmetic surgery is performed primarily to alter or enhance personal appearance. Curative surgery is performed to resolve a health problem by repairing or removing the cause. Diagnostic surgery is performed to determine the origin and cause of a disorder or the cell type for cancer.

59. Which action is appropriate for the nurse to delegate to the assistive personnel (AP) when caring for clients with diabetes? -Monitoring a client who reports palpitations and anxiety -Verifying the infusion rate on a continuous infusion insulin pump -Performing a blood glucose check on a client who requires insulin -Assessing a client who reports tremors and irritability

Performing a blood glucose check on a client who requires insulin Performing bedside glucose monitoring is a task that may be delegated to an AP who has been educated in this technique because it does not require extensive clinical judgment to perform. There is no evidence the client is unstable at this time. The nurse will follow up with the results and insulin administration after assessing the less stable clients. Intravenous therapy and medication administration are not within the scope of practice for AP. The client with tremors and irritability is displaying symptoms of hypoglycemia requiring further assessment and intervention that are not within the scope of practice for AP. The client reporting palpitations and anxiety may have hypoglycemia, requiring further intervention. This client must be assessed by licensed nursing staff.

5. A client with extensive burn injuries is to be weaned from long-term opioid use. What type of opioid dependence does the nurse expect this client to have? -Tolerance -Pseudoaddiction -Physical dependence -Addiction

Physical dependence The nurse expects the client to have a physical dependence on the opioid. Physical dependence occurs in people who take opioids over a period of time. When it is necessary to discontinue opioid analgesia for the client who is opioid dependent, slow tapering (weaning) of the drug dosage lessens or alleviates physical withdrawal symptoms. Addiction is a condition influenced by genetic, psychosocial, and environmental factors and characterized by impaired control over drug use, compulsive use, craving, or continued use despite harm; this description does not accurately reflect the client's situation. Tolerance is similar to physical dependence, but occurs earlier and consists of a decrease in one or more of the effects of the opioid. Pseudoaddiction is a condition created by the undertreatment of pain, and is characterized by behaviors such as anger and escalating demands for more or different medications; this description does not accurately reflect the client's situation.

8. A client who is dying cannot swallow and is accumulating audible mucus in the upper airway (death rattles). These noises are upsetting to family members. What nursing action is appropriate? -Place the client in a side-lying position so secretions can drain. -Use a Yankauer suction tip to remove secretions from the client's upper airway. -Position the client in a high-Fowler position to minimize secretions. -Assist the family in leaving the room so that they can compose themselves.

Place the client in a side-lying position so secretions can drain. Placing the client in a side-lying position to facilitate draining of secretions (by gravity) is the appropriate nursing care intervention. As secretions diminish, noisy respirations will decrease. Asking the family to leave at this important time is not appropriate. Placing the client in a high-Fowler position is ineffective in helping the client who has lost the ability to swallow and increases the danger of choking and aspiration. Oropharyngeal suctioning is not recommended for removal of secretions, because it is not effective and may even agitate the client.

61. The nurse is performing catheter care. Which nursing action demonstrates proper aseptic technique? -Sending a urine specimen to the laboratory for testing -Irrigating the catheter daily -Positioning the collection bag below the height of the bladder -Applying Betadine ointment to the perineal area after catheterization

Positioning the collection bag below the height of the bladder Proper aseptic technique during catheter care involves positioning the collection bag below the height of the bladder. Urine collection bags must be kept below the level of the bladder at all times. Elevating the collection bag above the bladder causes reflux of pathogens from the bag into the urinary tract. Applying antiseptic solutions or antibiotic ointments to the perineal area of catheterized clients has not demonstrated any beneficial effect. A closed system of irrigation must be maintained by ensuring that catheter tubing connections are sealed securely; disconnections can introduce pathogens into the urinary tract, so routine catheter irrigation would be avoided. Sending a urine specimen to the laboratory is not indicated for asepsis.

59. Which assessment is a priority for the nurse to make when a client with diabetic ketoacidosis (DKA) who is being monitored while receiving an insulin infusion begins to show an irregular heart beat with inverted T-waves? -Rate of IV infusion -Urine output -Potassium level -Breath sounds

Potassium level After DKA therapy starts, serum potassium levels drop quickly. An ECG showing an irregular pattern and inverted T-waves is most likely related to low potassium levels (hyperkalemia). Hypokalemia is a common cause of death in the treatment of DKA. Detecting and treating the underlying cause of the cardiac irregularities is essential. The cardiac issues are not associated with changes in urine output even though hyperglycemia will cause osmotic diuresis. The client with DKA is not at risk for hypoventilation or poor gas exchange. Increased fluids treat the symptoms of dehydration secondary to DKA, but do not treat the hypokalemia.

60. A client had a computed tomography (CT) scan with contrast dye 8 hours ago. Which nursing intervention is the priority for this client? -Promoting fluid intake -Medicating for pain -Monitoring for hematuria -Maintaining bedrest

Promoting fluid intake The priority nursing intervention for this client is to promote fluid intake. The nurse must ensure that the client has adequate hydration to dilute and excrete the contrast media. The nurse urges the client to take oral fluid or, if needed, administers IV fluids to the client. Hydration reduces the risk for kidney damage. Bedrest is not indicated for the client who has undergone a CT scan with contrast dye. CT with contrast dye is not a painful procedure, so pain medication is not indicated. The client who has undergone CT with contrast dye is not at risk for hematuria.

59. Which assessment finding in a client with diabetes mellitus indicates to the nurse that the disease is damaging the kidneys? -White blood cells (WBCs) in the urine during a random urinalysis -Ketone bodies in the urine during acidosis -Glucose in the urine during hyperglycemia -Protein in the urine during a random urinalysis

Protein in the urine during a random urinalysis Urine should not contain protein and the presence of proteinuria in a client with marks the beginning of renal problems known as diabetic nephropathy, that progresses eventually to end-stage renal disease. Chronically elevated blood glucose levels cause renal hypertension and excess kidney perfusion with leakage from the renal vasculature. The excess leakiness allows larger substances, such as proteins, to be filtered into the urine.

62. The nurse is preparing a client for nephrostomy tube insertion. Which factor must be assessed by the nurse before the procedure? -Blood urea nitrogen (BUN) and creatinine -Prothrombin time (PT) and international normalized ratio (INR) -Intake and output (I&O) -Hemoglobin and hematocrit (H&H)

Prothrombin time (PT) and international normalized ratio (INR) Before insertion of a nephrostomy tube into a client, it is essential for the nurse to monitor the client's PT and INR. The procedure will be cancelled or delayed if coagulopathy in the form of prolonged PT/INR exists because dangerous bleeding may result. Nephrostomy tubes are placed to prevent and treat kidney damage. Monitoring BUN and creatinine is important but is not essential before this procedure. H&H is monitored to detect anemia and blood loss. This would not occur before the procedure. This client would be on I&O during the entire hospitalization. I&O is not necessary only before the procedure, but throughout the admission.

9. The nurse assesses a client's wound 24 hours postoperatively. Which finding causes the nurse to contact the surgeon? -Sanguineous drainage at the suture site -Crusting along the incision line -Serosanguineous drainage on the dressing -Redness and swelling around the incision

Redness and swelling around the incision The nurse's concern is redness and swelling around the incision. This needs to be reported to the surgeon because these signs could indicate an infection. Crusting along the incision line, sanguineous drainage, and serosanguineous drainage are normal.

63. The nurse is caring for a client with acute kidney injury and a temporary subclavian hemodialysis catheter. Which assessment finding requires nursing action? -Mild discomfort at the insertion site -Temperature 100.8° F (38.2° °C) -Anorexia -1+ ankle edema

Temperature 100.8° F (38.2° °C) In this client situation, the nurse reports an assessment finding of a temperature of 100.8° F (38.2° C) to the HCP. Infection is a major complication of temporary catheters. All symptoms of infection, including fever, must be reported to the provider because the catheter may have to be removed. Mild discomfort at the insertion site is expected with a subclavian hemodialysis catheter. During acute injury, oliguria with resulting fluid retention and 1+ ankle edema is expected. Rising blood urea nitrogen may result in anorexia, nausea, and vomiting.

60. The nurse is caring for client who has just returned from the operating room for cystoscopy performed under conscious sedation. Which assessment finding requires immediate nursing action? -Temperature of 100.8° F (38.2° C) -Lethargy -Pink-tinged urine -Urinary frequency

Temperature of 100.8° F (38.2° C) The nurse is immediately concerned when a postoperative cystoscopy client who had conscious sedation returns to the unit with a temperature of 100.8° F (38.2° C). Fever, chills, or an elevated white blood cell count after cystoscopy suggest infection after an invasive procedure. The provider must be notified immediately. Pink-tinged urine is expected after a cystoscopy. Frequency may be noted as a result of irritation of the bladder. Gross hematuria would require notification of the surgeon. If sedation or anesthesia was used, lethargy is an expected effect.

63. A client admitted to the medical unit with a history of vomiting and diarrhea and an increased blood urea nitrogen requires 1 L of normal saline infused over 2 hours. Which staff member would be assigned to care for the client? -LPN/LVN with experience working on the medical unit. -New graduate RN who just finished a 6-week orientation. -RN who has floated from pediatrics for this shift. -RN who usually works on the general surgical unit.

RN who usually works on the general surgical unit. The RN who usually works on the general surgical unit would have the most experience in taking care of surgical clients and would be most capable of monitoring the client receiving rapid fluid infusions. This client is at risk for complications such as pulmonary edema and acute kidney failure. The pediatric float RN and the new graduate RN will have less experience in caring for this type of client. The LPN/LVN would not be assigned to a client requiring IV therapy and who is at high risk for complications.

61. Which nursing intervention or practice is effective in helping to prevent urinary tract infection (UTI) in hospitalized clients? -Recommending that catheters be placed in all clients -Encouraging fluid intake -Irrigating all catheters daily with sterile saline -Reevaluating the need for indwelling catheters

Reevaluating the need for indwelling catheters The nursing intervention that is effective in helping to prevent UTIs in hospitalized clients is reevaluating the need for indwelling catheters. Studies have shown that this intervention is the best way to prevent UTIs in the hospital setting. Encouraging fluids, although it is a valuable practice for clients with catheters, will not prevent the occurrence of UTIs in the hospital setting. In some clients, their conditions do not permit an increase in fluids, such as those with heart failure and kidney failure. Irrigating catheters daily is contraindicated, because any time a closed system is opened, bacteria may be introduced. Placing catheters in all clients is unnecessary and unrealistic. This practice would place more clients at risk for the development of UTI.

61. A client who is 6 months pregnant comes to the prenatal clinic with a suspected urinary tract infection (UTI). What action will the nurse take with this client? -Discharges the client to her home for strict bedrest for the duration of the pregnancy. -Instructs the client to drink a minimum of 3 L of fluids daily to "flush out" bacteria. -Recommends that the client refrain from having sexual intercourse until after delivery. -Refers the client to the clinic nurse practitioner for immediate follow-up.

Refers the client to the clinic nurse practitioner for immediate follow-up. When a client who is 6 months pregnant comes to the prenatal clinic with a suspected UTI, the nurse needs to refer the client to the clinic nurse practitioner for immediate follow-up. Pregnant women with UTIs require prompt and aggressive treatment because simple cystitis can lead to acute pyelonephritis. This in turn can cause preterm labor with adverse effects for the fetus. It is unsafe for the client to be sent home without analysis of the symptoms that she has. Her problem needs to be investigated without delay. Although drinking increased amounts of fluids is helpful, it will not cure an infection. Having sexual intercourse (or not having it) is not related to the client's problem. The client's symptoms need follow-up with a primary health care provider.

58. Which changing trends in a client's serum laboratory values indicate to the nurse that thyroid hormone replacement therapy for hypothyroidism is effective? -Declining thyroglobulin (Tg) levels; rising thyrotropin receptor antibody (TRAb) levels -Declining thyroid hormone (TH) levels; rising thyroid-stimulating hormone (TSH) levels -Rising thyroglobulin (Tg) levels; declining thyrotropin receptor antibody (TRAb) levels -Rising thyroid hormone (TH) levels; declining thyroid-stimulating hormone (TSH) levels

Rising thyroid hormone (TH) levels; declining thyroid-stimulating hormone (TSH) levels Drug therapy for hypothyroidism hormone replacement therapy with synthetic thyroid hormones, which would result in rising TH levels. As these levels rise, the negative feedback loop, which tries to stimulate the thyroid gland to produce TH would be suppressed, causes declining TSH levels. Thyroglobulin levels are related to active thyroid tissue. In hypothyroidism, these levels are low and drug therapy does not increase them. TRAbs are not a cause of hypothyroidism and do not develop with drug therapy.

56. Which laboratory finding in a client with a possible pituitary disorder will the nurse report to the health care provider immediately? -Blood glucose 148 mg/dL (7.4 mmol/L) -Blood urea nitrogen (BUN) 40 mg/dL (14.3 mmol/L) -Serum sodium 110 mEq/L (110 mmol/L) -Serum potassium 3.2 mEq/L (3.2 mmol/L)

Serum sodium 110 mEq/L (110 mmol/L) The normal range for serum sodium is 135 to 145 mEq/L (135 to 145 mmol/L). A result of 110 mEq/L (110 mmol/L) represents severe hyponatremia, requiring immediate action to prevent increased intracranial pressure, seizures, and death as the intravascular fluid shifts into brain tissue. The most likely cause of the problem is an increased vasopressin level that is increasing water reabsorption and diluting the serum sodium level. Although all the other laboratory values are also out of the normal range, none are close to reaching a critically low or high value.

57. Which change in serum electrolyte values in the past 12 hours for a client with syndrome of inappropriate antidiuretic hormone (SIADH) being treated with tolvaptan will the nurse report immediately to the health care provider? -Serum sodium increases from 122 mEq/L to 140 mEq/L. -Serum potassium decreases from 4.2 mEq/L to 3.8 mEq/L. -Serum chloride decreases from 109 mEq/L to 99 mEq/L. -Serum calcium increases from 9.5 mg/dL to 10.2 mg/dL.

Serum sodium increases from 122 mEq/L to 140 mEq/L. The purpose of tolvaptan is to restore a normal sodium concentration to the blood and other extracellular fluid. In the case of syndrome of inappropriate antidiuretic hormone, excessive amounts of antidiuretic hormone have caused more water to be absorbed, causing the serum sodium to be diluted. When tolvaptan therapy brings the serum sodium level to normal levels, it must be discontinued to prevent hypernatremia. A serum sodium of 140 mEq/L is within the normal range.

57. Which client report of changes in appearance indicates to the nurse that a client's adrenal insufficiency is related to direct malfunction of the adrenal glands? -5-lb weight loss -Dry, cracked lips -Thinning pubic hair -Skin darkening

Skin darkening Clients whose adrenal insufficiency is caused by adrenal glands that cannot produce appropriate levels of adrenal hormones have overall skin darkening. When the problem is in the adrenal gland and not either the hypothalamus or pituitary, plasma ACTH and melanocyte-stimulating hormone (MSH) levels are elevated in response to the adrenal-hypothalamic-pituitary feedback system. (Both ACTH and MSH are made from the same prehormone molecule.) Anything that stimulates increased production of ACTH also leads to increased production of MSH. Elevated MSH levels result in areas of increased pigmentation. Skin darkening does not occur when adrenal insufficiency is caused by hypofunction of the hypothalamus or pituitary gland. Although dehydration and weight loss can occur with adrenal insufficiency, they are not specific to problems in the adrenal glands.

9. A client has just undergone a surgical procedure with general anesthesia. Which finding indicates that the client needs further nursing assessment? -Pain at the surgical site -Verbal stimuli needed to awaken -Sore throat upon swallowing -Snoring sounds when inhaling

Snoring sounds when inhaling Snoring sounds when inhaling may indicate respiratory depression. Postsurgical pain at the surgical site is normal. Requiring verbal stimuli to awaken and a sore throat on swallowing are normal postsedation assessment findings.

9. A client with opioid depression has received naloxone. Vitals signs are currently recorded as BP 110/70, P 70, R 16, and T 98.9° F. Which additional treatment does the nurse anticipate will be needed? -Restraints due to naloxone causing agitation -Activation of the Rapid Response Team -Supplemental pain medication -External pacing to regular heartbeat

Supplemental pain medication Supplemental pain medication will be anticipated, as reversal of the opioid via naloxone reduces the analgesic effect also. The vital signs do not warrant activation of the Rapid Response Team, external pacing, nor restraints.

59. Which action will the nurse recommend to a client with type 1 diabetes on insulin therapy who has been having a morning fasting blood glucose (FBG) level of 160 mg/dL (8.9 mmol/L) and is diagnosed with "dawn phenomenon" to achieve better control? -Eat a bedtime snack containing equal amounts of protein and carbohydrates." -Avoid eating any carbohydrate with your evening meal." -Take your evening insulin dose right before going to bed instead of at supper time." -Inject the insulin into your arm rather than into the abdomen around the navel."

Take your evening insulin dose right before going to bed instead of at supper time." A client with "dawn phenomenon," diagnosed by checking blood glucose levels during the night, has morning hyperglycemia that results from a nighttime release of adrenal hormones causing blood glucose elevations at about 5 to 6 a.m. It is managed by providing more insulin for the overnight period (e.g., giving the evening dose of intermediate-acting insulin at 10 p.m. instead of with the evening meal).Bedtime snacks are needed for "Somogyi phenomenon" that is morning hyperglycemia caused by the counterregulatory response to nighttime hypoglycemia. Changing the injection site would not prevent morning hyperglycemia. Not eating any carbohydrate with a meal is more likely to cause severe hypoglycemia during the night and is dangerous.

9. An older client's adult child tells the nurse that the client does not want life support. What does the nurse do first? -Call the legal department to draft the paperwork. -Thank the adult child for sharing the parent's desires. -Talk to the client to be sure of their wishes. -Document the conversation in the electronic health record.

Talk to the client to be sure of their wishes. The nurse would first talk to the client in order to determine the client's wishes and state of mind. As long as the client is lucid, he or she can articulate his or her own wishes regarding life support or the absence of such. Once the nurse has assessed that the client has certain end-of-life wishes, the nurse can confirm that the client wants these officially documented. If the client agrees, then the legal department can be contacted. Finally, the nurse can thank the adult child for sharing that the client has thoughts about life support, as this was the catalyst that allowed the nurse to further assess the client's wishes. The nurse could not act on the adult child's indications alone.

8. A hospice client becomes too weak to swallow. What does the nurse do initially to increase the client's comfort? -Explains to the family that aspiration may be a concern. -Administers nutrition and fluids through a nasogastric tube. -Teaches the family how to provide oral care. -Obtains a physician order to initiate an IV line.

Teaches the family how to provide oral care. Because the oral mucosa will become dry, the initial action taken by the nurse would be to teach the family members how to moisten the lips and mouth. Although fluids can be given through a nasogastric tube and through an IV line, these are generally considered to increase discomfort by prolonging the client's suffering. Aspiration is not a concern in terminally ill clients, because fluids are not given orally to clients with decreased swallowing.

63. When caring for a client who receives peritoneal dialysis (PD), which finding does the nurse report to the provider (HCP) immediately? -Temperature of 101.2° F (38.4° C) -Sinus bradycardia, rate of 58 beats/min -Pulse oximetry reading of 95% -Blood pressure of 148/90 mm Hg

Temperature of 101.2° F (38.4° C) The nurse needs to immediately report a peritoneal dialysis client's temperature of 101.2° F (38.4° C) to the HCP. Peritonitis is the major complication of PD, caused by intra-abdominal catheter site contamination. Meticulous aseptic technique must be used when caring for PD equipment. A pulse oximetry reading of 95% is a normal saturation. Although a heart rate of 58 beats/min is slightly bradycardic, the HCP can be informed upon visiting the client. Clients with kidney failure tend to have slightly higher blood pressures due to fluid retention. This is not as serious as a fever.

58. Why is a goiter often present in clients who have Graves disease? -The low circulating levels of thyroid hormones stimulates the feedback system and triggers the anterior pituitary gland to secrete more thyroid-stimulating hormone, which increases the numbers and size of glandular cells in the thyroid gland. -The excessive autoantibodies bind to the thyroid-stimulating hormone receptor sites, which increases the number and size of glandular cells in the thyroid gland. -The autoantibodies stimulate blood vessel growth and blood storage within the thyroid gland, increasing its overall size. -The autoantibodies stimulate the inflammatory and immune responses to increase the number of white blood cells circulating in the thyroid gland, which increases tissue size without increasing the number of glandular cells.

The excessive autoantibodies bind to the thyroid-stimulating hormone receptor sites, which increases the number and size of glandular cells in the thyroid gland. Graves disease is an autoimmune disorder in which antibodies (thyroid-stimulating immunoglobulins [TSIs]) are made and attach to the thyroid-stimulating hormone (TSH) receptors on the thyroid tissue. The thyroid gland responds by increasing the number and size of glandular cells, which enlarges the gland, forming a goiter and overproduces thyroid hormones (thyrotoxicosis).

59. How will the nurse evaluate the level of glycemic control for a client with diabetes whose laboratory values include a fasting blood glucose level of 82 mg/dL (mmol/L) and an A1c of 5.9%? -The values indicate that the client has poorly managed his or her disease. -The values indicate that the client has managed his or her disease well. -The client's glucose control for the past 24 hours has been good but the overall control is poor. -The client's glucose control for the past 24 hours has been poor but the overall control is good.

The values indicate that the client has managed his or her disease well. Fasting blood glucose levels provide an indication of the client's adherence to drug and nutrition therapy for DM has been for the previous 24 hours. This client's FBG is well within the normal range.A1c provides an indication of general blood glucose control for the past several months because when glucose attaches to hemoglobin, the attachment is permanent for as long as those hemoglobin molecules are present within red blood cells. Normal red blood cell life span is about 120 days. This client's A1c level is within the desirable range, indicating good long-term glucose control as well as short-term control.

62. Which assessment data in a client with chronic glomerulonephritis (GN) warrants the nurse to contact the primary health care provider? -Itchy skin -Serum potassium of 5.0 mEq/L (5.0 mmol/L) -Mild proteinuria -Third heart sound (S3)

Third heart sound (S3) When a third heart sound (S3) is heard in a client with chronic glomerulonephritis, the nurse needs to contact the primary health care provider. S3 indicates fluid overload secondary to failing kidneys. The primary health care provider would be notified and instructions obtained.Mild proteinuria is an expected finding in GN. A serum potassium of 5.0 mEq/L (5.0 mmol/L) reflects a normal value. Intervention would be needed for hyperkalemia. Although itchy skin may be present as kidney function declines, it is not a priority over fluid excess.

62. The nurse is caring a client who had a nephrostomy tube inserted 4 hours ago. Which assessment requires nursing action? -Small amount of urine leaking around the catheter -Creatinine of 1.8 mg/dL (160 mcmol/L) -Dark pink-colored urine -Tube that has stopped draining

Tube that has stopped draining The nurse will need to inform the primary health care provider when a nephrostomy tube that was inserted 4 hours ago does not drain. It could be obstructed or dislodged. Pink or red drainage is expected for 12 to 24 hours after insertion and would gradually clear. The nurse may reinforce the dressing around the catheter to address leaking urine. However, the primary health care provider must be notified if there is a large quantity of leaking drainage, which may indicate tube obstruction. A creatinine level of 1.8 mg/dL (160 mcmol/L) is expected in a client early after nephrostomy tube placement (due to the minor kidney damage that required the nephrostomy tube).

63. While assisting a client during peritoneal dialysis, the nurse observes the drainage stop after 200 mL of peritoneal effluent drains into the bag. What action will the nurse implement? -Document the effluent as output. -Instruct the client to cough. -Reposition the catheter. -Turn the client to the opposite side.

Turn the client to the opposite side. The nurse's first action in this situation is to turn the client to the opposite side. With peritoneal dialysis, usually 1 to 2 L of dialysate is infused by gravity into the peritoneal space. The fluid dwells in the peritoneal cavity for a specified time, then drains by gravity into a drainage bag. The peritoneal effluent or outflow generally is a continuous stream after the clamp is completely open. Potential causes of flow difficulty include constipation, kinked or clamped connection tubing, the client's position, fibrin clot formation, and catheter displacement. If inflow or outflow drainage is inadequate, reposition the client to stimulate inflow or outflow. Turning the client to the other side or ensuring that he or she is in good body alignment may help. Instructing the client to cough will not promote dialysate drainage. Increased abdominal pressure from coughing contributes to leakage at the catheter site. The nurse needs to measure and record the total amount of outflow after each exchange. However, the nurse needs to reposition the client first to assist with complete dialysate drainage. An x-ray is needed to identify peritoneal dialysis catheter placement. Only the health care provider repositions a displaced catheter.

57. Which assessment finding in a client with diagnosis of diabetes insipidus (DI) indicates to the nurse that desmopressin therapy is effective? -Urine output of 30 to 50 mL/hr -Blood glucose level of 110 mg/dL (6.1 mmol/L) -Respiratory rate of 20 breaths/min -Potassium level of 3.9 mEq/L (mmol/L)

Urine output of 30 to 50 mL/hr With DI, insufficient amounts of vasopressin (antidiuretic hormone [ADH]) prevent reabsorption of water, leading to profound diuresis that can result in dehydration. Desmopressin, a synthetic form of ADH, is the drug of choice to stop fluid loss. A blood glucose result of 110 mg/dL (6.1 mmol/L) is within the range of normal blood glucose levels, as are the respiratory rate and the potassium level.

62. A client is referred to a home health agency after being hospitalized with overflow incontinence and a urinary tract infection. Which nursing action can the home health RN delegate to the home health aide (assistive personnel [AP])? -Using a bladder scanner to check residual bladder volume after the client voids -Inserting a straight catheter as necessary if the client is unable to empty the bladder -Teaching the client how to use the Credé maneuver to empty the bladder more fully -Assisting the client in developing a schedule for when to take prescribed antibiotics

Using a bladder scanner to check residual bladder volume after the client voids The home health RN delegates the task of using a bladder scanner to check residual bladder volume after the client voids, to the UAP. Use of a bladder scanner is noninvasive and can be accomplished by a home health aide (AP) who has been trained and evaluated in this skill. Assisting the client in developing a schedule for when to take prescribed antibiotics, inserting a straight catheter, and teaching the client to use the Credé maneuver all require more education and are in the legal scope of practice of the LPN/LVN or RN.

5. A client who had a hip replacement 2 days ago, reports having pain rated as a 7 on a pain scale of 0-10. What nursing intervention is the highest priority? -Teaching key points of the relaxation response -Incorporating activities of daily living as soon as possible -Encouraging diversional activities -Using preemptive analgesia

Using preemptive analgesia The nursing intervention with the highest priority in the client's care plan is the use of preemptive analgesia. This technique is designed to decrease pain in the postoperative period, decrease the requirements for a postoperative analgesic, prevent morbidity, and decrease the duration of hospital stay. Use of diversion in treating pain is often effective, but it would not be appropriate for acute pain expected on the second postoperative day. Getting the client to perform activities of daily living is an important step in recovery; however, it is not related to pain relief, but rather to other postoperative complications, such as circulation and elimination problems. Use of the relaxation response in treating pain is often effective, but it would not be appropriate for acute pain expected on the second postoperative day.

9. The nurse is providing preoperative care for a client who will have an arthroscopy of the left knee. As part of The Joint Commission National Patient Safety Goals (NPSG), what will the nurse do as the priority? -Ensure that the correct procedure is noted in the client's health record. -Witness marking of the left knee site with the client awake and the surgeon present. -Communicate with the surgeon confirming the client will have a left knee arthroscopy. -Verify with the client that a left knee arthroscopy will be performed.

Witness marking of the left knee site with the client awake and the surgeon present. The nurse will be required to mark the left knee site with the client awake and the surgeon present. The Joint Commission NSPG requires that the surgical site be marked by an independent licensed professional and should, when possible, involve the client. The surgeon is accountable and should be present. The nurse will also ensure that the correct procedure is in the clients health record; verify with the client that the left knee arthroscopy will be performed, and communicate with the surgeon that the client is having a left knee arthroscopy. However, these are all done after the priority of witnessing the client awake and surgeon present to mark the left knee site.