NCLEX-Adult Health

Which comment by the client indicates understanding of possible complications of long term hypertension? 1. "I would like to have my serum creatinine checked at this visit." 2. "My blurred vision is part of getting older." 3. "I have leg pain caused by excessive exercise." 4. "Adding salt to my food is permissible."

1. Correct: Hypertension is one of the leading causes of end stage renal disease. The client understands that renal function is reflected by serum creatinine levels. This request demonstrates understanding of the disease and possible complications. 2. Incorrect: The appearance of the retina provides important information about the severity and duration of hypertension. Manifestations of severe retinal damage include blurred vision, retinal hemorrhage, and loss of vision. 3. Incorrect: Intermittent claudication is a complication of peripheral vascular disease (PVD). Hypertension speeds up the process of PVD. 4. Incorrect: Lifestyle modifications include dietary sodium reduction, weight reduction, Dietary Approaches to Stop Hypertension (DASH) eating plan, moderation of alcohol consumption, regular physical activity, avoidance of tobacco use, and management of psychosocial risk factors.

Which statement made by a client diagnosed with Addison's disease indicates to the nurse that the client needs further teaching about fludrocortisone therapy? 1. "Taking my medicine at night will help me sleep." 2. "It is important to wear a medical alert bracelet all of the time." 3. "My medication dose may change based on my daily weight." 4. "I may need more medication if I feel weak or dizzy."

1. Correct: Steroids can cause insomnia so the client does not need to take the medication prior to going to bed. 2. Incorrect: This is a correct statement of understanding by the client. Wearing a medical alert bracelet is an excellent way of informing healthcare providers of a life threatening condition if the client is unable to verbalize that information. 3. Incorrect: Another correct statement. Steroid therapy is adjusted according to the client's weight and signs of fluid volume status. 4. Incorrect: This statement indicates that the client understands therapy. Signs of being undermedicated include weakness, fatigue, and dizziness. The client will need to report these symptoms so more medication can be given to the client.

A client returns to the clinic two days after receiving treatment for diarrhea caused by a Campylobacter jejuni infection. The client reports a tingling sensation that began in the toes yesterday and has spread to the feet and legs today. The nurse notes muscle weakness in the legs and that the client is having difficulty walking steadily. Based on this data, what does the nurse suspect is wrong with the client? 1. Guillain-Barré Syndrome 2. Multiple Sclerosis 3. Myasthenia Gravis 4. Systemic Lupus Erythematosus

1. Correct: The clues in this stem are diarrhea from Campylobacter jejuni, tingling sensation that began in the toes, spread to the feet and legs today, muscle weakness in the legs, and difficulty walking steadily. These s/s point to Guillain-Barré Syndrome. 2. Incorrect: Multiple Sclerosis damages nerves but not in an ascending progression from toes to head. 3. Incorrect: Myasthenia gravis is caused by a breakdown in the normal communication between nerves and muscles. Myasthenia gravis is characterized by weakness and rapid fatigue of any of the muscles under voluntary control. 4. Incorrect: Systemic lupus erythematosus, the most common form of lupus, is a chronic autoimmune disease that can cause severe fatigue and joint pain.

What is the nursing priority for the client experiencing hyperparathyroidism? 1. Continuous cardiac monitoring. 2. Initiate fall precautions. 3. Administer IV normal saline. 4. Begin preparations for emergency parathyroidectomy.

1. Correct: To much calcium equals sedation. Life threatening complications such as airway obstruction and cardiact arrest may occur from severely high levels of calcium. 2. Incorrect: Preventing injury is important because of bone density loss and risk of fractures. But it is not the priority. Done after maintaining airway and circulation. 3. Incorrect: IV normal saline in large volumes is done to promote calcium excretion, but it is not the priority over airway and circulation. 4. Incorrect: Surgery is indicated "when medically feasible". Cardiac monitoring is the priority at this time.

Which food selections would need to be removed from the tray by the nurse for a client recovering from thyroidectomy? 1. Roasted almonds 2. Mashed vegetables 3. Scrambled eggs 4. Ice cream

1. Correct: Too hard and crunchy. Need soft diet because esophagus is right behind the thyroid and trachea. This would be difficult to swallow after surgery due to pain. 2. Incorrect: Mashed vegetables will be soft and easy to swallow. 3. Incorrect: This would be good for the client. The food is soft and easy to swallow. 4. Incorrect: Ice cream with neck surgery. Cold and soft.

The nurse is working with a group of elderly clients to promote better nutrition. Prior to developing the health promotion plan, the nurse assesses individual members of the group. Which assessment findings are expected as the nurse works with this group? Select all that apply 1. Some clients may have dental issues, making chewing difficult. 2. There may be a decreased appetite in clients. 3. Caloric and nutritional needs may vary somewhat depending on activity levels. 4. Access to fresh foods is adequate. 5. The desire and interest in cooking is increased.

1., 2. & 3. Correct: Many elderly people have dental issues that affect chewing and intake of nutritionally dense foods. Appetite may decrease due to changes in taste, medications, depression or isolation. Many elderly people are active; therefore, it is important to assess each one individually in regard to activity levels. 4. Incorrect: Many elderly clients may not have access to fresh foods due to infrequent grocery shopping, limited budgets, and a desire to not waste good food.5. Incorrect: Many elderly do not have a desire to cook for one or two. Pain and physical impairment may also decrease desire or interest in cooking.

A home health nurse is interpreting Mantoux skin test results of clients who received the test 48 hours ago. Which clients have a positive tuberculin skin test reaction? Select all that apply 1. HIV+ client with an induration of 6 millimeters. 2. Client who immigrated from Haiti 6 months ago who has an induration of 10 millimeters. 3. Client working at a nursing home with an induration of 8 millimeters. 4. 3 year old client with an induration of 12 millimeters. 5. Healthy client with no known TB exposure who has an induration of 5 millimeters.

1., 2. & 4. Correct: HIV infected clients are considered to have a (+) TB skin test with an induration of 5 millimeters or more. An induration of 10 millimeters or more is considered positive in recent immigrants (less than five years) from high-prevalence countries such as Haiti, and in children less than 4 years of age. 3. Incorrect: An induration of 10 millimeters or more is considered positive for residents and employees of high-risk congregate settings.5. Incorrect: An induration of 15 millimeters or more is considered positive in any person with no known risk factors for TB.

A client's central venous pressure (CVP) reading has changed significantly from the last hourly reading. Which data would the nurse assess that reflect changes in the CVP reading? Select all that apply 1. Heart sounds 2. Skin turgor 3. Temperature 4. Nail bed color 5. EKG rhythm 6. Urinary output

1., 2. & 6. Correct: The CVP reading reflects the client's fluid volume status. If the CVP is elevated, indicating FVE, then the nurse is likely to hear S3 sounds when auscultating the heart sounds. The client's skin turgor and urine output would reflect the client's fluid volume status. 3. Incorrect: The CVP reading reflects the client's fluid volume status. The client's temperature would not reflect the client's fluid volume status. 4. Incorrect: The CVP reading reflects the client's fluid volume status. The nail bed color would not reflect the client's fluid volume status. 5. Incorrect: The CVP reading reflects the client's fluid volume status. The EKG rhythm would not reflect the client's fluid volume status.

What should the nurse include in the teaching plan for a client who has iron deficiency anemia? Select all that apply 1. Consume iron rich foods such as dried lentils, peas, and beans. 2. Notify primary healthcare provider of glossitis, anorexia, and paresthesia. 3. Iron is needed for white blood cell development. 4. Educate about ferrous sulfate supplement. 5. After drinking liquid iron, follow immediately by water.

1., 2., & 4. Correct: These are examples of iron rich foods. Foods high in iron will help with correcting iron deficiency anemia. Glossitis, anorexia, and paresthesias can result from iron deficiency anemia. Foods high in vitamin C such as citrus fruits, dark green leafy vegetables and strawberries help with absorption. 3. Incorrect: Iron is needed for red blood cell development and oxygen transport to the cells. Iron is not needed for white blood cell development. White blood cell development. White blood cells are produced in the bone marrow. 5. Incorrect: Clients should dilute liquid iron with water or juice, drink with a straw, and rinse mouth after swallowing. Iron will stain the teeth.

A nurse is developing a proposal to implement a pet therapy program at a nursing home. What information should the nurse include in the proposal to support this program? Select all that apply 1. Evidence has shown that animals can directly influence a person's mental and physical well-being. 2. Bringing a pet into a nursing home for the elderly has been shown to enhance social interaction. 3. Petting an animal can be helpful in lowering a client's blood pressure. 4. Some researchers believe that animals actually may retard the aging process among those who live alone. 5. Nursing home clients are more submissive after petting an animal.

1., 2., 3. & 4. Correct: All of these statements are correct in reference to pet therapy programs. Petting a dog or cat has been shown to lower blood pressure. Studies indicate a 7 mm Hg drop in systolic and an 8 mm Hg decrease in diastolic BP when volunteers talked to or would pet their dogs as opposed to reading aloud or resting quietly. 5. The clients are not more submissive or passive after participating in pet therapy. Evidence does show increased mental and physical well being with pet therapy.

A nurse, planning an educational seminar on chronic kidney disease, would invite clients with which medical conditions? Select all that apply 1. Polycystic kidney disease 2. Diabetes 3. Hypertension 4. Glomerulonephritis 5. Acute urinary tract infections (UTI)

1., 2., 3., & 4. Correct: Polycystic kidney disease is a genetic condition that causes damage to the kidneys. Clients with diabetes and hypertension make up more than 67% of clients diagnosed with chronic kidney disease. Glomerulonephritis damages the kidneys and can lead to permanent damage. 5. Incorrect: Acute UTIs do not generally lead to chronic kidney disease.

Which assessment findings would the nurse expect to see in a client diagnosed with idiopathic thrombocytopenic purpura (ITP)? Select all that apply 1. Ecchymosis 2. Bleeding gums 3. Palpable spleen 4. Pain 5. Petechiae

1., 2., 3., & 5. Correct: The word thrombocytopenia means low platelets. Any client with low platelets is at risk for bleeding, which is indicated by ecchymosis (bruising), bleeding gums, and petechiae (red to purple dots on the skin, 1-3 mm in size). Spleen and liver are often slightly palpable. 4. Incorrect: Pain is not associated with ITP unless there are other associated problems. However, the stem of the question gave no indication that other problems exist.

Which signs and symptoms does the nurse expect to see in a client admitted to the medical unit with Parkinson's disease? Select all that apply 1. Blank affect. 2. Decreased ability to swing arms. 3. Waddling gait. 4. Walking on toes. 5. Pill-rolling tremor. 6. Stiff muscles.

1., 2., 5., & 6. Correct: Classic characteristics of Parkinson's disease include a blank facial expression, forward tilt in the posture, slow/slurred speech, tremor, and a short shuffling gait. These symptoms also are manifested by a decreased ability to swing the arms and stiff muscles. 3. Incorrect: This is a sign of Duchenne Muscular Dystrophy. The client with Parkinson's disease has a shuffling gait. 4. Incorrect: This is a sign of Duchenne Muscular Dystrophy. The client with Parkinson's disease has a shuffling gait.

A client with acute pancreatitis is prescribed total parenteral nutrition (TPN), methylprednisolone, and sliding scale insulin. What is the rationale for the insulin prescribed? Select all that apply 1. Impaired endocrine function of the pancreas 2. Inability of the liver to convert glucose 3. Steroid therapy side effects 4. Dextrose concentration of TPN 5. Re-establish serum potassium level

1., 3., & 4. Correct: Really what we are saying here is why would the client be on insulin? Well, the pancreas is damaged and so the endocrine function of the pancreas is impaired. We know that hyperglycemia or pseudo diabetes is a side effect of steroid therapy and TPN is high in glucose and may require additional insulin. These are the three rationales for why they might need insulin. 2. Incorrect: If the liver can't convert glucose that will decrease the insulin need so that one is false. 5. Incorrect: Is not related at all. The NCLEX people want you to say,"I remember something about potassium and glucose, but I am not sure what. Don't fall for that, this is false. The rationale for the Insulin order is not to re-establish potassium in this question.

Which teaching points would the nurse include in a client's nutritional teaching plan to accomplish the goal of a gluten free diet? Select all that apply 1. Gluten is a protein found in wheat. 2. The main starchy foods that a person can eat are made with barley. 3. Fruits can be eaten on a gluten free diet. 4. Pure, non-contaminated oats are an acceptable grain food that the client can consume. 5. Accidentally eating food with gluten may result in abdominal pain and diarrhea.

1., 3., 4., & 5. Correct: A gluten-free diet is used in the treatment of celiac disease. Gluten is a protein found in barley, rye, and wheat. All products containing these grains are to be avoided. Rice and corn may be used. In addition, pure oats that have not been cross-contaminated with wheat, barley and/or rye can be safely consumed by most individuals with celiac disease or other gluten sensitivity. A reduction in the fiber content of the diet is also frequently recommended. Fruits, vegetables, nuts, diary products and meats not prepared with gluten containing ingredients can be eaten. Accidentally ingesting food with gluten may result in abdominal pain and diarrhea. Some people do not experience signs and symptoms, but this does not mean it is not damaging their small intestines. Even trace amounts of gluten may be damaging. 2. Incorrect: The main starchy foods that a person can eat are made with rice, corn, potatoes, quinoa, and Tapioca.

A client diagnosed with cancer has been losing weight. What should the nurse teach the client regarding methods for improving nutritional needs to maintain weight? Select all that apply 1. Add butter to foods. 2. Cup of cubed beef broth. 3. Add powdered creamer to milkshake. 4. Use biscuits to make sandwiches. 5. Fish sauted in olive oil. 6. Put honey on top of hot cereal.

1., 3., 4., & 6. Correct: Butter added to foods adds calories. This client needs more calories and more protein. Spread peanut butter or other nut butters, which contain protein and healthy fats, on toast, bread, apple or banana slices, crackers or celery. Use croissants or biscuits to make sandwiches which provides more calories. Add powered creamer or dry milk powder to hot cocoa, milkshakes, hot cereal, gravy, sauces, meatloaf, cream soups, or puddings to add more calories. Top hot cereal with brown sugar, honey, dried fruit, cream or nut butter. 2. Incorrect: One cube of beef broth is 11 calories. Supplementing the diet with beef broth would not add significant calories. 5. Incorrect: Although cooked in olive oil, fish is low in calories.

The nurse is providing teaching for a client who is being scheduled for outpatient 24 hour electrocardiogram monitoring using a Holter monitor. What should the nurse tell the client to avoid while monitoring is in progress? Select all that apply 1. Taking a shower or bath 2. Performing daily exercises 3. Working around high voltage equipment 4. Being screened at airport security 5. Eating foods that are sources of potassium

1., 3., and 4. Correct: The nurse should teach this client to continue the usual activities while wearing the monitor with a few exceptions. The monitor should be kept dry to ensure that it functions properly. The client should avoid taking a shower or bath or swimming while wearing the monitor. The electrodes could also become detached from the skin if they get wet, which would also interfere with the accuracy of the reading. The client should be advised to not work around high voltage equipment because areas of high voltage can interfere with the function of the electrocardiogram monitoring. In addition, magnetic fields, such as those used for airport screenings, can interfere with the function of the Holter monitor and should be avoided. 2. Incorrect: This client should be encouraged to continue regular routine unless otherwise directed by the primary healthcare provider. The client can perform the usual daily exercise, but should be advised to avoid activities that may cause excessive perspiration that could lead to the electrodes becoming loosened from the skin. 3. Incorrect: There are generally no dietary restrictions while wearing the Holter monitor unless otherwise prescribed by the primary healthcare provider.

The nurse is caring for a client following a total thyroidectomy. What findings would alert the nurse to potential complications? Select all that apply 1. Neck dressing intact, clean and dry 2. Increased blood pressure and pulse 3. High-pitched, harsh respirations 4. Vocal quality weak and clear 5. Left-sided cheek twitching

2, 3 and 5. CORRECT: There are several potential complications following a thyroidectomy. One life-threatening problem is the potential for a thyroid storm in which a large bolus of thyroid hormone is dumped into the system, causing increased blood pressure and pulse which could lead to intracranial hemorrhage. High pitched, harsh respirations indicate increasing edema and the potential for obstructed airway. A third potential problem may occur if one or more parathyroid glands are removed, placing the client at risk for hypocalcemia, as evidenced by a positive Chvostek's sign. 1. INCORRECT: The surgical dressing around the neck should definitely be intact and dry post-op. Any drainage that may develop would take a while to seep through the dressing. No concerns here. 4. INCORRECT: The client has just had surgery on the thyroid, causing swelling that could affect vocal cords. A weak initial voice is not unusual as long as the vocal quality is clear.

A client is to be discharged following a left modified-radical mastectomy. When reviewing ADL's to be completed at home, the nurse anticipates the client will experience the most difficulty doing what tasks? Select all that apply 1. Cooking a meal. 2. Shampooing hair. 3. Doing the laundry. 4. Vacuuming carpets. 5. Changing bed linens.

2, 3, & 5. CORRECT: The modified-radical mastectomy is a surgical approach to cancer in which the breast tissue, nipple, and axillary lymph nodes are removed but the chest muscles remain intact. Following surgery, individuals usually experience pain and stiffness when resuming normal daily activities, particularly tasks which require stretching the arm above the head. Shampooing or drying hair would be challenging, as would moving loads of heavy laundry between washer and dryer. Also difficult is changing bed sheets because it involves lifting and stretching across the bed. 1. INCORRECT: The process of cooking food can be modified in such a way the client would not need to extend the surgical arm above the head or in a painful position. 4. INCORRECT: Vacuuming carpet does not require lifting or reaching if the client uses an upright sweeper. This task should not present difficult challenges and can be completed with the non-surgical arm.

After reinforcing dietary teaching to a client diagnosed with Crohn's Disease, the nurse recognizes client understanding when the client selects which low-residue foods? Select all that apply 1. Broccoli 2. Oatmeal 3. Green peas 4. Spaghetti 5. Cantaloupe 6. Raisins

2, 4,& 5 Correct: A low residue diet is recommended for clients with inflammatory bowel diseases such as Crohn's Disease, diverticulitis or Ulcerative Colitis. This special diet is designed to decrease fiber in order to limit bowel peristalsis while still including nutritional elements for clients. Cooked oatmeal or pasta are both good choices as well as fruits with no skin and little pulp. Insoluble fiber—the kind in raw veggies, fruits, and nuts—draws water into the colon and can worsen diarrhea for those with IBD. But oatmeal has soluble fiber, which absorbs water and passes more slowly through your digestive tract. Cantaloupe is an excellent choice, since it is a great source of nutrients but has little pulp. 1. Incorrect: Broccoli is a very fibrous vegetable that causes excessive peristalsis, even when cooked. This will create excessive gas and increase discomfort for clients. 3. Incorrect: Green or yellow peas are rough, fibrous vegetables that will cause gas and cramping for most clients with inflammatory bowel diseases, even if cooked. This vegetable is discouraged along with beans, lentils, seeds, and nuts. 6. Incorrect: Raisins are high in fiber, as are other dried fruits such as prunes. Even cooked raisins tend to increase peristalsis which will lead to cramping and excessive bowel movements daily. Clients also need to avoid most fresh fruits with skin, pulp, or seeds.

Immediately following a below-the-knee amputation (BKA), the nurse positions the client to prevent complications. What intervention related to position of the residual limb is a priority at this time? 1. Flat on the bed 2. Elevate foot of the bed 3. In a position of comfort 4. In a dependent position

2. Correct: It is normal to experience post-operative swelling after a BKA. Immediately after surgery, the foot of the bed should be elevated to reduce swelling. An ACE compression bandage will be used to reduce swelling and prevent hemorrhage. The other positions would not be as appropriate since swelling is an issue after a below-the-knee amputation. 1. Incorrect: Flat on the bed will not relieve swelling. Post-operatively for a BKA, hemorrhage and swelling are the biggest concerns immediately following surgery. 3. Incorrect: Position of comfort may increase swelling. Immediately following a BKA, elevating the foot of the bed and the ACE compression wrap are used to present hemorrhage and swelling. Positioning for comfort is not appropriate. 4. Incorrect: Placing in a dependent position will increase swelling. Swelling post-operative is a normal occurrence and elevating the foot of the bed and the use of an ACE wrap will help prevent swelling.

A client has been admitted for observation after having a minor automobile accident. During the admission history, the client admits to being an alcoholic. Two hours after admission the nurse notes the client's cardiac rhythm displayed on the telemetry monitor shows Torsades. The client reports shortness of breath, chest discomfort, and nausea. What initial action should the nurse take? 1. Cardiovert at 200 joules. 2. Administer magnesium 1 gm IVP over 30 seconds. 3. Begin cardiopulmonary resuscitation (CPR). 4. Obtain a 12 lead ECG.

2. Correct: Magnesium is the drug of choice for suppressing Torsades and terminating the arrhythmia. Magnesium can be given at 1-2 g IV initially in 30-60 seconds, which then can be repeated in 5-15 minutes. 1. Incorrect: In an otherwise stable client, cardioversion is kept as a last resort because Torsades is paroxysmal in nature and is characterized by its frequent recurrences following cardioversion. Although torsade frequently is self-terminating, it may degenerate into ventricular fibrillation, which requires direct defibrillation. 3. Incorrect: This client is awake and has a pulse. CPR is not indicated at this time. 4. Incorrect: Getting a 12 lead ECG will not fix the problem and it is delaying treatment. Do something to fix the problem.

A client, who is receiving an IV vesicant agent, reports pain at the intravenous site. What is the priority nursing action? 1. Apply a cold compress to the IV site 2. Stop the infusion 3. Check the IV for a blood return 4. Notify the primary healthcare provider

2. Correct: Stop the infusion to stop the vesicant from getting into the tissue and causing more extravasation. 1. Incorrect: This is a right response, but it's not what I would do first. You have to stop the infusion first. Why do we use a cold compress and not a warm compress? We don't want the vesicant to spread out through vasodilation (warm compress), we want to keep it contained, so cold compress to vasoconstrict. 3. Incorrect: You may do this but the priority with pain and swelling is to stop the infusion before more damage is done. 4. Incorrect: The healthcare provider may be notified, but first the infusion must be stopped to prevent further extravasation.

After discontinuing a peripherally inserted central line (PICC), it is most important for the nurse to record which information? 1. How the client tolerated the procedure. 2. The length and intactness of the central line catheter. 3. The amount of fluid left in the IV solution container. 4. That a dressing was applied to the insertion site.

2. Correct: This is the most important information that needs to be documented. This information would be important in determining if a potential safety issue/complication could occur as a result of the PICC line being removed or a portion of the line breaking off before removal. 1. Incorrect: This is not the most important information that needs to be documented. There are no client safety issues with charting the client's tolerance of the procedure. 3. Incorrect: This would be charted so the intake and output could be calculated. This is not the most important data that needs to be documented related to the removal of the PICC line. 4. Incorrect: This would need to be documented because a dressing is applied to the insertion site after removal. However, this is not the most important data that would need to be documented after this procedure.

A client who must use crutches, is being taught by the nurse how to perform a three-point gait. What information should the nurse provide? 1. Move right crutch forward, then left foot. Next move left crutch forward, then right foot. 2. Move both crutches forward without bearing weight on the affected leg, then move the unaffected leg forward. 3. Move left crutch and right foot forward together, then move the right crutch and left foot forward together. 4. Move both crutches ahead together, then lift body weight by the arms and swing both legs to the crutches.

2. Correct: This method is correct for the three-point gait. Client has to bear weight on the unaffected foot and both crutches. The affected leg does not touch the ground. 1. Incorrect: This is the four-point alternate gait. This type of gait is used commonly when =both legs are weakened. 3. Incorrect: This is the two-point alternate gait. Two point requires at least partial weight bearing on each foot. 4. Incorrect: This is the swing-to gait. This gait is indicated for individuals with limited use of lower extremities and trunk instability.

A client is transported to the emergency department following a 20 foot fall from a ski lift. The nurse records initial assessment findings on the chart. Based on that data, what actions should the nurse implement immediately? BP 90/40; HR 125; RR 30 and labored; + jugular venous distention (JVD) with subcutaneous emphysema noted to right shoulder area. Select all that apply 1. Apply occlusive dressing to chest. 2. Initiate large gauge IV line. 3. Prepare for chest tube placement. 4. Administer high flow oxygen. 5. Position client on right side.

2., 3. & 4. Correct: Based on the assessment data recorded by the nurse, the client most likely has a tension pneumothorax secondary to blunt force trauma from the fall. Immediate actions must focus on preventing tracheal deviation and a fatal outcome. The need for intravenous fluids and medications in any trauma requires at least one large bore IV line or more. This client will need immediate chest tube placement to relieve increasing intrathoracic pressure. While preparing the client for this procedure, high-flow oxygen should be administered via nonrebreather mask because of the client's respiratory distress. 1. Incorrect: There is no indication in the question of an open chest wound, or that a dressing is needed. The occlusive chest dressing will be placed over the insertion site of the chest tube after placement is completed. 5. Incorrect: This trauma client will be secured to a back board, most likely with a cervical collar in place, until x-rays confirm there has not been a cervical spine injury. Placing the client on the right side is counterproductive and in fact could further impair respiratory efforts.

What interventions should the nurse initiate while caring for a client who has a cooling blanket in place? Select all that apply 1. Assess temperature every hour. 2. Perform comparison check with another thermometer periodically. 3. Assess client skin condition hourly. 4. Turn blanket off when temperature is at goal temperature. 5. Observe for signs of chilling.

2., 3., & 5. Correct. Perform comparison check with another thermometer periodically to ensure there is no problem associated with equipment failure. For cooling treatments, extended periods of cooling can cause areas of decreased perfusion, skin burns, and tissue injury. Chilling can increase metabolism and body needs. 1. Incorrect: Check the client's temperature every 15 minutes. If the client is cooled too quickly, chilling, increased metabolism, and adverse reactions may occur. 4. Incorrect: The blanket will not immediately return to room temperature and will continue to cool the client even after it is turned off. Turning it off shortly before the goal temperature is achieved will prevent altering the client's core temperature beyond the desired outcome.

What should a nurse teach a group of teenage boys who admit to using smokeless tobacco? Select all that apply 1. Smokeless tobacco increases risk for lung cancer. 2. Inspect mouth frequently for lesions. 3. White patches in mouth should be reported to healthcare provider. 4. Risk for stomach cancer can be decreased by not swallowing smokeless tobacco juice. 5. Report decreased saliva to primary healthcare provider. 6. Smoking cessation.

2., 3., & 6. Correct: The mouth should be inspected frequently for painless lesions that do not heal. This may be a sign of oral cancer and should be reported to the primary heathcare provider. White patches (leukoplakia) is a sign of potential oral cancer as well. Nicotine is addictive and is found in smokeless tobacco. Clients using smokeless tobacco can benefit from smoking cessation information/classes. 1. Incorrect: Use of smokeless tobacco increases the risk developing of esophageal cancer, cancers of the mouth, throat, cheek, gums, lips, tongue, pancreatic cancer, stomach cancer, kidney cancer. 4. Incorrect: This is an incorrect statement. Some amount of tobacco juice will be swallowed and can lead to esophagus and stomach cancer. 5. Incorrect: Decreased saliva is not associated with oral cancer.

A nurse has been educating a client newly diagnosed with diabetes, about proper foot care. The nurse knows teaching will need to be reinforced again when the client makes what statement? Select all that apply 1. "I should cut my toenails with nail clippers." 2. "Drying both feet thoroughly is important." 3. "I should never use nail polish on my toes." 4. "Weekly foot inspection must include the soles of the feet." 5. "I need larger shoes that don't pinch my toes."

3, 4 and 5 CORRECT: The nurse is evaluating the client for an understanding of proper diabetic foot care; therefore, an incorrect statement would require further instruction. There is no reason a client with diabetes could not use nail polish on toenails. Inspection of both feet, including the soles of the feet, must be done daily and not weekly. Most importantly, properly fitted shoes are crucial to prevent complications that might result in a blister or eventually an amputation. 1. INCORRECT: Diabetic clients are advised to use small clippers rather than scissors which could result in an injury from cutting too deep. It is easier to cut toenails straight across, as prescribed, with clippers. This comment indicates the client understood the teaching. 2. INCORRECT: It is crucial to thoroughly dry feet following a shower or if feet get wet, since moist skin can breakdown easily. Although diabetics have very dry skin, no lotion should be applied between toes. Absorbent, white cotton socks are best for diabetic clients, and may need to be changed more than once daily. This response indicates the client understands the information from the nurse.

A client being prepared for surgery is to be given a pre-operative medication. What is the nurse's priority action when administering the medication? 1. Verify client has signed all consent forms. 2. Escort the client to the bathroom to void. 3. Check that identification band is in place. 4. Raise side rails and put call bell in place.

3. CORRECT. All the actions mentioned are important, but the priority is client identification. Regardless of whether the nurse is administering medication, preparing the client to leave for surgery or for testing, the I.D. band must be in place during the entire hospitalization. If the band falls off or is removed for any reason, the client must be re-identified and banded before proceeding with any orders. 1. INCORRECT. While it is important for a client to sign pre-operative forms, this is not the nurse's responsibility. The primary healthcare provider or surgeon must witness and verify the client has signed all consent forms prior to surgery. 2. INCORRECT. Having the client void prior to transport to the O.R. can easily be accomplished by any staff member, including a UAP or LPN. This action would be extremely important if the nurse was going to administer a narcotic or sedative. But the scenario does not indicate the type of pre-op med to be administered. 4. INCORRECT. Again, raising side rails is generally completed after administration of a pre-operative medication, especially narcotics or sedatives. The call bell should always be within the client's reach, and although side rails are an important safety factor, it is not the first priority.

A client has returned to the unit following an upper gastrointestinal series (Upper GI). What is the nurse's priority action? 1. Keep client NPO until the gag reflex returns. 2. Perform an immediate cleansing enema. 3. Administer 30 mLs milk of magnesia orally. 4. Monitor vital signs every ten minutes until stable.

3. CORRECT. An Upper GI involves the ingestion of a barium based contrast under fluoroscopy to view the esophagus, stomach, and small intestine. Following such a procedure, it is vital for the client to pass all the barium before a blockage occurs. The client is encouraged to drink large amounts of fluid and is administered an over the counter laxative, such as milk of magnesia, to remove barium. 1. INCORRECT. The client's gag reflex was not inactivated. The reflex must remain intact in order for the client to drink the barium based contrast during the test. 2. INCORRECT. The barium would not yet have reached the colon following the Upper GI and therefore a cleansing enema would not be effective. If the client had received a lower GI, an enema may have been ordered. 4. INCORRECT. The client is fully awake and conscious during the entire procedure. No medications were administered that would alter the vital signs; therefore, every 10 minute vital signs are not necessary.

he nursing supervisor is reviewing several instances in which restraints have been used. The nurse is aware the only acceptable use of restraints is what? 1. An elderly male had a chest restraint applied after crawling over bed rails several times. 2. An Alzheimer client's room door is closed to prevent wandering during shift change. 3. A confused client with a closed head injury had hand mitts applied after pulling out IV 4. A dementia client with sundowners is placed in Geri-chair with lap belt at nurse's station.

3. CORRECT: Restraints are considered a last resort when caring for a client, whether soft cloth or chemical restraints. The most acceptable use is to prevent a client from harming self or others. In this instance, a confused client has previously pulled out a prescribed IV. Therefore, the use of hand mitts is the most appropriate, least-restrictive method to prevent the client from further self-harm. 1. INCORRECT: There are several problems here. The client had side rails up, which are considered a form of restraint and in many facilities are no longer permitted. By applying a chest restraint, the client has been restrained twice. Just because a client is elderly does not mean restraints are needed. This restraint is not acceptable. The nurse should provide regular toileting periods and determine why this client is climbing out of bed. 2. INCORRECT: Closing a client into a room is overly restrictive and unsafe. This Alzheimer's client needs to be observed and closing the room door prevents visual access. Additionally, closing the door may violate fire safety codes in certain facilities. At shift change, when staff is occupied with report, special arrangements should be made so that the client can be observed and not restrained. 4. INCORRECT: Depending on the facility, placing a client upright at night, using a Geri-chair and a lap belt is overly restrictive. A client with dementia is challenging, particularly in the presence of sundowner syndrome. However, keeping a client upright all night, belted into a chair for the purpose of observation, is neither safe nor healthy for the client.

The nurse is planning a teaching session with the family members of a client diagnosed with moderate Alzheimer's disease. Which topic is most important for the nurse to discuss? 1. Encouraging dependence on family members 2. Performing passive range of motion 3. Providing a safe environment 4. Monitoring vital signs every 8 hours

3. Correct: A safe home environment is a priority. When you see a safety answer always consider it. This client has a memory deficit and may wander away, leave food on the stove cooking or burn themselves with hot water. Safety is a priority. 1. Incorrect: It is important to promote independence in self-care activities to promote dignity and autonomy. The client cannot make decisions alone but the family can give the client choices to pick from., Never promote dependency. 2. Incorrect: Active range of motion and regular exercise are encouraged, but this is not the most important topic. The stem does not mention that the client is mobility impaired. Walking is usually intact until late stages of Alzheimer's. 4. Incorrect: Focus is on cognitive and behavioral symptoms. V/S would be monitored as needed. This client is at home with family and nothing indicates the need to take the client's vital signs three times a day.

A client with a history of eczema has been admitted with cellulitis of the left forearm. Which admission order should the nurse question immediately? 1. Start IV of normal saline at 100 mL per hour. 2. Keep left arm elevated on pillow at all times. 3. Apply ice packs to affected area every shift. 4. Ibuprophen 800 mg po every 6 hours prn pain.

3. Correct: Cellulitis is a bacterial skin infection resulting in warm, redden and edematous tissue, sometimes accompanied by fever and chills. Swelling in the affected area impedes blood flow and increases pain. In order to decrease the edema, warm, moist compresses are used to stimulate circulation and speed reabsorption of the fluid within the tissue. This order should be questioned immediately. 1. Incorrect: An infection serious enough to require hospitalization indicates this client is either septic or may need intravenous antibiotics. Fluids are a primary treatment for sepsis along with bedrest and antibiotics. A basic solution of normal saline at 100/mL per hour would be an appropriate order for this client. 2. Incorrect: The swelling characteristic in cellulitis in painful and diminishes circulation to the area. Elevation on one or two pillows at all times helps to improve blood flow so that healing can take place. In some facilities, clients are provided with a wedge shaped cushion that provides better support of the affected area. This order is appropriate. 4. Incorrect: Ibuprophen provides relief from both pain and inflammation associated with cellulitis. A dose of 800 milligrams by mouth every 6 hours as needed for pain would be appropriate for this client. This is not an order the nurse should question.

A client with a history of intolerance to fatty foods is admitted to the hospital with a sudden onset of severe right upper quadrant pain radiating to the right shoulder. What should be included in the nurse's initial focused assessment of this client? 1. "Do you have pain in the middle of your stomach that is relieved by vomiting?" 2. "Have you noticed any red splotches on your skin?" 3. "Please describe your bowel habits and stool." 4. "Tell me how often you eat high fat meals."

3. Correct: Clay colored stools are a sign of biliary obstruction and are due to lack of bile in the stool. Bile adds a darker color to the stool. Asking the client to describe stool is open ended and will give the nurse more detail. 1. Incorrect: Epigastric pain relieved by vomiting is found with clients who suffer from peptic ulcers. 2. Incorrect: Spider angiomas are seen in clients with liver disease 4. Incorrect: This does not relate to the client's pain and will not obtain needed information about the client's current condition.

A client who had a triple lumen catheter placed in the right subclavian vein 30 minutes ago reports chest discomfort and shortness of breath. The assessment reveals BP 92/58, HR 104, Resp 28, and unequal breath sounds over lung fields. What problem should the nurse suspect this client is exhibiting? 1. Myocardial infarction 2. Atelectasis 3. Pneumothorax 4. Pneumonia

3. Correct: Pneumothorax is the number one potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds. 1. Incorrect: The hints point to a pneumothorax rather than an MI. The triple lumen catheter and unequal breath sounds are the biggest hints. 2. Incorrect: Atelectasis is the collapse of alveoli and is caused by a blockage of the air passages or by pressure on the outside of the lung. Examples of causes of atelectasis are mucus that plugs the airways, anesthesia, pleural effusion, prolonged bedrest with few position changes, and shallow breathing. 4. Incorrect: Pneumonia is an infection that causes inflammation of the air sacs in one or both lungs. The air sacs may fill with fluid or pus (purulent material), causing a cough with phlegm or pus, fever, chills, and difficulty breathing

A client arrives at the emergency department (ED) in obvious emotional distress, reporting perioral numbness and tingling of the fingers and toes. The nurse notes a respiratory rate is 56/min. What should be the initial intervention performed by the nurse? 1. Send the client for a CT of the head. 2. Place on 100% O2 per non-rebreathing face mask. 3. Have the client breathe into a paper bag. 4. Administer diazepam 2 mg IV push.

3. Correct: Recognize the respiratory rate is too fast. This client is hyperventilating and blowing off too much CO2 which has resulted in symptoms of respiratory alkalosis, perioral numbness, and tingling of the fingers and toes. The nurse should try to help calm the client and encourage the client to slow the rate of breathing. This will help hold onto CO2. By breathing into a paper bag, the client will re-breathe CO2 therefore increasing the CO2 level. 1. Incorrect: The client is not demonstrating signs of a stroke. A CT is not warranted based on the information provided. 2. Incorrect: Administration of O2 is not warranted at this time. The client is blowing off too much CO2 and needs to re-breathe CO2 using a paper bag. Increasing O2 will not fix the problem of emotional distress. 4. Incorrect: Diazepam has sedative effects. Although hysterical clients may have to be sedated to decrease the respiratory rate, the less invasive means of using the paper bag should be attempted first.

When planning post procedure care for a client who is having a barium enema, what must the nurse include? 1. Cardiac monitoring for potential arrhythmias 2. Monitoring urinary output 3. Administration of a laxative or enema after the procedure 4. Reordering the client's diet

3. Correct: The client must expel the barium post procedure. If the barium is not eliminated, it can harden in the colon and cause an obstruction. 1. Incorrect: It is not standard practice to place clients on a cardiac monitor after a barium enema. 2. Incorrect: Monitoring urine output has nothing to do with this procedure and does not answer the specific question related to this diagnostic procedure. 4. Incorrect: Reordering the client's diet is important but is not as life-threatening as a bowel obstruction.

A nurse is caring for a client admitted to the hospital for a total hip replacement. In preparing the post-operative plan of care for this client, the nurse recognizes which goal as the highest priority? 1. Prevent complications of shock. 2. Prevent dislocation of prosthesis. 3. Prevent respiratory complications. 4. Prevent skin breakdown.

3. Correct: The postoperative client with a total hip replacement is at risk for thromboembolism and fat emboli which can travel to the lungs and cause respiratory distress. Without proper turning, coughing, and deep breathing, pneumonia and atelectasis may occur. So preventing respiratory complications is high on the priority list. Remember the ABCs - airway, breathing, then circulation. Preventing respiratory complications is the highest priority because of the possibility of sudden death from the complications of deep vein thrombosis and pulmonary embolism. 1. Incorrect: This client is at risk for hemorrhage and/or hematoma formation related to surgical trauma to blood vessels (the hip is a very vascular area) and use of anticoagulants or antiplatelet agents before and after surgery. So the nurse will need to monitor for shock caused by loss of volume. The nurse should monitor drains, wound dressings, and intake and output. But remember, Airway and Breathing take priority. 2. Incorrect: Dislocation of the prosthesis is another complication to worry about. It will cause pain and possible deformity and is very important, but airway is the priority. Dislocation of the hip prosthesis is related to weakness of the hip muscles, improper positioning or movement of the operative extremity, and/or noncompliance with weight-bearing limitations 4. Incorrect: The client is at risk for skin breakdown if not turned and repositioned properly or ambulated as soon as prescribed. However, Airway is still the priority for this client.

Which assessment by the nurse indicates a tension pneumothorax? 1. Sudden hypertension and bradycardia 2. Productive cough with yellow mucus 3. Tracheal deviation and dyspnea 4. Sudden development of profuse hemoptysis and weakness

3. Correct: Yes, as pleural pressure on the affected side increases mediastinal displacement occurs with resultant respiratory and cardiovascular compromise. Symptoms of tension pneumothorax include dyspnea, chest pain radiating to the shoulder, tracheal deviation, decreased or absent breath sounds on the affected side, neck vein distention and cyanosis. 1. Incorrect: Hypoxia causes tachycardia rather than bradycardia. The client would more likely to be hypotensive due to decreased cardiac output. 2. Incorrect: Yellow mucus indicates infection, such as from pneumonia. This does not indicate a tension pneumothorax. 4. Incorrect: Profuse hemoptysis and weakness may indicate a serious condition such as a ruptured vessel, but it is not an indication of a mediastinum shift.

A new nurse asks the charge nurse for assistance in interpreting arterial blood gases (ABGs) for a client. What acid/base imbalance should the charge nurse tell the new nurse these ABGs indicate in the client? pH - 7.5 PaO2 - 94% PaCO2 - 58 HCO3 - 35 1. Metabolic acidosis 2. Respiratory alkalosis 3. Metabolic alkalosis 4. Respiratory acidosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

3., & 6. Correct: Partially compensated metabolic alkalosis is indicated by these ABGs. The pH is 7.5 (normal 7.35-7.45) which is high, which means alkalosis. The PaCO2 is 58 (normal 35-45) which is high. Greater than 45 is acidosis from too much CO2. The HCO3 is 35 (normal 22-26) which is high. A high bicarb level equals alkalosis. The HCO3 matches the pH as both indicate alkalosis. The initial problem was a kidney problem or metabolic alkalosis. The lungs are trying to compensate by holding on to more acid. So the correct answer is partially compensated metabolic alkalosis.

The nurse is preparing to administer a dose of sacubitril/valsartan 24/26 mg by mouth. The nurse has not administered this medication before and is using a drug reference to review information about the medication. Which client and drug reference information supports the nurse's decision to withhold the sacubitril/valsartan? 1. Bilateral crackles noted to posterior lung fields. 2. Potassium- 4.8 mEq/L (4.8 mmol/L). 3. Currently taking trandolapril 2 mg by mouth daily. 4. Concomitant use or use within 36 hours of ACE inhibitors. 5. ACE inhibitors increase risk of angioedema. 6. Decreased Hematocrit.

3., 4., & 5. Correct: This client is currently taking trandolapril, which is an ACE inhibitor. The drug reference guide specifically said, "concomitant use (of sacubitril/valsartan) or use within 36 hours of ACE inhibitors" is contraindicated because giving with ACE inhibitors can increase the risk of angioedema. 1. Incorrect: Bilateral crackles noted to posterior lung fields. 2. Incorrect: Potassium- 4.8 mEq/L (4.8 mmol/L). This is within normal limits and would not require withholding the sacubitrin/valsartan. 6. Incorrect: This client's Hematocrit is 43%, which is normal. Normal values: Adult males: 42-52% (0.42-0.52). Adult women: 37-47% (0.37-0.47). Therefore, this would not influence the administration of the sacubitril/valsartan.

Which risk factor should the nurse include when planning to educate a group of women about breast cancer? 1. Menopause before the age of 50 2. Drinking one glass of wine daily 3. Multiparity 4. Early menarche

4. Correct: Early menarche before age 12 is a known risk factor for breast cancer. The increased risk of breast cancer linked to a younger age at first period is likely due, at least in part, to the amount of estrogen a woman is exposed to in her life. A higher lifetime exposure to estrogen is linked to an increase in breast cancer risk. The earlier a woman starts having periods, the longer her breast tissue is exposed to estrogens released during the menstrual cycle and the greater her lifetime exposure to estrogen. 1. Incorrect: Studies show women who go through menopause after age 50 have increased risk of breast cancer. The risk for breast cancer increases as time period between menarche and menopause increases. 2. Incorrect: Small increase in risk with moderate alcohol consumption, not one glass of wine daily. Drinking low to moderate amounts of alcohol, however, may lower the risks of heart disease, high blood pressure and death. But, drinking more than one drink per day (for women) and more than two drinks per day (for men) has no health benefits and many serious health risks, including breast cancer. Alcohol can change the way a woman's body metabolizes estrogen (how estrogen works in the body). This can cause blood estrogen levels to rise. Estrogen levels are higher in women who drink alcohol than in non-drinkers. These higher estrogen levels may in turn, increase the risk of breast cancer. 3. Incorrect: Nulliparity (no pregnancies) is a known risk factor for breast cancer. Factors that increase the number of menstrual cycles also increase the risk of breast cancer, probably due to increased endogenous estrogen exposure.

The head nurse on a busy surgical unit is evaluating several fresh post-operative clients. Which observation should the nurse report immediately to the primary healthcare provider? 1. A post transurethral resection client with cherry colored urine 2. A post mastectomy client drains 40 mL of bloody drainage within 3 hours of the surgery 3. A post ileostomy client with a beefy red stoma and mucus drainage 4. A post thyroidectomy client reporting tingling in toes and fingers

4. Correct: One potential risk during a thyroidectomy is the accidental removal of some or all of the parathyroid glands. The client would develop signs and symptoms of hypocalcemia from decreased blood levels of calcium. As muscles become rigid and twitch, the resulting tetany would cause the client to experience a tingling sensation in toes and fingers. The nurse needs to notify the primary healthcare provider so that a calcium level can be drawn and the client given supplemental calcium. 1. Incorrect: Following a transurethral resection of the prostate (TURP), it is normal for urine to be cherry red in color. Continuous bladder irrigation will keep clots from developing over several days and the deep red color of urine is an expected finding following this procedure. 2. Incorrect: Mastectomy clients return from surgery with one or more drains placed under skin flaps in the breast tissue. These drains are part of a collection system that allows serous drainage to be removed from the surgical site, thus enhancing the healing process. Because this client has just returned from surgery, 40 mL over 3 hours is not an excessive amount. This is an expected finding that does not need to be reported. 3. Incorrect: The sign of a healthy stoma immediately post-op is a beefy red appearance and slightly elevated above the level of the abdomen. It is expected that the stoma will have a mucoid discharge for a day or so until normal stool begins to form again. This client displays normal post-operative findings with nothing unexpected.

A client is admitted for treatment of fluid volume excess. The nurse reviews the admitting lab work and the primary healthcare provider's prescriptions. Which prescription would be of concern to the nurse? 1. Bedrest 2. 2 gram Na diet 3. Spironolactone 4. Potassium Chloride (KCL)

4. Correct: The client has been prescribed spironolactone, a potassium sparing diuretic, so KCL supplement is not necessary. 1. Incorrect: Bed rest induces diuresis, which is good for this client. 2. Incorrect: This client needs to be on a low sodium diet to reduce fluid retention. 3. Incorrect: Spironolactone is a potassium sparing diuretic which can be prescribed for this client

An 18 year old football player is admitted to the ortho unit after a femur fracture. He is scheduled for a rod to be placed in the morning, but suddenly develops severe shortness of breath, a petechial rash on his chest, and unstable vital signs. What should the nurse do first? 1. Decrease rate of IV fluids. 2. Neurovascular checks of affected leg. 3. Elevate the head of the bed. 4. Call the active response team.

4. Correct: The client is exhibiting symptoms of a fat embolism, particularly with the petechial rash on his chest and severe shortness of breath. Due to his age, high risk behaviors with contact sports, and the large long bone fracture, he is the classic example of a client that may experience a fat embolus. This constitutes a medical emergency and activation of the response team. 1. Incorrect: This does not affect breathing here and will do nothing to resolve the fat embolism. 2. Incorrect: Neurovascular checks of the leg will not help the client's breathing and are not the first priority for the nurse. 3. Incorrect: The nurse may elevate HOB to assist with breathing unless client is hypotensive. Either way, this is not the best first answer.

A client returns to the unit after having extracorporeal lithotripsy. Which would be the best indicator that the treatment has been effective? 1. The client is relieved of the pain. 2. The urine is free of red blood cells. 3. The urinary output has increased since return to the unit. 4. There is sediment in the urinary catheter drainage bag.

4. Correct: This answer provides visible proof that the renal calculi has been broken up by the shock waves. 1. Incorrect: Pain can occur because of spasm of smooth muscle when the stone is moving. 2. Incorrect: There will be blood in the urine for several days after treatment. 3. Incorrect: Blocked urine flow from stone fragments may cause decreased urine output.

Following hip replacement surgery, an elderly client is being transferred to a long term care facility for therapy. What priority action by the nurse best promotes continuity of care for the client? 1. Explain future care requirements to the family. 2. Call facility's nurse manager to give oral report. 3. Discuss client's needs with healthcare provider. 4. Send written summary of client needs to facility.

4. Correct: Written documentation is the most complete legal record for continuity of client care. In this format, the same specific information is then available to all staff having direct care contact with the client. 1. Incorrect: While the family will definitely need to be informed of the client's current and future therapeutic needs, such a discussion would have taken place prior to being discharged to long term care. Another action takes priority. 2. Incorrect: An oral report is vital prior to the client's arrival at a new facility so that an appropriate room and needed equipment can be available for the client's arrival. Though such an action is important, there is a better method to promote continuity of care. 3. Incorrect: Talking with the primary healthcare provider must be done at the time orders for transfer have been written to clarify specifics, which would then be relayed to the long term care facility. This is not the nurse's current priority.

A client newly diagnosed with Celiac disease is being instructed on a gluten-free diet. What statement by the client would indicate to the nurse that further teaching is needed? 1. "I will still have occasional abdominal discomfort." 2. "I may need to take iron or vitamin supplements." 3. "I can have eggs but no wheat toast for breakfast." 4. "I should avoid fresh apples and strawberries."

4. Correct:The nurse is evaluating client statements for any lack of understanding and the need to provide further instruction. With Celiac disease, intestinal villi become inflamed whenever gluten is introduced to the gut through food intake. However, fresh fruits and vegetables do not contain gluten; therefore, fresh apples and strawberries would definitely be acceptable foods for this client. This statement by the client is inaccurate, indicating the need for further explanation by the nurse. 1. Incorrect:The client correctly acknowledges that some episodes of abdominal discomfort may still occur, since it is nearly impossible to totally eliminate gluten. Despite buying "gluten-free" products, occasionally small amounts of gluten may contaminate foods and causing symptoms to resurface. Eating in a restaurant may also be a challenge for those with Celiac disease. Because the client recognizes these possible symptoms, teaching was successful. However, the question asks for evidence the client needs further instruction. 2. Incorrect: This is an accurate statement by the client about Celiac disease. Because inflammation of the intestinal villi may lead to poor absorption of nutrients or anemia, clients may indeed need to take supplements for extended periods of time. This response does not indicate any problems with the client's comprehension of teaching. 3. Incorrect: It is important for a Celiac client to eat as healthy and diverse a diet as possible, since malnutrition occurs secondary to poor nutrient absorption in the bowel. Protein is a vital component in the diet, including such choices as eggs, dairy and beans. Those foods creating the worst symptoms include grains like wheat, rye, and barley as well as the "malt barley" used as a thickening agent in certain products. The client has precisely stated that a breakfast including eggs but minus the wheat toast would be appropriate, evidence that teaching was successful.

HCO3 ranges

22-26 <26 alkalosis >22 acidosis

PaCO2 ranges

35-45 >45 acidosis <35 alkalosis

pH ranges

7.35-7.45 >7.45 alkalosis <7.35 Acidosis

What dietary information should the nurse provide to a client diagnosed with Celiac disease? Select all that apply 1. "The most cost effective way to follow the lactose free diet is to eat more fruits and vegetables." 2. "Creamed based canned soups are a source of hidden wheat." 3. "You can eat foods containing fax, corn, or rice." 4. "Avoid foods and beverages that contain malt." 5. "Do not eat traditional wheat products such as pasta."

2., 3., 4., & 5. Correct: Soups and sauces are one of the biggest sources of hidden gluten, as many companies use wheat as a thickener. It is always a good idea to read the label of any pre-prepared or canned soups and sauces, paying special attention to those that are cream based. Grains that are naturally gluten free include rice, corn, potato, quinoa, kasha, flax, and nut flours. Malt flavoring or extract, which contains gluten may be found in cornflakes and puffed rice cereal. It is also found in beers, ales, and malt vinegars. As a rule, traditional wheat products such as pastas, breads, crackers, and other baked goods are not gluten-free. However, there are many gluten-free options available that use alternative flours and grains. 1. Incorrect: The client who has Celiac disease is prescribed a gluten free diet rather than a lactose free diet.

Uncompensated

pH and either bicarb or CO2 is abnormal

Fully compensated

pH is normal

The nurse walks into a client's room and discovers the radioactive uterine implant lying on the bed. In what order should the nurse properly dispose of the implant? 1.)Put on gloves 2.)Call radiation department to take the implant out of the room 3.)Pick up implant with tongs 4.)Place implant in lead lined container

1,3,4,2 The first thing the nurse should do is put on gloves. Second, pick up the implant with tongs. Third, place the implant in a lead lined container. Fourth, call the radiology department to take the implant out of the room.

A client consumes a lacto-ovo vegetarian diet at home. During hospitalization, the primary healthcare provider prescribes an increased calorie diet. Which foods are appropriate for the nurse to serve as between meal snacks to boost caloric intake? 1. Cheese sandwich and milk 2. Boiled eggs but no dairy products 3. Fish sticks and cocktail sausages 4. Fresh vegetables but no milk or eggs

1. Correct: A lacto-ovo vegetarian diet is a vegetarian diet that does not include meat, but does contain eggs and dairy. The client can eat milk and dairy products along with grain products on this diet.2. Incorrect: Dairy products and eggs are allowed on this diet. Milk, cheese and yogurt can be consumed on a lacto-ovo vegetarian diet. 3. Incorrect: The client does not consume meats. Meats should not be provided as a snack. 4. Incorrect: The client can consume milk and eggs as well as fresh fruits and vegetables. Milk and eggs can be consumed on a lacto-ovo vegetarian diet.

For a client with a major burn, which evaluation criterion identified by the nurse best indicates that fluid resuscitation has been effective during the first 24 hours of care? 1. Urine output of 860 mL / 24 hours. 2. Increase in weight from preburn weight. 3. Heart rate of 122 beats per minute 4. Central venous pressure of 18 mm

1. Correct: Urine output is the best indicator of adequate fluid replacement during the first 24 hours. 2. Incorrect: The weight is not a good indicator now because of the large volume of fluids being infused. These extra fluids would increase the weight. Edema is a problem because of third spacing. 3. Incorrect: The heart rate should come down with adequate fluid replacement. 4. Incorrect: The CVP reading is too high. This indicates that too many fluids have been given.

A male client diagnosed with primary hyperaldosteronism is receiving spironolactone. Which potential side effect should the nurse educate the client regarding? Select all that apply 1. Erectile dysfunction 2. Gastrointestinal upset 3. Gynecomastia 4. Hypernatremia 5. Hypokalemia

1., 2., & 3. Correct: Spironolactone blocks androgen and progesterone receptors and may inhibit the action of these hormones. Side effects can include gynecomastia, decreased sexual desire, impotence, menstrual irregularities, and gastrointestinal distress. 4. Incorrect: Hyponatremia, rather than hypernatremia, may be seen. 5. Incorrect: Hyperkalemia, rather than hypokalemia, may be seen.

What signs or symptoms should the nurse assess for when monitoring a client who has a brain injury? Select all that apply 1. Increased pulse 2. Rhinorrhea 3. BP 150/60 4. Papilledema 5. Projectile vomiting

2., 3., 4. & 5. Correct: Rhinorrhea is an important symptom that is associated with leakage of cerebrospinal fluid (CSF) The pulse pressure of 150/60 is 90 {greater than 40 is a sign of increased intracranial pressure (ICP)}. Signs of increased intracranial pressure also include papilledema, elevated systolic pressure, widened pulse pressure, decreased pulse, and slow respirations. Projectile vomiting is classically associated with increased ICP. 1. Incorrect: The major focus of a client with a brain injury is increased ICP, which is associated with bradycardia.

A middle-aged client has a strong positive family history of type 2 diabetes mellitus. What should the nurse teach the client regarding the best method to prevent or delay the development of this disease? 1. Test serum glucose values monthly. 2. Avoid starches and sugars in the diet. 3. Obtain a normal body weight and exercise regularly. 4. Maintain a normal serum lipid panel.

3. Correct: Genetics and body weight are the most important factors in the development of type 2 diabetes mellitus. The client cannot alter his genetics. Therefore, a normal body weight is imperative. Regular exercise reduces insulin resistance and permits increased glucose uptake by cells. This serves to lower insulin levels and reduce hepatic production of glucose. 1. Incorrect: Monthly glucose monitoring is not sufficient. It will tell you when the client becomes a diabetic but will not prevent it from happening. 2. Incorrect: Starch and sugar intake should be decreased, not avoided. 4. Maintaining a normal serum lipid panel may not be achievable in some clients, but it is always the goal. Medication may be needed.

A client is admitted to the critical care unit after suffering from a massive cerebral vascular accident. The client's vital signs include BP 160/110, HR42, Cheyne-Stokes respirations. Based on this assessment the nurse anticipates the client to be in which acid/base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

1. Correct: Causes of respiratory acidosis include any causes of decreased respiratory drive, such as drugs (narcotics) or central nervous system disorders. With a massive cerebral vascular accident (CVA or stroke), the respiratory center in the brain is impaired and affects oxygenation. Cheyne-Stokes respirations are characterized by progressively deeper and sometimes faster respirations followed by periods of apnea. This leads to acidosis and often times respiratory arrest. 2. Incorrect: Respiratory alkalosis includes hyperventilation and tachypnea which does not describe the characteristics of Cheyne-Stokes respirations. 3. Incorrect: Metabolic acidosis includes tachypnea with deep respirations called Kussmaul's respirations caused by disorders like DKA. 4. Incorrect: The most common cause of metabolic alkalosis is vomiting, and this is clearly a respiratory problem, not metabolic.

What is the first nursing action that should be taken in caring for a client with suspected tuberculosis? 1. Identify the client's symptoms promptly. 2. Instruct the client to cover the mouth and nose with tissues when sneezing. 3. Isolate the client in a negative pressure room. 4. Place a surgical mask on the client.

1. Correct: First, identify the client's symptoms.

The nurse is caring for a client in the emergency department who presents with hematemesis. What information is most important for the nurse to obtain during the initial assessment? Select all that apply 1. Vital signs 2. History of prior bleeding episodes 3. Medications the client is taking 4. Urinary output 5. Level of consciousness

1., 4., & 5. Correct: A set of vital signs and assessment for hypovolemic shock take priority for this client. S/S of shock include thready, rapid pulse, decreased LOC, shortness of breath, cold and clammy skin, and decreased urinary output. 2. Incorrect: History of prior bleeding episodes is important but does not address the immediate problem. 3. Incorrect: Medication history is important, but the nurse must first determine whether or not the client is in shock.

A nurse is in the mall when a shopper suddenly becomes non-responsive. Taking an available automatic external defibrillator (AED) from the wall, the nurse would immediately initiate interventions in what order? 1.)Place pads on client's torso. 2.)Uncover the client's chest. 3.)Tell everyone to stand clear. 4.)Await analysis of rhythm. 5.)Turn on the AED machine. 6.)Press the shock button.

The procedure for use of an AED is consistent, whether in a medical setting or a public environment. First, turn on the AED and follow the visual and / or audio prompts. Second, the client is then placed supine and the skin of the chest is exposed (do not expose more than necessary). Next, the electrode pads are then placed to mid-chest and left lateral chest, as is pictured on the AED machine. Then, once the pads are attached, the nurse would wait for the machine to analyze the client's rhythm. IF a shock is advised by the machine, the nurse will then shout "clear", being certain that no one is touching the client in any manner. The final action is to press the shock button when the AED advises to do so.

Partial compensation

everything is abnormal