NCLEX

The nurse is implementing cast care instructions for a client with a plaster cast applied 2 hours ago. Which cast care instruction would be included? SATA 1. Rest cast on a soft pillow. 2. Keep the cast uncovered until air dried. 3. Mark the cast if there is breakthrough bleeding. 4. Place ice packs on side of the cast for first 24 hours. 5. Use the palms of hands when moving the cast for first 6 hours.

1,2,3,4 rationale: Until the cast has dried completely, the cast care instructions are to prevent indentations on the cast, reduce swelling, and evaluate any breakthrough bleeding.

Following chemotherapy for acute lymphocytic leukemia (ALL), the client's lab results indicate a white blood count of 1000 cells mm3. What measures should the nurse institute immediately? SATA 1. Request to change IM antiemetic medication to oral pill. 2. Have client increase fresh fruits and vegetables in diet. 3. Obtain client's temperature at least every two hours. 4. Move client into isolation with a negative flow room. 5. Remove fresh flowers and limit visits from children.

1,3,5 rationale: The client has neutropenia, an extreme decrease in the neutrophils of white blood cells. As the main infection fighting faction of WBCs, the client will be at great risk for infection. Reducing invasive procedures by eliminating an intramuscular injection is an important and positive change. Fever is generally an early sign of infection, so taking the client's temperature frequently may alert staff to problems before a serious complication occurs. Fresh flowers contain a variety of bacteria that could be deadly to this client while children are often carriers of viruses without actually showing indications of illness.

A nurse on a surgical unit is assigned a client who had a total thyroidectomy 3 days ago. As the nurse enters the room which nursing assessment is the priority for this client? 1. Eating a soft diet. 2. Positioned at 15 degrees in bed. 3. States hands are tingling. 4. Expresses frontal neck pain level of 5 out of 10.

3 rationale: Hypocalcemia is a severe complication of a thyroidectomy due to damage to the parathyroid. The negative feedback of a low parathyroid hormone (PTH) results in a decrease in serum calcium. PTH regulates the amount of calcium levels in the blood. Symptoms of hypocalcemia include numbness, and tingling on the extremities and face. As the calcium levels decrease the client may present with tetany and spasm of the larynx.

What action by the nurse, who is administering platelets to a client, would require the charge nurse to intervene? 1. Verifies prescription for platelet transfusion. 2. Confirm client has provided informed consent. 3. Hangs platelets immediately upon arrival from blood bank refrigerator. 4. Infuse platelets with normal saline solution.

3 rationale: The charge nurse needs to intervene here. NEVER infuse cold platelets, because the spleen will reject them if they are cold and not absorb them. So, room temperature for your platelets or they will do you no good.

The nurse is teaching a client who has been prescribed peritoneal dialysis. What statement by the client indicates to the nurse that teaching was successful? 1. "I need to decrease protein in my diet since my kidneys no longer work." 2. "Heating the dialysate in the microwave for 30 seconds will prevent abdominal cramping." 3. "I will notify my primary healthcare provider if the peritoneal drainage is cloudy." 4. "The automated peritoneal dialysis (APD) cycler is used every few hours during the day."

3 rationale: The number 1 complication of peritoneal dialysis is infection. So, the client does need to monitor the drainage, which should be clear or straw-colored. If it is cloudy, that indicates infection and the primary healthcare provider should be notified.

While performing wound care to a donor skin graft site, the nurse notes some scabbing around the edges and a dark collection of blood. What is the nurse's next action? 1. Leave the scabbing area alone and apply extra ointment. 2. Notify the primary healthcare provider. 3. Gently remove the debris and re-dress the wound. 4. Apply skin softening lotion for 3 hours and then re-dress.

3 rationale: What likes to live in the scabs and dried blood? Bacteria. That is why it is important to remove the debris to prevent infection.

The emergency department nurse is monitoring a client being admitted in diabetic ketoacidosis (DKA). Which arterial blood gas value would be expected? SATA 1. pH 7.32 2. PaCO2 32 3. HCO3 25 4. PaO2 78 5. SaO2 82

1,2 rationale: Correct: In DKA, the client is acidotic. Normal pH is 7.35-7.45. A pH of 7.32 indicates acidosis and will be expected for a client in DKA. Normal PaCO2 is 35-45. Remember CO2 is considered an acid. The client in DKA will have an increased respiratory rate, so the PaCO2 will either be normal or low. This value of 32 is low and is an expected finding as the body is compensating for the acidosis.

A client was diagnosed with a fractured ulna 8 hours ago. Which assessment data may indicate a compartment syndrome? SATA 1. The pain is located at the elbow area. 2. The prescribed opioid does not relieve the pain. 3. When forearm is elevated, the swelling in the forearm is reduced. 4. The pain in the forearm is described as a 9 on a 10 scale and throbbing. 5. When placing a cold compress on the forearm, the pain level is reduced.

2,4 rationale: Compartment syndrome occurs when swelling occurs within the compartment. This results in increased pressure on the capillaries, nerves, and muscles in the compartment. The pain is very intense. The client is expressing pain at a 9 on a 10 scale and throbbing. The pain is also unrelieved by opioid administration.

The nurse is reviewing the primary healthcare provider's (PHP) initial prescriptions for a client diagnosed with diabetic ketoacidosis (DKA)? Which prescription from the PHP would the nurse question? SATA 1. Arterial blood gases 2. 500 ml D5W at 100 mL per hour 3. Serum glucose levels every hour 4. Hourly adjustment of Regular insulin IV according to serum glucose level protocol 5. 100 mL O.45% sodium chloride (NaCL) with potassium chloride KCL 10mEq IV

2,5 rationale: The clinical manifestation of DKA is a serum glucose level of greater than 300mg/dL. The goal of the treatment for DKA is to reduce the serum glucose level. Prescribing D5W will increase the client's serum glucose level which is already elevated. The prescription should begin with 0.9% NaCL. to compensate for the effects of polyuria, IV normal saline, an isotonic solution. An isotonic solution is composed of equal concentrations of solutes and water which will increase vascular volume. Initially the potassium is normal or high and can decrease when treatment begins. This prescription should be questioned.

A client returns to the room post appendectomy. In what position should the nurse place the client? 1. Sims' 2. Prone 3. Semi-fowler's 4. Right lateral

3 rationale: After any major abdominal surgery, the position of choice is to elevate the head of the bed 35-45 degrees. This will decrease pressure on the abdomen and suture line.

A client is admitted to the cardiac floor in heart failure. The lung sounds reveal crackles bilaterally, and the BP is 160/98. The client has been on diuretics at home and the potassium level is 3.3 mEq/L (3.3 mmol/L). Which diuretic would the nurse anticipate being prescribed for this client to minimize potassium loss? 1. Spironolactone 2. Furosemide 3. Bumetanide 4. Hydrochlorothiazide

1 rationale: The client's potassium level is low. Spironolactone is a potassium sparing diuretic which would cause the potassium to be retained.

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

1 rationale: The first thing the nurse should do is to put on gloves

Which assessment findings would indicate to the nurse that a client may have a fracture? SATA 1. Swelling 2. Deformity 3. Crepitus 4. Discoloration 5. Tenting of skin

1,2,3,4 rationale: Swelling, deformity, crepitus, and discoloration are signs of a fracture. The swelling is caused by fluids and blood that move into the soft tissues. The leaking of blood from the soft tissue or from the bone will result in a discoloration or bruising at the injury site. The most accurate sign of a broken bone is deformity of the bone. An example would be when a bone is bending in an inappropriate direction.

The nurse is educating a client newly diagnosed with chronic stable angina about Nitroglycerin SL. What points should the nurse include? SATA 1. Nitroglycerin increased blood flow to the heart. 2. Take one nitroglycerin every five minutes until pain stops. 3. Sit or lie down when taking nitroglycerin. 4. The most common side effect is a headache. 5. Keep nitroglycerin in a clear, plastic bottle.

1,3,4 rationale: Nitroglycerin dilates the coronary arteries to allow more oxygen to get to the heart muscle. Because nitroglycerin also dilates all arteries and veins, the client's BP will drop. So they could faint. To prevent this, they should sit or lie down when taking the nitro. The most common side effect is that the client will get a headache. It is not life threatening, but advise the client that this will occur

A client has returned to the room post stem cell transplant. What early signs of rejection should the nurse monitor for in the client? SATA 1. Abdominal pain 2. Straw colored urine 3. Jaundice 4. Pruritus 5. Diarrhea

1,3,4,5 rationale: These are early signs of rejection that the nurse must monitor for: abdominal pain, jaundice, pruritus or itching, and diarrhea.

The nurse is caring for a surgical client who developed a pulmonary embolus (PE). Which diagnostic test would be the most sensitive for providing a definitive diagnosis for a PE? 1. D-dimer 2. Pulmonary function test 3. Pulmonary angiography 4. Chest X-ray Submit

3 rationale: Pulmonary angiography is the most sensitive and specific test for a PE. However, since it is very expensive and invasive, the computerized tomography angiogram (CTA) is the most frequently used test to diagnose a PE.

What immediate action should the occupational health nurse take once flames have been extinguished from a burned victim? 1. Remove jewelry. 2. Wrap in a clean blanket. 3. Cover burns with clean, dry cloth. 4. Briefly soak burned area in cool water.

4 rationale: Although all options are correct, the priority is to stop the burning process. Just putting out the flames is not enough to stop the burning process. You need to apply cool water briefly (no more than 10 minutes) to soak the burn area. Any longer can cause extensive heat loss.

A client has responded positively to a series of electroconvulsive treatments (ECT), but reports concerns about on-going memory loss. What is the most appropriate response by the nurse? 1. "It's only been a couple weeks so don't worry." 2. "Are you afraid your memory will not return?" 3. "I will ask the psychiatrist to come talk with you." 4. "You seem very concerned about your memory."

4 rationale: The nurse/client relationship is collaborative and nonjudgmental with the goal of facilitating the client's emotional growth. Open-ended statements or questions encourage the client to express feelings and continue verbalizing. This comment by the nurse is open-ended and acknowledges the client's concerns.

Which medication prescription should the nurse question for a client diagnosed with nephrotic syndrome? 1. Ibuprofen 2. Enalapril 3. Prednisone 4. Cyclophosphamide

1 rationale: The prescription of ibuprofen, a NSAID, would be questioned. Ibuprofen is a nonsteroidal ant-inflammatory medication. NSAIDs can cause acute interstitial nephritis and acute tubular nephritis. The client with nephrotic syndrome currently has damage to the micro blood vessels in the kidneys.

The nurse is caring for a client being admitted to the emergency department after being stabbed in the chest. An occlusive dressing is covering the chest wound upon arrival. The client's condition begins to deteriorate. Assessment reveals tracheal deviation, diminished breath sounds bilaterally, and asymmetrical chest wall movement. What would be the priority nursing intervention? 1. Administer high flow O2 per face mask. 2. Remove the occlusive dressing. 3. Notify the healthcare provider. 4. Initiate rapid IV resuscitation.

2 rationale: Based on these signs and symptoms, we recognize that the client has developed a tension pneumothorax due to the occlusive dressing not only preventing air from getting in, but not allowing the air to escape. Therefore, management of this emergency situation would be the nurse's priority. Removal of the occlusive dressing would allow the air to escape and should help reduce the pressure that is causing the mediastinal shift. Needle decompression may also be needed to relieve the tension pneumothorax. If available, a good option for covering an open or "sucking" chest wound would be a petroleum gauze dressing which would be taped down on only three sides. This creates a flutter valve mechanism that allows air to escape but prevents air from re-entering through the open wound.

The nurse has been assigned to a client with a Steinman pin insertion 48 hours ago. Which pin site care interventions would the nurse implement? SATA 1. Perform pin care daily. 2. Rinse pins with water. 3. Clean with chlorhexidine. 4. Dry the area with clean gauze. 5. Monitor pin site every 10 hours.

1,3 rationale: Pin care is prescribed 48 to 72 hours after insertion. The pin care is initiated once a day. Chlorhexidine is prescribed to clean the pin insertion site.

The nurse performs an assessment on a client who reports abdominal pain. Based on the assessment findings, what problem does the nurse suspect? EXHIBIT Awake, alert, and oriented reporting diffuse abdominal pain rated 9/10. Skin warm and dry. Cullen's sign noted. Abdomen rigid with guarding. Temperature 101 degrees F (38.3 degrees C), BP 96/64, HR 102, RR 26. 1. Cirrhosis 2. Pancreatitis 3. Peptic ulcer 4. Ulcerative colitis

2 rationale: These s/s point to pancreatitis. Look at the big clues: Cullen's sign, rigid abdomen with guarding, and fever

The nurse is caring for a client diagnosed with heart failure who has developed pulmonary edema. Which finding best indicates that bumetanide is having a therapeutic effect? 1. Apical pulse 108/irregular. 2. Foamy sputum. 3. Urine output 175 mL for one hour. 4. Respiratory rate 28/min

3 rationale: Bumetanide is a diuretic that can be given IVP or continuous IV to provide rapid fluid removal. We know the medication is working because we have a good hourly urinary output.

A client is experiencing a panic attack. What priority action should the nurse take? 1. Instruct client to deep breathe with the nurse. 2. Teach relaxation techniques. 3. Inform client that symptoms will be gone in 20-30 minutes. 4. Hold the client gently for 5 minutes.

1 rationale: The most important action for the nurse to take is to slow down the client's breathing so that they do not end up in respiratory alkalosis from hyperventilation

A client's skeletal traction has been accidently released. What signs/symptoms does the nurse expect to see? SATA 1. Pain 2. Foot drop 3. Muscle spasm 4. Bone displacement 5. Itching under the straps

1,3,4 rationale: The purpose of traction is to stabilize and realign bone fractures and reduce pain. If the skeletal traction is interrupted by losing the traction on the bone, the result may include pain, muscle spasm, and bone displacement.

A client has a history of deep vein thrombosis (DVT) and pulmonary embolism (PE). What should be included in the teaching by the nurse as preventive measures for the development of a DVT and PE? SATA 1. Drink plenty of fluids on a daily basis. 2. Stop and move around every 4 hours when taking a long trip. 3. Perform isometric and stretching exercises in the lower extremities. 4. Need for weight management. 5. Walk around 4-6 times per day.

1,3,4,5 rationale: In order to get this question correct, you must first consider some of the risk factors for developing a DVT and PE. Some causes include: dehydration, venous stasis from prolonged immobility or surgery, obesity, birth control pills, clotting disorders, and heart arrhythmias like A-Fib. Therefore preventive measures would include such things as hydration by increasing fluid intake, prevention of stasis by isometric and stretching exercises of the feet, knees, and hips every 2 to 4 hours, prevention of obesity, and walking around at least 4 to 6 times per day.

A client is admitted to the emergency department (ED) following blunt trauma to the chest from a motor vehicle accident. A hemothorax and pneumothorax are suspected. What signs and symptoms would the nurse anticipate recording to support this diagnosis? SATA 1. Shortness of breath 2. Decreased heart rate 3. Wheezing in the affected area 4. Chest pain 5. Cough 6. Subcutaneous emphysema

1,4,5,6 rationale: With a hemothorax, we recall that blood has accumulated in the pleural space, and with a pneumothorax, we know that it is air that has accumulated in the pleural space. The presence of either of these causes the lung to collapse. The signs that the nurse expects to see includes shortness of breath, chest pain, and cough. We may also see subcutaneous emphysema as the air that escaped from the lung becomes trapped in the surrounding tissues.

What is the best position for the nurse to place a client for a thoracentesis of the right lung? 1. Lying supine with pillow removed and head of bed flat 2. Sitting on side of bed and leaning over the bedside table 3. Lying on the right side with the head of bed at 45 degrees 4. Lying supine with the left arm raised over the head

2 rationale: For maximum accessibility for the thoracentesis to be performed, the client should be positioned in a sitting position on the side of the bed, leaning over a bedside table, with arms propped on pillows and the feet supported. If the client is not able to sit up, the alternative position would be to lie on the unaffected side with the head of bed elevated 45 degrees.

The nurse completed discharge teaching on a client with two fractured ribs. Which statement by the client would indicate the need for further teaching? 1. "I will take deep breaths using my incentive spirometer every 2 hours." 2. "I will wrap my chest in an elastic bandage to support and immobilize my ribs." 3. "I will talk to my healthcare provider before taking the narcotic pain medicine that I currently have at home." 4. "I will notify my healthcare provider if I develop any change in my respirations or secretions."

2 rationale: Immobilizing, and therefore restricting the chest wall movement, with binders and straps is not recommended as it leads to shallow breathing, atelectasis, and pneumonia. The client should be taught to use the hands to support the injured area.

A client presents to the emergency department (ED) with flu symptoms, fever, and chills. The nurse notes that the vital signs are: T 102.8°F (39.3°C), P 128, RR 30, B/P 154/88. ABG results are: pH-7.5, PaCO2 32, HCO3 23. What acid/base imbalance does the nurse determine that this client has developed? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

2 rationale: This client has a high fever. Hyperventilation due to anxiety, pain, shock, severe infection, fever, and liver failure can lead to respiratory alkalosis. Here, the ABGs reflect respiratory alkalosis. pH > 7.45, PCO2 < 35, HCO3 normal.

Assessment of a trauma client in the emergency department reveals paradoxical chest wall movement, respiratory distress, cyanosis, and tachycardia. The family is asking why the client needs positive end-expiratory pressure (PEEP). What should the nurse inform them regarding the rationale for this treatment? SATA 1. Ventilation is improved as positive pressure is exerted into the airways as the client begins to take in a breath. 2. Gas exchange is improved, and the work of breathing is decreased. 3. It expands and realigns the ribs to aid in the healing process. 4. Allows for positive pressure to be applied continuously during inspiration and expiration. 5. It is less invasive and does not require the client to be on the ventilator.

2,3 rationale: I hope that you were able to recognize that the signs and symptoms are characteristic of a flail chest. This occurs with multiple rib fractures. The client will have pain, be anxious, and short of breath. The classic sign of a flail chest is the paradoxical (see-saw) chest movement in which the affected part of the chest sucks inwardly on inspiration and puffs out on expiration (opposite of what the normal side is doing). Dyspnea, cyanosis, and tachycardia are also generally seen. So, what is done about this unstable chest? PEEP may be used because it helps to improve gas exchange and decreases the work of breathing. As it exerts pressure in the lungs, it also facilitates the expansion and realignment of the ribs so that they can start growing back together.

The nurse is providing teaching to a group of clients newly diagnosed with chronic stable angina. What points should the nurse include? SATA 1. Wait 1/2-1 hour after eating to exercise. 2. Attend classes such as guided imagery to reduce stress. 3. Temperature extremes can precipitate an angina attack. 4. Gradually increase weightlifting training to improve cardiac output. 5. Eat a low fat, low fiber diet to lose weight. 6. Medications prescribed to prevent angina work by increasing the workload of the heart.

2,3 rationale: We want to teach clients who have angina to do whatever they can to decrease the workload of the heart. Stress can increase the workload on the heart, so learning ways to decrease or deal with stess is a positive step. This can be done through guided imagery or music therapy. Temperature extremes can precipitate an attack, so the client should dress warmly in cold weather and be cautious out in extremely hot weather.

A client in the intensive care unit who is on the ventilator, suddenly exhibits signs of decreased cardiac output. A quick assessment reveals that the client has cyanosis, absence of breath sounds on the right side, neck vein distention, and the trachea is deviating to the left. What initial emergency measure should the nurse expect to be performed? 1. Insertion of a chest tube in the 7th intercostal space 2. Immediate removal of client from the ventilator 3. Needle decompression in the right 2nd intercostal space 4. Emergency thoracentesis of the left lung

3 rationale: Did you recognize the signs of a tension pneumothorax? This client may have developed this because of a high PEEP level and/or compromised lung status combined with mechanical ventilation. Regardless of the cause, this is an emergency situation and the initial treatment involves the insertion of a large bore needle into the 2nd intercostal space, midclavicular line of the affected side. In this case, you should recognize that the absence of breath sounds on the right side indicate that the problem is on the right side. Needle decompression is done to release the pressure that is building up in the pleural space and causing the organs and vessels to be compressed. The mediastinal shift occurs toward the opposite (left) side. The client will most likely have a chest tube inserted on the right side, but the initial life saving measure for this would be the needle decompression.

Which laboratory test should be assessed by the nurse prior to administering radioactive iodine (RAI) to a female client? 1. Thyroid Scan 2. Serum calcium 3. Pregnancy test 4. Metanephrine tes

3 rationale: RAI crosses the placenta and will affect the development of the fetus. If RAI is administered to a client who is pregnant, the fetus can experience mental retardation, hypothyroidism, and develop increased cancer risk. It is imperative that a pregnancy test should be prescribed prior to administering RAI. RAI should not be administered to a client who has a positive pregnancy test.

The client has been instructed on crutch safety. The nurse identifies that further teaching is needed when the client makes which statement? 1. "The crutches are adjusted according to my height." 2. "I will support my weight on the hand grips when not walking." 3. "I plan to place my affected leg on the step first when ascending stairs." 4. "I will position the crutches 1 -2 inches below the axilla when walking with crutches."

3 rationale: This statement is incorrect and further client teaching is needed. When going up stairs, the client should lead with the unaffected leg. The unaffected leg will provide the support required to then move the affected leg to the step.

The nurse is providing stump care discharge instructions to the client with a right below-the-knee amputation (BKA). The client responds, "What is the purpose of the compression sock on my stump?" Which statement by the nurse is appropriate? 1. "The compression sock on the stump will increase your balance when crutch walking." 2. "Phantom limb pain will decrease by applying the compression sock tightly around the stump." 3. "A compression sock is applied to shape the stump smaller and rounder on the bottom." 4. "The application of a compression sock will decrease the risk of the incidence of deep vein thrombosis (DVT)."

3 rationale: Wrapping the stump with an ace bandage will assist in configuring the stump into a cone shape. The cone shape is smaller and rounded on the bottom. The cone shaped stump will result in the stump fitting easier into the prosthesis.

Which interventions would the nurse implement for a client with a right total hip arthroplasty performed 6 hours ago? SATA 1. Remove the abductor pillow. 2. Place a pillow under both knees. 3. Position the feet with the toes pointed upward. 4. Assess client's popliteal, dorsalis pedis, and posterior tibial pulses. 5. Report to the healthcare provider the 15g/dL (9.31mmol/L) Hemoglobin.

3,4 rationale: These are correct interventions. The feet should be placed in a neutral rotation position with the toes pointed to the ceiling. This positioning of the feet prevents the hips from rotating inwardly or outwardly. If the hips are not positioned appropriately, there is a postoperative risk for dislocation of the hip. The postoperative neurovascular assessment of the right leg includes evaluating the client's popliteal, dorsalis pedis, and posterior tibial pulses. The nurse should evaluate the peripheral pulses distal to the hip. The primary healthcare provider should be notified of any alterations in the peripheral pulses.

A client, who received blunt chest trauma from an all-terrain vehicle accident, is admitted to the unit at 7 PM following insertion of a chest tube at 5 PM. The drainage collection chamber has 80 mL of drainage present upon arrival to the unit. Which assessment finding would be of concern to the nurse? SATA 1. Continuous bubbling is occurring in the suction control chamber. 2. Intermittent bubbling is noted in the water seal chamber. 3. CDU is sitting upright on the bedside table with fluid levels as prescribed. 4. Slight fluctuations of water level in water seal chamber with respirations. 5. 190 mL of drainage noted in drainage collection chamber at 8 PM.

3,5 rationale: Do you see the problem with the bedside table? Yes! It's too high! The chest tube system should always be kept below the level of the chest to prevent backflow of drainage or air into the pleural space. You want to promote gravity drainage. The next problem that we see is excessive drainage. The chest tube was inserted at 5 PM and the client was admitted to the unit 2 hours later. The amount of drainage at upon arrival at 7 PM was 80 mL. At 8 PM, there was 190 mL of drainage. This is 110 ml of drainage in one hour. Drainage of 100 mL or greater any hour after the first hour is considered excessive. The healthcare provider would need to be notified of this amount of drainage.

A nurse is caring for a client with fat embolus syndrome (FES). Which data would support the nurse's assessment that the FES has resolved? 1. Respirations - 24. 2. Oxygen saturation - 94%. 3. Arterial blood gas - pH 7.34. 4. No infiltrates noted on chest x-ray.

4 rationale: A fat embolism is caused by droplets of bone marrow fat that is released into the venous system. The droplets may lodge in the lungs. An x-ray of the lungs with the bone marrow fat will have a "snowstorm" appearance. A chest x-ray that does not identify any filtrates and does not have a "snowstorm" appearance is indicative the fat embolus is decreasing in size or completely resolved.

A client is admitted to the emergency room with an open fracture of the left tibia which has been temporarily splinted. Which nursing intervention would the nurse implement? 1. Physically reduce the fracture. 2. Externally rotate the left leg. 3. Position the bed into a high Fowler's position. 4. Cover the fractured site with a sterile dressing.

4 rationale: An open fracture is when the bone has broken the skin and underlying soft tissue, and the bone is protruding from the wound. The nurse should cover the fracture site with a sterile dressing to prevent contamination of deeper tissues.

The nurse notes continuous bubbling in the water seal chamber of the chest tube system. What should be the nurse's initial action? 1. Clamp the chest tube closest to the chest wall. 2. Increase the water level in the water seal chamber. 3. Have the client take a deep breath and do valsalva maneuver. 4. Notify the healthcare provider.

4 rationale: Continuous bubbling in the water seal chamber indicates that there is an air leak in the system. The healthcare provider should be notified. The healthcare provider may prescribe for the tube to be clamped at intervals along the tube for only a few seconds to determine the location of the air leak, but clamping of the tube should never be done without a prescription.

The client has been prescribed 0.6 units of insulin/kg /day. The client weighs 214 pounds (97 kg). What is the amount of insulin the client can receive in a day? (Round to the nearest whole number)

58 rationale: 58 units per day 97 kg x 0.6 units = 58.2 units = 58 units The average adult dose of insulin is 0.4-1.0 units/kg/day. Rounding Rules for Whole Units: 0.1 -0.4 = round down to whole unit 0.5-0.9 = round up to whole unit

A client with chronic liver disease has ascites and is being treated with an albumin infusion. What should the nurse anticipate and monitor in this client? 1. Fluid volume excess 2. Cellular edema 3. Severe hypotension 4. Decreasing CVP

1 rationale: Albumin is a hypertonic solution. This type of solution will draw fluid from the cell into the vascular space. This builds up the volume in the vascular space. Therefore, the nurse must watch for fluid volume excess. Hypertonic solutions are used in clients who have 3rd spacing, severe edema, or ascites.

A client who has terminal cancer tells the nurse that the opioid prescription, which is at the highest recommended dose, is not relieving the pain. What should the nurse tell the client? 1. "I will ask your primary healthcare provider to increase your dose of medication." 2. "You cannot have a higher dose of pain medication since you are at the maximum dose." 3. "Opioid addiction is a major concern. You don't want to take too much of this medication." 4. "Let's try some lemon essential oil to decrease your pain level."

1 rationale: There is no ceiling on the dose of an opioid for a cancer client. Dosage is only limited by side effects. It is client dependent, so this is an appropriate response by the nurse

A client, admitted to the surgical unit post left thoracotomy, is drowsy. Vital signs on admit are T 99.8ºF (37.6ºC), HR 94, R 16/shallow, BP 100/68. ABGs are pH 7.33, PCO2 48, HCO3 24. What action should the nurse initiate? 1. Have client take deep breaths. 2. Administer naloxone. 3. Tell the client to breathe faster. 4. Medicate for pain

1 rationale: This client had chest surgery and the pCO2 is high. What are you worried about? Hypoventilation. Yes, the client is probably hurting due to the incision and does not want to take deep breaths. In order to get rid of the excess CO2 the client needs to turn, cough, and deep breathe. Incentive spirometry can be provided to assist the client with this effort.

A client who had a cerebral vascular accident (CVA) is now having Cheyne-Stokes respirations ranging from 12-30 breaths/minute. BP 158/108, HR 46. Based on this assessment, which acid/base imbalance does the nurse anticipate that this client will develop? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

1 rationale: 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.

The nurse is preparing a class on cancer prevention. Which risk factor should the nurse discuss with the class as being a preventable risk factor? SATA 1. Smoking tobacco 2. Drinking alcohol 3. Eating a high fiber diet 4. Increasing fish consumption 5. Protect skin from sunlight by using tanning beds

1,2 rationale: Tobacco is the #1 cause of preventable cancer. Alcohol plus tobacco are co-carcinogenic.

A client reports dizziness and weakness while walking down the hall. The nurse notes the client's cardiac rhythm displayed on the telemetry monitor. What actions should the nurse take? W SATA 1. Assist client in ambulating back to bed. 2. Obtain client's blood pressure. 3. Auscultate lung sounds. 4. Prepare for cardioversion. 5. Initiate 100% oxygen per nonrebreather mask.

1,2,3 rationale: The client is dizzy and weak. This client is at risk for falling, so think safety and get the client back in bed. Use a wheelchair to accomplish this. Then obtain the client's BP. It may be low, indicating poor tissue perfusion to the vital organs. One cause of premature ventricular contractions (PVCs) includes heart failure, so assess the lungs for adventitious sounds.

Which signs/symptoms does the nurse expect to see in a client diagnosed with schizophrenia? SATA 1. Auditory hallucinations 2. Grandiose delusions 3. Religious preaching all the time. 4. Flat affect 5. Abstract reasoning

1,2,3,4 rationale: Correct: Auditory hallucinations are commonly experienced by the client diagnosed with schizophrenia. Delusions of grandiosity like believing they are a famous person or religious figure is a false fixed belief experienced by the client. If the client is in the acute phase of schizophrenia, the person may be overwhelmed by anxiety and is not able to distinguish thoughts from reality. It is thought that delusions may develop to cope with the anxiety. Religiosity is common. The client may carry a bible all of the time and preach to everyone all of the time. The client may have an inappropriate affect, a flat affect, or a blunted affect.

A 70 year old female client reports an occasional choking sensation over the past 12 hours. What additional symptoms reported by the client would indicate to the nurse that the client may be having a myocardial infarction? SATA 1. Unusual fatigue. 2. Indigestion. 3. Aching jaw. 4. Feeling faint 5. Pain between the shoulder blades. 6. Left arm paresthesia.

1,2,3,4,5 rationale: Look at the hints - elderly, female, choking sensation. Women often present with GI signs and symptoms, epigastric complaints, or pain between the shoulders, aching jaw, or choking sensation. The triad of symptoms: feeling of fullness in the abdomen, unusual fatigue, and an inability to "catch one's breath". Remember that the elderly may just faint or only have SOB.

The nurse is caring for a client following a cholecystectomy. The client reports dizziness, sweating and palpitations after eating meals. The nurse would recommend which actions to alleviate these symptoms? SATA 1. Drink between meals. 2. Reduce intake of carbohydrates. 3. Eat small, frequent meals daily. 4. Sit semi-recumbent for meals. 5. Remain upright for one hour after eating. 6. Lie down on left side after eating.

1,2,3,4,6 rationale: Clients are instructed to eliminate all fluids during meals. In some cases, clients may also need to eliminate fluids for one hour before and immediately after meals in order to control symptoms and slow the progress of food through the digestive tract. The symptoms described indicate the client is experiencing dumping syndrome, an adverse response following gastric or bariatric surgery. Clients may also experience tachycardia, nausea or cramping with the intake of food due to surgical restructuring of the gastrointestinal tract. Because this will be a lifetime issue, the nurse must teach the client to adjust eating habits and patterns. Reduction of carbohydrates will help decrease the problem since carbohydrates speed through the digestive track too quickly. Eating smaller, more frequent meals in a semi-recumbent position will further slow food through the digestive tract and eliminate most of the uncomfortable symptoms. After eating, the client should lie down on the left side to keep food in the stomach longer.

A client sustains a high-voltage electrical injury while at work. Which interventions should the occupational health nurse initiate? SATA 1. Assess entry and exit wound. 2. Monitor vital signs. 3. Place on a spine board. 4. Connect to cardiac monitor. 5. Perform the rule of nines. 6. Apply cervical collar to neck.

1,2,3,4,6 rationale: ou need to understand that high-voltage current of electricity damages the vascular system and the nerves nearby. This alteration in the vascular system can damage vital organs, so we worry about organ failure. Electrical burns have two wounds: an entrance burn wound that is generally small and an exit burn wound that is much larger. The electricity goes throughout the body causing damage, and then exits the body. So look for 2 burn wounds. Remember, vessels, nerves, and organs can be damaged. The nurse needs to monitor vital signs frequently, especially those assessing the respiratory and cardiac systems, since we worry about organ damage. Electricity can damage the heart muscle, so the client is at risk for dysrhythmias within 24 hours following an electrical burn. Put the client on continuous cardiac monitoring during this time. Why place the client on a spine board and put a c-collar on? Contact with electricity can cause muscle contractions strong enough to fracture bones, or vertebrae. The force of the electricity can actually throw the victim forcefully.

What sign/symptom would indictate to the nurse that a client has had an inhalation injury? SATA 1. stridor 2. Swallowing difficulty 3. Singed nasal hair 4. Blisters to upper arms 5. Wheezing

1,2,3,5 rationale: Substernal/intercostal retraction and stridor are bad signs. Remember you will see difficulty swallowing, singed nasal and facial hair, and wheezing.

What interventions would the nurse implement for a client diagnosed with nephrotic syndrome? SATA 1. Weigh daily 2. Measure abdominal girth 3. Provide skin care 4. Position in semifowlers 5. Intake and output

1,2,3,5 rationale: The client with nephrotic syndrome is producing less urine. Due to the decrease in urinary output the client is retaining fluid. The client should be weighed daily, and the girth would be measured to evaluate fluid retention. Edematous skin is prone to skin breakdown, so adequate skin care is necessary. Intake and output is required whenever there is a fluid volume problem.

What signs/symptoms should the nurse assess for when caring for a client at risk for thrombocytopenia? SATA 1. Conjunctival hemorrhage 2. Petechiae on inside of mouth 3. Purpura 4. Fever 5. Blood oozing from IV site

1,2,3,5 rationale: The problem is a low platelet count, so we are looking for signs/symptoms of bleeding such as conjunctival hemorrhage, petechiae on the arms, legs or inside the mouth, and ecchymosis or purpura.

The nurse is planning care for a client admitted with a diagnosis of Alzheimer's Disease. What interventions should the nurse include? SATA 1. Encourage participation in light exercise. 2. Identify doors with pictures. 3. Monitor food intake. 4. Assign unlicensed assistive personnel to bathe client daily. 5. Reminisce about successful and unsuccessful life events. 6. Weigh weekly.

1,2,3,6 rationale: It is important to keep the client as active as possible by participating in enjoyable things like light exercise, dancing, singing, simple games, and painting. Identify all doors with pictures or easily identifiable labels. Doors to rooms, closets, and bathrooms are especially important for the client to be able to recognize. Monitor food and liquid intake daily. The client can easily forget to eat and drink. This is one reason the client should be weighed weekly as well.

The nurse on a medical unit is reviewing the data on a client admitted to a medical unit. Which data supports the diagnosis of glomerulonephritis? SATA 1. Malaise 2. Blood pressure - 16O/92 3. 24 hour urinary output - 960 mL 4. Costovertebral angle tenderness 5. Urine specific gravity of 1.040

1,2,4,5 rationale: A client with glomerulonephritis is retaining toxins. The result is the client has a overall sense of being ill with possible fatigue and decrease interest in activities. A client with glomerulonephritis is producing less and less urine. Due to the retention of fluid, the client's blood pressure is elevated. Costovertebral angle tenderness (CVAT) is elicited by percussing the flank area of the back over both the kidneys. If pain is present, the client would be assessed for a kidney infection. The normal range of urine specific gravity ranges from 1.010 to 1.030. An elevated urine specific gravity of 1.040 is reflective of highly concentrated urine. The client is not diuresing appropriately. The client's specific gravity of 1.040 supports glomerulonephritis.

The nurse is planning care for a client admitted with a diagnosis of acute renal injury. What interventions should the nurse include in this plan? SATA 1. Provide meticulous skin care. 2. Reposition every 2 hours. 3. Maintain a high carbohydrate, high protein diet. 4. Provide foods low in phosphate. 5. Monitor intake and output. 6. Give IV medications in smallest volume allowed.

1,2,4,5,6 rationale: The leading cause of death from acute renal injury is infection, so meticulous skin care and aseptic technique are critical. Repositioning every 2 hours will help to prevent pressure ulcers. Clients in acute renal injury have high phosphorus levels and low calcium levels (remember that inverse relationship?). So they need foods low in phosphorus. Monitor intake and output. The client cannot handle excess fluid at this time. This is also why all IV meds should be administered in the smallest possible volume allowed.

What signs/symptoms would lead the nurse to suspect that a client diagnosed with cirrhosis may be developing hepatic coma? SATA 1. Asterixis 2. Fetor 3. Grey Turner's sign 4. Hyperactive reflexes 5. Squiggly handwriting

1,2,5 rationale: Signs and symptoms that a client diagnosed with cirrhosis is getting worse and headed for hepatic coma include asterixis, fetor, and handwriting changes.

A client is placed on neutropenic precautions. What interventions should the nurse initiate? SATA 1. Use antimicrobial soap for handwashing. 2. Post neutropenic precautions sign on door. 3. Administer acetaminophen for fever greater than 101 degree F (38.3 degrees C). 4. Administer platelets as prescribed. 5. Vital signs at least every 4 hours.

1,2,5 rationale: We want to use antimicrobial soap to wash hands. Anyone planning to enter the client's room needs to know what to do prior to entering, so a sign with necessary instructions should be placed on the closed door. Vital signs should be done every 4 hours, minimally. If needed, take vital signs more frequently.

What actions would be appropriate for the nurse to take when performing peritoneal dialysis on a client diagnosed with renal injury? SATA 1. Dialysate is warmed to body temperature by allowing it to sit out for a short period of time. 2. The dialysate is infused through the catheter into the stomach. 3. Once infused, dialysate remains for prescribed dwell tiime. 4. Withdraws dialysate using a large piston syringe. 5. Assists client to stand if all the drainage is not removed. Submit

1,3 rationale: these actions are correct. The dialysate should be warmed to body temperature by allowing it to sit out for a short period of time. The dwell time is the length of time that the dialysate stays in the peritoneal cavity. This allows for toxins to be drawn out of the blood and into the peritoneal cavity for removal.

Which clinical manifestation does the nurse expect to see in a client diagnosed with Addison's disease? SATA 1. Confusion 2. Hypertension 3. Vitiligo 4. Hyperkalemia 5. Hypernatremia 6. Weight gain

1,3,4 rationale: Clients with Addison's disease may present with nonspecific symptoms of confusion. As the continual reduced functioning of the adrenal medulla and adrenal cortex occurs, the client will present with cognitive impairment, delusions, and hallucinations. The reduced blood cortisol increases the adrenocorticotropic hormones (ACTH) and the melanocyte-stimulating activity. The feedback mechanism results in the hyperpigmentation of skin. A deficiency of mineralocorticoids will result in the decreased excretion of potassium which results in hyperkalemia.

A client is admitted with hypocalcemia. Which treatment would the nurse anticipate for this client? SATA 1. PO Calcium 2. Rapid IV Push Calcium 3. Vitamin D 4. Sevelamer hydrochloride 5. Phosphate supplements

1,3,4 rationale: Since this client has hypocalcemia, PO Calcium replacement would be an appropriate treatment. Now, let's look at the others that are not as obvious. Vitamin D helps to improve calcium absorption, which will help increase the calcium levels. So, what is sevelamer hydrochloride and how will this help hypocalcemia? Well, it is a phosphate binder. And remember that we said if you bind the phosphorus, the phosphorus levels go down. And since phosphorus and calcium have inverse relationships, as the phosphorus levels go down, the calcium levels will go up!

The nurse is preparing discharge teaching instructions for a client post right radical mastectomy with reconstruction. What instruction should the nurse include? SATA 1. Squeeze tennis ball with right hand every 2-4 hours while awake. 2. No blood pressure readings in right arm for one year. 3. Wear gloves when gardening. 4. Wear your watch on the left wrist. 5. Brush your hair with your left hand until pain free.

1,3,4 rationale: Squeezing a tennis ball will help promote new circulation. Protect the hand and arm at all times. A tiny cut could turn into a major infection, so wearing gloves while gardening is a good idea. Since the mastectomy was on the right breast, the client can wear a watch on the left wrist. Do not wear anything constricting on the right wrist, or arm.

A client with deep partial thickness burns to arms and legs is admitted to the burn unit. The nurse knows elevated results are most likely to be noted initially in what laboratory tests? SATA 1. Hematocrit 2. Albumin 3. Potassium 4. Creatinine 5. Magnesium

1,3,4 rationale: The physiology of the body changes significantly following a major burn. Hematocrit increases as the fluid from the vascular spaces leaks into the interstitial tissues. Because of lysis of cells, potassium is released into the circulation, leading to hyperkalemia. The kidneys are impacted by the decreased cardiac output as well as the myoglobin released by the lysed cells. This causes creatinine to become elevated.

The nurse is developing the plan of care for a client admitted for the treatment of mania. Which interventions should the nurse include? SATA 1. Give one cigarette to client at a time. 2. Discuss delusional belief with client. 3. Have finger foods available at mealtime. 4. Give high calorie fluids between meals. 5. Provide soothing music in room during waking hours.

1,3,4 rationale: We need to protect this client from hazards in their environment. They have no control or awareness of these hazards. If they smoke, only give the client one or two cigarettes at a time, or the client will light a whole pack at once. Finger foods should be provided because the cleint is too busy to stop and eat. They are also too busy to drink, so they can become dehydrated. This is why we provide high calorie fluids for them throughout the day.

What signs/symptoms does the nurse expect to see in a client who has ulcerative colitis? SATA 1. Abdominal cramping 2. Hematemesis 3. Diarrhea 4. Fever 5. Rebound tenderness 6. Rectal bleeding

1,3,4,5,6 rationale: Ulcerative colitis is an ulcerative inflammatory bowel disease in the large intestines. Common s/s include abdominal cramping, diarrhea, fever, rebound tenderness, and rectal bleeding.

A client admitted to a psychiatric facility is refusing all medications. The nurse notes the client appears to be responding to auditory hallucinations. What actions by the nurse would be appropriate? SATA 1. Assign staff to stay with client. 2. Place client into a seclusion room. 3. Ask client to explain auditory sounds. 4. Frequently reorient client to reality. 5. Turn up radio to mask hallucinations.

1,4 rationale: Auditory hallucinations, also called "paracusia", are extremely frightening. The client's intense fear may result in striking out at staff, visitor or other clients, and can even cause the client to do self-harm. Nurses must focus on safety by remaining with the client at all times in a quiet room. Reinforcing that feeling of being safe while frequently reorienting the client to reality are priority actions that may continue for hours until the client becomes calmer.

Which selection by the client indicates to the nurse that the client understands food allowed during a vanillylmandelic acid (VMA) test? SATA 1. Milk 2. Caffeine 3. Citrus fruit 4. Chicken 5. Vanilla ice cream

1,4 rationale: Milk intake will not alter the production of epinephrine or norepinephrine. The client can drink milk prior to a VMA test. The period prior to a VMA test which measures the amount of production of epinephrine and norepinephrine would not require the client to eliminate chicken. Eating chicken would not alter the production of epinephrine or norepinephrine

The nurse is educating a group of college students about cancer prevention and screening. Which secondary prevention actions should the nurse include? SATA 1. Annual mamogram starting at age 40. 2. Maintain normal body weight. 3. Cancer support group. 4. Colonoscopy beginning at age 50. 5. Limit or eliminate alcohol intake.

1,4 rationale: Secondary prevention includes screenings to pick up on cancer early. Screening is very important because then we have a greater chance for cure or control. Annual mamogram starting at age 40 with two views of each breast is recommended if the client has no family history of breast cancer. Colonoscopy at age 50, then every 10 years after that if there has been no problem is also recommended.

The nurse has informed a client diagnosed with heart failure about the treatment plan, including prescriptions for an ACE inhibitor and a 2 gm sodium diet. Which statement by the client would indicate to the nurse that the client understands the treatment plan? SATA 1. "I plan to elevate the head of my bed on concrete blocks so I can sleep better." 2. Instead of using salt, I should use a salt substitute to season my food." 3. "It is important that I weigh myself weekly to monitor for weight gain." 4. "I need to eat foods high in potassium while taking an ACE inhibitor." 5. "A low sodium diet will help decrease swelling in my legs."

1,5 rationale: Lying flat when a client has heart failure will cause excess fluid, which has pooled in the extremities while up, to move into the thorax and back up into the lungs. This is why the client can breathe better when the head of the bed is elevated. A low sodium diet decreases fluid retention which decreases preload, the amount of fluid entering the right side of the heart. So, yes, a low sodium diet can help decrease dependent edema.

How would the nurse interpret this client's Arterial Blood Gas (ABG) results? -pH 7.30 -PaCO2 55 mm Hg -Bicarb 25 mEq/liter -PaO2 93 mm Hg -SaO2 95% SATA 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

1,5 rationale: Now will a pH of 7.30 make the patient have acidosis or alkalosis? Well it's less than 7.35 so that's a low pH, and you know that a low pH is acidosis. So now we know acidosis, but we still must figure out if it is respiratory or metabolic. Look at the PaCO2, it is 55. That's a lot of CO2, and it's greater than the normal range of 35-45, so the PaCO2 must be acidosis. Now the Bicarb is 25, and a Bicarb of 25 is within the normal range of 22-26. To determine whether this is respiratory or metabolic acidosis, we need to match the pH with either the PaCO2 or the HCO3. The pH that we're trying to match is acidosis, so keep in mind you're trying to match the word acidosis with one of the chemicals. Well look at our problem, the CO2 is also acidosis. So, since these two match and they are both acidosis, we can say this is clearly Respiratory Acidosis because the "respiratory" chemical (CO2) is the one that matches the pH. Now, look at the Bicarb level. The bicarb is normal and doesn't match our pH which is acidosis, so, we can just mark it out. There you have it; this is Respiratory Acidosis. So, is there any compensation going on? No, not yet. The bicarb is still within normal limits. These values indicate uncompensated respiratory acidosis.

A nurse has performed teaching with a client diagnosed with Cushing's disease. Which statement by the client would best indicate understanding of the teaching? 1. "The increased level of ADH will cause my potassium level to be too high." 2. "I will be retaining sodium and water due to the increased amount of aldosterone." 3. "I will be losing lots of fluid due to the hormonal imbalance I have." 4. "I will feel jittery and nervous due to the elevated thyroxine levels."

2 rationale: Cushing's is a disease that results in increased secretion of aldosterone. Having too much aldosterone causes the client to be at risk for fluid volume excess (FVE) due to the increased retention of both sodium and water.

The nurse is providing dietary instructions to a client newly diagnosed with type 2 diabetes. Which food examples should make up the highest percentage of this client's recommended diet? 1. Pecans, eggs, pork chop 2. Wheat bread, dried beans, brown rice 3. Lean hamburger, fish, skinless chicken 4. Whole milk, cheese, dark chocolate

2 rationale: A calorie is the unit of energy needed to raise the temperature of 1 kilogram of water 1 degree of Celsius. Wheat bread, dried beans, and brown rice are complex carbohydrates. The breakdown of complex carbohydrates occurs at a slower rate which decreases the possibility of increases and decreases in the serum glucose level. The recommended percentage of calories from carbohydrates is 45% of the daily diet.

A client is admitted with prolonged nausea and vomiting. The client's admission sodium level is 149 mEq/L (149 mmol/L). What action by the nurse would be most appropriate at this time? 1. Administer 3% NS at 150 mL/hr 2. Perform neurological assessment 3. Increase oral intake of sodium 4. Decrease fluid intake

2 rationale: Did you recognize that the sodium level of 149 is too high? The normal sodium level is 135-145 mEq/L (135-145 mmol/L). Think about the testing strategy that we mentioned to you. Look for neuro changes when the sodium level is not within normal limits. The brain does not like it when the sodium level is messed up. So, performing a neurological assessment on this client would be important.

A client is admitted to a chemical dependency unit for addiction treatment. Which of the client's belongings should the nurse remove from the client's room? 1. Shampoo and conditioner 2. Mouthwash and hand sanitizer 3. Toothpaste and dental floss 4. Lotion and foot powder

2 rationale: Mouthwash and hand sanitizers have alcohol in them, which the client may drink.

A client arrives at the clinic reporting a sharp pain, rated 10/10, radiating from the right flank around to the lower right abdomen. The client also reports nausea and vomiting. Based on this data, what problem does the nurse suspect? 1. Glomerulonephritis 2. Renal lithiasis 3. Nephrotic syndrome 4. Acute kidney injury

2 rationale: These signs and symptoms are classic for renal lithiasis or kidney stones.

A client who has been given steroids for a prolonged period to treat asthma, reports dizziness, tingling of the fingers, and muscle weakness. What action should the nurse take first? 1. Determine current blood pressure 2. Connect client to a cardiac monitor 3. Administer oxygen 4. Obtain arterial blood gases

2 rationale: These symptoms are indicative of hypokalemia and metabolic alkalosis. What do steroids do to the body? Steroids make you retain sodium and excrete potassium. So, you could become hypokalemic. Low potassium levels cause an increase in the reabsorption of bicarb by the kidneys. That is why you sometimes see metabolic alkalosis with Cushing's disease and prolonged steroid use. What electrolyte imbalance do we see with metabolic alkalosis? It's hypokalemia. So, if you have a client who is hypokalemic then they may have muscle weakness, hypotension and life threatening arrhythmias. And we know when the potassium is messed up, we should always think about the heart first. Connect the client to the cardiac monitor.

A client had radiation seeds implanted to treat prostate cancer. When entering the room to initiate discharge teaching, the nurse observes the spouse emptying the client's urinal. What is the nurse's priority action? 1. Immediately escort spouse to ED to check radiation levels. 2. Begin discharge teaching to the client and spouse. 3. Have spouse wash hands thoroughly and apply sterile gloves. 4. Explain that spouse must remain outside the room until urinal is emptied.

2 rationale: internal radiation, also called brachytherapy, is placed inside the body as close to the cancer as possible. Internal radiation therapy can be permanent or temporary as well as sealed or unsealed, which refers to the amount of radiation risk posed by the client. Implanted seeds used to treat prostate cancer are a type of sealed radiation, indicating the body fluids are not radioactive. Emptying the urinal poses no risk to the spouse.

The nurse is planning care for a client admitted for chemotherapy. What interventions should the nurse initiate to prevent infection? SATA 1. Change IV tubing every 48 hours. 2. Place supplies for client in room. 3. Limit nursing personnel in room. 4. Bathe perineum once daily. 5. Place in protective isolation.

2,3 rationale: They need their own cups; they need their own everything. You don't need to go to a general closet and get supplies for this client. They need their own blood pressure cuff and own stethoscope in the room. Their own stuff because you only want their bacteria in the room. Limit people in the room who could pass on an infection to the client. Limit visitors, nurses, and nursing personnel to only those necessary to care for the client.

A client receiving chemotherapy reports nausea and vomiting after every treatment. What interventions should the nurse initiate to reduce this side effect? SATA 1. Administer antiemetic immediately after treatment. 2. Provide music therapy. 3. Provide ginger ale to drink. 4. Apply accupressure bands to wrists. 5. Place pepperment essential oil diffuser in room.

2,3,4,5 rationale: All of these interventions will help prevent or decrease nausea and vomiting. Music therapy is a form of behavioral therapy that can help with relaxation and distraction. Ginger is a natural antiemetic, so providing ginger ale to drink is beneficial. Sea bands or accupressure bands on the wrist help to relieve nausea and vomiting. Peppermint is one essential oil that relieves nausea. It can be used in a diffuser so that client can small the peppermint.

A client is to begin external beam radiation for Ewing's sarcoma. What symptoms would the nurse teach the client to expect during radiation treatments? SATA 1. Nausea and Vomiting 2. Skin shedding 3. Erythema with pain 4. Pancytopenia 5. Exhaustion

2,3,4,5 rationale: External beam radiation uses high energy proton rays to deliver radiation from outside the body. This therapy prevents cell reproduction and destroys cancer cells. Expected side effects can be topical or physiological, depending on the area radiated. Skin radiated by the beam becomes reddened (erythema), dry and peeling. Shedding skin and even blistering may occur because of multiple treatments. As radiation enters tissues, damage affects even healthy tissue like bone marrow. The client may eventually develop pancytopenia: a lack of all blood components, including red cells, white cells and platelets. As the body struggles with cancer and the effects of radiation, the client may experience severe or overwhelming fatigue which needs reported to the primary healthcare provider.

A client arrives at the emergency department after sustaining full thickness burns. What does the nurse estimate the total body surface area (TBSA) burned to be when using the rule of nines?

22.5 rationale: Posterior trunk = 18 Posterior arm = 4.5 TBSA burned = 22.5%

The nurse is initiating a client assessment. What signs and symptoms would validate the client's diagnosis of Cushing's disease? SATA 1. Hypoglycemia 2. Mood alterations 3. Lipolysis 4. Truncal obesity 5. Hirsutism 6. Hyperkalemia

2,3,4,5 rationale: The client will experience mood swings. Several of the clinical manifestations of Cushing's are related to significant physical changes which can result in periods of depression for the client. Another clinical manifestation is lipolysis which is the breakdown of adipose tissue and the thinning of the extremities. Truncal obesity (apple-shaped obesity) is the distribution of adipose tissue located in the abdominal area. Hirsutism is when a female develops male characteristics such as increased hair on the face. When the adrenal cortex is stimulated there is an increase production of adrenal androgen. This results in the increased production of testosterone, a sex hormone.

A primary healthcare provider has prescribed restraints for a violent adult client. Which measures would the nurse provide as proper interventions for this client? SATA 1. Observe the client in restraints every hour. 2. Ensure that circulation to extremities is not compromised. 3. Assist client with needs related to nutrition and elimination. 4. Provide help with personal hygiene. 5. Renew restraint prescription in 4 hours if needed.

2,3,4,5 rationale: These are correct interventions for safety when a violent client requires restraints. When applying restraints you do not want the restraint so tight that extremity circulation is diminished. The client must still be provided with proper nutrition, hydration, and allowed to go to the restroom. If the client is restrained, the client will need help with basic care and comfort measures. Prescriptions for restraints used on an adult client must be renewed every 4 hours if needed.

The nurse is educating a client diagnosed with cirrhosis about the functions of the liver. What functions should the nurse include? SATA 1. Removes old RBCs from the body. 2. Produces clotting factors. 3. Detoxifies the body. 4. Releases digestive enzymes. 5. Breaks down medications.

2,3,5 rationale: Three of the four functions are listed: the liver produces clotting factors, detoxifies the body, and breaks down medications. It also synthesizes albumin.

A client is admitted following a severe burn. What changes related to fluid status would the nurse anticipate? SATA 1. Fluid volume excess 2. Hypovolemia 3. Third spacing 4. Increased urine output 5. Low CVP 6. Increased urine specific gravity

2,3,5,6 rationale: Causes of fluid volume deficit (hypovolemia) include loss of fluid from anywhere as well as third spacing of fluid that occurs with such things as burns. Burns can result in fluid loss from the burn area as well as the third spacing, which increases the risk for hypovolemia and shock. As the fluid volume decreases, the BP and CVP both decrease. Remember, less volume, less pressure. Also, when the fluid volume becomes depleted, the urine output will decrease in an effort to hold on to the fluid (compensate) or the kidneys are not being perfused. You will see the urine specific gravity increase because the small amount of urine being produced will be very concentrated.

A nurse is caring for a client with a possible diagnosis hyperparathyroidism. Which serum laboratory value would validate this diagnosis? SATA 1. BUN 12 mg/dL (4.28 mmol/L) 2. Calcium 12 mg/dL (3 mmol/L) 3. Sodium 140 mg/dL (140 mmol/L) 4. Phosphate 2.8 mg/dL (0.9 mmol/L) 5. Potassium 3.5 mEq/L (3.5 mmol/L)

2,4 rationale: Normal calcium range is 9.0 -10.5 mg/dl (2.25-2.62 mmol/L). The client's calcium level is 12 mg/dL (3 mmol/L) which is above normal range. Parathyroids secrete parathormone (PTH) for remodeling of the bones. PTH stimulates transfer calcium from the bone to the blood. Parathyroidism, an excess of PTH production by the parathyroids, will result in an increase in calcium movement from the bone to the blood. The normal range for phosphate is 3.0 - 4.5 mg/dL (0.97-1.45 mmol/L). The client's phosphate level is 2.8 mg/dL (0.9 mmol/L) which is below normal range. Parathyroidism, an excess of PTH production by the parathyroids, reduces the reabsorption of phosphorus in the kidneys. The result is that there is an increase in the excretion of phosphorus in the urine resulting in a decreased serum phosphorus level.

The nurse is preparing a teaching plan for a client newly diagnosed with fluid retention and heart failure. What should the nurse advise the client to avoid? SATA 1. Broiled, fresh fish 2. Effervescent soluble medications 3. Seasoning with lemon pepper 4. Chicken noodle soup 5. Deli-ham sandwiches

2,4,5 Rationale: Think about fluid volume excess and heart failure. Things such as effervescent soluble medications and canned/processed foods should be avoided because they all contain a lot of sodium which increases fluid retention. Therefore, the chicken noodle soup and the cold cut deli-ham sandwiches should be avoided.

The nurse is preparing to administer magnesium sulfate IV to an alcoholic client with hypomagnesemia. Prior to the initiation of IV magnesium, which assessment data would be important for the nurse to document? SATA 1. Liver function 2. Respiratory rate 3. Calcium levels 4. Deep Tendon Reflexes (DTRs) 5. Urinary output

2,4,5 rationale: As you learned, magnesium acts like a sedative. Since we know that magnesium can cause respiratory depression, the nurse should always have a baseline respiratory assessment prior to initiating an infusion of magnesium. Muscle tone and DTRs can also become depressed, so a baseline assessment of DTRs would be very important. How is magnesium excreted? That's right! Through the kidneys. The nurse should always assess kidney function and urinary output prior to and during IV magnesium administration because of the risk of magnesium toxicity if it is being retained.

What information on burn prevention strategies should the nurse include when providing an education program at a community center? SATA 1. Have chimney professionally inspected every 5 years. 2. Clean the lint trap on the clothes dryer after each use. 3. Keep anything that can burn at least 1 foot (0.30 meters) away from space heaters. 4. Do not hold a child while holding a hot drink. 5. Home hot water heater should be set at a maximum of 120°F (48.8°C).

2,4,5 rationale: Lint that accumulates in the lint trap of a dryer can cause a fire, so the lint trap should be cleaned after each use. A hot beverage can easily spill on a child by accident when trying to handle both the beverage and child at the same time. Home hot water heater should be set at a maximum of 120°F (48.8°C), especially when small children, the elderly, or diabetics are in the home

The nurse performs a rapid assessment on a client who states, "I feel really sick and my heart is beating so fast." What signs and symptoms would indicate to the nurse that the client's cardiac output is inadequate? SATA 1. CVP 5 mm Hg. 2. Moist skin. 3. Urinary output 150 mL over 4 hours. 4. Weak radial pulses. 5. BP 90/50, HR 200, RR 22. 6. Mild chest discomfort.

2,4,5,6 rationale: When cardiac output is inadequate, the vital organs are not being perfused properly. Skin will be cool and clammy (moist) because the skin is not being perfused. Radial pulses will be weak and thready, because less blood is pumping through the arteries. Less volume means less pressure, so BP is low. The heart rate is too fast, so blood does not have time to get in the ventricles before it is contracting again which decreases cardiac output. Less blood is being pumped to the body. Chest pain means oxygenated blood is not reaching the heart muscle.

A client was admitted with reports of prolonged diarrhea. The client's admission potassium level was 3.3 mEq/L (3.3 mmol/L) and is receiving an IV of D5 ½ NS with 20 mEq KCL at 125 mL/hr. The UAP reports an 8 hour urinary output of 200 mL. The previous 8 hour urinary output was 250 ml. What should be the nurse's priority action? 1. Encourage the client to increase PO fluid intake. 2. Administer a supplemental PO dose of potassium. 3. Stop the IV potassium infusion. 4. Administer polystyrene sulfonate PO

3 rationale: First, you need to recall that potassium is excreted by the kidneys. If the kidneys are not working well, the serum potassium will go up! You always monitor the urinary output before and during IV potassium administration. Since the urine output has decreased below 30 mL/hr, we know that the urinary output is not adequate. Therefore, the client could start retaining too much potassium. The priority action would be to stop the infusion and then follow this action by notifying the healthcare provider.

A client with a history of paranoid personality disorder is admitted to the hospital with extreme weight loss. Family states client has been refusing medications and food due to fears of being poisoned. What initial response by the nurse is most important? 1. "Tell me about your fears of being poisoned." 2. "No one is trying to poison your food or meds." 3. "You certainly are having scary thoughts." 4. "You are starving yourself needlessly."

3 rationale: The client is so fearful of being poisoned that physical harm has occurred secondary to personal starvation. The responsibility of the nurse is to address the client's fears and establish a trusting nurse/client relationship in order to meet the goal of helping the client feel safe enough to begin to eat

The nurse has initiated discharge instructions for a client diagnosed with glomerulonephritis. What statement by the client would indicate to the nurse that further teaching is needed? 1. "I will have protein in my urine for several months." 2. "My urinary output will increase in 1 to 3 weeks." 3. "I should keep a record of the headaches I experience over 3 months." 4. "I should notify my primary healthcare provider if my urinary output decreases."

3 rationale: The client should report headaches sooner than 3 months to their primary healthcare provider. The headaches are related to the fluid retention due to the decreased filtration of the glomerulus. The retention of fluid will result in hypertension. This client will require additional discharge instructions.

What should the nurse do after administering a chemotherapeutic drug intravenously (IV) to a client in the outpatient infusion unit? 1. Hang a 250 mL normal saline (NS) bag to flush the IV line. 2. Wear shoe covers during disposal of the drug. 3. Place the IV bag and tubing into a chemotherapy waste container. 4. Disposal of personal protective equipment (PPE) in a biohazardous container.

3 rationale: The disposable items such as the IV bag and tubing should remain intact and be disposed of in a securely sealed chemotherapy waste container. Tubing should never be disconnected from an IV bag containing a hazardous drug because of the risk of splashing.

While preparing chemotherapy, the nurse accidently punctures the bag, spilling the solution on the floor. After activating the emergency spill protocol, what action should the nurse take first? 1. Place absorbent pads and absorbent powder over the spill. 2. Apply chemotherapy approved personal protective gown and gloves. 3. Obtain the proper spill kit for the specific chemotherapy drug used. 4. Post the "Caution-Chemo Spill" sign outside the room door.

3 rationale: The first step in handling an accidental chemotherapy spill is to obtain the specific spill kit for that type of drug since each medication may require a different cleanup protocol.

The nurse is educating a group of college students about early signs and symptoms of cancer. When explaining the mnemonic "C-A-U-T-I-O-N", the nurse explains the 'N' stands for what sign/symptom? 1. Nausea 2. Nipple drainage 3. Nagging cough 4. Nose bleeds

3 rationale: The mnemonic "C-A-U-T-I-O-N" represents an easy way to recall the seven early warning signs and symptoms of potential cancer. Each letter indicates a specific body alteration that should be reported to the primary healthcare provider. 'N' stands for a nagging cough or hoarseness.

An elderly client with partial and full-thickness burns has begun receiving fluids at 600 ml/hour, as determined by the Parkland (Consensus) Formula. Based on the assessment data for the first four hours, what should the nurse report to the primary healthcare provider? EXIBIT hour:02:00 temp:94.0 pulse: 135 BP: 85/40 Resp: 36 CVP: 2.0 hour:03:00 temp 95.1 pulse: 124 BP: 90/50 resp: 32 CVP: 3.80 hour:4:00 temp: 95.9 pulse: 118 BP: 98/58 resp: 28 CVP: 4.40 hour:5:00 temp: 96.1 pulse: 110 BP: 104/64 resp: 24 CVP: 5.80 hour: 6:00 temp: 96.4 pulse: 100 BP:110/68 resp: 22 CVP: 6.01. 1. The cardiovascular system is becoming seriously overloaded 2. The speed of the IV should be reduced since CVP is now normal 3. The changes in vital signs indicate an expected response to fluids 4. The client is deteriorating because of age and extent of the burns

3 rationale: The purpose of infusing large amounts of fluid into burn victims during the first 24 hours is to help maintain perfusion until the body's physiology returns to normal functioning. The serial vital signs indicate the cardiovascular system is stabilizing, as evidenced by pulse decreasing to the normal range while blood pressure increases. Though respirations are still slightly elevated, the client would likely be experiencing pain. Most importantly, the CVP (central venous pressure) has increased to the normal range, indicating the fluid replacement is adequate at this time

What is the most important action for the nurse to take prior to a client having a liver biopsy? 1. Make certain the consent has been signed. 2. Obtain vital signs. 3. Check clotting study results. 4. Position client supine with right arm above head.

3 rationale: This is a priority question. All actions should be done by the nurse, however, the nurse better check the clotting study results. The client could hemorrhage if the clotting factors are too messed up

The nurse is teaching a group of female clients how to perform a self-breast exam. One client reports no family history of breast cancer and indicates disinterest in learning the technique. What is the most appropriate response by the nurse? 1. "You can ask your healthcare provider to do this with your yearly physical." 2. "If you have no family history of cancer, you won't need to worry about this." 3. "Self-breast exams may detect changes early enough for successful treatment." 4. "You have the right to refuse anything related to health because of client rights."

3 rationale: The nurse responds to this client's incorrect statement by presenting an accurate fact in a non-judgmental and open manner, allowing for further discussion about breast cancer facts. The nurse has a responsibility to provide the client important data about the topic of self-breast exams.

The nurse is teaching a group of clients in cardiac rehabilitation how blood flows through the heart. What information should the nurse include? SATA 1. Deoxygenated blood enters the heart through the pulmonary vein. 2. Blood flows from the right atrium through the mitral valve to the right ventricle. 3. The right ventricle pumps the blood to the lungs via the pulmonary artery where the blood becomes oxygenated. 4. From the lungs, oxygenated blood goes to the left atrium via the pulmonary vein, then to the left ventricle. 5. The right ventricle pumps the blood out through the aorta to the body.

3,4 rationale: These are true statements. The right ventricle pumps the blood to the lungs via the pulmonary artery where the blood becomes oxygenated. From the lungs, oxygenated blood goes to the left atrium via the pulmonary vein, then to the left ventricle.

A client is scheduled to be admitted to the surgical unit post total laryngectomy. What nursing intervention should the nurse include in the plan of care? SATA 1. Position left-side lying, supine. 2. Place on clear liquid diet after peristalsis returns. 3. Monitor tracheostomy for pulsations with heart beat. 4. Provide mouth care every 2 hours. 5. Maintain a humidified environment.

3,4,5 rationale: If a client's trach is pulsating with the heartbeat, you need to notify the primary healthcare provider immediately, as this could lead to rupture of the innominate artery. Frequent mouth care will decrease the bacterial count in the mouth. We are trying to prevent pneumonia. When breathing in and out through a trach, the client will not be able to warm, filter, and humidify the air. The air is really dry, so it irritates the trach. That is why when the client first gets the trach it has a lot of secretions. A humidified environment will help.

A client is diagnosed with a duodenal ulcer due to Helicobacter pylori (H Pylori). In addition to antibiotic therapy, the nurse anticipates that the client will also receive what class of pharmacologic agents? SATA 1. Miotic inhibitor 2. Serotonin antagonist 3. H2 antagonist 4. Acetylsalicyclic acid 5. Proton pump inhibitor

3,5 rationale: H2 antagonist or receptor blockers are used to decrease excess stomach acid seen with ulcers. Antisecretory agents like proton pump inhibitors are indicated for the treatment of peptic ulcer disease. Antisecretory agents decrease the secretion of gastric acids. Protein pump inhibitors, a combination of antibiotics and bismuth salts are most commonly used for treatment of H Pylori.

What interventions should the nurse include when caring for a client who is receiving total parenteral nutrition (TPN)? SATA 1. Change tubing and filter every 48 hours. 2. Monitor IV drip rate hourly. 3. Compare new bag with prescription prior to infusing. 4. Weigh weekly. 5. Cover TPN with dark bag. 6. Check urine for protein.

3,5 rationale: Remember safety and that TPN is a medication. You must make sure that what is in the bag is what was prescribed, so double check the bag against the prescription. Cover the IV bag with a dark bag to prevent chemical breakdown.

How would the nurse interpret this client's Arterial Blood Gas (ABG) results? pH: 7.35 PaCO2: 30 mmhg Bicarb: 19 mEq/liter PaO2: 89 mmhg SaO2: 90% SATA 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

3,7 rationale: These ABG values indicate metabolic acidosis. The pH is normal, but it is on the acidosis side of normal at 7.35. Now, which other chemical says acidosis? Look at the bicarb; the bicarb is low, indicating acidosis so there's your match! The bicarb matches the pH. What chemical problem does the bicarb relate to - respiratory or metabolic? It's metabolic. Metabolic acidosis. Has compensation begun? Yes. The lungs are compensating for the metabolic acidosis by getting rid of CO2, which is an acid. Therefore, the PaCO2 is below the normal range of 35-45. Since the pH is normal, full compensation has occurred.

A nursing instructor is presenting a discussion on nephrotoxic medications? Which class of medications would the instructor discuss? 1. Opioids 2. Antidiabetic 3. Corticosteroids 4. Aminoglycoside

4 rationale: Aminoglycoside antibiotics are nephrotoxic. Nephrotoxic medications can cause damage to the kidneys. Examples of aminoglycoside antibiotics are tobramycin, gentamicin, streptomycin, and paromomycin. Clients with kidney damage should not be prescribed aminoglycoside antibiotics.

An elderly client arrives at the emergency room reporting a severe headache and blurred vision. The client indicates having awakened this morning with flu-like symptoms including nausea, vomiting and dizziness. The nurse notes the client appears very weak with shortness of breath and dark cherry red lips. Based on assessment findings, what life-threatening problem does the nurse expect? 1. Guillian Barre 2. Severe dehydration 3. Advanced influenza 4. Carbon monoxide poisoning

4 rationale: Carbon monoxide is a colorless, odorless, tasteless gas which permeates the blood stream, displacing the oxygen in hemoglobin. Symptoms are often confused with other illnesses, such as the flu. Assuming exposure is not fatal, the client may also experience extreme weakness, dizziness and blurred vision with confusion. Additionally, the carbon monoxide will cause lips and skin to become red in color. Without treatment, the client will die.

A client weighing 166 pounds (75 kg) is brought to the emergency room with burns to the front and back of both legs and feet. Using the American Burn Association formula to calculate the amount of fluid needed for the first 24 hours, the nurse should set the infusion rate at what for the first eight hours? (Round to nearest whole number).

338 rationale: The American Burn Association formula is 2 - 4mL x weight in kilograms x total surface area burned. Based on the Rule of Nines for adults, a leg is 9% on the front and 9% on the back, which includes the feet. So both legs equal 36% (9% times 4) total surface area burned. The standard multiplier for thermal burns is considered to be 2 mL. Therefore: 2mL x 75 kg x 36 = 5,400 mL for 24 hours. Half that amount, or 2700 mL, should be infused in the first eight hours. Dividing that amount by 8 hours, the infusion rate would be 338 mL per hour.

A client is admitted to the ICU with diabetes insipidus following a head injury. Which finding would the nurse anticipate in this client? 1. Low serum hematocrit 2. High serum glucose 3. High urine protein 4. Low urine specific gravity

4 rationale: Diabetes insipidus is a condition that results from decreased ADH production. Therefore, the client will be diuresing large volumes of water which leads to a fluid volume deficit. We worry about shock in these clients. Keep in mind that concentrated makes #s go up and dilute makes #s go down in reference to specific gravity, sodium, and hematocrit. Here, the urine is very dilute which means the urine specific gravity will be low.

A client, who receives hemodialysis three times a week, has been placed on a fluid restriction of 1000 mL/day. What is the nurse's best action when the client is seen drinking a 12 ounce (360 mL) soft drink? 1. Take the soft drink away from the client. 2. Document the client is noncompliant. 3. Notify dietary to no longer send beverages with food trays. 4. Reinforce the importance of the fluid restriction with the client.

4 rationale: Educate the client on appropriate choices and lifestyle changes that are necessary to manage the client's condition.

The family of a client being treated for bleeding esophageal varices asks the nurse why the client is receiving octreotide. How should the nurse respond? 1. "Octreotide is an antibiotic given to decrease the risk of developing an infection." 2. "Taking this medication forms a protective barrier over the varices to prevent bleeding recurrence." 3. "Octreotide helps eliminate ammonia from the body." 4. "This medication lowers the pressure in the liver, so bleeding stops."

4 rationale: Octreotide is a synthetic hormone that selectively inhibits the release of vasodilating hormones in the internal organs. By doing this it decreases blood flow to the liver. When you decrease blood flow to the liver, the pressure in the liver lowers. Less volume, less pressure. So, bleeding should stop.

The nurse is assessing a client one hour post coronary artery bypass graft surgery (CABG). Based on the assessment data, what action should the nurse take? EXHIBIT Client increasingly more difficult to arouse. Skin cool/damp. Distended neck veins. Lungs clear bilaterally. Heart sounds distant. CVP 8 mm Hg. BP 90/60. 1. Administer stat dose of clopidogrel. 2. Notify cath lab to prepare for angioplasty. 3. Set up for a central catheter line. 4. Prepare for immediate pericardiocentesis.

4 rationale: The assessment findings point to cardiac tamponade, which is an emergency situation. Did you pick up on the classic s/s of this? Here we see the decreasing level of consciousness and evidence of poor perfusion from decreased cardiac output, distended neck veins from the backward pressure, muffled lung sounds from the fluid collection around the heart, increasing CVP, and the narrowing pulse pressure as the heart is being compressed. Treatment involves a pericardiocentesis to remove blood that has formed around the heart. The primary healthcare provider will insert a needle into the pericardial space to remove the fluid.

An adolescent is admitted to the psychiatric unit following a repeat suicide attempt. What is the nurse's priority action? 1. Have staff check on client once every hour. 2. Ask client to explain why suicide was a choice. 3. Place client in quiet seclusion with lights off. 4. Assign a staff member to stay with the client.

4 rationale: The client is newly admitted following a repeat suicide attempt and therefore safety is the priority issue. The client should not be left alone, even when using the bathroom, until the primary healthcare provider determines the risk of suicide has abated.

During a clinic visit 3 months following a client's diagnosis of type 2 diabetes, the client reports following a 1200 calorie diet and did not bring their glucose-monitoring record. The nurse will anticipate the prescription of which laboratory test? 1. Fasting blood glucose test 2. Urine glucose test 3. Glucose tolerance test (GTT) 4. Glycosylated hemoglobin level (HbA1C

4 rationale: The glycosylated hemoglobin (Hb A1C) test identifies the average serum glucose attached to hemoglobin over 90 days. The 90 days is correlated with 90 day life of hemoglobin. This test is reflective of how well the client's diabetes is controlled. The client has no restrictions prior to the test.

The nurse is caring for a client post cardiac catheterization that was performed via the right femoral artery. What assessment finding in the right lower extremity would be of concern to the nurse? 1. Right pedal pulse 2+/4+. 2. Capillary refill 2 seconds. 3. Erythema. 4. Slight oozing of blood.

4 rationale: The number 1 complication is bleeding. So slight oozing of blood is a problem. Assume the Worse! This is bleeding and you must do something.

Which initial arterial blood gas (ABG) results would the nurse likely see in a client who has overdosed on acetylsalicylic acid (ASA)? 1. pH 7.50, PaCO2 42, PaO2 63, SaO2 91, HCO3 28 2. pH 7.32, PaCO2 36, PaO2 83, SaO2 95, HCO3 19 3. pH 7.28, PaCO2 28, PaO2 72, SaO2 90, HCO3 16 4. pH 7.48, PaCO2 30, PaO2 88, SaO2 92, HCO3 24

4 rationale: his ABG result indicates respiratory alkalosis. Initially, acetylsalicylic acid stimulates the respiratory center and causes an increase in respiratory rate and depth. This causes respiratory alkalosis by blowing off CO2 and causing the pH to increase. Losing CO2 (acid) makes the client more alkalotic, which is reflected with an increased pH, decreased PaCO?2 and normal HCO?

A client arrives at the clinic with reports of persistent vomiting, weakness and leg cramps. The nurse notes that the client is irritable. BP 102/58, HR 108, RR 14. Based on this data, what acid/base imbalance does the nurse expect? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

4 rationale: Symptoms of alkalosis are often due to associated potassium loss and may include irritability, weakness, and cramping. Excessive vomiting eliminates gastric acid and potassium, leading to metabolic alkalosis.

What does the nurse need to remember when caring for clients on the oncology unit who have a radiation implant? SATA 1. Nursing assignments should be rotated weekly. 2. The nurse should care for no more than 3 clients with a radiation implant per shift. 3. Limit visitors to 60 minutes per day. 4. Wear film badge throughout assigned shift. 5. Educate visitors to stay at least 6 feet from the client.

4,5 rationale: Wear a film badge at all times so that you know how much radiation you are getting.Visitors should stay at least 6 feet from the source to decrease exposure to radiation. The closer you get the more radiation exposure.

How would the nurse interpret this client's Arterial Blood Gas (ABG) results? pH: 7.44 PaCO2: 51 mm Hg Bicarb: 31 mEq/liter PaO2: 91 mm Hg SaO2: 91% SATA 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

4,7 rationale: The pH is on the alkalosis side of normal (7.35-7.45). Anything above 7.0 is on the alkalotic side of normal. Look at the CO2. The CO2 is high, which indicates acidosis, so this does not match the alkalotic pH, does it? No. Look at the Bicarb. The bicarb is high, indicating alkalosis, so there is your match. The bicarb is higher than 26, so there is a lot of base in the body. So, this is metabolic alkalosis. Has compensation begun? Yes. The PaCO2 is high. The lungs are attempting to compensate by holding on to carbon dioxide, an acid, to make the pH normal. Since the pH is normal, full compensation has occurred.