NUR 124 Final Practice Test Questions

A client is scheduled for a serum cortisol level. When would the nurse anticipate the test specimen to be drawn? a) 7 am b) Noon c) 4 pm d) 10 pm

a) 7 am Because of the diurnal variation of cortisone levels, the highest level is in the morning, when the client awakens. It is lowest before going to sleep. The other listed times would not be representative of providing accurate information about adrenal function. (Lewis, et al, 8 ed., p. 1215.)

A client with type 2 diabetes is going to have major abdominal surgery. How will the nurse anticipate controlling blood sugar levels in this client during the immediate postoperative period? a) Keeping the client NPO until blood sugar levels are stable b) Daily administration of oral hypoglycemics c) A 1500-calorie diet as soon as tolerated d) Insulin on a sliding scale basis

d) Insulin on a sliding scale basis In the first few hours and/or days after surgery, the blood sugar frequently fluctuates. Even though the client has type 2 diabetes, insulin is often used to control the blood sugar in the first few postoperative days. The oral hypoglycemics do not provide a predictable, even control of blood sugar. Dietary control and reestablishment of oral hypoglycemics will begin during the client's recovery phase. (Lewis, et al, 8 ed., pp. 339, 348.)

The nurse is caring for a client with a suspected intestinal obstruction. In what order would the nurse perform the abdominal assessment? (1-4). _Auscultate for presence of bowel sounds. _Observe the contour of the abdomen. _Palpate to determine areas of tenderness. _Percuss to identify solid areas versus air.

1) Observe the contour of the abdomen. 2) Auscultate for presence of bowel sounds. 3) Palpate to determine areas of tenderness. 4) Percuss to identify solid areas versus air. Assessment of the abdomen should include inspection first to observe for contour, symmetry, and any skin abnormalities. Auscultation is the next step. This is done prior to palpation and percussion to prevent the alteration of bowel sound. Next, palpation is used to detect any tenderness or rigidity. Finally, percussion is performed to determine if any fluid, distention, or masses exist. (Lewis, et al, 8 ed., p. 908-910.)

What is a characteristic symptom of hypoglycemia that should alert the nurse to an early insulin reaction? a) Diaphoresis b) Drowsiness c) Severe thirst d) Coma

a) Diaphoresis Diaphoresis and a shaky feeling (nervousness) are early signs of hypoglycemia. Severe thirst is a sign of hyperglycemia, whereas drowsiness and coma are late symptoms of hypoglycemia. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 1245.)

A client states that he has been maintaining good control of his diabetes. This would be reflected in a glycosylated hemoglobin (HbA1C) level of: a) Less than 7% b) Greater than 8% c) Less than 10% d) Between 11% and 13%

a) Less than 7% For good diabetic blood sugar control, the HbA1C level should be lower than 7%. The serum test result reflects about 120 days of average control of the blood sugar level. (Lewis, et al, 8 ed., p. 1223.)

The nurse practitioner orders half-strength enteral formula at a rate of 55 mL/hr. A can holds 250 mL. How many cans would the nurse need for the next 24 hours? Fill in the blank. _____ cans.

3 cans 55 mL/hr × 24 hr/day = 1320 total cc for 24 hours or 5.28 cans ÷ 2 (half-strength) = 2.64 cans or 3 cans.

The nurse practitioner orders an enteral formula at a rate of 50 mL/hr. A can holds 250 mL. How many cans would the nurse need for the next 24 hours? ______ cans.

5 cans 50 × mL/hr × 24 hours/day = 1200 total mL for 24 hours 1200 mL/24 hr ÷ 250 mL/can = 4.8 cans or 5 cans.

The nurse understands that a helpful acronym for diabetes is the 3 Ps. Pheochromocytoma can be characterized by 5 Ps, which are: Select all that apply. a) Pressure (BP) increases b) Polyuria c) Palpitations d) Pitting edema e) Perspiration—profuse and generalized f) Pain—headache, chest, and abdominal

a, c, d, e, f These symptoms (elevated BP, palpitations, pallor, perspiration, and pain) are associated with hypertension that is noted in pheochromocytoma. In addition to these symptoms, other clinical findings include weight loss, constipation, hypertensive retinopathy, hyperglycemia, and hypercalcemia. Polyuria is associated with diabetes mellitus. Pitting edema is present in clients with heart failure. (Lewis, et al, 8 ed., p. 1284.)

The nurse is titrating the IV administration of dopamine for treatment of a client's decreased blood pressure. In assessing for the desired response to this medication, the nurse would anticipate: a) An increase in the urinary output b) A substantial decrease in the blood sugar level c) An increase in pulse with a decrease in pulse deficit d) An improvement in the quality of breath sounds

a) An increase in the urinary output An increase in blood pressure will increase cardiac output, which ultimately increases renal perfusion and urinary output. The other options do not represent the desired action of the medication for this client. (Lehne, 7 ed., p. 157.)

A 70-year-old man is admitted to the hospital for elective repair of an abdominal aortic aneurysm. The client's history includes hypertension, hyperlipidemia, and smoking. The client asks the nurse what caused the aneurysm. The nurse's response would be based on what information? a) Aneurysms are caused most often by atherosclerotic plaque formation, which damages the arterial wall. b) A congenital defect in the arterial wall allows for dilatation of the wall and formation of the aneurysm. c) Chronic hypertension and increased cholesterol cause the weakness in the intima layer of the arterial wall. d) A history of heart disease and renal problems are frequently the cause of the damage to the arterial wall.

a) Aneurysms are caused most often by atherosclerotic plaque formation, which damages the arterial wall. Atherosclerosis is a primary contributing factor to the development of an aneurysm. Male gender, age 65 years or older, and tobacco use are major risk factors for AAAs of atherosclerotic origin. Other risk factors include high BP, PAD, CAD, and hyperlipidemia. This client has most all of these risk factors. (Lewis, et al, 8 ed., p. 868.)

The nurse is planning care for a client scheduled for esophagogastroduodenoscopy (EGD) and a barium swallow. What will the nursing care plan include? a) Anticipating the client will receive a clear liquid diet in the evening and then receive nothing by mouth (NPO status) 6 to 12 hours before the test. b) Discussing with the client the NG tube and the importance of gastric drainage for 24 hours after the test. c) Explaining to the client that he will receive nothing by mouth (NPO status) for 24 hours after the test to make sure his stomach can tolerate food. d) Discussing the general anesthesia and explaining to the client that he will wake up in the recovery room

a) Anticipating the client will receive a clear liquid diet in the evening and then receive nothing by mouth (NPO status) 6 to 12 hours before the test. NPO status before a barium swallow and a esophagogastroduodenoscopy (EGD) and a clear liquid diet the evening before the procedures are routine orders for these tests. There is no general anesthesia. The client can eat or drink as tolerated after procedure, and there is no routine placement of NG tubes. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 915.)

A client has sclerotherapy for treatment of his superficial varicose veins. What would the nurse include in the discharge teaching for this client? a) Apply your antiembolism stockings every morning before you get out of bed. b) Take an aspirin every day to prevent the development of clots in your legs. c) Avoid prolonged sitting; stand whenever you can. d) Walk rather than run for your exercise.

a) Apply your antiembolism stockings every morning before you get out of bed. Antiembolism stockings should be applied when the venous pressure is decreased to avoid trapping fluids in the legs. This reduces the venous pressure in the lower extremity. Walking is recommended to prevent the problem and should be continued; however, it does not have significant value in caring for the legs after sclerotherapy. Aspirin would not be recommended after sclerotherapy. Standing for long periods increases venous pressure and is not recommended. (Lewis, et al, 8 ed., p. 891.)

The client returns to his room after a thoracotomy. What will the nursing assessment reveal if hypovolemia from excessive blood loss is present? a) CVP of 3 cm H2O and urine output of 20 mL/hr b) Jugular vein distention with the head elevated 45 degrees c) Chest tube drainage of 50 mL/hr in the first 2 hours d) Increased BP and increased pulse pressure

a) CVP of 3 cm H2O and urine output of 20 mL/hr A low-range CVP reading and the decrease in urine output would be associated with hypovolemia caused by hemorrhage. Normal CVP is 2 to 6 cm H2O. The decrease in urine output is reflective of poor renal perfusion. Jugular vein distention is indicative of increased CVP, which does not occur with hypovolemia. Chest tube drainage is within the normal expectations. The blood pressure decreases with hemorrhage. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 1720.)

The nurse is assessing a client who had a transurethral resection of the prostate (TURP) 6 hours ago. He has a urinary catheter with continuous bladder irrigation running. What nursing observations would indicate a complication is developing? a) Catheter drainage of 50 mL in the past hour and increase in suprapubic pain b) Dark, grossly bloody catheter drainage with pieces of tissue c) Client states that he feels like he needs to void d) Moderate amount of bloody discharge from around the catheter

a) Catheter drainage of 50 mL in the past hour and increase in suprapubic pain The primary complication is the obstruction of the urinary catheter with clots or tissue. There should be a large amount of drainage from the catheter because the irrigating fluid is infusing into the bladder. The catheter drainage should be closer to 300 to 400 mL/hr. It is not unusual for the drainage to be grossly bloody on the operative day, but it should begin to clear over the next 24 hours. It is common to have a feeling of needing to void with a catheter in place. (Lewis, Dirksen, Heitkemper, et al, 8 ed., pp. 1383-1386.)

The nurse is assessing a client who is recovering from a surgery that was performed under a local anesthetic. The client's speech has become very slurred. What would be the nurse's priority action? a) Check IV placement, blood pressure, pulse, and respiratory status. b) Recognize this as a symptom of anxiety and encourage the client to sleep off the effects. c) Determine whether the client consumed a large quantity of alcohol before surgery. d) Do nothing because this frequently occurs in clients who receive large doses of local anesthetics.

a) Check IV placement, blood pressure, pulse, and respiratory status. It is important for the nurse to recognize that this is an abnormal symptom. The nurse should check the IV for patency in case rapid treatment is needed and obtain a complete set of vital signs to assess for cardiovascular effects. The nurse should complete the appropriate assessments, given the change in the client's condition. Client alcohol consumption should have been determined before the procedure. The client's change in condition should be assessed appropriately, and the nurse should contact the health care provider and provide a condition report after the assessment. (Lewis, et al, 8 ed., pp. 367-374.)

A client is admitted with a history of gastrointestinal bleeding. His hemoglobin (Hgb) is 9.6 g/dL, and the hematocrit (Hct) is 30%. A nasogastric tube has been inserted and connected to low suction. Which order would the nurse question? a) Clear liquids as tolerated b) Vital signs every 2 hours c) Type and cross-match for 2 units of blood d) Bed rest with bathroom privileges

a) Clear liquids as tolerated If a client has an NG tube, he is absolutely NPO. The only exception is occasional ice chips for oral comfort; he should not have clear liquids. All of the other options are appropriate orders for this client. (Lewis, et al, 8 ed., p. 995.)

The nurse is caring for a client postoperative for a thyroidectomy. Which observation should the nurse be most concerned about? a) Client's wrist spontaneously flexes when the blood pressure cuff is tightened. b) Client complains of soreness around the throat. c) Client has blood pressure of 140/90 mm Hg, pulse of 90 beats/min, respiration of 18 breaths/min. d) Client supports her neck with both hands when turning.

a) Client's wrist spontaneously flexes when the blood pressure cuff is tightened. Spontaneous flexing of the wrist is an early indication of carpal spasms, which may be indicative of hypocalcemia or tetany (Trousseau sign). Soreness around the throat would be expected. Blood pressure is elevated and should be monitored, but this is not as critical as the hypocalcemia. Nurses should encourage the client to support the head and neck when turning or changing positions after a thyroidectomy. (Lewis, et al, 8 ed., p. 1269.)

When assessing a client with a complaint of severe abdominal pain, the nurse notes that the abdomen is flat and firm with no bowel sounds. What diagnostic study would the nurse anticipate being ordered immediately? a) Complete blood count (CBC) and differential b) Serum electrolytes c) Hemoglobin S d) Coombs antiglobulin test

a) Complete blood count (CBC) and differential The client is demonstrating classic symptoms of appendicitis. The nurse would anticipate a differential white blood cell (WBC) count. Hemoglobin S is specific for sickle cell disease. Coombs antiglobulin test shows the presence of antigen-antibody complexes. (Lewis, et al, 8 ed., p. 1020.)

On the second day after gastric resection, the client's NG tube is draining bile-colored liquid containing coffee-ground material. What is the best nursing action? a) Continue to monitor the amount of drainage and correlate it with any change in vital signs. b) Reposition the NG tube and irrigate the tube with normal saline solution. c) Call the physician and discuss the possibility that the client is bleeding. d) Irrigate the NG tube with iced saline solution and attach the tube to gravity drainage.

a) Continue to monitor the amount of drainage and correlate it with any change in vital signs. Coffee-ground material is characteristic of old blood. Bright red bleeding would indicate hemorrhage. This is a normal occurrence on the third postoperative day and should be correlated with the vital signs. The tube is in the correct position since it is draining gastric secretions. There is no indication to notify anyone or to irrigate the NG tube. (Lewis, Dirksen, Heitkemper, et al, 8 ed., pp. 981, 998.)

A client has been diagnosed with Crohn's disease. The client asks the nurse when will he get well. The nurse's response would be based on what pathophysiologic principle of Crohn's disease? a) Crohn's disease is a chronic problem with periods of remissions and reoccurrences. b) After the initial treatment the client can expect to be cured and not have any further episodes of diarrhea. c) After the initial exacerbation and diagnosis, the condition is usually in remission and is easily controlled with medications. d) Most clients will require surgery and an ileostomy to control the diarrhea and to maintain a normal lifestyle.

a) Crohn's disease is a chronic problem with periods of remissions and reoccurrences. Remissions and unpredictable exacerbations are characteristic of Crohn's disease. The client may be able to control the diarrhea and inflammation with medications; other clients may choose to have surgery. The condition has no cure; it is chronic and the client is at an increased risk for the development of cancer. (Lewis, et al, 8 ed., p. 1022.)

The nurse is caring for a client immediately after repair of an abdominal aortic aneurysm. What changes in vital signs would cause the nurse the most concern? a) Decrease in blood pressure and increased pulse b) Decrease in blood pressure and decreased pulse c) Increase in blood pressure and increased pulse d) Increase in blood pressure and decreased pulse

a) Decrease in blood pressure and increased pulse As a result of extensive vascular surgery, the client is at increased risk for hemorrhaging and development of shock. Signs of shock consist of decreased blood pressure with increased pulse, compensating for the drop in the blood pressure. An increase in blood pressure with a decreased pulse may occur with increasing intracranial pressure. Increasing blood pressure and pulse may indicate anxiety or pain. Decreased blood pressure and decreased pulse may occur in the overly sedated client. (Lewis, et al, 8 ed., pp. 870-871.)

A client is started on continuous tube feedings of a full-strength commercial formula at 75 mL/hr. After about 12 hours of feeding, the client begins to have diarrhea stools. What would be the best nursing action? a) Decrease the tube feeding to 50 mL/hr. b) Do not administer any water via the tube. c) Check for residual, if above 50 mL, hold the feeding for 2 hours. d) Assess the abdomen for presence of peristalsis and distention.

a) Decrease the tube feeding to 50 mL/hr. Diarrhea shortly after beginning the feeding indicates poor tolerance of the feeding. The feeding can be slowed, or the concentration can be decreased. Water added to the feeding or used during irrigation does not cause diarrhea. Water is frequently used to dilute the feeding and increase absorption. The nurse may check for residual; however, a residual of 50 mL is not significant and does solve the problem with the diarrhea. The abdomen also may be assessed; however, this does not offer any information regarding the diarrhea. (Potter, Perry, 8 ed., p. 1111.)

The nurse is preparing a teaching plan for a client who is to have a colon resection and colostomy. It is anticipated that the client will have a nasogastric tube postoperatively. What is the purpose of the nasogastric tube? a) Decreases/prevents abdominal distention because the activity in the intestines will be slowed as a result of surgery b) Provides a method by which gastric contents can be measured after surgery to evaluate for complications c) Provides a means of administering a nutritional supplement because the client will not be able to eat after surgery d) Keeps the stomach secretions removed to protect the functioning of the colostomy in the early stages

a) Decreases/prevents abdominal distention because the activity in the intestines will be slowed as a result of surgery It is important to prevent abdominal distention in the client who has had bowel surgery until after peristalsis has returned, bowel sounds are evident, and the colostomy begins to function. Measuring gastric contents after surgery is unnecessary. The client will not need a nutritional supplement administered via the nasogastric tube, and keeping the stomach secretions removed does not protect the functioning of the colostomy. (Lewis, et al, 8 ed., p. 1017.)

Results of blood and urine tests return for a client diagnosed with Crohn's disease. The nurse understands that an increase in urine specific gravity and serum osmolarity would indicate what problem? a) Dehydration b) Insulin-dependent diabetes c) Hypoaldosteronism d) Diabetes insipidus

a) Dehydration Crohn's disease inflames the area around the cecum and the large bowel, causing increased peristalsis with subsequent diarrhea and loss of fluid, which is reflected in the blood work with hemoconcentration and elevated serum osmolality and urine specific gravity, which can lead to dehydration. Diabetes and hypoaldosteronism are not issues with Crohn's disease. (Lewis, et al, 8 ed., p. 1025.)

An adolescent with diabetes who has recently been started on insulin has asked whether disposable needles and syringes can be used more than once. What would be an appropriate nursing response? a) Disposable needles and syringes are safe for reuse if uncontaminated and recapped after each use. b) Disposable needles and syringes are acceptable for use in a 24-hour period. c) Disposable needles and syringes can be reused only if the client has no other means to purchase new ones. d) Disposable needles and syringes are not safe for reuse.

a) Disposable needles and syringes are safe for reuse if uncontaminated and recapped after each use. If disposable needles and syringes are handled in an aseptic manner and recapped after each use, they can be reused, which is certainly a cost-saving measure for the client. (Potter, Perry, 7 ed., p.749.)

A client returns to the unit after surgical creation of a continent diversion (Kock's pouch). What will the care of this ileostomy include? a) Draining the reservoir or pouch with a soft catheter b) Irrigating it with normal saline solution after 24 hours c) Attaching an ostomy bag with careful checking for watertight seal d) Assessing for skin excoriation and increased drainage caused by location of stoma

a) Draining the reservoir or pouch with a soft catheter The reservoir must be drained on a regular schedule with insertion of a soft catheter. This usually begins when the client starts eating and stool begins to form. The client is taught how to catheterize his stoma whenever he feels any dilatation. The potential for fluid and electrolyte imbalance is decreased, the stoma is not pouched on continuous bases, and the stoma should not leak. (Lewis, et al, 8 ed., p. 1157.)

A client is taking psyllium (Metamucil) for chronic constipation. What will be important for the nurse to teach the client about this drug? a) Drink an 8 oz glass of water when the medication is taken. b) Use the medication only when constipated, prolonged use causes dependence. c) Limit fluid intake for 2 hours after taking the medication. d) Take a multivitamin daily with the medication.

a) Drink an 8 oz glass of water when the medication is taken. A high fluid intake is needed when patients are using bulk-forming laxatives to avoid worsening constipation. Although bulk-forming laxatives are generally safe, the nurse should encourage the client to increase fluid intake to prevent the possibility of constipation resulting from inadequate fluid intake. A multivitamin daily is okay, but it has nothing to do with the medication. (Lilley, 6 ed., p. 803.)

The nurse is caring for a client who is 6 hours postpartum. What nursing actions are directed toward the prevention of postpartum thrombophlebitis? a) Encourage early ambulation and increased fluid intake. b) Allow bathroom privileges only and elevate the lower extremities. c) Administer anticoagulants and evaluate the clotting factors. d) Encourage the client to breastfeed the infant as soon as possible.

a) Encourage early ambulation and increased fluid intake. Early ambulation is the most effective and safe way to prevent thrombophlebitis with any type of client. This promotes venous return and prevents venous stasis. Anticoagulants (heparin and Coumadin) are administered as ordered in postpartum with a diagnosis of thrombophlebitis; they are not used for prevention. The legs should be elevated when the client is in a sitting position. There is no evidence that breastfeeding in any way affects blood coagulation. (Lowdermilk, Perry, Cashion, et al, 10 ed., pp. 822-823. Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 885.)

What is the priority nursing action for the client who is complaining of nausea in the recovery room after gastric resection? a) Evaluate the NG tube for patency. b) Call the physician for an antiemetic order. c) Place client in semi-Fowler's position so that he will not aspirate. d) Medicate the client with a narcotic analgesic.

a) Evaluate the NG tube for patency. Evaluate the NG tube patency; it is important to prevent the nausea and vomiting. The next action would be to put the client in semi-Fowler's position. It is very important to assess the client and take nursing measures to determine the source of the nausea and to decrease the nausea before calling the doctor. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 998.)

A client with pancreatitis has a nasogastric tube in place, and it is attached to wall suction. The nurse notices that very little drainage is in the container. What should the first action of the nurse be? a) Evaluate the client for distention. b) Check the tubing for blockage. c) Pull the tube out approximately 3 inches and then re-insert it. d) Remove and replace the tube with a smaller size tube.

a) Evaluate the client for distention. The nurse should check the client first and then the equipment. If the client's abdomen is soft and is not distended and the client has no complaints of nausea, a problem may not exist. If distention and/or nausea occur, the nurse should check the tubing for blockage. As with any drainage equipment, the nurse should start the assessment on the body first and then evaluate the equipment. (Potter, Perry, 7 ed., p. 1210.)

A client is receiving NPH insulin 20 units subcutaneously at 0700 hours daily. At 1500 hours, the nurse finds the client apparently asleep. How would the nurse know whether the client was having a hypoglycemic reaction? a) Feel the client and bed for dampness. b) Observe the client for Kussmaul respirations. c) Smell the client's breath for acetone odor. d) Note if the client is incontinent of urine.

a) Feel the client and bed for dampness. When clients are sleeping, the only observable symptom of hypoglycemia is diaphoresis. Kussmaul breathing and acetone odor to breath are indicative of hyperglycemia. Incontinence is not associated with hypoglycemia and polyuria may be associated with hyperglycemia. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 1245.)

The nurse would understand that moist skin with fine hair, prominent eyes, lid retraction, and a staring expression are characteristics associated with: a) Graves disease b) Multiple sclerosis c) Cushing's syndrome d) Diabetes

a) Graves disease Graves disease, or hyperthyroidism, is an autoimmune disorder affecting the thyroid gland that has the following symptoms: moist skin, fine hair, prominent eyes, tachycardia, hypertension, and a staring expression. Multiple sclerosis is an autoimmune disorder of the nervous system and is characterized by muscle weakness and visual field disturbances (diplopia). Cushing's syndrome is caused by hypersecretion of corticosteroids by the adrenal glands and is characterized by thinning hair, hirsutism in women, gynecomastia in men, moon face, buffalo hump, abdominal striae, weight gain, truncal obesity, thin limbs, acne, hypertension, and mood changes. Diabetes is characterized by polyuria, polyphagia, and polydipsia. (Lewis, et al, 8 ed., p. 1264.)

The nurse is working in a gynecologic clinic. A woman comes in complaining of a white "cheesy" vaginal discharge. On examination, the nurse observes erythema of the labia. What would be important for the nurse to determine? a) Has the woman taken a wide-spectrum antibiotic lately? b) Does the woman's sexual partner have any symptoms? c) Does the woman experience any pain during intercourse? d) When was the woman's last menstrual period?

a) Has the woman taken a wide-spectrum antibiotic lately? Candidiasis is a very common vaginal yeast infection. It is frequently precipitated by taking antibiotics. Pregnancy, birth control pills, diabetes, and a multitude of other conditions can also precipitate the problem. Painful intercourse may occur from the irritation of the vaginal area but is not important in determining the cause of the problem. It is not considered a sexually transmitted disease, but intercourse may introduce additional bacteria. The last menstrual period has no relevance. (Lehne, 7 ed., p. 1064; Lewis, et al, 8 ed., p.1356.)

A client is diagnosed with chronic pancreatitis. What would the nurse expect to find as findings for this condition on the assessment? a) Hyperglycemia b) Elevated body temperatures c) Increase in weight d) Low blood pressure

a) Hyperglycemia The client with chronic pancreatitis has symptoms related to destruction of the pancreatic cells, which leads to increased blood sugar and weight loss. Low-grade fever is an indication of acute pancreatitis. (Lewis, et al, 8 ed., pp. 1089, 1093.)

After a thyroidectomy, the nurse assesses the client for possible complications. The nurse determines the client is experiencing tingling and numbness of the fingers and toes, muscle twitching, and muscle spasms. What complication may be developing? a) Hypocalcemia b) Hypovolemia c) Hyponatremia d) Hypokalemia

a) Hypocalcemia Accidental removal or damage to the parathyroid glands, which regulate calcium metabolism, can occur during a thyroidectomy. The symptoms of a decreased calcium level (hypocalcemia, tetany) relate to the decrease in the calcium levels secondary to a decrease in the parathyroid hormone level. (Lewis, et al, 8 ed., pp. 318, 1263, 1269.)

When providing care to a client with a diagnosis of panhypopituitarism, the nurse would expect which findings on the admission assessment? a) Hypotension b) Hyperglycemia c) Tachycardia and cardiac palpitations d) Decreased ACTH and cortisol

a) Hypotension Clients with panhypopituitarism have no circulating pituitary hormones. Hypotension and hypoglycemia occur, along with bradycardia (because of a decrease in thyroid hormones). Serum ACTH and cortisol levels will be low. Changes may be noted in the secondary sex characteristics resulting from loss of those hormones from the anterior pituitary (FSH and LH). (Lewis, et al, 8 ed., p. 1258.)

The nurse is assigned to care for a new client with acute pancreatitis. What would the nurse anticipate finding during the assessment of this client? a) Hypotension, abdominal pain, fever b) Fever, hypoglycemia, dehydration c) Melena, persistent vomiting, hyperactive bowel sounds d) Hypoactive bowel sounds, decreased amylase and lipase levels

a) Hypotension, abdominal pain, fever Symptoms of acute pancreatitis are steatorrhea (fatty stools), hyperglycemia, elevated lipase and amylase levels, abdominal pain with muscle guarding, nausea, vomiting, and fever. Hypotension, jaundice, and tachycardia may also be present. Bowel sounds are most often hypoactive or absent, and there is no melena present. (Lewis, Dirksen, Heitkemper, et al, 8 ed., pp. 1089-1090.)

A client is being treated with dopamine (Intropin) and dobutamine (Dobutrex) for septic shock. What is the desired therapeutic effect of these two drugs? a) Increased myocardial contractility and cardiac output without increased oxygen demand b) Decreased renal perfusion and peripheral vasodilatation c) Decreased cardiac output, vasodilatation, and increased blood pressure d) Increased renal perfusion, increased blood pressure, and decreased myocardial contractility

a) Increased myocardial contractility and cardiac output without increased oxygen demand Dopamine (Intropin) increases myocardial contractility, which increases cardiac output and oxygen delivery to vital tissues. It also causes vasoconstriction and ventricular dysrhythmias. Dobutamine (Dobutrex) usually is given in conjunction with dopamine because it has a vasodilation effect, improves cardiac output, and is less likely to cause dysrhythmias. (Lehne, 7 ed., p. 157.)

In interpreting a radioactive iodine uptake (RAIU) test, the nurse would know that RAIU: a) Increases in hyperthyroidism and decreases in hypothyroidism b) Decreases in hyperthyroidism and increases in hypothyroidism c) Increases in both hyperthyroidism and hypothyroidism d) Decreases in both hyperthyroidism and hypothyroidism

a) Increases in hyperthyroidism and decreases in hypothyroidism RAIU increases in hyperthyroidism and decreases in hypothyroidism. Iodine is necessary for the synthesis of thyroid hormones. In hyperthyroidism, more iodine is taken up by the thyroid, so more thyroid hormones may be synthesized. In hypothyroidism, less iodine is taken up because fewer thyroid hormones are synthesized. (Lewis, et al, 8 ed., p. 1266; Ignatavicius, Workman, 7 ed., p. 1396.)

The nurse is caring for a client who has been diagnosed with a bleeding duodenal ulcer. What data identified on a nursing assessment would indicate an intestinal perforation and require immediate nursing action? a) Increasing abdominal distention, with increased pain and vomiting b) Decreasing hemoglobin and hematocrit with bloody stools c) Diarrhea with increased bowel sounds and hypovolemia d) Decreasing blood pressure with tachycardia and disorientation

a) Increasing abdominal distention, with increased pain and vomiting Perforation is characterized by increasing distention and boardlike abdomen. There is frequently increasing pain with fever and guarding of the abdomen. Peritonitis occurs rapidly. The nurse should maintain the client NPO, keep the client on bed rest, and immediately notify the physician. Decreasing hemoglobin and hematocrit and decreasing blood pressure are associated with hemorrhage rather than perforation. Remember to select an answer that reflects what the question is specifically asking. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 995.)

After a transurethral resection of the prostate (TURP), a client has a three-way urinary catheter with continuous bladder irrigation. The nurse is preparing to hang another container of solution to the bladder irrigation. The nurse would obtain what type of solution? a) Isotonic sterile irrigating solution b) Distilled, sterile water c) Normal saline solution with 2000 units of heparin d) Nonsterile saline irrigating fluid

a) Isotonic sterile irrigating solution The isotonic sterile irrigating solution is critical to prevent absorption of the irrigation fluid, which could result in fluid overload. Distilled water should never be used for irrigations, and the solution for continuous bladder irrigation should always be sterile. Heparin would not be used. (Lewis, et al, 8 ed., p. 1384.)

A client is taking ranitidine (Zantac) for treatment of his peptic ulcer disease. What would be important for the nurse to teach the client regarding the administration of this medication? a) It should not be taken within an hour of taking an antacid. b) It should be taken with food. c) It should be taken only when gastric symptoms are present. d) NSAIDs may be taken for gastric discomfort.

a) It should not be taken within an hour of taking an antacid. Antacids containing magnesium and aluminum will decrease the effectiveness of the medication, ranitidine (Zantac). For best results, it should be taken after meals and at bedtime. It should be taken on a regular basis, and NSAIDs should not be taken by a client with peptic ulcer disease. (Lilley, 6 ed., p. 790.)

A woman is newly diagnosed with Raynaud's disease. What would be important for the nurse to teach this client? a) Keep your hands warm, wear gloves when handling cold objects. b) Maintain regular exercise of about 30 minutes each day. c) Return to the clinic for blood pressure checks. d) Avoid prolonged standing.

a) Keep your hands warm, wear gloves when handling cold objects. Raynaud's disease primarily affects the fingers bilaterally. There are spasms of the arterioles in the fingers, causing numbness and tingling. The client should be advised to keep her hands warm and not exposed to cold temperatures. The other options are not relevant to Raynaud's disease. (Lewis, et al, 8 ed., p. 882.)

Before initiating a preoperative teaching plan for a client scheduled for craniotomy, what is a priority nursing assessment? a) Level of consciousness b) Educational background c) Age d) Health history

a) Level of consciousness Although the client may have impaired cognition, preoperative teaching should be individualized according to the level of consciousness of the client. The health history would have been obtained from the client or family on admission. Although educational background and age are important considerations for providing teaching at an appropriate level for the client, these are not priorities. (Lewis, et al, 8 ed., pp. 52-55.)

A client is recovering from an acute episode of thrombophlebitis and is being treated with warfarin (Coumadin). In planning discharge teaching, it would be important for the nurse to include what information? a) Maintain a constant intake of cauliflower, mayonnaise, and green leafy vegetables. b) Limit dairy products because they tend to decrease medication effectiveness. c) Do not walk for exercise; aerobic exercises are more effective. d) Maintain a daily record of intake and output to evaluate renal function.

a) Maintain a constant intake of cauliflower, mayonnaise, and green leafy vegetables. Although Vitamin K is an antidote for Coumadin and green, leafy vegetables, mayonnaise, and cauliflower are rich sources of the Vitamin, the client does not have to avoid these foods. Instead they need to keep a constant, consistent intake, so that Coumadin doses can be adjusted according to their dietary practice. There is no interference with Coumadin's anticoagulation from dairy products. Clients should be encouraged to exercise. It is not necessary for the client to monitor daily intake and output.(Lehne, 7 ed., p. 608; Lilley, 6ed., p. 438.)

A client with a history of an abdominal aortic aneurysm is admitted for surgical repair. During the nursing assessment on admission the client begins to complain of severe back pain. His vital signs are BP 100/60, pulse 130, respirations 30. The nurse notifies the surgeon regarding the client's status. What would the nurse anticipate the treatment to include? a) Maintain bed rest, keep client NPO, and prepare for emergency surgery. b) Notify radiology for a stat x-ray of the abdomen and closely monitor vital signs. c) Prepare for a paracentesis to determine presence of blood in the abdomen. d) Prepare for insertion of a pulmonary artery catheter to monitor cardiac status.

a) Maintain bed rest, keep client NPO, and prepare for emergency surgery. The client is exhibiting symptoms of a ruptured aneurysm and developing hypovolemic shock. The nurse should anticipate emergency surgery. The client should be kept in a supine position and an IV line should be established if time permits and oxygen started. The emphasis is to get the client into the operating room as soon as possible because of the hemorrhage from the ruptured aneurysm. (Lewis, et al, 8 ed., p. 869.)

The child has a nasogastric (NG) tube in place and is connected to suction. The child is complaining of nausea, and minimal drainage is in the NG tube. What would be the first action by the nurse? a) Make sure the suction is working and check the tube for kinks. b) Irrigate the NG tube with 30 mL sterile normal saline. c) Notify the physician about the nausea. d) Reposition the NG tube and observe for increased drainage.

a) Make sure the suction is working and check the tube for kinks. The least invasive and quickest approach is to begin outside of the client. The nurse should first check NG tube and external equipment for blockage or malfunctions. The nurse would then reposition the child, validate tube placement, and irrigate the tube to check for patency. If the nausea continues, the NG tube may need to be repositioned, depending on the child's condition. If the child continues to complain of nausea after these measures, the physician should be notified. (Hockenberry, Wilson, 9 ed., p. 1123.)

A client with rheumatoid arthritis has a history of long-term nonsteroidal antiinflammatory drug (NSAID) use and has developed peptic ulcer disease. Which medication would the nurse anticipate administering? a) Misoprostol (Cytotec) b) Ticlopidine (Ticlid) c) Cyanocobalamin (vitamin B12) d) Prednisolone (Prelone)

a) Misoprostol (Cytotec) Misoprostol (Cytotec) is a gastric antisecretory agent, which reduces acid secretion from the gastric parietal cell, stimulates bicarbonate production from gastric and duodenal mucosa, and replaces the protective prostaglandins. NSAIDs decrease prostaglandin synthesis. Cyanocobalamin is used to treat vitamin B12 deficiency. Ticlopidine is an antiplatelet agent used to reduce the risk of stroke. Prednisolone is a glucocorticoid used to treat several inflammatory disorders and contributes to gastric ulcer development. (Lilley, 6 ed., p. 792.)

A client had surgical removal of her thyroid gland because of hyperthyroidism. The nurse is assessing for complications on the first postoperative day. Symptoms that would confirm the client is experiencing a complication would be: a) Muscle spasms and a positive Chvostek sign b) A rash over the trunk and decreased peristalsis c) Back pain with nausea and vomiting d) Urinary output of 300 mL in 8 hours

a) Muscle spasms and a positive Chvostek sign Tetany is a postoperative complication of thyroidectomy surgery. This may occur if the parathyroid glands were accidentally damaged or removed. The problem occurs because of low calcium levels. The symptoms of tetany are muscle spasms and positive Chvostek and Trousseau signs. (Lewis, et al, 8 ed., pp. 318, 1263, 1269.)

The nurse is assigned to care for a new client with acute pancreatitis. What would the nurse anticipate finding on the assessment of this client? a) Nausea and vomiting, severe abdominal pain, fever b) Fever, hypoglycemia, dehydration c) Melena, persistent vomiting, hyperactive bowel sounds d) Hypoactive bowel sounds, bradycardia, abdominal distention

a) Nausea and vomiting, severe abdominal pain, fever Symptoms of acute pancreatitis are steatorrhea (fatty stools), hyperglycemia, elevated lipase and amylase levels, severe abdominal pain with muscle guarding, fever, and nausea and vomiting. Hypotension, jaundice, and tachycardia may also be present. Bowel sounds are most often hyperactive, and no melena is present. (Lewis, et al, 8 ed., p. 1091.)

On the first postoperative day, a client who had a gastroduodenostomy begins to complain of increasing abdominal pain. The nurse determines the bowel sounds are absent, and there is about 250 mL of bright red gastric drainage over the past hour. What would be the priority nursing intervention? a) Notify the health care provider and maintain the client on bed rest. b) Irrigate the nasogastric tube with 50 mL of cool normal saline. c) Administer an analgesic and monitor the vital signs every hour. d) Determine placement of the nasogastric tube, readjust for adequate drainage.

a) Notify the health care provider and maintain the client on bed rest. Pain and bright red bloody drainage are concerns in this postoperative client. The nurse should be concerned about the possibility of hemorrhage; the surgeon or health care provider should be notified regarding the changes in the client's condition. The nasogastric tube is draining; therefore it does not need to be irrigated or readjusted. The client may need an analgesic for pain; however, an analgesic could mask the development of shock. (Lewis, et al, 8 ed., p. 998.)

The nurse is making an initial client assessment. The client has a peripheral parenteral nutrition infusing, and the bag is almost empty. A new bag is not yet available from the pharmacy. What is the best nursing action? a) Plan on hanging D5W until the new solution is available. b) Slow the rate of infusion until the new solution arrives. c) Flush the line with a heparin flush solution and hang new solution when it arrives. d) Slow infusion and periodically check the client's blood glucose until solution is available.

a) Plan on hanging D5W until the new solution is available. The nurse should plan to hang a solution of D5W until the parenteral solution is available. This will assist to prevent problems with hypoglycemia. This is a peripheral parenteral solution, not a parenteral solution in a central line; therefore there is not a highly concentrated solution infusing. The nurse should not decrease the rate of infusion, and the line should not be flushed with heparin solutions. Monitoring the blood glucose is appropriate, but the solution rate should not be slowed. (Lewis, et al, 8 ed., p. 938.)

The nurse is preparing to administer spironolactone (Aldactone) to a client. After assessing the client, what data indicate the need to withhold the medication? a) Potassium level of 5.8 mEq/L b) Apical pulse rate of 58 beats/min c) BP of 130/90 mm Hg d) Urine output of 30 mL/hr

a) Potassium level of 5.8 mEq/L Aldactone is a potassium-sparing diuretic. The client's potassium level is high; therefore, the medication should be held, and the doctor should be notified. Urine output of 30 mL/hr is normal output. The BP is elevated, which is the reason the client is receiving the medication. The pulse rate is not affected by this medication. (Lehne, 7 ed., p. 450.)

A young client has uncontrolled diabetes and is admitted to the hospital. Which complication would be a priority for the nurse? a) Progressive dehydration b) Lactic acidosis c) Hyperinsulinemia d) Glucosuria

a) Progressive dehydration Failure to recognize emerging diabetic ketoacidosis caused by uncontrolled diabetes can lead to progressive dehydration, ketosis, acidosis, circulatory collapse, tissue hypoxia, and shock. The dehydration would be a priority. Once tissue hypoxia occurs, it results in lactate accumulation and lactic acidosis, which dramatically decreases the rate of survival. Insulin levels would not be elevated (hyperinsulinemia) in uncontrolled diabetes. (Lewis, et al, 8 ed., p. 1242-1243.)

A hospitalized client is diagnosed with diarrhea caused by the Clostridium difficile. What would be a priority nursing action for this client? a) Put the client in a private room and initiate contact precautions. b) Monitor fluid loss from excessive vomiting. c) Explain to the client that he should drink only clear liquids for next 24 hours. d) Discuss with client and family hand washing and proper food handling.

a) Put the client in a private room and initiate contact precautions. Clostridium difficile> is highly contagious. The client should be placed in a private room and contact precautions should be initiated to prevent the spread of this organism to other clients. Adequate fluid intake is important; restriction of fluids to clear liquids may not be necessary; diet would be considered after establishing contact precautions. The problem most often occurs after a round of antibiotics, especially after administration of some of the penicillin and cephalosporin drug groups. (Potter, Perry, 7 ed., p. 663.)

The nurse is assessing a child with a tentative diagnosis of appendicitis. The nursing assessment is most likely to reveal what characteristics concerning the pain? a) Rebound tenderness in the right lower quadrant, associated with decreased bowel sounds and vomiting b) Gnawing pain, radiating through to the lower back, with severe abdominal distention c) Sharp pain with severe gastric distention, frequently associated with hemoptysis d) Pain on light palpation in midepigastric area, chronic low-grade fever, and diarrhea

a) Rebound tenderness in the right lower quadrant, associated with decreased bowel sounds and vomiting Rebound pain is elicited by pressing firmly over the area known as McBurney's point; pain occurs when pressure is released. The rebound pain, decreased bowel sounds, fever, and tender abdomen are all characteristic of the clinical picture of appendicitis. Gastric distention, diarrhea and gnawing radiating pain are not a common signs of appendicitis. Remember, all the items in an option have to be correct if it is the correct answer. (Hockenberry, Wilson, 9 ed., p. 1311.)

A client has had her blood pressure evaluated weekly for 1 month. At the end of the month, the nurse averages out the weekly blood pressures at 150/96 mm Hg. The client is 20 pounds overweight, and her cholesterol is 240 mg/dL. What is important information for the nurse to include in the teaching plan for this client? a) Refer her to the doctor for further follow-up and medications. b) Increase the fiber in her diet and begin a daily 30-minute workout. c) Reduce her sodium intake and decrease the dietary calories that come from fat. d) Reduce her cholesterol intake for 1 month and check her BP 3 times a week.

a) Refer her to the doctor for further follow-up and medications. The client should be referred for further evaluation of blood pressure. The blood pressure is definitely elevated, the client is overweight, and she has an increased level of cholesterol. A multifocal approach is necessary to control the blood pressure. Because of the multiple risk factors, increasing fiber in the diet and exercise would not likely be sufficient to reduce the hypertension. Neither would just dietary changes. This patient needs a multifocal approach. (Lewis, Dirksen, Heitkemper, et al, 8 ed., pp. 745 - 751.)

A parenteral nutrition (PN) solution containing amino acids was ordered for infusion through a central line. The nurse is making an initial assessment and notices the present bag of solution was hung at 2 pm on the previous day and it is now 5 pm on the following day. There is about 100 mL still remaining to be infused. What is the best nursing action? a) Remove the current bag and remaining solution and hang another bag of solution. b) Increase the rate so that the remaining 100 mL will be infused and a new bag of solution can be hung. c) Check the client's serum blood glucose to see if he is tolerating the current rate of infusion of solution. d) Leave the current bag infusing and hang another bag with the bag is empty.

a) Remove the current bag and remaining solution and hang another bag of solution. IV solutions, especially parenteral nutrition solutions, should not hang for longer than 24 hours. The current bag should be removed and another bag hung. The rate should not be increased and the current bag should not be left to infuse. Checking the client's blood glucose does not solve the problem. (Lewis, et al, 8 ed., p. 937.)

A client has returned from abdominal surgery, and the nurse is assessing the incisional area. The dressing has some bright red blood on it, and on closer examination, the nurse determines that there is an area of evisceration. What is the best nursing action? a) Remove the dressing and place a sterile, saline-soaked dressing on the wound and dry reinforcement dressings on top. b) Remove the dressing and with sterile gloves apply very gentle pressure to replace the exposed bowel. c) Leave the dressing in place and apply an abdominal pressure dressing to prevent further exposure of the bowel. d) Remove all of the soiled dressing, cleanse the wound area with Betadine solution, and replace the dressing.

a) Remove the dressing and place a sterile, saline-soaked dressing on the wound and dry reinforcement dressings on top. A protrusion of the bowel through the incision is an evisceration. The best nursing action is to cover the exposed bowel with a sterile saline-soaked dressing to prevent drying and tissue damage to the exposed bowel; then the physician should be notified. The nurse should not make an attempt to replace the exposed bowel, because the bowel may have vascular impairment below the surface. The dressing needs to be replaced with a moist one to protect the bowel; the wound should not be cleansed, it is not a dirty wound. (Potter, Perry, 8 ed., p. 1287.)

An older adult client tells the nurse, "I seem to be having more problems with constipation, I have to use laxatives more than I used to." What is the best nursing action? a) Review with the client her normal bowel schedule and identify risk factors for constipation. b) Encourage client to drink at least 2500 mL fluid every day. c) Encourage the client to eat more foods that contain vegetables and whole grains. d) Determine when and how often the client normally has a bowel movement.

a) Review with the client her normal bowel schedule and identify risk factors for constipation. Before the nurse can recommend any activities to eliminate the problem of constipation, the client's activities, normal bowel pattern, and risk factors for constipation must be assessed. This answer is the most comprehensive response taking into consideration all of the other options that are appropriate after the nurse has determined the client's risk factors, her bowel pattern, and current actions to prevent constipation. (Lewis, et al, 8 ed., p. 1012.)

What will be important for the nurse to do when collecting a stool specimen for an occult blood (Hemoccult) test? a) Samples should be taken from two areas of the stool. b) Three separate stool samples will be required for accuracy of test. c) The nurse should collect about 20 mL of stool sample. d) Any red color on or near the specimen is considered positive.

a) Samples should be taken from two areas of the stool. Stool samples should be taken from different areas of the stool to more accurately reflect the presence of occult blood. The nurse only needs to collect a small sample of stool for the test. The test is done on the nursing unit and is not sent to the laboratory for further evaluation. Three separate samples will more accurately validate the presence of blood, but it is not required. Diets rich in red meat may cause a false-positive result. (Potter, Perry, 7 ed., p. 1189.)

What is the nurse's priority concern for a client admitted to the hospital with a diagnosis of diabetes insipidus? a) Sleep disturbance caused by nocturia b) Decreased physical mobility due to muscular cramping c) Fluid volume excess caused by water retention d) Skin breakdown caused by generalized edema

a) Sleep disturbance caused by nocturia Diabetes insipidus (DI) is associated with a decrease (or deficiency) in the secretion of antidiuretic hormone (ADH). Lack of ADH leads to increased urinary output (as much as 5 to 20 L/day). Clients with DI become very fatigued from nocturia. Fluid volume deficit can occur due to the excess urine output. There is no edema or muscle weakness. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 1261.)

The nurse is administering a misoprostol (Cytotec) to a client with a diagnosis of peptic ulcer disease. The client asks the nurse about the medication. Which of the following explains the action of the misoprostol (Cytotec)? a) Stimulates secretion of mucous to protect the stomach mucosa b) Increases the speed of gastric emptying c) Works as an antacid d) Helps to break down food products by lowering acid production

a) Stimulates secretion of mucous to protect the stomach mucosa Any form of ulcer on the lining of the stomach will need as much protection as possible to allow for healing. Misoprostol (Cytotec) protects the lining of the stomach by stimulating the secretion of mucous and increasing the bicarbonate production. It does not stimulate motility or reduce the acidity of the stomach content; however, it does help to decrease acid production. (Lilley, 6 ed., p. 792.)

A client with hyperthyroidism is being treated with radioactive iodine (RAI). The client asks the nurse if she will need to continue taking her blood pressure medicine after the procedure. The nurse's response will be based on what principle? a) The RAI will take several days to weeks to become effective; the client will need to continue with her blood pressure medication. b) Even after the hyperthyroid condition is under control, the client will continue to need the antihypertensive medications indefinitely. c) The blood pressure is difficult to control after the administration of RAI and will see dramatic fluctuations. d) Response to the RAI is immediate, and the client will not need to continue on the blood pressure medication.

a) The RAI will take several days to weeks to become effective; the client will need to continue with her blood pressure medication. After ablation therapy (RAI) it frequently takes several weeks before the production of thyroid hormone is sufficiently decreased for the blood pressure to return to normal. Frequently beta-adrenergic blockers are used to maintain the client's blood pressure and pulse rate until the RAI has sufficiently decreased the output of the thyroid hormone. (Lewis, et al, 8 ed., p. 1265.)

The nurse is caring for a woman diagnosed with thrombophlebitis. A continuous heparin infusion is in progress, and the nurse is monitoring coagulation studies. At what point would the nurse determine that the heparin has reached the desired range of anticoagulation? a) The activated partial thromboplastin time is approximately 1 to 2 times the level before the heparin therapy. b) The prothrombin time has doubled over the past 6 hours. c) The international normalizing ratio (INR) is calculated to be 3.0 to 3.5. d) The initial level of the plasma fibrinogen was decreased; 2 hours later, it is increased.

a) The activated partial thromboplastin time is approximately 1 to 2 times the level before the heparin therapy. The coagulation study to monitor the anticoagulation level of heparin is the activated partial thromboplastin time. When it has increased by 1 to 2 times, the client is said to be adequately anticoagulated. INR and prothrombin time are used for Coumadin monitoring. (Lehne, 7 ed., p. 600.)

A client has had a complicated episode of peritonitis and is now in a negative nitrogen balance. To meet the nutritional needs for this client to heal, the nurse would anticipate the following may be ordered: a) Total parenteral nutrition (TPN) b) Jejunostomy tube feedings c) Gastrostomy tube feedings d) Nasogastric tube

a) Total parenteral nutrition (TPN) If the lower gastrointestinal (GI) system (small or large bowel) is inflamed, nutritional substances (total parenteral nutrition) are delivered intravenously, bypassing the entire GI system to avoid having food in the GI tract should a perforation occur. Although the client may have a nasogastric tube in place to decrease gastric distention, this does not answer the question related to nutritional needs. (Lewis, et al, 8 ed., p. 935.)

An older adult has a history of decreased force of the urinary stream, dribbling after voiding, and nocturia. The nurse understands that normal lab values for an adult may vary in an older client. Which laboratory finding would the nurse expect to find when reviewing laboratory values of this older male client? a) Urinalysis reveals microscopic hematuria and bacteriuria b) Potassium 5.7 mEq/L and sodium 120 mEq/L c) Blood sugar of 188 mg/dL and slight elevation in liver enzymes d) WBC 10,500 mm3 and RBC 3.9 million mm3

a) Urinalysis reveals microscopic hematuria and bacteriuria This older adult client in this situation has prostate enlargement and incomplete emptying of the bladder, which can lead to subclinical renal infections, in addition to kidney changes as a result of aging. Older adults frequently experience asymptomatic bacteriuria and microscopic hematuria, as a result of incomplete bladder emptying. The other laboratory findings are not considered normal findings in an older adult. (Lewis, et al, 8 ed., p. 1383.)

A client is receiving is receiving normal saline IV at a rate of 250 mL/hr for rehydration after an episode of gastrointestinal bleeding. Which assessment data would cause the nurse the most concern and require reporting immediately to the health care provider? a) Wet breath sounds and increasing restlessness occur. b) The client's blood pressure has increased from 100/90 to 126/80 mm Hg. c) Abdomen is distended and the bowel sounds are hypoactive. d) The nasogastric tube is draining dark coffee-ground material.

a) Wet breath sounds and increasing restlessness occur. The nurse should be concerned about fluid overload when rapidly infusing normal saline, especially in older adults. Wet breath sounds and increasing restlessness and confusion may be indicative of the development of pulmonary edema. The coffee ground material is old blood and is to be expected. The blood pressure has increased to a normal level. The abdominal distention and the hypoactive bowel sounds should be monitored, but it is not a priority. (Lewis, et al, 8 ed., p. 372.)

The nurse is caring for a client with inflammatory bowel disease. Which medication might be prescribed to the client? Select all that apply. a) Sulfasalazine (Azulfidine) b) Hydrocortisone c) Azathioprine (Imuran) d) Metronidazole (Flagyl) e) Antispasmodics f) Bisacodyl (Dulcolax)

a, b, c, d, e Numerous drugs are used in the treatment of inflammatory bowel disease, which include sulfasalazine (Azulfidine), hydrocortisone, azathioprine (Imuran), metronidazole (Flagyl), antispasmodics, bulk-forming agents (Metamucil), and antidiarrheal medications (loperamide [Imodium]). Stimulant laxatives such as bisacodyl (Dulcolax) are not indicated. (Lehne, 7 ed., p. 943.)

The nurse would note which findings on the physical assessment of a client with a diagnosis of Cushing's disease? Select all that apply. a) Buffalo hump b) Thinning hair c) Acne d) Hirsutism e) Gynecomastia f) Bulging eyes

a, b, c, d, e Typical clinical findings of Cushing's disease include thinning hair, hirsutism in women, gynecomastia in men, moon face, buffalo hump, abdominal striae, weight gain, truncal obesity, thin limbs, acne, hypertension, and mood changes. This may be due to externally administered steroids or excessive production of steroids by the adrenal glands. Bulging eyes are associated with hyperthyroidism. (Lewis, et al, 8 ed., p. 1278.)

When assessing a client with a problem of the endocrine system, the nurse would expect which findings on the assessment? Select all that apply. a) Excessive thirst b) Abnormal menstrual cycle c) Cardiac palpitations d) Diarrhea e) Abrupt change in level of consciousness f) Weight loss

a, b, c, d, f The endocrine system can affect many body systems. Excessive thirst and hunger, along with polyuria, are noted in diabetes mellitus. An abnormal menstrual cycle can be a finding with a problem of the thyroid or pituitary gland. Cardiac palpitations, weight loss, and diarrhea, along with tachycardia, hypertension, and tremor are found in hyperthyroidism. Although there are changes in personality and how the client may act with pituitary problems (e.g., hypersecretion or tumor), usually the level of consciousness does not change abruptly, which would be indicative of increased intracranial pressure. (Lewis, et al, 8 ed., pp. 1223, 1246, 1249, 1265, 1266, 1275.)

Which of the following client factors place them at an increased risk of developing Clostridium difficile (C. difficile) infection? Select all that apply. a) Just completed taking Levaquin (levofloxacin) 21 days b) Takes Protonix (pantoprazole) daily for gastroesophageal reflux disease c) Received a kidney transplant 3 months ago d) Eats a diet high in smoked meats e) Recently hospitalized for a week f) Takes a daily probiotic supplement that contains Saccharomycees boulardii

a, b, c, e Some antibiotics, especially cephalosporins (Keflex) and fluoroquinolones (Levaquin), kill off normal flora in the gut, making the client more susceptible to pathogenic strains of C. difficile. Medications such as proton-pump inhibitors (Protonix) decrease stomach acid, which normally acts to kill pathogens in the intestine, thus increasing susceptibility to C. difficile. Clients receiving immunosuppressant medications (e.g., post-transplant) are at increased risk, as are clients that are in health care settings such as hospitals or nursing homes (165,000 hospital-acquired cases and 265,000 nursing home cases annually with a combined mortality rate of more than 25,500 and a health care cost of more than $3.5 billion). Eating smoked meats will not place the client at additional risks for C. difficile infections, and a probiotic supplement with S. boulardii (and lactobacillus GG) does not cause C. difficile and may help prevent/treat C. difficile infections by reestablishing normal bacterial colonies in the colon. (Lewis, et al, 8 ed., p. 1007-1010, www.CDC.gov.)

A client is being treated with tamsulosin (Flomax) for benign prostatic hypertrophy. What should the nurse include in the teaching plan for this client? Select all that apply. a) Be careful about sitting up standing up too quickly. b) Slowly the medication will improve symptoms by shrinking the prostrate. c) Medication may cause problems with ejaculation. d) Blood pressure may elevate and needs monitoring. e) Increased urinary flow will occur very quickly upon taking the medication. f) Medication may increase residual urine volume.

a, b, c, e Tamsulosin (Flomax) is an alpha-adrenergic blocker that is indicated for the treatment of benign prostatic hypertrophy (BPH). The medication can cause dizziness and hypotension, so getting up slowly to preventing orthostatic hypotension is important to teach, along with information that the medication will improve symptoms by shrinking the prostrate, may cause problems with ejaculation, quickly increases urinary flow, and decreases residual urine volume. (Lehne, 7 ed., p. 782.)

Which of the following are appropriate nursing interventions when caring for a client with hyperthyroidism? Select all that apply. a) Implement a salt restriction. b) Instill artificial tears as needed. c) Provide several high-calorie meals. d) Keep the environment warm and quiet. e) Encourage rest periods throughout the day. f) Initiate a planned exercise program.

a, b, c, e, f A salt restriction can help reduce periorbital edema. The client with hyperthyroidism needs a calm, cool, quiet room, because increased metabolism causes sleep disturbances, so resting throughout the day is important. With the increased metabolic demands on the body, meals that are small and of high caloric content are best. Initiating a planned exercise program involving large muscle groups (tremors can interfere with small-muscle coordination) to allow the release of tension and restlessness is also appropriate. Artificial tears are helpful in preventing drying of the eyes secondary to exopthalmos. (Lewis, et al, 8 ed., pp. 1267, 1268.)

The nurse understands that hyperglycemia in a client with a type 2 diabetes mellitus is a result of: Select all that apply. a) Insulin resistance b) Insulin deficiency c) Gestational diabetes d) Liver dysfunction e) Hyperinsulinemia f) Alpha cell dysfunction

a, b, d Type 2 diabetes mellitus is due to insulin resistance, insulin deficiency, and inappropriate glucose production by the liver. Beta cells in the pancreas increase production for a period of time, then they can no longer compensate. Insulin resistance and secondary failure of the pancreas to secrete enough insulin result in hyperglycemia, even though the cells receive inadequate amounts of glucose. (Lewis, et al, 8 ed., p. 1221.)

Which clients on a gastrointestinal unit are at increased risk for developing dumping syndrome? Select all that apply. a) Client with stomach cancer who a gastric resection b) Obese client who had combination restrictive/malabsorptive surgery c) Client who developed peritonitis after surgery for closure of ruptured appendix d) Older clients with a long history of gastroesophageal reflux disease e) Client with severe peptic ulcer disease and surgery to repair perforation f) Client with a malignancy of the colon and abdominal perineal resection

a, b, e These clients all had gastric surgery that significantly reduced the size of the stomach and removed the pyloric sphincter. Dumping syndrome occurs when stomach contents are dumped into the small intestine before they are adequately mixed with gastric enzymes. The stomach no longer controls the rate at which the food moves from the stomach to the intestine. Fluid shifts and distention of the bowel lumen cause the symptoms. (Lewis, et al, 8 ed., pp. 959, 996.)

Which of the following nursing actions are appropriate for decreasing the risk of enteral feeding misconnections? Select all that apply. a) Teach visitors not to reconnect gastrostomy tube to the feeding lines. b) Check and trace all lines to their source when taking over care of a new client. c) Provide specific instructions to the nursing technician on how to reconnect the nasogastric tube to the tube feeding after ambulation. d) Route all client lines to one side at the head of the bed to facilitate assessment. e) Label or color-code feeding tubes and connectors. f) Do not modify or adapt intravenous equipment or feeding devices to make them connect.

a, b, e, f Visitors and nonclinical staff should not be reconnecting any enteral feeding lines. At the change of shift, or whenever taking over care of a client receiving an enteral feeding, the nurse should carefully trace all lines to their source to identify any misconnections. Labeling or color-coding lines may alert the nurse to misconnections. Modifying lines may result in misconnections and should not be done. Nursing technicians should not be reconnecting any enteral feeding devices, although in some settings they are allowed to reconnect NG tubes to wall suction. Routing tubes and catheters in different directions such as intravenous lines toward the head of the bed and enteral feeding lines toward the foot of the bed are better than orienting them in one location, which does not visibly differentiate their sources. (Lewis, et al, 8 ed., p. 935.)

The nurse would identify which of the following clients to be at an increased risk for the development of a fecal impaction? Select all that apply. a) Post barium enema b) Obese client in traction c) Poorly hydrated older adult d) Client with rectal polyps e) Three days after colostomy f) Acute appendicitis

a, c A barium enema procedure can lead to fecal impaction caused by barium left in the colon. An obese client in traction who is immobile and a poorly hydrated older adult (decreased motility and fluid intake) may also experience fecal impaction. These three conditions can contribute to the development of an impaction that may require manual removal. Rectal polyps could be dislodged or irritated, and bleeding could be caused by manual manipulation. Acute appendicitis would be a condition in which no rectal enemas or manipulation would be indicated. (Lewis, Dirksen, Heitkemper, et al, 8 ed., pp. 913, 1012.)

The nurse understands that the cardiovascular complications of sustained hypertension on target organs include which of the following? Select all that apply. a) Nephrosclerosis b) Aortic regurgitation c) Stroke d) Left ventricular hypertrophy e) Deep vein thrombosis f) Retinal damage

a, c, d, f Hypertension is a major risk factor for coronary artery disease and leads to alterations in the structure and function of the vascular system, resulting in target organ damage related to ischemia and edema. Renal damage and impairment lead to end-stage renal failure from prolonged hypertension. Damage to the retinal vessels in the eye can lead to blurring of vision and eventual blindness. Cerebral atherosclerosis leads to stroke. There is left ventricular hypertrophy and decreased ability of the heart to pump enough blood to meet the body needs. This is frequently associated with coronary artery disease and myocardial infarction as well. Cardiac failure is a common outcome of chronic, sustained hypertension because of the inability of the heart to compensate for the peripheral resistance associated with hypertension. Valvular heart disease, such as aortic regurgitation, and deep vein thrombosis are not typically associated with hypertension. (Lewis, et al, 8 ed., pp. 743-744.)

Which of the following would be an anticipated nursing problem in a client with a diagnosis of peritonitis? Select all that apply. a) Nausea, vomiting, and anorexia b) Skin irritation from incontinence of stool c) Anxiety and fear d) Acute pain and abdominal distention e) Coping problems related to chronic disease, lifestyle changes, and stress f) Dehydration related to fluid in the peritoneal cavity

a, c, d, f Peritonitis (usually acute in onset) is an inflammation of the peritoneum, the thin membrane that lines the abdominal wall, and is characterized by abdominal pain, distention caused by inflammation and possible fluid leaking into the peritoneal cavity, fever, nausea, vomiting, and altered bowel habits (inability to pass gas and feces). Peritonitis is a potentially life-threatening condition that requires immediate medical attention. Surgery is often necessary to remove the source of infection, such as an inflamed appendix, or to repair a tear in the walls of the gastrointestinal or biliary tract. Anticipation of surgery and other associated problems can lead to anxiety. (Lewis, et al, 8 ed., p. 1021.)

The clinical laboratory notifies the nurse that a client has Clostridium difficile. The nurse should: Select all that apply. a) Move the client to a private room. b) Move the client to a negative pressure room. c) Use gloves and gowns. d) Use a respirator device. e) Have hand hygiene supplies available.

a, c, e If a client has Clostridium difficile, a private room, gloves, gowns, and hand hygiene supplies are required. A negative pressure room and a respirator device are required for airborne precautions. (Potter, Perry, 7 ed., p. 663.)

The nurse is caring for a client with venous blood pooling in the lower extremities caused by chronic venous insufficiency. The nurse would identify what assessment data that would correlate with this diagnosis? Select all that apply. a) Stasis dermatitis. b) Diminished peripheral pulses. c) Peripheral edema. d) Gangrenous wounds. e) Venous stasis ulcers. d) Skin hyperpigmentation.

a, c, e, f Long-term impairment of venous return leads to chronic venous insufficiency that is characterized by leathery, brawny appearance from erythrocyte extravasation to the extremity, persistent edema, stasis dermatitis, and pruritus. Venous leg (stasis) ulcers characteristically form near the ankle on the medial aspect with wound margins that are irregularly shaped with tissue that is a ruddy color. Gangrenous wounds and diminished peripheral pulses are associated with arterial occlusive disease. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 892.)

A client is scheduled for transsphenoidal hypophysectomy for treatment of an anterior pituitary tumor. What would be important preoperative teaching for this client? Select all that apply. a) Elevate the head of the 30 degrees. b) Encourage hourly coughing, deep breathing, and incentive spirometry. c) Monitor for symptoms of increasing intracranial pressure. d) Monitor urine output for a decrease in volume. e) Provide frequent oral hygiene with nonirritating solutions; avoid using a toothbrush. f) Take cortisone, thyroid hormone, and ADH-regulating medications.

a, c, e, f To provide supportive care and preoperative teaching the nurse would elevate the head 30 degrees, discourage coughing, sneezing, or straining at stool to prevent cerebrospinal fluid leak, assess for symptoms of increasing intracranial pressure, evaluate urine for excessive increase in volume (<200 mL/hr) or specific gravity >1.005 (i.e., development of diabetes insipidus), and provide frequent oral hygiene with nonirritating solutions to avoid disruption of the suture line. The client should avoid brushing the teeth for 10 days after surgery. The client will require medication to support pituitary target organs involved (pancreas, thyroid, adrenals, gonads), cortisone and thyroid hormone replacement throughout lifetime, and ADH-regulating medications. (Lewis, et al, 8 ed., p. 1257.)

The nurse is assessing a child with a tentative diagnosis of appendicitis. The nursing assessment is most likely to reveal what characteristics concerning the pain? Select all that apply. a) Colicky, cramping abdominal pain located the umbilicus b) Tenderness in the left lower quadrant, associated with decreased bowel sounds c) Nausea, vomiting, and anorexia following onset of pain d) Gnawing pain, radiating through to the lower back, with severe abdominal distention e) Sharp pain with severe gastric distention, frequently associated with hemoptysis f) Tenderness at McBurney's point

a, c, f Colicky, cramping abdominal pain located around the umbilicus often noted as "referred pain" for its vague periumbilical localization is characteristic of appendicitis. The most common point of tenderness is over the area known as McBurney's point. Typically, nausea, vomiting, and anorexia follow onset of pain. Diarrhea, poor feeding, lethargy, and irritability may accompany peritonitis. Tenderness in the right lower quadrant (not the left) that occurs during palpation or percussion is called Rovsing's sign. Gastric distention and gnawing radiating pain are not common signs of appendicitis; gnawing pain is more characteristic of ulcers. Hemoptysis is not seen in appendicitis, but in pulmonary edema. Remember, all the items in an option have to be correct if it is the correct answer. (Hockenberry, Wilson, 9 ed., p. 1311.)

Which of the following are appropriate nursing interventions for the recently admitted client who is seriously malnourished and is receiving aggressive nutritional support with total parenteral nutrition (TPN) via a central line? Select all that apply. a) Instruct the nursing technician to and record client daily weights. b) Check the infusion rate hourly when TPN solution is delivered by gravity drip. c) Notify the physician immediately for a phosphate level of 2.2 mg/dL. d) Hang a bag of 0.45% saline at the same rate as the prescribed TPN formula if the TPN bag has infused and the new TPN bag is not immediately available from the pharmacy. e) Assess the client vital signs at least every 12 hours during TPN therapy. f) Assess the client for edema and neurologic disturbances such as paresthesias during therapy.

a, c, f Daily weights are desirable because they provide an indication of the client's hydration status as TPN therapy progresses. Hypophosphatemia (less than 2.4 mg/dL) is a hallmark sign of the development of refeeding syndrome, and the physician must be notified immediately of this potential life-threatening level. Edema and neurologic disturbances may indicate fluid or electrolyte abnormalities related to the TPN administration. TPN solutions should be administered via an IV pump, not by gravity. If the next TPN bag is not available, the nurse should hang a bag of the same dextrose solution that comprises the base of the prescribed TPN solution, which is usually a 5% or 10% dextrose solution, not 0.45% saline. Vital signs should be assessed every 4 to 8 hours, not every 12 hours, in the client who is receiving TPN. (Lewis, et al, 8 ed., pp. 319, 938-939.)

A nurse knows the clinical manifestations of a client with Addison's disease include which of the following? Select all that apply. a) Nausea b) Hypothermia c) Hypertension d) Hyperpigmentation e) Hypotension f) Hypernatremia

a, d, e Addison's disease is due to a hypofunctioning of the adrenal cortex. The clinical manifestations have a very slow onset, and skin hyperpigmentation (melanosis) is a classic sign. This bronze coloring of the skin is seen primarily in those areas exposed to the sun, pressure points, joints, and in skin creases (especially on the palms, knuckles, and elbows). Fatigue, nausea, weight loss, hypotension, hyponatremia, and hyperkalemia are other findings associated with the condition. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 1280.)

A client has a diagnosis of diabetes insipidus. What are appropriate nursing interventions for this client? Select all that apply. a) Monitor urine for specific gravity. b) Reduce IV fluids and electrolytes. c) Administer lispro. d) Monitor for increase in weight gain. e) Sodium restricted diet.

a, e Urine specific gravity will be low (1.001 to 1.005) and dilute, so it should be monitored. One of the characteristics of diabetes insipidus is a decrease in antidiuretic hormone, which leads to decreased urine output and electrolyte depletion. Vasopressin is administered, not lispro. Because of the excessive urine volume, dehydration occurs, not weight gain. Limiting sodium intake to no more than 3g per day is thought to help decrease the urine output. (Lewis, et al, 8 ed., pp. 1261-1262.)

A client with diabetes asks the nurse about the glycosylated hemoglobin (HbA1C) test. What is the nurse's best response regarding the purpose of this test? a) "It determines how close the client is to having an insulin reaction." b) "It reflects blood glucose control for 3 months before the current status." c) "It determines how much glucose is excreted over a 24-hour control period." d) "It helps determine the amount of retinopathy the client is experiencing."

b) "It reflects blood glucose control for 3 months before the current status." The glycosylated hemoglobin test provides information regarding the client's control of blood sugar for about 120 days or 3 months. This is beneficial for clients who experience fluctuations in control. It measures the reaction when the glucose combines with the hemoglobin molecule and is indicative of the general blood sugar control the client has had over the previous 3 to 4 months. It is not influenced by the type of treatment, the current level of blood sugar, or the client's intake over the past several hours. An HbA1C of more than 6.5% indicates an increased risk of microvascular disease such as retinopathy. (Lewis, et al, 8 ed., pp. 1222-1223.)

"Why did the doctor tell me I may not know when my blood sugar is low?" The nurse's response to the client may include: a) "When you drink alcohol, you are less likely to have a diabetic reaction." b) "The medication for your heart can hide the symptoms of hypoglycemia." c) "Younger adults are less likely to experience diaphoresis with hypoglycemia." d) "Since you are older, we want to keep your blood glucose in tight control."

b) "The medication for your heart can hide the symptoms of hypoglycemia." Older adults and clients using beta-adrenergic blockers (atenolol, propranolol) are less likely to experience early signs of hypoglycemia. No indication is given that the client is using alcohol. Younger adults should experience symptoms of hypoglycemia unless they are using a beta-adrenergic blocker. (Lewis, et al, 8 ed., p. 1246.)

A client with diabetes receives a combination of regular and NPH insulin at 7 am, or 0700 hours. The nurse would observe the client for signs of hypoglycemia at: a) 12 pm to 1 pm (1200 to 1300 hours) b) 11 am and 5 pm (1100 and 1700 hours) c) 10 am and 10 pm (1000 and 2200 hours) d) 8 am and 11 am (0800 and 1100 hours)

b) 11 am and 5 pm (1100 and 1700 hours) Regular insulin (a short-acting insulin) peaks in 1 to 5 hours, and NPH insulin (an intermediate-acting insulin) peaks in 6 to 14 hours. (Lehne, 7 ed., p. 665.)

A client is found to be comatose and hypoglycemic with a blood glucose level of 50 mg/dL. What nursing action is implemented first? a) Infuse 1000 mL of D5W over a 12-hour period. b) Administer 50% glucose intravenously. c) Check the client's urine for the presence of sugar and acetone. d) Encourage the client to drink orange juice with added sugar.

b) Administer 50% glucose intravenously. The unconscious, hypoglycemic client needs immediate treatment with 50% intravenous glucose (highly concentrated). Administering 1000 mL of D5W over 12 hours does not provide enough glucose to treat the problem. Trying to give oral fluids to an unconscious client should never be done because it increases the risk for aspiration. Urine sugar does not need to be evaluated if the serum blood glucose is available. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 1246.)

An adolescent client is receiving antibiotics for a severe laceration on his leg, which is infected. The client complains of being cold, the nurse determines that the client has a temperature of 102° F. What is the best nursing action? a) Check the temperature again in an hour. b) Administer ibuprofen, 400 mg, PO. c) Apply a cooling blanket. d) Notify the health care provider.

b) Administer ibuprofen, 400 mg, PO. Adolescents can receive the adult dose of medications. The nurse should closely observe the client for continued temperature elevation or the development of further symptoms. Ibuprofen is an NSAID, with antipyretic properties, as well as pain control. The temperature should be checked again in an hour after the administration of the ibuprofen. At this time, calling the physician or to begin using a cooling blanket is not necessary. (Potter, Perry, 7 ed., p. 518.)

An older adult client comes to the clinic with complaints of increased weakness and fatigue. He has a history of heart failure and is currently taking furosemide (Lasix) and digitalis (Lanoxin). What would be most important for the nurse to assess on this client? a) Increased central venous pressure and jugular vein distention b) Any complaints of gastrointestinal problems and current level of serum potassium c) Recent weight gain or loss and presence of peripheral edema d) Bilateral breath sounds and recent history of dyspnea

b) Any complaints of gastrointestinal problems and current level of serum potassium Clients taking loop diuretics frequently develop problems of hypokalemia. This is most critical when the client is also on digitalis because hypokalemia enhances the action of digitalis. The early signs of digitalis toxicity are gastrointestinal problems; therefore the nurse should assess for evidence of digitalis toxicity in addition to the current potassium levels, because the client's complaints may indicate hypokalemia. (Lehne, 7 ed., p. 526.)

The nurse is planning home care for a client with venous leg ulcers. What would be most important for the nurse to include in her teaching? a) Apply the antibiotic cream twice a day. b) Apply a hydrocolloid dressing over the open ulcers. c) Massage both legs whenever they are in the dependent position. d) Return for regular checks of clotting levels.

b) Apply a hydrocolloid dressing over the open ulcers. The ulcerated areas should be covered with a moist environmental dressing; this may be hydrocolloid, transparent film, impregnated film, etc. Keeping the legs elevated assists to decrease pressure in the vascular bed of the lower extremities. Massaging the legs is not recommended and the client is not usually on anticoagulants, so checking clotting levels is not necessary. (Lewis, et al, 8 ed., p. 892.)

The nurse would question which medication order for a client who is receiving heparin? a) Cortisone b) Aspirin c) Glipizide (Glucotrol) d) Digoxin (Lanoxin)

b) Aspirin Aspirin is contraindicated because it is a gastric irritant and can cause gastric ulceration and bleeding. Aspirin also suppresses platelet aggregation, which is desirable in prevention of strokes and MIs; however, it would further compromise the client with gastric irritation. (Lehne, 7 ed., p. 600.)

A client is admitted to the emergency department with complaints of a sudden onset of severe abdominal pain, anorexia, and chills. The nursing assessment reveals rebound tenderness midline below the umbilicus. The client's pulse is 135, respirations are 34, temperature is 101.6° F orally, and blood pressure is 90/50. Of the following orders received, which order would the nurse implement first? a) Ciprofloxacin 400 mg IVPB every 12 hours b) Begin infusion of 1000 mL lactated Ringer's, infuse 500 mL over 30 minutes c) CT scan of the abdomen with contrast d) Administer acetaminophen 300 mg for temperature more than 101° F orally

b) Begin infusion of 1000 mL lactated Ringer's, infuse 500 mL over 30 minutes Fluid resuscitation is the priority order for this client and should be done first. The antibiotics and CT can be done after the fluid has been infused The client will be NPO until the diagnostic workup is complete, so the acetaminophen will not be given at this time. (Lewis, et al, 8 ed., p. 1016.)

What is a priority assessment for a client with a pheochromocytoma? a) Breath sounds b) Blood pressure c) Daily weight d) Abdominal girth

b) Blood pressure Hypertension is the principal clinical finding with pheochromocytoma. It is related to the release of catecholamines, primarily norepinephrine, and requires frequent assessment of the client's blood pressure. Rapid elevations in blood pressure should be reported to the physician, because they may cause a complication, such as a stroke. Assessment of weight and abdominal girth is associated with fluid overload and conditions that contribute to fluid imbalance, such as congestive heart failure and liver problems. Assessing breath sounds is part of a routine pulmonary assessment. (Lewis, et al, 8 ed., p. 1284.)

What nursing action would help reduce a reservoir of infection for a client? a) Keeping all of the client's articles in the room b) Changing the dressings when soiled with drainage c) Providing tissues to cover the mouth and nose when coughing d) Wearing clean gloves when providing any direct care

b) Changing the dressings when soiled with drainage All drainage and body fluids are potential reservoirs for bacterial growth. Proper handling of any drainage and body fluid assist in preventing transmission or exit of bacteria from the client. Providing tissues and keeping the client's articles in the room would control a port of exit for bacteria. Wearing clean gloves helps protect the introduction of bacteria to the client. (Potter, Perry, 7 ed., pp. 643-644.)

The nurse is monitoring an IV infusion of sodium nitroprusside (Nipride). Fifteen minutes after the infusion is started, the client's blood pressure goes from 190/120 mm Hg to 120/90 mm Hg. What is a priority nursing action? a) Recheck the BP and call the doctor. b) Decrease the infusion rate and recheck the blood pressure in 5 minutes. c) Stop the medication and keep the IV open with D5W. d) Assess the client's tolerance of the current level of BP.

b) Decrease the infusion rate and recheck the blood pressure in 5 minutes. Nipride is a very powerful, rapid vasodilator. The nurse should decrease the infusion first before the pressure drops further, then assess the client's response to the decreased rate. If the client's urinary output remains adequate and there is no dizziness or neurologic change, then the client is probably tolerating the blood pressure level. (Lehne, 7 ed. pp. 492-493).

A client is recently diagnosed with hyperthyroidism. Which laboratory finding would the nurse expect to find on the admission laboratory tests? a) Decreased triiodothyronine (T3) level b) Decreased TSH level c) Increased thyrotropin-releasing hormone (TRH) level d) Decreased thyroxine (T4) level

b) Decreased TSH level When a client has hyperthyroidism, the TSH is low because of an increased anterior pituitary secretion of TSH. The thyroxine (T4) level and triiodothyronine (T3) level are elevated. Measurement of the thyrotropin-releasing hormone (TRH) level indicates the function of the hypothalamus. (Lewis, et al, 8 ed., p. 1265.)

The nurse is assessing a client with peripheral arterial disease. What would the nurse expect to find on assessment of this client? a) Thin, fragile toenails b) Dependent rubor c) Bounding arterial pulses d) Warm, erythematous legs

b) Dependent rubor The classic indications of arterial insufficiency include intermittent claudication; decreased or absent pulses; paresthesia or numbness and tingling in the extremity; thin, shiny, hairless skin; thick, ridged toenails; cool skin temperature; pallor when leg is elevated; and dependent rubor (reactive hyperemia or redness of the foot when in a dependent position). Thin, fragile toenails may be the result of an endocrine problem. Bounding arterial pulses would not be present in arterial insufficiency, and the legs would be cold rather than warm. (Lewis, et al, 8 ed., p. 874.)

A client in the recovery room after a thyroidectomy is asked frequently by the nurse to speak. The rationale for the nurse continuing to evaluate the client's voice is to: a) Assess for the continued effects of the anesthesia b) Detect spasms or edema in the area of the vocal cords c) Assess the client's cognitive ability d) Assess for damage to the cricoid process

b) Detect spasms or edema in the area of the vocal cords The nurse would have the client talk to detect possible swelling around the glottis or damage to the recurrent laryngeal nerve. This would not be an effective way to evaluate anesthesia recovery. The cricoid process does not have anything to do with speech. To assess cognitive ability, the nurse would focus on what the client was saying rather than whether the voice was getting hoarser or whether the client could not speak at all. (Lewis, et al, 8 ed., p. 1269.)

An obese client has had a combination restrictive malabsorptive bariatric surgery (Roux-en-Y gastric bypass). What will be important for the nurse to include in discharge teaching for this client? a) Increase intake of foods high in iron, calcium, and vitamin B12 to prevent deficiencies. b) Do not take any added fluids with meals or immediately after meals. c) Elevate bed to prevent development of gastroesophageal reflux during sleep. d) Plan intake of three balanced meals a day with increased fluids between meals.

b) Do not take any added fluids with meals or immediately after meals. Dumping syndrome is not uncommon after a combination bariatric surgery. Precautions such as limiting the amount of fluids taken with a meal should be implemented. The intake of foods high in iron, calcium, and B12 may not prevent the vitamin or mineral deficiencies since the problem is with the absorption of these elements; supplements may be necessary. The surgery frequently prevents or corrects the problem with gastroesophageal reflux. The client should plan to eat 6 small meals a day to decrease distention of the remaining stomach. (Lewis, Dirksen, Heitkemper, et al, 8 ed. pp. 958-959.)

A woman is being treated with miconazole (Monistat) for her vaginal candidiasis. What would be important to teach the woman regarding her medication? a) Discontinue the use of the medication during menstrual periods. b) Do not use this medication if you are taking warfarin (Coumadin). c) Douche before applying the topical medication. d) Discontinue when symptoms subside.

b) Do not use this medication if you are taking warfarin (Coumadin). Intravaginal miconazole can intensify the anticoagulant effects of warfarin, thereby causing warfarin levels to rise. Medication should be used during menses, and the client should not douche. The client should complete the full course of the medication, even after symptoms subside. (Lehne, 7 ed., p. 1066.)

A young mother asks the nurse about her 4-year-old child who has been diagnosed with juvenile hypothyroidism. What is a common clinical manifestation of the condition? a) Tremor b) Dry skin c) Diarrhea d) Mental retardation

b) Dry skin Dry skin, puffiness around the eyes, sparse hair along with sleepiness, and constipation are symptoms typical of juvenile hypothyroidism. Symptoms of juvenile hypothyroidism depend on the extent of the dysfunction and the child's age of onset. Impaired growth and development issues are less when hypothyroidism is acquired at a later age. Because brain growth is nearly complete by age 2 to 3, mental retardation and neurologic problems are not usually associated with juvenile hypothyroidism. Tremor and diarrhea are associated with hyperthyroidism. (Hockenberry, Wilson, 9 ed., pp. 1579-1580.)

A client who had a gastric resection is 6 days postoperative. About 30 minutes after he eats, he experiences dizziness, weakness, and palpitations. What will the nurse teach the client to do to avoid this problem? a) Lie down on your right side for about 30 minutes after eating. b) Eat several small, high-protein meals per day. c) Increase the amount of water with each meal. d) Take an antacid after meals.

b) Eat several small, high-protein meals per day. The client is experiencing problems with dumping syndrome. The problem may be decreased by eating small high protein meals, lying down on the left side to delay stomach emptying, and decreasing the amount of liquids taken with means. Antacids will not prevent the problem with dumping syndrome. (Lewis, et al, 8 ed., p. 996.)

A teenager enters the evening clinic with the complaint of generalized abdominal pain. He has had no bowel movement for 24 hours and has a low-grade fever. Which order would the nurse question? a) Draw blood for a stat complete blood count (CBC) and measurement of electrolytes. b) Encourage ambulation to stimulate peristalsis. c) Keep the client NPO until further diagnostics can be performed. d) Admit and place client on 24-hour hospital observation.

b) Encourage ambulation to stimulate peristalsis. The client should avoid ambulation. The nurse should not stimulate peristalsis or activities that increase pain, such as walking. The client has an undiagnosed abdominal pain, which could be appendicitis, and activity would increase risk of rupture. The client is kept on bed rest, NPO, and minimal analgesics until problem is diagnosed. (Hockenberry, Wilson, 9 ed., p. 1310.)

The nurse is caring for a client with venous thromboembolism (VTE) in the lower left leg. What is a priority nursing intervention for this client? a) Maintain both legs in a dependent position to facilitate arterial circulation. b) Encourage the client to ambulate as tolerated. c) Avoid compression stockings until actively ambulating. d) Maintain the client on bed rest.

b) Encourage the client to ambulate as tolerated. Newest evidence based guidelines have found that early ambulation neither increased the incidence of pulmonary embolism (PE) or complication rate of VTE. All nursing measures are aimed at increasing circulation to the lower extremities. However, the legs do not need to be maintained in a dependent position at all times. EBP has found that elastic compression stockings do stimulate fibrinolysis, which suggests that the sooner they are applied, the better. Because of the results of current research, bed rest is no longer recommended in the early phase of a VTE. (Ackley, et al, 1 ed., pp. 212-213.)

A client becomes increasingly restless and agitated in the afternoon after a morning surgery for repair of an abdominal aortic aneurysm. His vital signs are: temperature 100° F, apical pulse increase from 88 to 110/min, respirations increased 18 to 24/min, and BP decrease from 120/80 to 116/78. What intervention should the nurse implement first? a) Administer a PRN dose of a prescribed analgesic. b) Evaluate the CVP and assess for gastric distention. c) Begin taking vital signs every hour; increase oxygen to 6 L/min. d) Evaluate quality of pedal pulses and assess for pulse deficit.

b) Evaluate the CVP and assess for gastric distention. The nurse's priority is to observe for possible hemorrhage. The client is at high risk for hypovolemic shock and could be exhibiting early symptoms. Remember, in early shock the BP may be stable and a minimal, if any, increase in pulse rate may occur. The nurse should assess the CVP and other hemodynamic measurements if available. The client should be assessed for pain; however, the vital signs are not congruent with an increase in pain. If there is no obvious indication of bleeding, increased abdominal distention, decreased CVP, no obvious drainage on the dressing, and good urine output, then the client should continue to be closely monitored. The vital signs this close postoperatively should already be scheduled hourly. (Lewis, 8 ed., p. 871)

During an office visit, a client tells the nurse that he is experiencing pain in his legs after walking. He says the pain stops when he sits down. What would be the best nursing action? a) Evaluate the client's legs for presence of edema and discoloration. b) Evaluate the client's peripheral pulses and compare the quality of pulses on each leg. c) Assess the client's legs for tortuous veins. d) Determine if the pain is related to changes in temperature.

b) Evaluate the client's peripheral pulses and compare the quality of pulses on each leg. The client is describing intermittent claudication that is most often the result of peripheral artery disease. Tortuous veins occur in varicose veins, and pain with temperature changes occur in Raynaud's or Buerger's disease (thromboangitis obliterans). Edema and discoloration are more consistent with venous problems, venous stasis, and/or deep vein thrombosis. (Lewis, et al, 8 ed., p. 874.)

The nurse is caring for a client who has exophthalmos associated with thyroid disease. What is the cause of exophthalmos? a) Impaired vision, which causes the client to squint in order to focus b) Fluid in the retro-orbital tissues that increases pressure behind the eyes c) Increased intraocular pressure from an increase in circulating thyroid hormone d) Decrease in extraocular eye movements, which results in the "thyroid stare"

b) Fluid in the retro-orbital tissues that increases pressure behind the eyes Impaired venous drainage from the orbit of the eye causes fluid and fat accumulation in the areas behind (retro-orbital) the eyeballs, which forces the eyes forward and out of their sockets. It is the increased pressure in the area that causes the eyeballs to be forced outward and protrude. There is no decrease in extraocular eye movements. The upper lids are usually retracted and elevated giving a "thyroid stare" appearance. Vision is not impaired, and it is possible that the exophthalmos could lead to increased intraocular pressure. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 1212.)

The nurse is preparing to administer daleparin (Fragmin) subcutaneously to an immobilized client who has been receiving the medication for 5 days. Which finding indicates that the nurse should hold the prescribed dose and notify the health care provider? a) Tachypnea b) Guaiac positive stool c) Multiple small abdominal bruises d) Dependent pitting edema

b) Guaiac positive stool Fragmin is an anticoagulant used to prevent DVT in the at-risk client. If the client develops indications of bleeding, such as a guaiac positive stool (occult blood), while receiving an anticoagulant, the medication should be held and coagulation studies completed. Tachypnea is not an indication to hold the medication unless accompanied by signs of bleeding. Bruising is an expected result and pitting edema is related to fluid balance rather than anticoagulant therapy. (Lehne, 7 ed., p. 602.)

The nurse is providing preoperative care for an 18-month-old child who is scheduled for a 10 am procedure. What is a priority intervention in the preoperative preparation? a) Administer the preoperative on call medication within 1 hour of surgery. b) Have parents confirm identification information on the child and procedure to be performed. c) Determine from the nursing history that the client has been NPO since midnight. d) Determine where the parents will be waiting after procedure.

b) Have parents confirm identification information on the child and procedure to be performed. The child is too young to participate in confirmation of identification and the procedure to be performed. It is imperative that parents are involved with confirming identification and procedure to be done on their child. Preoperative on-call medication, confirming NPO status, and knowing where the parents will be after surgery are all part of the preoperative process; however, the identification is the priority. (Hockenberry, Wilson, 9 ed., pp. 1005-1008.)

A client has been on heparin for the past 3 days and is now being started on warfarin (Coumadin). The client questions why the health care provider is changing the medication. How will the nurse explain this to the client? a) Coumadin will provide additional prophylaxis against the development of emboli. b) Heparin has an immediate action and a short half-life; Coumadin takes several days to be effective. c) Both anticoagulants have a synergistic effect in preventing the development of a thrombus and emboli. d) It is necessary to administer the medications together to maintain long-term coagulation.

b) Heparin has an immediate action and a short half-life; Coumadin takes several days to be effective. Heparin has an immediate action and it must be given parenterally. When a client is going to continue anticoagulation, Coumadin often is started. They both have to be given together until the INR indicates adequate anticoagulation from the Coumadin. This prevents the client from experiencing a period of not being coagulated between the end of the action of heparin and the beginning action of Coumadin. The two medications do not have a synergistic effect. (Lehne, 7 ed., p. 604.)

An older adult client has been taking chlorothiazide (Diuril) for several months for treatment of his blood pressure. What nursing assessment findings would correlate with an electrolyte imbalance? a) Elevated blood pressure b) Increased weakness and fatigue c) Numbness and tingling of extremities d) Hyperactive bowel sounds

b) Increased weakness and fatigue Clients taking thiazide diuretics most often develop problems with hypokalemia, which is characterized by hypotension, tachydysrhythmias, muscle weakness, abdominal pain, diminished bowel sounds, and paralytic ileus. The other options (elevated blood pressure, numbness and tingling of extremities, hyperactive bowel sounds) are not pertinent to chlorothiazide (Diuril). (Lewis, et al, 8 ed., pp. 314, 448-449.)

The nurse is caring for a client on the operative day after repair of an abdominal aortic aneurysm. The client's CVP has decreased from 10 to 8 mm H2O, urine output has been 20 mL/hr for 2 hours, and the blood pressure gradually decreases from 128/88 to 100/70. The nurse notifies the health care provider and would anticipate what order? a) Increase IV rate to 150 mL/hr and prepare client for emergency surgery to re-explore graft site. b) Infuse bolus of 250 cc lactated Ringer's solution and obtain a serum BUN and creatinine. c) Obtain a STAT hemoglobin and hematocrit, and infuse 2 units of whole blood. d) Obtain a STAT chest x-ray and increase oxygen flow from 4 L to 6 L.

b) Infuse bolus of 250 cc lactated Ringer's solution and obtain a serum BUN and creatinine. The client is exhibiting signs of hypovolemia and poor renal perfusion. The nurse would anticipate the BP and urine output to increase with the increase in fluids. If the infusion of fluids does not increase the urine output, then the possibility of renal damage and or emboli will be investigated. The other options do not address the immediate problem of decreasing blood pressure and urine output. (Lewis, et al, 8 ed., p. 871.)

A client with thyroid storm may be given potassium iodide or a strong iodine solution to: a) Increase thyroid hormone metabolism b) Inhibit the synthesis of triiodothyronine (T3) and thyroxine (T4) c) Prevent thyroid hormone synthesis d) Alleviate symptoms of tachycardia and hypertension

b) Inhibit the synthesis of triiodothyronine (T3) and thyroxine (T4) Thyrotoxic crisis, or thyroid storm, is an acute condition that can be life threatening and is treated with high doses of potassium iodide or strong iodine solution, which inhibits the synthesis of triiodothyronine and thyroxine and blocks the release of these hormones in the circulation. Propranolol (Inderal) or atenolol (Tenormin) may be ordered for the client to treat the tachycardia and hypertension. (Lewis, et al, 8 ed., p. 1265.)

A client is being seen in the clinic for problems of venous stasis and venous insufficiency. Compression or antiembolism stockings have been ordered. What information would be important for the nurse to teach the client regarding the stockings? a) Put the stockings on each night when you go to bed, remove them in the morning. b) Make sure the hole at the end of the stockings is under the toes. c) If the hose are not long enough to go to your thigh, then roll them down. d) Wear the stockings when you are sitting for extended periods and your feet swell.

b) Make sure the hole at the end of the stockings is under the toes. The hole at the end of the stockings goes under the toe, frequently clients think the toes should protrude through the hole. Stockings are to be applied in the morning preferably before getting out of bed and are worn during the day. They can be removed for bathing and skin care. The hose should never be rolled down, because this causes a constricting band around the leg and impedes venous return. (Lewis, et al, 8 ed., p. 885.)

The nurse is caring for several clients. In providing care, which activity and client would require the use of gloves? a) Assessing vital signs on a client with congestive heart failure b) Performing a bed bath on a client with gonorrhea c) Palpating the abdomen of a client who is HIV positive d) Assessing the skin for evidence of Kaposi's sarcoma

b) Performing a bed bath on a client with gonorrhea Care of the client with gonorrhea is a situation in which possible contact can occur with body secretions and possible transmission of bacteria. The other options do not involve contact and/or transfer of body fluids. (Potter, Perry, 7 ed., p. 667.)

A client requires bowel preparation for a lower gastrointestinal radiology series. The nurse anticipates the bowel preparation will include which of the following medications? a)Methylcellulose (Citrucel) b) Polyethylene glycol-electrolyte solution (GoLYTELY) c) Loperamide HCl (Imodium) d) Docusate sodium (Colace)

b) Polyethylene glycol-electrolyte solution (GoLYTELY) Bowel preps, such as polyethylene glycol-electrolyte solution (GoLYTELY), are ordered for colonoscopies and other diagnostic radiologic procedures. As an osmotic laxative used for bowel cleansing, polyethylene glycol is used specifically because it provides the best and most complete evacuation of the gastrointestinal tract of all the available laxatives. Docusate (Colace) is a stool softener or surfactant laxative. Methylcellulose is a bulk-forming laxative. Loperamide is an antidiarrheal drug. (Lewis, et al, 8 ed., p. 915.)

Which medication should be readily available while a client is receiving a continuous IV heparin infusion? a) Procainamide hydrochloride (Pronestyl) b) Protamine sulfate c) Atenolol (Tenormin) d) Calcium gluconate

b) Protamine sulfate Protamine sulfate is a heparin antagonist. It combines with the heparin and inactivates it. Protamine should be easily available for the client who is receiving a large amount of heparin by IV infusion. Atenolol is a beta-blocker used to manage hypertension and angina; calcium gluconate is a calcium replacement; Pronestyl is used to treat ventricular dysrhythmias. (Lehne, 7 ed., p. 600.)

A client is admitted to the hospital with a diagnosis of acute exacerbation of ulcerative colitis. The client states he has been having abdominal pain and 12 to 16 bloody stools a day. What will be the initial nursing action? a) Determine when the diarrhea started. b) Put the client on NPO status. c) Plan on administering psyllium (Metamucil) to provide bulk to the stool. d) Assist the client to determine what foods cause the diarrhea.

b) Put the client on NPO status. When the client with IBD or ulcerative colitis has an acute exacerbation, the bowel must be put to rest; therefore the client should be NPO. It is not appropriate to give a bulk laxative with an acute exacerbation. After the acute attack is under control, then the nurse may assist the client to determine if any foods are precipitating the problem. (Lewis, et al, 8 ed., p. 995.)

A 6-week-old infant is brought by her parent into the clinic. The parent explains to the nurse that after feedings the infant "vomits real strong." The nurse recognizes the symptoms of projectile vomiting. The nurse would correlate this symptom with what condition? a) Tracheoesophageal fistula b) Pyloric stenosis c) Intussusception d) Volvulus

b) Pyloric stenosis Vomiting in an infant with pyloric stenosis begins to develop between 4 and 6 weeks of age. The vomiting grows increasingly forceful until it is projectile, possibly projecting as much as 3 to 4 feet. Breastfed infants begin developing symptoms at approximately 6 weeks, because the curd of breast milk is smaller than that of cow's milk, and it passes through a hypertrophied muscle more easily. Symptoms of volvulus often follow those related to intestinal obstruction and include constipation, colicky abdominal pain, nausea, and abdominal distention. Symptoms of intussusception are characterized by sudden, severe abdominal pain; vomiting; and abdominal distention; infant may pass a bloody stool (i.e., "currant-jelly" appearance). Symptoms of tracheoesophageal fistula include choking, coughing, and intermittent cyanosis during feeding, along with abdominal distention; these are diagnosed most often at birth with the first feeding. (Hockenberry, Wilson, 9 ed., p. 1322.)

A client with hypercortisolism demonstrates an understanding of the need to call the provider when there is: a) Upset stomach b) Rapid weight gain c) Striae on the abdominal skin d) Development of a buffalo hump

b) Rapid weight gain Rapid weight gain, which is a sign of fluid retention, must be reported to the health care provider, because it may indicate excess steroids in the body, which will lead to symptoms of Cushing's syndrome. Gastric irritation and upset stomach are results of the steroid medication irritating the stomach and can be minimized with food ingestion before taking the medication. Striae are noted in the diagnosis of hypercortisolism because high levels of cortisol degrade collagen but do not need to be reported, as does the buffalo hump. (Lewis, et al, 8 ed., p. 1276.)

A 4-year-old is early postoperative following abdominal surgery for a repair of an umbilical hernia. The nurse notes that the heart rate is 24 beats/min less than it was preoperatively. What is the priority nursing action? a) Notify the surgeon of the drop in heart rate. b) Reassess the pulse and blood pressure in 15 minutes. c) Question the parents if this is the child's usual heart rate. d) Reassess the heart rate by following physician's orders and check in 2 hours.

b) Reassess the pulse and blood pressure in 15 minutes. A drop of 24 beats/min in the heart rate of a 4-year-old child is a significant change in vital signs. It will be important for the nurse to monitor and reassess the child's heart rate and blood pressure in 15 minutes to determine whether the child's condition is stable. Rechecking the vital signs in 2 hours is not safe practice, because of the disparity in the heart rate findings between preop and postop. Parents typically do not know their child's heart rate. Before the nurse contacts the surgeon, additional assessment data should be obtained, such as the reassessment of the heart rate, blood pressure, respiratory rate, and pain status. (Hockenberry, Wilson, 9 ed., p. 1009.)

A child has been admitted with a diagnosis of an intestinal obstruction and is scheduled for surgery. What would be important for the nurse to closely assess for in this child before surgery? a) Hyperactive bowel sounds below the obstructed area b) Respiratory compromise because of pressure on diaphragm c) Abdominal cramping and distention d) Nausea, vomiting, increasing restlessness

b) Respiratory compromise because of pressure on diaphragm Respiratory compromise may occur because of the pressure from the distended abdomen on the diaphragm. The other symptoms listed in the other options are characteristic of an intestinal obstruction and would be expected to occur. A sudden decrease in the abdominal pain and distention would be suggestive of an intestinal rupture. (Hockenberry, Wilson, 9 ed., p. 1322.)

A client is scheduled for a TURP (transurethral resection of the prostate). His wife stops the nurse in the hall and expresses concern about his ability to maintain fertility after the TURP. The nurse's best response would be based on which of the following? a) Fertility is not altered after prostate surgery. b) Retrograde ejaculation can occur after surgery. c) Physicians routinely save the client's sperm before the surgery. d) Erectile dysfunction is absolutely not a complication after a TURP.

b) Retrograde ejaculation can occur after surgery. Retrograde ejaculation can occur and is a disadvantage after a TURP. This allows the ejaculated sperm to flow back into the bladder rather than through the penis. The client can still reach sexual climax but may ejaculate very little or no semen (dry orgasm). Retrograde ejaculation is not harmful, but it can cause fertility problems. Sperm banking is not routinely performed but could be done should the client request it. Erectile dysfunction is not a common complication but is possible if nerves are damaged during the surgery. A small percentage of men do experience ED after this type of surgery. (Lewis, et al, 8 ed., p. 1386.)

The nurse is assisting a client immediately before a colonoscopy. The nurse will direct the client and help him move into what position? a) Prone b) Sims' lateral c) Slight Trendelenburg d) Flat with lithotomy stirrups

b) Sims' lateral Sims' lateral position is most commonly used for best access and visualization during the procedure, as well as for the client's comfort. Lithotomy position with stirrups is used for gynecologic exams and prostate surgery. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 915.)

The nurse is performing an initial assessment on a client recently diagnosed with thromboangitis obliterans, or Buerger's disease. Regarding the client's diagnosis, what information from the client's history would be of most concern? a) Chronic hypertension for 4 years b) Smoking a pack a day for 10 years c) Mother was diagnosed with Raynaud's disease at age 45 years d) History of type 2 diabetes

b) Smoking a pack a day for 10 years Smoking is directly correlated with the development of thromboangitis obliterans, or Buerger's disease. The client will need to stop smoking to effectively control the arterial spasms in her hands. Hypertension, familial traits, and history of type 2 diabetes are not significant to the development of the condition. (Ignatavicius, Workman, 7 ed., p. 797.)

What medication would the nurse identify as increasing a client's risk of infection? a) Beta-blockers b) Steroids c) Aspirin d) Calcium-channel blockers

b) Steroids Long-term steroid use depresses the immune system, making the client susceptible to infection. Aspirin may increase bleeding tendencies; beta-blockers and calcium-channel blockers may be used to treat hypertension. (Lewis, et al, 8 ed., p. 1283.)

Sulfasalazine (Azulfidine) is prescribed for a patient who has been diagnosed with ulcerative colitis. What is the desired action of this medication? a) Decreases the infection and prevent diarrhea b) Suppresses inflammation in the large intestine c) Assists to prevent constipation d) Decreases gastric motility to prevent diarrhea

b) Suppresses inflammation in the large intestine Sulfasalazine (Azulfidine) suppresses the inflammatory process that causes the symptoms of ulcerative colitis. It is not used to treat infections. It is not given to decrease the infection. The medication has no effect on constipation and it does not decrease gastric motility. (Lewis, et al, 8 ed., p. 1025.)

The nurse is assessing a client who had exploratory surgery for a ruptured appendix 24 hours ago. What assessment finding would suggest the client is developing peritonitis? a) Abdominal pain in the area of the incision; pain increases with coughing b) Temperature increase to 102° F, rigid abdomen, decreased or absent bowel sounds c) Purulent drainage from the surgical wound; nausea and vomiting after clear liquid intake d) Absent bowel sounds, decreased white cell count, low-grade fever

b) Temperature increase to 102° F, rigid abdomen, decreased or absent bowel sounds Peritonitis, or an inflammation/infection of the lining of the peritoneal cavity, occurs if the appendix ruptures before removal. Symptoms include those associated with an acute infection, in addition to peritonitis (increasing abdominal pain and distention, rigid guarding of the abdomen, shallow respirations, and absent bowel sounds.) The client will have an increase in the white blood cell count. (Lewis, et al, 8 ed., p. 1022.)

The nurse is administering propranolol (Inderal) to a client who is being treated for hypertension. What is the desired response to this medication? a) Vasodilation occurs, resulting in a decrease in the cardiac afterload. b) The cardiac rate is decreased with a resulting decrease in the cardiac output. c) Cardiac output is decreased, and the arterial BP rises. d) Pericardial fluid is decreased, thus decreasing the cardiac workload.

b) The cardiac rate is decreased with a resulting decrease in the cardiac output. The primary action of the beta blocker, Inderal, is to slow the cardiac rate. The medication is effective in the treatment of hypertension or dysrhythmias that result in tachycardia. With a decrease in cardiac rate, there is also a decrease in cardiac output. The beta blockers do not cause vasodilation. A decrease in cardiac output would cause a decrease in arterial BP, not an increase. Beta blockers do not have an effect on pericardial fluid. (Lehne, 7 ed., pp. 502-503.)

In planning discharge teaching for the client who has undergone a gastrectomy, the nurse includes what information regarding dumping syndrome? a) The syndrome will be a permanent problem, and the client should eat 5 to 6 small meals per day. b) The client should decrease the amount of fluid consumed with each meal and for 1 hour after each meal. c) The client should increase the amount of complex carbohydrates and fiber in the diet. d) Activity will decrease the problem; it should be scheduled about 1 hour after meals.

b) The client should decrease the amount of fluid consumed with each meal and for 1 hour after each meal. Dumping syndrome is self-limiting; it is not a permanent problem. Decreasing fluid intake with and after meals, eating small meals, and decreasing carbohydrate and salt intake will decrease the dumping effect. Activity does not play an essential role in preventing dumping syndrome. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 997.)

A client had a gastrectomy 2 days ago. There is an order to clamp the nasogastric tube for 4 hours. About 2 hours after clamping, the client begins to complain of nausea. What is the best nursing action? a) Aspirate the stomach contents to prevent problems with vomiting. b) Unclamp the nasogastric tube and connect it back to the previous level of suction. c) Call the doctor and advise him of the client's nausea. d) Administer the antiemetic that is ordered on a PRN basis.

b) Unclamp the nasogastric tube and connect it back to the previous level of suction. The nausea may lead to vomiting and should be addressed early. Opening the tube to drainage and suction will assist in preventing distention on the suture line, vomiting, and possible aspiration of gastric contents. (Lewis, et al, 8 ed., p. 998.)

Which symptom is most likely experienced by a client with an acute episode of diabetes insipidus? a) Low serum albumin b) Urine specific gravity of 1.003 c) Pulse oximeter reading of 84% d) HbA1C of 9%

b) Urine specific gravity of 1.003 Diabetes insipidus causes a pronounced loss of intravascular volume as evidenced by 5 to 20 L of urine output per day. This would lead to dilute urine (very low specific gravity) and concentrated blood (as evidenced by hypernatremia). Nutrition (low albumin), gas exchange (poor oxygen saturation), and a high glycosylated hemoglobin (as is seen in diabetes mellitus) are not related to diabetes insipidus. (Lewis, et al, 8 ed., p. 1261.)

Which medications would most likely contribute to constipation? Select all that apply. a) Antibiotics, such as erythromycin. b) Opioids, such as oxycodone/acetaminophen (Percocet) c) Antacids, such as aluminum hydroxide (Amphogel) d) Anticholinergics, such as benztropine (Cogentin) e) H2-receptor antagonists, such as ranitidine (Zantac) f) Anti-epileptics, such as carbamazepine (Tegretol)

b, c, d Constipation is a frequent side effect of opioids (oxycodone/acetaminophen), anticholinergics (benztropine), and some antacids (aluminum hydroxide). Erythromycin often causes diarrhea, not constipation. Ranitidine (Zantac) and carbamazepine (Tegretol) are not associated with constipation. (Lehne, 7 ed., pp. 929-930).

The nurse is teaching a client about home care and treatment of venous stasis ulcers on his leg. What should be included in the nurse's instructions? Select all that apply. a) Dressings do not need to changed frequently because there is minimal drainage. b) Healing will be facilitated by wearing leg compression devices. c) When the client is in the sitting position, he should keep his legs elevated. d) Avoid standing for prolonged periods of time. e) Cool packs can be applied to the ulcers to decrease inflammation. f) Soak the affected extremity in warm water every evening.

b, c, d Healing of venous stasis ulcers is dependent on relieving the venous congestion in the extremity. Compression devices and elevation of the extremity are the most effective methods. The client should avoid standing for long periods since this increases venous stasis. Moist cool and/or warm packs are not used, but moist environment dressings are utilized. Dressings need to be changed as frequently as necessary, because there may be excessive drainage. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 892.)

What is appropriate nursing education for the client with acute gastritis secondary to taking nonsteroidal antiinflammatory medications and low-dose aspirin? Select all that apply. a) Avoid drinking more than 8 oz of beer or more than 2 oz of hard alcohol per day. b) Avoid intense emotional upsets if possible. c) Educate the client about the benefit of taking a proton-pump inhibitor medication to provide symptomatic relief. d) Avoid spicy foods including hot sauces and hot peppers. e) Reduce or eliminate smoking.

b, c, d, e Intense emotional upsets may produce inflammation of the mucosal lining and can aggravate gastritis. Proton-pump inhibitors decrease gastric hydrochloric acid secretion and are desirable in the client with gastritis. Alcohol and spicy foods are irritating to the gastric mucosa and should not be consumed when the client has gastritis. Smoking also may increase the symptoms of gastritis. (Lilley, 8 ed., pp. 985-986.)

The nurse should notify the health care provider immediately about which assessment finding in a client who has hypercortisolism? Select all that apply. a) Reddish-purple striae present on the and thighs b) Crackles heard throughout the lungs c) Weight gain of 3 lb since the previous day d) Increasing peripheral edema e) Decreased urinary output f) Increased pulse from 80 to 100 beats/min

b, c, d, e, f Hypercortisolism is hypersecretion of the adrenal cortex and is commonly called Cushing's disease or syndrome, which leads to a myriad of symptoms, including alterations in water and mineral metabolism. Cushing's syndrome clients have the potential for fluid volume overload, which can quickly lead to pulmonary edema and ultimately death, if undiagnosed early and treated. Fluid retention and fluid volume excess because of excess water and sodium reabsorption are symptoms associated with pulmonary edema, which may manifest as the presence of crackles in the client's lungs, increase in pulse and peripheral edema, weight gain, and reduced urine output. Reddish-purple striae (stretch marks) are common findings in clients with Cushing's disease and are due to the destructive effect of cortisol on collagen. (Ignatavicius, Workman, 7 ed., pp. 1384-1385.)

A client is admitted for abdominal surgery in the morning. Which preoperative orders should the nurse anticipate? Select all that apply. a) Shaving the abdomen during the evening b) Administering polyethylene glycol solution c) Serving a full liquid diet for dinner d) Ensuring an informed consent is signed and on the medical record e) Completing the last dose of the oral antibiotics the patient has been taking

b, d, e Preparation for abdominal surgery includes use of a laxative (usually polyethylene glycol) to clean out the bowel, ensuring the consent is signed and completing any antibiotics that were ordered (to decrease the bacterial flora in the bowel). Shaving the abdomen is not routinely done and, if needed, is done at the time of surgery to decrease the risk of infection. The patient is on clear liquids the day before surgery, not full liquids. (Lewis, et al, 8 ed., p. 1037; Potter, Perry, 7 ed., p. 1387.)

Which of the following findings suggest that a client with peripheral artery disease needs urgent attention? Select all that apply. a) Intermittent claudication b) Increased tingling in a limb with pain c) Reduced hair on limbs d) Sudden numbness or burning in a leg or foot e) Rest pain that awakens the client at night f) Dependent rubor when foot is dependent

b, d, e Prolonged ischemia associated with severe arterial disease requires urgent attention if the limb is to be restored to optimal health. Burning in the distal forefoot, numbness or tingling in a leg or foot, and pain in the legs that causes the client to awaken at night (rest pain), are important symptoms that should be reported to the physician. Circulation may be restored if revascularization is attempted. Loss of hair, dependent rubor, and intermittent claudication are indications of arterial disease; however, they do not signal the need for urgent care. (Lewis, et al, 8 ed., p. 874.)

An obese client asks the nurse about using medications for weight reduction. What would be the best nursing response? a) "Weight loss medications can cause depletion of vitamins and minerals." b) "Medications should be used only after all other weight reduction options have been tried." c) "Weight gain is likely to reoccur unless the diet and activity levels change." d) "Medications have not proven to be successful in long-term weight loss."

c) "Weight gain is likely to reoccur unless the diet and activity levels change." Medications may be very valuable in the client's weight loss program; however, if the client does not change dietary habits and incorporate exercise into his lifestyle, weight gain is likely to reoccur. Medications may be used early in the client's weight loss program, not necessarily after all other options have been tried. Weight loss medications do not cause a significant change in absorption of vitamins and minerals. (Lewis, et al, 8 ed., p. 954.)

A client has been experiencing nausea, vomiting, and diarrhea for the past 24 hours. As the nausea begins to resolve, what would be the first fluid the nurse encourages the client to drink? a) A cup of coffee with sugar b) A cup of hot chicken soup c) A dish of strawberry gelatin d) A glass of flavored sports drink

c) A dish of strawberry gelatin Water and clear liquids are the first foods started after a patient has been nauseated. Fruit juices, hot foods, coffee, or sports drinks are not tolerated as well as the clear liquids. (Potter, Perry, 7 ed., p. 1111.)

A young adult is admitted with hypersecretion of growth hormone. The nurse understands that because the young adult has epiphyseal closure he is most likely to have assessment findings characteristic of: a) Gigantism b) Panhyperpituitarism c) Acromegaly d) Dwarfism

c) Acromegaly When epiphyseal closure occurs, the client will have symptoms of acromegaly because of hypersecretion of growth hormone. Typical findings are enlargement of the hands and feet, hypertrophy of the skin, and changes in facial features: protruding jaw, slanting forehead, and an increase in the size of the nose. If excessive growth hormone production starts before the growth plates have closed in children, the condition is called gigantism. Typical findings of gigantism are excessive growth of the long bones, resulting in unusually large stature, and lengthening of the arms and legs. Puberty may be delayed, and the genitals may not develop fully. Dwarfism is characterized by the client being abnormally small. (Lewis, et al, 8 ed., p. 1256.)

A pregnant woman has been treated with antithyroid medication throughout the pregnancy. The delivery room nurse notes a large goiter on the newborn. What would be the best nursing management? a) Administer antithyroid medication immediately. b) Obtain stat thyroid panel blood work. c) Anticipate the need for emergency ventilation, oxygen, and a tracheostomy set. d) Position the infant in supine position with head turned to the side.

c) Anticipate the need for emergency ventilation, oxygen, and a tracheostomy set. Newborns born with a goiter require immediate precautions initiated for emergency ventilation, such as supplemental oxygen and a tracheostomy set nearby. Hyperextension of the neck, not turning the head to the side, facilitates breathing. The newborn would be placed on thyroid medication, not antithyroid medication, to reduce the goiter or may require surgery to remove large goiters. Thyroid blood work would be done, but it is not the priority. (Hockenberry, Wilson, 9 ed., p. 309.)

A client in a long-term facility reports to the nurse that he has not had a bowel movement in 2 days. Which intervention should the nurse implement first? a) Instruct the caregiver to offer a glass of warm prune juice at mealtimes. b) Notify the health care provider and request a prescription for a large-volume enema. c) Assess the client's medical record to determine the client's normal bowel pattern. d) Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day.

c) Assess the client's medical record to determine the client's normal bowel pattern. This client may not routinely have a daily bowel movement, so the nurse should first assess this client's normal bowel habits before attempting any intervention. Options may then be implemented if warranted. (Lewis, et al, 8 ed., p. 1012.)

An infant with a diagnosis of pyloric stenosis is admitted to the in the pediatric unit. Shortly after admission, he begins to vomit. What is an appropriate nursing action? a) Place the infant on his back. b) Offer the infant small amounts of rehydrating solution. c) Assess the infant for dehydration. d) Place the infant on the right side.

c) Assess the infant for dehydration. The child should be placed in a position to prevent aspiration, either on his side or semi-Fowler's position (infant seat). Physiologic need is the priority. The child is most often NPO before surgery, and the nurse should perform a thorough assessment after positioning the child. (Hockenberry, Wilson, 9 ed., p. 1322.)

A client begins to complain of abdominal pain and distention about 24 hours after a colon resection. What would be the best nursing action? a) Evaluate when client received pain medication last. b) Auscultate the abdomen for presence of bowel sounds. c) Assist the client to get out of bed and ambulate. d) Administer a prochlorperazine (Compazine) suppository.

c) Assist the client to get out of bed and ambulate. Ambulation will facilitate peristalsis and help the client pass the flatus and therefore reduce the distention. The client does not need further pain medication, because it may further reduce the peristalsis. Auscultating the abdomen for bowel sounds provides information regarding presence of peristalsis but does not provide any relief to the client. Prochlorperazine (Compazine) is an antiemetic. (Potter, Perry, 8 ed., p. 1405.)

A client is admitted with duodenal ulcers. What will the nurse anticipate the client`s history to include? a) Recent weight loss b) Increasing indigestion after meals c) Awakening with pain at night d) Episodes of vomiting

c) Awakening with pain at night Duodenal ulcers are characterized by high gastric acid secretion and rapid gastric emptying. Food buffers the effect of the acid; consequently, pain increases when the stomach is empty. Pain does not characteristically occur after eating, and the client does not usually have bouts with nausea unless bleeding or obstruction is a problem. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 987.)

The nurse is admitting a client with a history of vomiting and diarrhea for the past 3 days. Which order will the nurse implement first? a) Insert a nasogastric tube and connect to intermittent suction. b) Assess the anal area for excoriation related to the diarrhea. c) Begin an intravenous infusion of normal saline at 200 mL/hr. d) Offer the client small sips of oral rehydrating solutions.

c) Begin an intravenous infusion of normal saline at 200 mL/hr. Beginning an IV infusion can provide the most benefit to the client in the shortest period of time; rehydration is a priority. Offering small sips of rehydrating solution is not a priority until the IV fluids have been established and the nausea is under control. Other actions can be done after the IV is infusing. (Lewis, 8 ed., p. 967.)

An adolescent with type 1 diabetes mellitus is experiencing a problem with diabetic ketoacidosis. Which lab results reflect this condition? a) Hematocrit of 37% b) Serum glucose level of 150 mg/dL c) Blood pH of 7.28 d) Serum creatinine level of 5.6 mg/dL

c) Blood pH of 7.28 Diabetic ketoacidosis (DKA) is reflected in the decreased pH (7.28), which indicates metabolic acidosis. This often is accompanied by an increased temperature and urine output, dry mouth, abdominal pain, flushing, decreased energy, and an elevated blood glucose level greater than 300 mg/dL. The hematocrit is within normal range. The serum glucose is not high enough for DKA (usually the value is greater than 250 mg/dL). Creatinine is elevated three times normal, but this would not necessarily reflect DKA, because it is associated more with diabetic nephropathy. (Lewis, et al, 8 ed., p. 1243.)

The nurse would expect which medication to be part of a maintenance therapy treatment plan for hypoparathyroidism? a) Phosphorus supplements b) Parenteral parathyroid hormone c) Calcium supplements d) Vitamin C

c) Calcium supplements Clients with hypoparathyroidism require long-term drug therapy with oral calcium supplements. Hormone replacement (parathyroid hormone) is not used for treatment because of the expense and the need for parenteral replacement. Vitamin D will be prescribed for chronic resistant hypocalcemia. (Lehne, 7 ed., p. 870; Lewis, 8 ed., pp. 1275-1276.)

A client is started on rosuvastatin (Crestor). What would be important for the nurse to discuss with this client? a) Skin flushing after taking the medication is common. b) Take the medication in the morning and evening before eating. c) Call the office should you have muscle aches and pains unrelated to exercise. d) For the first 2 weeks, get up slowly and make sure you are not dizzy.

c) Call the office should you have muscle aches and pains unrelated to exercise. Any unusual muscle aches and pains that are not related to activity should be reported. Myopathy and rhabdomyolysis may occur as side effects; these should be reported immediately as they are potentially dangerous. Liver function tests also should be evaluated because the statin medications are potentially hepatotoxic. The medication is taken without regard to food and does not cause orthostatic hypotension or flushing. (Lehne, 7 ed., pp. 568-569.)

Four hours after aortic-femoral bypass graft surgery, the nurse assesses the client and is unable to palpate pulses in the operative leg. The client complains of pain in the leg. What is the first nursing action? a) Massage the leg and apply warm towels. b) Elevate the leg and recheck the pulse. c) Call the physician immediately. d) Help the client ambulate.

c) Call the physician immediately. Occlusion to the aortic/femoral bypass graft is considered a medical emergency, and physician notification is imperative. No other nursing options would alleviate the problem. Massaging the leg and having the client ambulate would be contraindicated. If the pulses cannot be palpated and the client is experiencing pain, the nurse should not wait to call the physician. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 878.)

A client admitted with a pheochromocytoma returns from the operating room after adrenalectomy. The nurse should carefully assess this client for: a) Hypoglycemia b) Hypokalemia c) Changes in blood pressure d) Increased sodium and water retention

c) Changes in blood pressure Pheochromocytoma is a tumor in the adrenal medulla that produces excess catecholamines (epinephrine and norepinephrine). An excess of these catecholamines can cause severe hypertension. Surgery (an adrenalectomy) alleviates the elevated blood pressure most of the time. In 10% to 30% of clients, hypertension remains and must be monitored and treated. Electrolyte imbalances and blood sugar are not typically affected. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 1284.)

The nurse is caring for a client postoperative thyroidectomy. What would be an important nursing intervention? a) Have the client speak every 5 to 10 minutes if hoarseness is present. b) Provide a low-calcium diet to prevent hypercalcemia. c) Check the dressing at the back of the neck for bleeding. d) Apply a soft cervical collar to restrict neck movement.

c) Check the dressing at the back of the neck for bleeding. If bleeding occurs, the blood will drain posteriorly or behind the client's neck. Serum levels of calcium are important to monitor because of possible damage to the parathyroids during surgery. Oral intake of calcium is not immediately significant. The client is often hoarse; it is important to monitor for increasing hoarseness that would be indicative of edema but not every 5 to 10 minutes. A cervical collar is not indicated. (Lewis, Dirksen, Heitkemper, et al, 8 ed., pp. 1266, 1269.)

A primary nursing intervention to prevent postoperative respiratory complications would include teaching the client to: a) Wear anti-embolism stockings when ambulating after surgery. b) Perform range-of-motion exercises on awakening. c) Cough and deep breathe as often as possible and at least every 2 hours. d) Increase fluid intake and maintain strict intake and output.

c) Cough and deep breathe as often as possible and at least every 2 hours. Coughing and deep breathing help to reduce the risk of fluid buildup in the lungs, atelectasis, and development of respiratory acidosis. Wearing anti-embolism stockings, performing range-of motion exercises, and increasing fluid intake may be done after surgery, but maintaining good respiratory hygiene is the priority action to prevent respiratory complications. (Potter, Perry, 7 ed., pp. 1238-1248.)

A client with venous thromboembolism (VTE) is started on a continuous infusion of heparin. What is an important nursing action for the client who is on heparin? a) Monitor rate and quality of peripheral pulses. b) Notify the physician if the prothrombin time is greater than 45 seconds. c) Decrease number of venipunctures by coordinating blood drawn for serum blood studies. d) Asses the client for adequacy of cardiac perfusion and urinary output.

c) Decrease number of venipunctures by coordinating blood drawn for serum blood studies. Coordinate the drawing of blood so the client does not receive multiple venipunctures. IM injections should also be avoided. Prothrombin time is used to evaluate the effectiveness of warfarin (Coumadin) Vitamin K is used to reverse warfarin. Pulse quality is affected by arterial disease not by DVT. (Lewis, et al, 8 ed., p. 889.)

A client is taking omeprazole (Prilosec) for his heartburn. In teaching the client about this medication, the nurse explains that this drug: a) Protects the lining of the stomach and esophagus by providing a protective coating b) Decreases the gastric acid reflux by increasing rate of gastric emptying c) Decreases production of hydrochloric acid by the parietal cells in the stomach d) Provides immediate relief by neutralizing the stomach acid

c) Decreases production of hydrochloric acid by the parietal cells in the stomach The proton-pump inhibitors decrease the rate of gastric acid secretion. Metoclopramide (Reglan) increases the rate of gastric emptying by increasing motility. Sucralfate (Carafate) protects the stomach by providing a protective barrier to acid. Antacids neutralize stomach acid and work rapidly. (Lilley, 6 ed., p. 791.)

A client is being treated for an Addisonian crisis, and 0.9% saline solution is being administered. What nursing observation would indicate this intervention may not be achieving the desired response? a) Ankle edema b) Serum potassium of 4.1 mEq/L c) Decreasing blood pressure d) Heart rate of 78

c) Decreasing blood pressure The purpose of the infusion of large volumes of saline is to reverse/prevent hypotension. Edema would not be expected, because this is associated with Cushing's syndrome. Hyperkalemia is associated with Addison disease. Sodium polystyrene sulfonate (Kayexalate) may be administered to clients experiencing higher-than-normal ranges of potassium levels in which bradycardia and irregular pulse are clinical findings. Decreasing blood pressure may be considered a late sign of cardiac decompensation with decreased atrial and ventricular output. Pedal edema would not be associated in clients experiencing hyperkalemia, because it is related to sodium retention. (Lewis, et al, 8 ed., p. 1281.)

The nurse is caring for a client after a gastric resection. What nursing assessment findings would indicate the client is experiencing a problem of postprandial hypoglycemia? a) Complaints of nausea and vomiting after oral administration of medications b) Absence of bowel sounds and inability to tolerate soft foods after the nasogastric tube has been removed c) Diaphoresis, anxiety, lightheadedness, and tachycardia about 15 to 30 minutes after eating d) Decrease in blood pressure and increase in pulse rate about 20 to 30 minutes after ambulating

c) Diaphoresis, anxiety, lightheadedness, and tachycardia about 15 to 30 minutes after eating Postprandial hypoglycemia is a physiologic problem associated with the too-rapid movement of food through the stomach after a gastric resection. Diaphoresis, anxiety, lightheadedness, and tachycardia about 15 to 30 minutes after eating describes the most common symptoms. The bolus of concentrated carbohydrates is dumped into the small intestine, which results in hyperglycemia, increased insulin production, and rebound hypoglycemia. Absent bowel sounds and inability to tolerate soft foods may be problems for this client, but they are not characteristic of postprandial hypoglycemia. (Lewis, et al, 8 ed., p. 996.)

The nurse is caring for a client 1 hour post op after a femoral popliteal bypass graft. Which assessment finding should be reported immediately? a) Doppler pedal pulses present and normal strength; body temperature of 99° F b) 2+ peripheral edema and slight pallor at the incision site c) Diminished pedal pulse and decreased ankle-brachial index measurement d) Serous drainage from the incision and a small hematoma

c) Diminished pedal pulse and decreased ankle-brachial index measurement During the first few hours after femoral bypass graft surgery, a client is at greatest risk for graft occlusion. A dramatic increase in the level of pain; loss of a palpable pulse or pulses distal to the operative site; extremity pallor or cyanosis; decreasing ankle-brachial index measurements; numbness, tingling, or a cold extremity temperature may indicate occlusion of the bypass graft and should be reported immediately. Pulses have usually returned to normal strength in the operating room after revascularization. Pain at the incision site and slight drainage are expected after the operation. (Lewis, et al, 8 ed., pp. 870-871.)

An 8-year-old boy with type 1 diabetes has been receiving NPH and regular insulin. His mother calls the nurse and explains that the child's morning blood glucose readings have been above 200 mg/dL. What should the nurse advise the mother to do? a) Raise his NPH dose by two units to cover the elevation in the early morning. b) Change the time of the night dose to 1 hour before sleep. c) Do blood glucose checks during the night. d) Keep a glass of water near the bed to dilute the sugar levels during the night.

c) Do blood glucose checks during the night. The child is having a rapid decrease in his blood glucose level during the night, causing a hyperglycemic rebound response. The rebound rise in the blood sugar reading is picked up in the morning blood glucose reading, which can lead to misinterpretation. This may be classified as a Somogyi effect. (Hockenberry, Wilson, 9 ed., p. 1603.)

The nurse is assessing the laboratory findings for a client and determines the test for Helicobacter pylori bacteria is positive. The nurse would identify this finding as associated with what condition? a) Gastroesophageal reflux disease b) Irritable bowel syndrome c) Duodenal ulcer d) Infectious esophagitis

c) Duodenal ulcer Helicobacter pylori is associated with the majority of duodenal and gastric ulcers. Factors that contribute to gastroesophageal reflux disease include incompetent lower esophageal sphincter and abnormal esophageal clearance. The most common pathogens for clients with infectious esophagitis are Candida albicans, herpes simplex, and cytomegalovirus. Infectious esophagitis is usually seen in immunosuppressed clients. Irritable bowel syndrome is a chronic functional disorder without structural or biochemical abnormalities. (Lewis, et al, 8 ed., p. 988.)

A client had a ruptured appendix and developed severe peritonitis postoperatively. The nurse is concerned about the client developing hypovolemic shock. What would the nurse identify as the major cause for the loss of circulating volume in this client? a) Loss of interstitial fluid during surgery b) Inadequate fluid replacement from nasogastric suctioning c) Extracellular fluid volume shift into the peritoneal cavity d) Loss of blood during surgery

c) Extracellular fluid volume shift into the peritoneal cavity Extracellular fluid shift (third spacing) may be precipitated by the peritonitis and the inflammatory process. Fluid moves out of the circulating volume into the peritoneal cavity. Clients with nasogastric tubes usually receive adequate fluid replacement to compensate for the nasogastric fluid loss. There should have been adequate blood replacement if blood loss were a problem during surgery. (Lewis, et al, 8 ed., p. 1719.)

A client newly diagnosed with type 1 diabetes mellitus is learning about diabetic foot care. The nurse would instruct the client to avoid: a) Emollient lotions b) Foot powder c) Foot soaks d) Nail files

c) Foot soaks Foot soaks macerate the skin and can increase the risk of breaks in the skin. Water-soluble lotions are recommended to moisturize the feet. Nail files are preferred over nail clippers or scissors. Foot powder may be used when foot perspiration exists. (Lewis, et al, 8 ed., p. 1251.)

The nurse is assessing a client with a diagnosis of peptic ulcer disease (PUD). What pain characteristics would the nurse expect the client to describe? a) Pain in the right shoulder, preceded by nausea b) Sudden, sharp abdominal pain, increasing in intensity c) Gnawing epigastric pain or boring pain in the back d) Heartburn and substernal discomfort when lying down

c) Gnawing epigastric pain or boring pain in the back The pain of PUD is typically described as "gnawing, burning, or boring." Pain in the right shoulder describes diaphragmatic irritation, most often caused by free air in the abdominal cavity, which may occur after abdominal surgery. Perforation is usually preceded by sudden, sharp abdominal pain; heartburn and substernal discomfort describe indigestion. (Lewis, et al, 8 ed., p. 989.)

What is an important nursing action when assisting the doctor with a pelvic examination? a) Instruct the client to bear down and hold her breath during the procedure. b) Explain to the client that she will not feel any pain. c) Have the client empty her bladder before the examination begins. d) Lubricate the speculum well before handing it to the doctor.

c) Have the client empty her bladder before the examination begins. Having the client void before the examination will make the procedure less painful and more accurate. There is no need for the patient to bear down or hold her breath. The patient should relax as much as possible during the procedure. The level of pain, if any, is highly dependent on the patient and her pain tolerance. Lubricant on the speculum may interfere with the Pap smear. The client should not douche or have intercourse before a pelvic exam, especially if any specimens are to be obtained, because changes in the normal flora and pH could occur from douching and the presence of semen. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 1303.)

The nurse is assessing the abdomen of a client who has a tentative diagnosis of an intestinal obstruction. What characteristic bowel sounds are frequently heard in clients in the early stages of this condition? a) Bowel sounds most often absent b) Loud bowel sounds (borborygmus), which would indicate decreased bowel motility c) Hyperactive bowel sounds proximal to area of obstruction d) Hypoactive bowel sounds precede the development of diarrhea

c) Hyperactive bowel sounds proximal to area of obstruction When a bowel obstruction occurs, the bowel sounds proximal to the obstruction are frequently hyperactive. The bowel sounds distal to the obstruction will be hypoactive. Bowel sounds are considered absent if they are not detected after listening to all four quadrants for a total of 5 minutes. Borborygmus and hyperactive bowel sounds accompany increased bowel motility, such as with diarrhea. (Lewis, et al, 8 ed., p. 1033.)

The nurse determines a nursing diagnosis of ineffective peripheral perfusion related to decreased arterial blood flow for a client with diabetes who had been diagnosed with peripheral arterial disease. The nurse would identify the need for further teaching based on what client statement? a) I will make sure my shoes fit well and do not rub any blisters. b) I will not sit in one position for longer than an hour. c) I will soak my feet in hot water to increase the circulation. d) I will walk every day and stop when I begin to have pain in my legs.

c) I will soak my feet in hot water to increase the circulation. Because of the peripheral arterial disease the client will have decreased sensation in his feet. He does not need to soak his feet in hot water. The other statements by the client are appropriate. (Lewis, et al, 8 ed., p. 874.)

After which procedure is a client most likely to experience an electrolyte imbalance? a) Bowel resection b) Transverse colostomy c) Ileostomy d) Gastric resection

c) Ileostomy Clients with ileostomies are likely to have problems with electrolyte imbalance, because they lose significant amounts of intestinal fluids through the stoma. The other clients do not lose as much intestinal fluid and electrolytes. (Lewis, et al, 8 ed., p. 1045.)

Which route is the most effective when administering the cyanocobalamin (vitamin B12) that is ordered after a total gastrectomy? a) Orally b) Intravenous injection c) Intramuscular injection d) Transdermal route

c) Intramuscular injection After a gastrectomy, the client no longer has the intrinsic factor available to promote vitamin B12 absorption in his gastrointestinal tract. Vitamin B12 may be given PO; however, it requires higher concentrations of medication. The most effective method is administered parenterally (IM or deep subcutaneous). Nasal spray is now available in a metered-dose device. The medication should not be given intravenously. (Lilley, 6 ed., p. 825.)

A client has undergone an abdominal perineal resection for treatment of his colon cancer. The client's family asks the nurse why he is receiving ranitidine (Zantac). The nursing response will be based on what action of this medication? a) It is an antiemetic and decreases the occurrence of nausea and vomiting. b) Medication assists to prevent aspiration of gastric contents in case of vomiting. c) It protects the stomach and assists to decrease the development of stress ulcers. d) It neutralizes gastric acid secretions and forms a protective coating in the stomach.

c) It protects the stomach and assists to decrease the development of stress ulcers. Ranitidine (Zantac) is administered to prevent the development of physiologic stress ulcers, which are associated with a major physiologic insult such as massive trauma and stressful surgical procedures. It does not decrease nausea or vomiting, prevent aspiration, or neutralize gastric acid secretions. (Lilley, 6 ed., p. 789.)

Which instruction should be included in discharge teaching for the client with a new prescription for simvastatin (Zocor)? a) Flushing occurs in almost all individuals. b) Sedation is common but will decrease with time. c) Liver enzyme levels should be monitored every few months. d) Watch closely for occurrence of postural hypotension.

c) Liver enzyme levels should be monitored every few months. Most of the "statin" drugs used for hyperlipidemia are hepatotoxic. Liver enzyme levels should be determined as a baseline before administration of the drug is started and then checked periodically throughout therapy. (Lehne, 7 ed., p. 569.)

A client is brought into the emergency department after an automobile accident in which she received a blunt force to the abdomen. The client is complaining of abdominal pain, splinting the abdomen. The nurse determines that bowel sounds are present but are hypoactive. A peritoneal lavage is performed, and the return is dark brown, foul-smelling fluid. What would be the priority nursing action? a) Prepare for a paracentesis to drain off the excess abdominal fluid. b) Administer pain medications and assess hydration status. c) Maintain the client NPO and prepare for immediate surgery. d) Monitor client's vital signs for evidence of hemorrhage.

c) Maintain the client NPO and prepare for immediate surgery. The results of the peritoneal tap and lavage indicate a perforation of the bowel has occurred and the client will need surgery immediately. The paracentesis would not be necessary and may compound the problem. Pain medications may mask the ongoing developing acute abdominal problems. The client's vital signs should continue to be monitored, but the preparation of surgery is a priority. (Lewis, et al, 8 ed., p. 1019.)

A client is diagnosed with a T5 spinal cord injury and has a BP of 100/68 and pulse of 68. The nurse understands that the client is experiencing: a) Anaphylactic shock b) Hypovolemic shock c) Neurogenic shock d) Cardiogenic shock

c) Neurogenic shock The client is experiencing neurogenic shock, which is due to the spinal cord injury leading to increased venous capacity due to a loss of peripheral vasomotor tone. This is the reason for the low blood pressure and bradycardia. Anaphylactic shock is caused by an antigen-antibody reaction with release of histamine. Cardiogenic shock occurs when the heart is unable to effectively circulate blood volume. Hypovolemic shock occurs because of reduced venous return due to reduced blood volume. (Ignatavicius, Workman, 7ed., pp. 811-815.)

An older adult client is nauseated and has vomited twice. What would be the best nursing action? a) Assess the client for symptoms of dehydration. b) Offer the client rehydrating liquids to decrease problem with electrolyte loss. c) Place client in low Fowler's position and offer small sips of water. d) Offer high-protein drinks to maintain nutrition.

c) Place client in low Fowler's position and offer small sips of water. It is important to place the client in low Fowler's position to prevent problems with aspiration. The client has only vomited twice; rehydrating fluid are not indicated at this time. It would be important to assess hydration status but only after positioning the client to prevent aspiration. High-protein drinks are not appropriate. (Potter, Perry, 7 ed., p. 1103.)

A nurse assessing a client with syndrome of inappropriate antidiuretic hormone (SIADH) would expect to find which laboratory values? a) Serum sodium = 150 mEq/L and low urine osmolality b) Serum potassium = 5 mEq/L and low serum osmolality c) Serum sodium = 120 mEq/L and low serum osmolality d) Serum potassium = 3 mEq/L and high serum osmolality

c) Serum sodium = 120 mEq/L and low serum osmolality SIADH occurs when excessive antidiuretic hormone (ADH) is released, even when the plasma (serum) osmolality is normal. The excess ADH increases the permeability of the renal tubules, causing reabsorption of water into the circulation. As a result of extracellular fluid expansion, serum osmolality decreases. Also, sodium levels decline (as a result of being diluted), leading to hyponatremia. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 1259.)

A client diagnosed with peripheral vascular disease (PVD) is being discharged. Which of the client's risk factors would be most important for the nurse to discuss with the client before discharge? a) Alcohol intake b) Age c) Smoking d) Hypoglycemia

c) Smoking Smoking causes vasoconstriction, which increases the complications brought about by PVD. This is a modifiable risk factor that will assist in increasing circulation. Age cannot be modified. The client with diabetes is at increased risk for the development of PVD, but it is not due to hypoglycemia. The client with diabetes needs to maintain good control of diabetes, but PVD is a complication of the disease process. Alcohol is not a significant risk factor for PVD. (Lewis, et al, 8 ed., p. 867.)

A client with peripheral artery disease (PAD) understands that the pain in his foot is caused by an inadequate blood supply. The nurse would confirm which client activity as one that would further diminish blood flow to the extremities? a) Lowering the limb b) Drinking alcohol c) Applying antiembolism stockings c) Smoking cigarettes

c) Smoking cigarettes Smoking causes an increase in arterial constriction as a result of the effect of nicotine on the peripheral vessels. Alcohol would have vasodilating effects. Antiembolism stockings would support the venous return in the lower extremities. PAD affects the arteries; lowering the limb will not have any desirable effect. (Lewis, et al, 8 ed., p. 875.)

Which of the following would be an appropriate nursing implication to teach the client in regards to the administration of cholestyramine (Questran)? a) Supplement with water-soluble vitamins in long-term therapy. b) Mix powder with only two (2) oz of fluid for administration. c) Teach the client to eat more fiber daily. d) Medication may be taken with meals.

c) Teach the client to eat more fiber daily. Questran can cause constipation as well as GI disturbances and increasing fiber is the appropriate nursing implication. Supplementing with water-soluble vitamins in long-term therapy is not appropriate, because the client needs to supplement with fat-soluble vitamins, not water-soluble. Increasing fluid intake and mixing with several ounces (not just 2 oz) of fluid is the best. Questran should be taken before meals not with meals to improve its absorption. (Lee, Hayes, McCuisition, 7 ed., p. 572, 687.)

While discussing her diagnosis of hypertension, a client asks the nurse how long she is going to have to take all of the medications that have been prescribed. On what principle is the nurse's response based? a) The client will be scheduled for an appointment in 2 months; the doctor will decrease her medications at that time. b) As soon as her blood pressure (BP) returns to normal levels, the client will be able to stop taking her medications. c) To maintain stable control of her BP, the client will have to take the medications indefinitely. d) The nurse cannot discuss the medications with the client; the client will need to talk with the doctor.

c) To maintain stable control of her BP, the client will have to take the medications indefinitely. Noncompliance with blood pressure medications is a common problem in the treatment of hypertension. The client must understand that the only way to keep her blood pressure under control is to continue to take her medications, potentially for the rest of her life. She will not be able to discontinue the medications unless there is a significant change in her condition as a result of weight loss, an exercise program, and/or decreased stress. Patients usually require follow-up and adjustments at monthly intervals until the goal BP is reached. Antihypertensives control BP, but do not cure hypertension; therefore, the medication cannot be stopped once the target reading is reached. (Lewis, Dirksen, Heitkemper, et al, 8 ed., pp. 751, 756.)

Finasteride (Proscar) is prescribed for a 50-year-old man who is experiencing a problem with urination caused by an enlarged prostate. What would be important for the nurse to include in her teaching regarding this drug? a) Increase his fluid intake. b) Refrain from sexual activity. c) Use contraceptives while taking the drug. d) Increase his intake of folic acid.

c) Use contraceptives while taking the drug. Women of childbearing age must not be exposed to the sperm of a client taking finasteride, because it can cause birth defects in the male fetus. Refraining from sexual activity is unnecessary, but precautions should be taken to prevent pregnancy. Pregnant women and those of childbearing age also should avoid handling crushed tablets. There are no implications regarding fluid intake or intake of folic acid. (Lehne, 7 ed., p. 782.)

A client has a history of atherosclerotic heart disease with a sustained increase in his blood pressure. What side effect may occur should he use an over-the-counter decongestant? a)Urinary frequency and diuresis b) Bradycardia and diarrhea c) Vasoconstriction and increased arterial pressure d) Headache and dysrhythmias

c) Vasoconstriction and increased arterial pressure Decongestants should be avoided by clients with hypertension, because they often contain pseudoephedrine and phenylephrine, which cause central nervous system stimulation with vasoconstriction and increased blood pressure. They also precipitate anxiety and insomnia. (Lilley, 6 ed., p. 557.)

For which tests must the nurse reduce the client's physical and emotional stress, so that the results will not be affected? Select all that apply. a) SH level b) Free thyroxine (T4) level c) 24-hour urine for 17-ketosteroids d) Dexamethasone suppression test e) Radioactive iodine uptake test f) Serum cortisol

c, d, f The nurse understands that physical and emotional stress can affect the results of tests that are measuring steroids, such as the 24-hour urine for 17-ketosteroids, dexamethasone suppression test, and serum cortisol. Tests for thyroid function are not affected by stress. (Lewis, et al, 8 ed., pp. 102, 488, 1215.)

A client is admitted to the hospital with nausea and hematemesis. The nurse is obtaining a health history on admission. What will be most important for the nurse to ask the client? a) "Do you have any family history of gastric bleeding or gastric diseases?" b) "Have you had any significant weight gain or loss over the past 2 months?" c) "What are the characteristics of your dietary intake?" d) "Do you regularly take any nonsteroidal antiinflammatory medications?"

d) "Do you regularly take any nonsteroidal antiinflammatory medications?" Chronic use of nonsteroidal antiinflammatory medications is associated with damage to the gastric mucosa. This can precipitate gastritis and gastric bleeding. Family history, changes in weight, and dietary preferences are not associated with gastritis. (Lewis, et al, 8 ed., p. 981.)

An infant is diagnosed with pyloric stenosis and is admitted for repair. The mother begins to cry and says, "I guess I am not a very good mother." What is the best nursing response? a) "Don't cry; your baby is going to be just fine." b) "This is really a hard time for you, isn't it? Can I call someone?" c) "Have you talked with the doctor about the cause of the problem?" d) "Tell me, what makes you feel that you are not a good mother?"

d) "Tell me, what makes you feel that you are not a good mother?" This option focuses on therapeutic communication: a reflective, clarifying comment about what the mother has just said and encouragement to describe her feelings. The question asks for interpretation of mother's comment. The other options do not encourage expression of feelings, or they are blocks to therapeutic communication. (Potter, Perry, 7 ed., p. 352.)

The nurse is reviewing an assigned group of clients. Which client would require a focused assessment for the presence of peripheral artery disease? a) A 35-year-old with a 10-year history of chronic hypertension b) A 60-year-old currently in atrial fibrillation c) A 55-year-old with renal insufficiency d) A 72-year-old with a 20-year history of type 2 diabetes

d) A 72-year-old with a 20-year history of type 2 diabetes Diabetes accelerates problems with atherosclerosis, and the development of PAD is a common problem for the client with diabetes. Hypertension and renal insufficiency are also to be considered; however, the assessment should focus on the status of the client's peripheral circulation because that has immediate implications for nursing care. Any client with peripheral artery disease should be carefully assessed for a history and current treatment of diabetes. Foot care is an important aspect in care of the diabetic client. (Lewis, et al, 8 ed., p. 867.)

A client is receiving treatment for Cushing's syndrome. Which laboratory measurement would provide an indication that treatment is successful? a) A decreased serum potassium level b) An increased urinary calcium level c) An increased serum sodium d) A decreased serum glucose level

d) A decreased serum glucose level Cushing's syndrome is characterized by hyperglycemia, hypokalemia, hypernatremia, and hypercalciuria. A drop in serum potassium and an increase in urinary calcium levels would not indicate improvement; however, a drop in serum glucose would indicate improvement. (Lewis, et al, 8 ed., p. 1279.)

A client is admitted to the hospital for a diagnostic workup for hypertension. What assessment data gathered by the nurse would confirm this diagnosis? a) A diastolic pressure fluctuating between 138 mm Hg and 170 mm Hg b) Decreasing urinary output with serum potassium level of 5.5 mEq/L and blood urea nitrogen level at 57 mg/dL c) A pulse pressure greater than 60 beats/min with a 20-point pulse deficit d) A sustained increase in systolic pressure above 140 mm Hg and diastolic pressure above 90 mm Hg

d) A sustained increase in systolic pressure above 140 mm Hg and diastolic pressure above 90 mm Hg The diagnosis is based on the sustained increases in systolic (lessThanFlag140 mm Hg) and diastolic (>90 mm Hg) pressures. (Lewis, et al, 8 ed., p. 741.)

A child is 6 hours postoperative for an appendectomy. The child is restless and begins to complain of abdominal pain and feeling hot. The nurse determines the child's temperature 102° F. The nurse would assess the child for what other symptoms that would support the development of peritonitis? a) Severe diarrhea and pain b) Hyperactive bowel sounds and vomiting c) White blood cell count of 4000/mm3 d) Abdominal distention and rigidity

d) Abdominal distention and rigidity Progressive abdominal distention, a board-like, rigid abdomen, and increasing abdominal pain are classic signs of peritonitis. Tachycardia, restlessness, and rapid, shallow breathing also occur with peritonitis. Bowel sounds would be hypoactive, and nausea and vomiting might occur. (Hockenberry, Wilson, 9 ed., p. 1311.)

The nurse is performing an assessment on the lower extremities of a client with peripheral artery disease (PAD). Which finding would prompt the nurse to immediately contact the health care provider? a) Warm with bounding pulses b) Edematous with slow capillary refill c) Postural color changes d) An ankle-brachial index (ABI) of 0.5

d) An ankle-brachial index (ABI) of 0.5 A normal resting ankle-brachial index (ABI) is 0.91 to 1.30. This means that the blood pressure at the ankle is the same as or greater than the pressure at the arm and indicates no significant narrowing or blockage of blood flow. A resting ABI of less than 1 is abnormal. If the ABI drops after exercise, this may indicate that significant peripheral vascular disease is present. The physician must intervene to prevent irreversible damage to the ischemic tissues. A warm extremity with bounding pulses is a positive sign of good circulation. Edema and postural color changes would be normal findings. (Lewis, et al, 8 ed., p. 875.)

The staff nurse is assigned to the following clients. Which client should the nurse assess first? a) An adult client with type 1 diabetes and fingerstick glucose level of 127 mg/dL. b) An older adult year with Cushing's syndrome and truncal obesity and peripheral edema 2+. c) An adult with a history of Graves disease and a heart rate of 90 beats/min. d) An older adult with hypothyroidism and a heart rate of 48 beats/min.

d) An older adult with hypothyroidism and a heart rate of 48 beats/min. The priority client to see first would be the client with the bradycardia who has hypothyroidism. This low pulse may have cardiac implications and should be evaluated first. Truncal obesity and peripheral edema are common findings with clients who have Cushing's syndrome. Clients who are diagnosed with Graves disease (hyperthyroidism) usually have a rapid heart rate, but 90 beats/min is within normal limits. The client with type 1 diabetes with a glucometer reading of 127 mg/dL may need watching but is not a priority. (Ignatavicius, Workman, 7 ed., pp. 1402.)

The nurse is caring for an infant with a tentative diagnosis of pyloric stenosis. The nurse would anticipate what test to be done to confirm this diagnosis? a) Anterior and lateral x-ray of the abdomen b) A colonoscopy with biopsy c) Hemoconcentration with increased sodium and potassium d) An upper gastrointestinal (GI) series

d) An upper gastrointestinal (GI) series An upper GI will indicate delayed gastric emptying and an elongated pyloric channel. Hemoconcentration is frequently present because of the dehydration status of the infant. Contrast materials are used to evaluate the gastric emptying; therefore an abdominal x-ray will not confirm the diagnosis. (Hockenberry, Wilson, 9 ed., p. 1323.)

A client returns to his room after having a colon resection. The nurse completes the initial assessment, and the client complains of feeling cold. What is the best nursing action? a) Apply a heating pad to the client's back for warmth. b) Recognize that this is a symptom of shock and notify the physician. c) Assess client's incision and abdomen for evidence of internal bleeding. d) Apply several blankets to maintain the body temperature at a normal level.

d) Apply several blankets to maintain the body temperature at a normal level. Feeling chilled is normal after surgery, because the temperature of the operating room is cool. The nurse should simply apply blankets to maintain the client's body temperature. The incision and the abdomen should have been evaluated with the original nursing assessment when the client was readmitted to the room. No indication is given that anything has changed from that assessment. (Potter, Perry, 7 ed., p. 1397.)

A nurse is caring for a client who has chronic venous insufficiency in the lower extremities. The physician orders for the patient to wear thigh-high compression stockings at home on a daily basis. The appropriate teaching intervention by the nurse is to: a) Remove the stockings while out of bed for 1 to 2 hours at least four times daily b) Roll the stockings below the knees if they are unable to remain on the thighs c) Massage the legs firmly in the lower leg area with lotion before applying the stockings to assist in better application d) Apply the stockings in the morning before getting out of bed

d) Apply the stockings in the morning before getting out of bed Applying the stockings in the morning before getting out of bed assists with venous stasis and assist the lower extremity blood flow back to the heart. Removing the stockings while out of bed for 1 to 2 hours at least four times daily is not correct because keeping the stockings on throughout the day assists in minimizing edema and promoting blood flow in addition to preventing venous stasis ulcers. Rolling the stockings below the knee is not correct, because this will restrict venous blood flow and will increase edema in the lower extremities. Massaging the legs is not correct because this could dislodge a developed clot, possibly leading to a pulmonary embolism. (Potter, Perry, 7 ed., pp. 1248-1249.)

A child is being observed in the ER for the possible development of appendicitis. Which doctor's order would the nurse question? a) Administer acetaminophen (Tylenol) for pain. b) Apply an ice bag to the area of pain. c) Assist client to maintain position of comfort. d) Apply warm moist packs to abdomen.

d) Apply warm moist packs to abdomen. Warm applications of any kind are contraindicated in the client with a diagnosis of possible appendicitis; this will cause increased inflammation and possible rupture. Encouraging a position of comfort and treating the pain with mild analgesic and/or an ice bag would be appropriate. The client should not receive a narcotic or an enema, and NPO status or a clear liquid diet is frequently maintained if surgery is anticipated. (Potter, Perry, 8 ed., p. 1330.)

The nurse plans to explain preoperative procedures, the operating room, the recovery room, and postoperative procedures to a 6-year-old girl. Which intervention is implemented first? a) Explain to the child the need for preoperative medications. b) Tell the child that her parents will be waiting in her room for her. c) Describe the appearance of the recovery room and the operating room. d) Ask the child to tell you what she knows about the operation.

d) Ask the child to tell you what she knows about the operation. The first step in the teaching/learning process is to determine the child's present knowledge. Further explanations are then planned accordingly. For the school-age child, demonstration with anatomic dolls and role-playing are effective preoperative teaching methods. (Hockenberry, Wilson, 9 ed., pp. 1000-1003.)

The nurse is caring for a client who is scheduled for a gastric endoscopy. Which of the following actions must the nurse perform before the client is able to eat or drink after the endoscopy? a) Check oxygen saturation. b) Give small sips of water. c) Check all vital signs. d) Assess the client's gag reflex.

d) Assess the client's gag reflex. Topical sedation during endoscopy helps block the gag reflex and numbs the esophagus, eliminating the discomfort of the tube. The nurse would know the dangers of allowing the client to eat or drink before the sedation has lost its effect. The nurse will test for the return of the client's gag reflex before allowing sips of water to be taken to avoid aspiration. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 915.)

The nurse is assisting the doctor to place a central line for administration of parenteral nutrition. Immediately after insertion of the line, what would be an important nursing action? a) Evaluate movement of both arms. b) Order electrolyte series to establish a base for comparison. c) Start the prescribed fluid at a slow rate. d) Auscultate the lungs for normal breath sounds.

d) Auscultate the lungs for normal breath sounds. During placement of a central line, it is very easy to cause a pneumothorax; immediate evaluation of the breath sounds is important. A chest x-ray film also should be obtained after the procedure is completed. The placement of the line should be verified before beginning administration of the solution. (Lewis, et al, 8 ed., p. 330.)

Norepinephrine (Levophed) has been ordered for a client in hypovolemic shock. Before administering the drug, the nurse should make sure that the client has: a) A heart rate of less than 120 beats/min b) Urine output of at least 30 mL/hr c) Received adequate anticoagulation d) Been receiving adequate IV fluid replacement

d) Been receiving adequate IV fluid replacement Hypovolemia must be corrected before the initiation of a potent vasopressor, such as Levophed. Without adequate volume replacement, the intense vasoconstriction effect will lead to a further reduction in tissue perfusion. A rapid heart rate is not a contraindication to the use of vasopressors. The nurse can anticipate that urine output will be low, but with effective treatment of the hypovolemic shock, the urine should be increasing to the minimum amount to indicate renal perfusion and function. Anticoagulant therapy does not need to be started. (Lehne, 7 ed., pp. 156-157.)

After abdominal surgery, a client experienced complications and is now receiving parenteral nutrition. Which assessment data indicate the parenteral nutrition is effective? a) Increase in weight of 5 pounds over 7 days b) Serum blood glucose level average 120 mg/dL c) No purulent drainage or increased inflammation at wound site d) Beginning formation of granulation tissue at the bottom of the wound

d) Beginning formation of granulation tissue at the bottom of the wound The primary purpose of parenteral nutrition is to restore nitrogen balance for adequate healing. The granulation tissue indicates an increase in the nitrogen balance and that healing is occurring. Other options may be used to monitor the client's tolerance of the procedure, control of infection, and hydration status. (Lewis, et al, 8 ed., p. 935.)

The nurse understands that methylcellulose (Citrucel) is a laxative that works by: a) Softening the feces b) Stimulating peristalsis c) Osmosis retaining water and softening the feces d) Bulk forming, similar to dietary fiber

d) Bulk forming, similar to dietary fiber Methylcellulose (Citrucel) is a bulk-forming laxative and works similarly to the action of increased dietary fiber in the stool. Methylcellulose is not a surfactant (soften feces), stimulant (stimulate peristalsis), or osmotic laxative (retaining water and thus softening the stool). (Lehne, 7 ed., p. 931.)

A client with peripheral artery disease is being discharged on clopidogrel (Plavix). What would be important for the nurse to teach the client about this medication? a) When seated, slowly stand to maintain equilibrium. b) Take the medication in the morning on an empty stomach. c) Return to the clinic in 2 weeks for evaluation of anticoagulation. d) Call the doctor if you have episodes of nasal bleeding.

d) Call the doctor if you have episodes of nasal bleeding. The action of Plavix is inhabitation of platelet aggregation; therefore the client has a tendency to bleed. Bloody stools, melena, hematemesis, or epistaxis should be reported. Orthostatis hypotension is not a problem with Plavix. Plavix decreases platelet aggregation, following up in 2 weeks for anticoagulation studies is unnecessary. Plavix can be taken without relation to food. (Lehne, 7 ed., pp. 609-610.)

The nurse understands that the disadvantage of using stimulant laxatives for a prolonged period is that they: a) Cause hyperkalemia b) Can cause ulcerative colitis c) Are all enteric-coated and cause bowel erosion d) Can cause dependence

d) Can cause dependence Dependence can occur with excessive or prolonged use of stimulant laxatives, which means that if the drug is stopped, a client is likely to experience constipation. Stimulant laxatives are not all enteric-coated and do not cause bowel erosion or ulcerative colitis. Prolonged use could lead to hypokalemia, not hyperkalemia, as a result of loss of electrolytes and fluids. (Lilley, 6 ed., p. 880.)

The nurse is performing an assessment on a client who has been receiving long-term steroid therapy. What would the nurse expect to find during the assessment? a) Jaundice b) Flank pain c) Bulging eyes d) Central obesity

d) Central obesity Cushing's syndrome develops because of an excess of cortisol, in this case from prolonged exogenous steroid administration. This syndrome may be characterized by truncal (central) obesity, hypertension, weakness, hirsutism, abdominal striae, edema, and hypokalemia. Flank pain is associated with kidney problems. Bulging eyes are found in hyperthyroidism. Jaundice is associated with liver and gallbladder problems. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 1276.)

Which client is a candidate for thrombolytic therapy? a) Client with acute pericarditis b) Client with cerebral neoplasm c) Client with dissecting aortic aneurysm d) Client with massive pulmonary emboli

d) Client with massive pulmonary emboli Thrombolytic drugs are prescribed to lyse clots. Acute pericarditis is treated with antiinflammatory drugs, bed rest, and appropriate antibiotics for the specific organism involved. A dissecting aortic aneurysm will require surgical treatment for decompression and repair. A cerebral neoplasm is a tumor of the brain, and treatment, which usually includes surgery, radiation, and chemotherapy, varies according to etiology. (Lewis, et al, 8 ed., p. 579.)

A client is scheduled for a routine glycosylated hemoglobin (HbA1C) test. What is important for the nurse to tell the client before this test? a) Drink only water after midnight and come to the clinic early in the morning. b) Eat a normal breakfast and be at the clinic 2 hours later. c) Expect to be at the clinic for several hours because of the multiple blood draws. d) Come to the clinic at the earliest convenience to have blood drawn.

d) Come to the clinic at the earliest convenience to have blood drawn. Glucose attaches to the hemoglobin molecule of the red blood cell. A glycosylated hemoglobin test gives an average of blood glucose over the past 3 to 4 months, and a blood sample can be obtained at any time during the day. It is not used in the diagnosis of diabetes and does not need to be a fasting specimen. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 1223.)

A client is admitted to the hospital with the diagnosis of intermittent claudication. With regard to this problem, what would the nurse expect to find on assessment of this client? a) Petechiae and itching of the lower part of the leg b) Extensive discoloration and edema of the upper leg c) Profuse rash and discoloration from trunk down to feet d) Complaints of pain on walking, relieved by sitting down

d) Complaints of pain on walking, relieved by sitting down Classically, intermittent claudication is described as pain on activity that is relieved by stopping the activity. This is an indication of the extent of the client's PAD. Pain occurring in the legs with no activity indicates the PAD is extensive. The other options are not relevant to evaluating intermittent claudication. (Lewis, et al, 8 ed., p. 874.)

A client has been taking aluminum hydroxide (Amphojel) daily for the past 2 weeks. Which of the following side effects would the nurse watch for? a) Hypernatremia b) Hyperkalemia c) Diarrhea d) Constipation

d) Constipation Aluminum hydroxide used as an antacid over a period of time can result in constipation. Remember: Hydroxide "holds" the bowel movement and magnesium "makes" the bowel movement happen. Stool softener and/or laxatives may be needed. The medication does not affect potassium and sodium levels. Aluminum hydroxide may increase urinary and stool loss of calcium. (Lilley, 6 ed., p. 793.)

The nurse instructs the client with peptic ulcer disease (PUD) to report stools that appear: a) Clay colored b) Frothy c) Ribbon shaped d) Dark brown or black

d) Dark brown or black Dark brown or black stools may be indicative of blood in the stool (melena). Clay-colored stools are associated with liver problems; frothy stools are associated with cystic fibrosis; ribbon-shaped stools are associated with cancer of the colon. (Lewis, et al, 8 ed., p. 993.)

A 23-year-old woman comes into the ambulatory care center complaining of lower abdominal pain that began suddenly about 4 hours ago. What would be the most important information for the nurse to initially determine from the client? a) Time of last meal b) Date of last bowel movement c) Client's activity when the pain began d) Date of last menstrual cycle

d) Date of last menstrual cycle In women of child-bearing age, the nurse should determine if the client could possibly be pregnant and therefore if an ectopic pregnancy is possible. It would also be important to know when the client ate last, in case surgery is anticipated. The elimination pattern and what the client was doing at the time the pain began are less significant. (Hockenberry, Wilson, 9 ed., p. 1311.)

The nurse is preparing discharge teaching for a client with hypertension who is being treated with furosemide (Lasix) and clonidine (Catapres). The nurse would caution the client about which over-the-counter medications? a) Antihistamines b) Acetaminophen c) Topical corticosteroid cream d) Decongestant cough preparations

d) Decongestant cough preparations Decongestants and over-the-counter cough medicines frequently contain pseudoephedrine. These medications will cause an increase in blood pressure and interfere with the effectiveness of the antihypertensive medications. (Lehne, 7 ed., pp. 514-515.)

The nurse is performing an assessment and finds the client has cold, clammy skin, pulse of 130 beats/min and weak, blood pressure of 84/56 mm Hg, and urinary output of 20 mL for the past hour. The nurse would interpret these findings as suggestive of which pathophysiology? a) Reduction of circulation to the coronary arteries, thus increasing the preload b) Decreased glomeruli filtration rate, resulting in volume overload c) Stimulation of the sympathetic nervous system, causing severe vasoconstriction d) Decrease in the cardiac output and inadequate tissue perfusion

d) Decrease in the cardiac output and inadequate tissue perfusion The symptoms suggest a decrease in cardiac output and circulation, resulting in symptoms of inadequate tissue perfusion, especially of the kidneys. The symptoms presented are the classic symptoms of developing shock. (Lewis, et al, 8 ed., pp. 1717-1718.)

The nurse is caring for a client the day of surgery for repair of an abdominal aortic aneurysm. The nurse determines that the client does not have a posterior tibial or dorsalis pedis pulse on his left leg, the leg is cool to touch. What is the best nursing action? a) Notify the surgeon immediately and anticipate client to return to surgery. b) Document the status of the pulses and check them again in an hour. c) Elevate the legs and cover them with a warm blanket. d) Determine the status of the client's pulses before surgery.

d) Determine the status of the client's pulses before surgery. Frequently clients with aneurysms also have peripheral arterial disease. The nurse should check the preoperative assessment to determine the status of pulses before surgery before notifying the surgeon. It would not be appropriate to apply a warm blanket and delay further action; the client could have an occluded graft. (Lewis, et al, 8 ed., p. 871.)

A client with diabetes receives 10 units of regular insulin at 6:00 am and does not eat breakfast. About noon, what observation would the nurse expect to see? a) Polydipsia b) Polyphagia c) Polyuria d) Diaphoresis

d) Diaphoresis The nurse would expect symptoms of hypoglycemia, which include diaphoresis, shakiness, fatigue, hunger, and low blood sugar. The three Ps—polydipsia, polyphagia, and polyuria—are observed in hyperglycemia. (Lehne, 7 ed., p. 665.)

A client returns to his room from surgery after having an ileostomy for treatment of his ulcerative colitis. What would be important for the nurse to include in a teaching plan for this client? a) Fluid intake may be restricted to prevent excessive liquid drainage from the ileostomy. b) The ostomy pouch should be changed every day to prevent odor and leakage. c) The ileostomy can be irrigated in the morning to decrease drainage during the day. d) Diet should be balanced from all food groups and with adequate fiber.

d) Diet should be balanced from all food groups and with adequate fiber. Dietary intake should be balanced and with an adequate amount of fiber. High-fiber foods should be thoroughly chewed to decrease possible problems of possible obstruction. The client should maintain a high fluid intake to replace fluids lost in the bowel; fluid intake does not control drainage from the ileostomy. The ostomy pouch should be drained as necessary, but the pouch is not changed unless a leak is present. An ileostomy does not require irrigation; the drainage is liquid and is not controlled by irrigations. (Lewis, et al, 8 ed., p. 1042.)

A client has been diagnosed with Addison's disease. Which of the following changes in appearance would the nurse expect to see? a) Moon face, truncal obesity, and purple abdominal striations b) Nervousness, breast engorgement, and hirsutism c) Truncal obesity, gaunt facial appearance, and skin tears d) Discoloration of the mucous membranes, copper-colored skin, and weight loss

d) Discoloration of the mucous membranes, copper-colored skin, and weight loss Addison's disease is characterized by fatigue, weight loss, anorexia, and skin hyperpigmentation (bronzing), hypotension, hyponatremia, hyperkalemia, nausea, vomiting, and diarrhea. The other symptoms are associated with Cushing's syndrome. (Lewis, et al, 8 ed., p. 1280.)

A client with insulin-dependent diabetes mellitus (type 1) has developed proteinuria. What would the nurse discuss with the client regarding the significance of this finding? a) It may require daily insulin dosages to be lowered. b) It indicates that the client's diabetes is uncontrolled. c) Additional protein must be added to the diet. d) End-stage renal failure will most likely develop in 5 to 10 years.

d) End-stage renal failure will most likely develop in 5 to 10 years. Diabetes is the leading cause of end-stage renal disease (ESRD), the result of chronic kidney disease. In both type 1 and type 2 diabetes, the first sign of deteriorating kidney function is the presence of small amounts of albumin in the urine, a condition called microalbuminuria. As kidney function declines, the amount of albumin in the urine increases, and microalbuminuria becomes full-fledged proteinuria. Usually within 5 to 10 years after the appearance of significant proteinuria, regardless of diabetic control, ESRD develops. (Lewis, et al, 8 ed., p. 1249.)

The nurse is caring for a client with venous leg ulcers on his ankle. What is the correct pathophysiology regarding the exudate in venous ulcers? a) All inflammatory exudate can be considered infectious. b) Exudate leads to chronic tissue defects characterized by granulation tissue. c) Platelets and fibrinogen promote the spread of the exudates. d) Exudate may be serous, sanguineous, or purulent.

d) Exudate may be serous, sanguineous, or purulent. The drainage of the pressure ulcers is frequently serous and excessive. Because of the venous stasis, excess pressure in the vessels moves serous drainage out of the vessel and into the bed of the ulcer. Exudate may be serous (clear, like plasma), sanguineous (bloody), or purulent (containing white blood cells and bacteria). Exudate is cleared by lymphatic drainage. Platelets and fibrinogen form a mesh-like matrix at the inflammatory site to prevent the spread of inflammation. Exudate may or may not be infectious; development of granulation tissue is an indication of healing. (Lewis, et al, 8 ed., pp. 891-892.)

Which nursing action would be most effective in preventing venous stasis in the postoperative surgical client? a) Raise the foot of the bed for 1 hour; then lower it to stimulate blood flow. b) Massage the lower extremities every 6 hours. c) Facilitate active range of motion of the upper body to stimulate cardiac output. d) Help the client walk as soon as permitted and as often as possible.

d) Help the client walk as soon as permitted and as often as possible. The postoperative client has decreased mobility, which may create an environment in which clotting can be caused by venous stasis. Active exercise, such as having the client ambulate as soon as possible, will stimulate circulation and venous return. This reduces the possibility of clot formation. The lower extremities should not be massaged because this may disrupt a clot and cause a pulmonary embolism. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 885.)

The nurse is assessing an 80-year-old client with type 2 diabetes. The assessment findings include rapid, deep, respirations at a rate of 36 breaths/min. Lethargy and tachycardia are present. Of what would the symptoms be most indicative? a) Hyponatremia b) Hypoglycemia c) Diabetic ketoacidosis (DKA) d) Hyperglycemic hyperosmolar syndrome (HHS)

d) Hyperglycemic hyperosmolar syndrome (HHS) Kussmaul's respirations, which are deep, regular sighing respirations with tachypnea, along with the presence of tachycardia and CNS symptoms (lethargy) correlate with hyperglycemia. Because of the age of the client, the problem would most likely be HHS (formerly known as hyperglycemic-hyperosmolar nonketotic syndrome/HHNS). Diabetic ketoacidosis (DKA) occurs most often in younger clients with type 1 diabetes. Hypoglycemia is a low blood glucose level. In DKA and in HHS, the blood glucose level is greater than 300 mg/dL. The sodium levels may be high, low, or normal. (Lewis, et al, 8 ed., p. 1245.)

The nurse notes that an adult is receiving somatropin. The nurse would anticipate a history of: a) Pheochromocytoma b) Type 2 diabetes c) Acromegaly d) Hypophysectomy of anterior pituitary

d) Hypophysectomy of anterior pituitary The nurse knows that adults with growth hormone deficiency (because of hypophysectomy [pituitary] surgery or a tumor) can be treated with somatropin (Genotropin), which is a recombinant growth hormone product. The medication is not used in the treatment of type 2 diabetes, acromegaly (too much growth hormone), or pheochromocytoma (tumor of adrenal medulla). (Lehne, 7 ed., p. 705; Lewis, et al, 8 ed., p. 1258.)

After the administration of mannitol (Osmitrol), the nurse should expect which outcome to occur? a) Decreased extracellular fluid volume b) Increased tubular reabsorption of water c) Decreased filtration of nitrogenous wastes d) Increased tubular excretion of water

d) Increased tubular excretion of water Mannitol is an osmotic diuretic that creates an osmotic force in the nephron and inhibits reabsorption of water. This results in the increased uptake of water at the tubule, resulting in diuresis and an increase in the volume of urine. (Lehne, 7 ed., p. 451.)

A client is admitted because of benign prostatic hypertrophy and is scheduled to have a transurethral prostate resection. What assessment data would indicate to the nurse that a complication is developing? a) The client has difficulty emptying his bladder. b) Client states he feels like he cannot empty his bladder. c) The client complains of frequency and nocturia. d) Increasing complaints of flank pain and hematuria.

d) Increasing complaints of flank pain and hematuria. Flank pain may be indicative of an infection or a ureteral obstruction causing increased pressure on the renal pelvis. Other options are symptoms of benign prostatic hypertrophy, for which he will be treated while he is in the hospital. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 1379.)

A child comes into the emergency room with a laceration on the forearm. The nurse would assess for what signs indicating an acute inflammatory process? a) Decrease in temperature around the injury b) Blanching of skin at the proximal end of the injury c) Increase in sanguineous drainage from the injured site d) Increasing pain at the injured site

d) Increasing pain at the injured site With increased blood flow to the site, the area becomes more painful and edematous. Inflammation, not blanching, occurs. There would be an increase in temperature around the injured area. Serosanguineous drainage is the cellular response to the injury. (Hockenberry, Wilson, 8 ed., p. 1062.)

What is the desired action of dopamine (Intropin) when administered in the treatment of shock? a) It increases myocardial contractility. b) It is associated with fewer severe allergic reactions. c) It causes rapid vasodilation of the vascular bed. d) It supports renal perfusion by dilation of the renal arteries.

d) It supports renal perfusion by dilation of the renal arteries. Dopamine will support renal perfusion when administered in low doses in the initial stages of shock. At higher doses and as the client becomes more decompensated, the effect of the dopamine on the renal perfusion decreases. Vasodilation would further complicate the shock situation, and allergies are not a common problem. Vasoconstriction is not a primary property of dopamine in low doses. Dopamine increases cardiac rate, but that is not the desired therapeutic action for a client in shock. (Lehne, 7 ed., p. 154.)

What is an important nursing intervention for a client who is scheduled for a 24-hour urine collection for 17-ketosteroids? a) Start the urine collection at 7 am after the client voids. b) Restrict the client's fluid intake to 2000 mL during the collection time. c) Anticipate inserting a urinary catheter after the initial blood specimen is collected. d) Keep 24-hour urine collection container on ice or refrigerate

d) Keep 24-hour urine collection container on ice or refrigerate To have an accurate 24-hour urine test for 17-ketosteroids, the nurse must either refrigerate the specimen during the collection time or keep it on ice. No fluid restriction or blood specimen collection is necessary. The initial voided specimen is discarded. (Lewis, et al, 8 ed., pp. 1119-1215.)

A client is beginning treatment with warfarin (Coumadin). What would the nurse teach the client regarding diet? a) Decrease whole grains and oats. b) Avoid milk and milk products. c) Increase intake of eggs and red meat. d) Keep a constant intake of leafy, green vegetables.

d) Keep a constant intake of leafy, green vegetables. Leafy, green vegetables, mayonnaise, canola oil, and soybean oil are high in vitamin K, which is the antidote for Coumadin. The client does not have to avoid or limit intake of these foods but should keep a constant, consistent intake of Vitamin K enriched foods, so that Coumadin dosage is adjusted to the client's dietary practice. (Lehne, 7 ed., p. 608; Lilley, 6 ed., p. 438.)

A school-age child with a diagnosis of celiac disease asks the nurse, "Which foods will make me sick?" Which food items would the nurse teach the child to avoid? a) Rice cereals, milk, and tapioca b) Corn cereals, milk, and fruit c) Corn or potato bread and peanut butter d) Malted milk, white bread, and spaghetti

d) Malted milk, white bread, and spaghetti The child with celiac disease will need a gluten-free diet, eliminating foods such as pastas and breads that are made from wheat or dessert foods made from malt whey. Remember ROW—rye, oats, and wheat. Barley is also to be avoided. Foods that would be appropriate include rice and corn cereals, milk, corn and potato breads, tapioca, peanut butter, and honey. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 1050.)

The nurse is admitting a client with a diagnosis of rule out intestinal obstruction. The nursing assessment reveals a distended abdomen, minimal bowel sounds in right upper quadrant, nausea, and vomiting. The client is NPO and an IV of D51/2 normal saline is infusing at 100 cc per hour. Which medication would the nurse question administering to this client? a) Hydroxyzine (Vistaril) deep IM q 6 hours b) Ranitidine (Zantac) IVPB q 6 hours c) Cephalexin (Keflex) IVPB q 6 hours d) Metoclopramide (Reglan ) IVPB q 4 hours

d) Metoclopramide (Reglan ) IVPB q 4 hours Metoclopramide (Reglan) is a GI stimulant and should not be given in situations in which an intestinal obstruction is suspected. Hydroxyzine (Vistaril) is an antiemetic and antianxiety medication. Ranitidine (Zantac) is an anti-ulcer medication that decreased gastric acid production, and cephalexin (Keflex) is an antibiotic that may be used as a prophylaxis before intestinal surgery. (Lilley, 6 ed., p. 814.)

Which abnormal lab finding indicates that a client with diabetes needs further evaluation for diabetic nephropathy? a) Hypokalemia and hyponatremia b) Positive ketones in urine c) Elevated serum cholesterol and triglycerides d) Microalbuminuria

d) Microalbuminuria The first sign of deteriorating kidney function is the presence of small amounts of albumin in the urine, a condition called microalbuminuria. As kidney function declines, the amount of albumin in the urine increases, and microalbuminuria becomes full-fledged proteinuria. Usually within 5 to 10 years after the appearance of significant proteinuria, regardless of diabetic control, end-stage renal disease (ESRD) develops. Hyperkalemia, not hypokalemia, is associated with end-stage renal disease. Serum lipids (cholesterol and triglycerides) may be elevated in ESRD. Positive ketones in the urine often indicate the onset of diabetic ketoacidosis. (Lewis, et al, 8 ed., pp. 1248-1249.)

The nurse is assessing a client who is being admitted from the emergency room with a history of vomiting bright red blood for the past 24 hours. What would be a priority nursing assessment? a) Inquire as to how much emesis the client has had in the last 6 hours. b) Evaluate bowel sounds and palpate abdomen for areas of tenderness. c) Determine the quality of bilateral breath sounds. d) Monitor the blood pressure and pulse.

d) Monitor the blood pressure and pulse. The nurse should be concerned about blood loss and the possibility of hypovolemic shock. Frequent monitoring of the vital signs is necessary to determine early symptoms of shock. The other areas can be assessed after the nurse determines the status of the vital signs. The amount of emesis over the past 6 hours may or may not be indicative of the amount of bleeding the client is experiencing. Regardless of the amount of emesis, the nurse is still going to be concerned about the possible development of hypovolemic shock. (Lewis, et al, 8 ed., p. 1719.)

The nurse is caring for a client who is 1 day postoperative after an abdominal perineal resection and formation of a colostomy. The colostomy is moist and red and protrudes about 1 inch from the abdomen, and an ostomy pouch is in place. The perineal incision has two Jackson Pratt drains in place. What would be a nursing priority in the care of this client? a) Monitor the stoma for evidence of any drainage. b) Assist the client to begin performing colostomy irrigations. c) Assess client's tolerance of soft diet. d) Monitor the perineal wound and assess the drainage.

d) Monitor the perineal wound and assess the drainage. The perineal wound is at a high risk for infection; the drainage from the wounds should be serosanguineous and in moderate amount. The nurse should assess the wound, empty the drain bulb, and reestablish suction when the drain is approximately half full. If the client is beginning to eat solid food, his tolerance should be evaluated, but this is not more important than the status of the perineal wound. The appearance of the colostomy is normal and the irrigations are not a priority this early postoperatively. (Lewis, et al, 8 ed., p. 1041.)

Which of the following clinical findings would the nurse expect to see in a child as hypovolemic shock progresses? a) Tremulousness b) Irritability c) Increasing apprehension d) Narrowing pulse pressure

d) Narrowing pulse pressure The pulse pressure (the difference between systolic and diastolic blood pressure) becomes narrowed, but the blood pressure may be maintained; however tachycardia is most often present. As shock progresses, intravascular volume is reduced, which results in decreased venous return to the heart, decreased preload, decreased stroke volume, and decreased cardiac output. This results in decreased tissue perfusion and impaired cellular metabolism. As the shock progresses, poor capillary filling will be poor, and the child will exhibit confusion, sleepiness, and decreased responsiveness. (Lewis, 8ed. pp. 1720-1721.)

A client has stage 2 hypertension. What are the most common symptoms reported at this stage of hypertension? a) Epistaxis b) Blurred vision c) Dyspnea on exertion d) No symptoms

d) No symptoms Hypertension is often called the "silent killer" because it is frequently asymptomatic until it becomes severe and target organ disease has occurred. In stage 2 hypertension, the systolic blood pressure is above 160 and/or the diastolic blood pressure above 100. In the past, symptoms of hypertension were thought to include headache, nosebleeds, and dizziness. Unless blood pressure is very high, these symptoms are not any more frequent than what is found in the general population, thus making it difficult to associate them with hypertension. (Lewis, et al, 8 ed., p. 743.)

A client had an aortic femoral bypass graft. The nurse assists the client back to bed after he has ambulated. What is most important for the nurse to assess? a) Blood pressure in both arms b) Radial pulse rate and quality c) Temperature of the affected extremity d) Pedal pulse of the affected extremity

d) Pedal pulse of the affected extremity After ambulation, it is important to determine the continued integrity of the graft, which is done by checking the pedal pulse. The other options do not offer any data regarding the status of circulation of the extremities. (Lewis, et al, 8 ed., pp. 878-879.)

The nurse is assessing the lower extremities of a client with early chronic venous insufficiency. What would the nurse expect to find? a) Dependent cyanosis b) Muscle atrophy c) Diminished peripheral pulses d) Pitting edema of the lower extremities

d) Pitting edema of the lower extremities In more severe forms of chronic venous disorders, lower extremity edema is usually the initial complaint. Pitting edema may be seen at first, but as the edema becomes more chronic, the skin and subcutaneous tissues are replaced by fibrous tissues, resulting in thick, hardened contracted skin. Venous perfusion is not evaluated by arterial pulses. Venous congestion does not cause muscle atrophy. (Lewis, et al, 8 ed., p. 892.)

Which of the following is an initial urinary sign or symptom of diabetes mellitus in a client? a) Dysuria b) Hematuria c) Urgency d) Polyuria

d) Polyuria An initial urinary symptom of diabetes mellitus is polyuria, which is produced by the osmotic effect of glucose. Dysuria is a clinical finding associated with bladder inflammation, trauma, or inflammation of the urethral sphincter. Urgency may be caused by a full bladder, bladder irritation from infection, incompetent urethral sphincter, or psychologic stress. Hematuria is noted with conditions such as neoplasms of the bladder or kidney, glomerular disease, infection of the kidney or bladder, trauma to urinary structures, calculi, or bleeding disorders. (Lewis, et al, 8 ed., p. 1221.)

A client visits the clinic to be screened for prostatic cancer. Which laboratory measure is used to screen for prostatic cancer? a) Creatinine phosphokinase (CPK) b) Aspartate aminotransferase (AST) c) Blood urea nitrogen (BUN) d) Prostate specific antigen (PSA)

d) Prostate specific antigen (PSA) The screening test for prostatic cancer is a prostate specific antigen (PSA) test. Creatinine phosphokinase (CPK) measurement is performed to measure damage to muscles (i.e., myocardial damage). The aspartate aminotransferase (AST) lab test provides information about liver damage, and the BUN level is a measure of the ability of the kidneys to clear protein. (Lewis, et al, 8 ed., p. 1387.)

If a client with hypovolemic shock has a urinary output of 30 mL/hr, a nurse would understand that the compensatory physiologic mechanism that leads to altered urinary output is: a) Alpha-adrenergic receptor stimulation, resulting in increased cardiac output with a compensatory increased heart rate and myocardial contractility b) Movement of interstitial fluid to the intravascular space, increasing renal blood flow c) Activation of the sympathetic nervous system, which leads to vasodilation of the renal arteries d) Release of aldosterone that increases serum osmolarity, which leads to the release of antidiuretic hormone

d) Release of aldosterone that increases serum osmolarity, which leads to the release of antidiuretic hormone During hypovolemic shock, peripheral and selective vasoconstriction occurs, leading to a decrease in blood flow to the kidneys, which activates the renin-angiotensin-aldosterone system. Aldosterone causes an increase in sodium reabsorption, which leads to an increase in serum osmolarity. An elevated osmolarity will initiate the release of antidiuretic hormone, causing a decrease in urine output. (Lewis, 8 ed. pp. 1720-1721.)

The client is 1 day postoperative for a bowel resection. There is a nasogastric (NG) tube to suction, but the client is complaining of abdominal distention and nausea. The nurse irrigates the NG tube and it irrigates easily, but there is no return of the irrigation fluid. What is the best nursing action? a) Irrigate the NG tube again using 50 cc of normal saline. b) Evaluate for the presence of bowel sounds. c) Remove the tube and replace it with a smaller tube. d) Reposition the NG tube and validate placement.

d) Reposition the NG tube and validate placement. After determining placement, the nurse may need to reposition the tube by inserting it slightly further into the stomach. This frequently will improve the drainage. Because the tube has already been irrigated and patency is determined, irrigating a second time will not be beneficial. Information about the status of the bowel sounds will not facilitate the drainage from the NG tube; at this point, it would not be necessary to remove the tube and replace it. (Potter, Perry, 7 ed., p. 1203.)

The nurse is planning a teaching program for the client with diabetes. After assessing the client's current level of knowledge, the nurse would: a) Explain how to test the blood sugar b) Develop a rapport with the client c) Teach procedure for insulin injections d) Set long- and short-term goals

d) Set long- and short-term goals This is a good example of following the nursing process. After assessing the client, the nurse plans, which involves setting goals. For a client to be involved in care, he or she needs to work with the nurse in setting goals. (Lewis, et al, 8 ed., p. 1238.)

What is important to teach a client with adrenal insufficiency who has a prescription for prednisone? a) Be sure to include foods that are low in potassium in the diet. b) Slowly change positions to avoid dizziness and fainting. c) Watch for signs of low blood sugar: headache, shakiness, and diaphoresis. d) Signs of fluid retention may occur while taking this drug.

d) Signs of fluid retention may occur while taking this drug. Report any excessive weight gain or swelling to the health care provider, because they may indicate an adverse effect of the medication. The client taking prednisone needs to consume a high potassium diet, as prednisone causes hypokalemia. Hypertension, not orthostatic hypotension, is a side effect of taking glucocortocoids. Hyperglycemia can occur with prednisone use, not hypoglycemia. (Lehne, 7 ed., pp. 854-855.)

A young child weighing 17 kg with a history of type 1 diabetes is admitted in ketoacidosis. The nurse would question which of the following admission orders? a) Rehydrate slowly over 48 hours. b) Weigh on admission and daily. c) Administer IV regular insulin via pump at 2 units/kg/hr after hydration bolus. d) Start IV of D5/ 0.45% normal saline with 20 mEq KCl.

d) Start IV of D5/ 0.45% normal saline with 20 mEq KCl. The order to question is the IV D5/ 0.45% normal saline with KCl. No indication is given regarding the child's urine output, and 0.9% normal saline would be indicated on admission for rehydration, not dextrose in the IV until the blood sugar and acidosis are corrected. Rehydration is accomplished slowly over a 48-hour period to reduce the risk of cerebral edema that may occur with rapid fluid replacement. Also, potassium would not be given until the child is rehydrated after the acidosis problem. An admission weight is an important baseline for determining the dosage of insulin to administer. The rest of the options would be all appropriate nursing interventions. (Hockenberry, Wilson, 9 ed., p. 1604.)

The nurse in an outpatient care center is preparing a client for a colonoscopy at 11 am. What information should the nurse report to the physician before continuing to prepare the client for the procedure? a) The client finished the polyethylene glycol (GoLYTELY) about 10 pm last evening. b) The client has a history of premature atrial beats resulting in an irregular heartbeat. c) The client is allergic to iodine-based preparations. d) The client has been on full liquids this morning.

d) The client has been on full liquids this morning. If the client had full liquids this morning, the bowel may not be effectively cleansed to allow for adequate visualization. Contrast media is not used for this procedure, so an allergy to iodine is not a problem. A history of an irregular heartbeat is good to know but will not affect the procedure. Finishing the GoLYTELY by 10 pm last evening is not a problem. (Lewis, et al, 8 ed., p. 915.)

What is an important nursing action in the safe administration of heparin? a) Check the prothrombin time (PT) and administer the medication if it is less than 20 seconds. b) Use a 20-gauge, 1-inch needle and inject into the deltoid muscle and gently massage the area. c) Dilute in 50 mL 5% dextrose in water (D5W) and infuse by intravenous piggyback (IVPB) over 15 minutes. d) Use a 25-gauge, ½-inch needle and inject the medication into the subcutaneous tissue of the abdomen.

d) Use a 25-gauge, ½-inch needle and inject the medication into the subcutaneous tissue of the abdomen. Medication should be administered with a small-gauge (25-gauge) needle into the subcutaneous tissue without aspirating or massaging the area. Partial thromboplastin time (PTT) is used to monitor the effects of heparin. Although heparin may be administered IV, it must be diluted in more than 50 mL D5W and would be administered over a longer period of time than 15 minutes. (Lehne, 7 ed., p. 601).

An insulin-dependent client wakes up at 3 am and calls the nurse complaining of slight headache, nausea, and trembling. While the nurse assesses the client, she notices that his extremities are cool and moist. What would be a priority nursing intervention? a) Call the lab for a stat blood glucose. b) Administer acetaminophen (Tylenol) and aprepitant (Emend). c) Have the client drink a glass of orange juice. d) Use a glucometer to obtain a capillary blood glucose.

d) Use a glucometer to obtain a capillary blood glucose. The client's symptoms indicate hypoglycemia. Because the client is insulin dependent, the blood glucose should be assessed initially in the most expedient manner, i.e., bedside glucometer. Once the blood sugar value is known; the nurse could offer orange juice. It is not necessary to administer medications such as acetaminophen (Tylenol) and aprepitant (Emend), because the pain and nausea should subside once the blood sugar is increased to normal levels. (Lewis, et al, 8 ed., p. 1246.)

According to evidence-based practice, what is the most important nursing action in preventing infections? a) Isolating infected infants b) Using separate gown technique c) Practicing standard precautions d) Washing hands

d) Washing hands Virtually all controlled clinical trials and research studies have demonstrated that effective hand washing is responsible for the prevention of nosocomial infection and transmission of infection in hospitalized clients. This is particularly important in nursery units. It is also important to maintain standard precautions, perform careful and thorough cleaning, frequently replace used equipment, and dispose of excrement and linens in an appropriate manner. (Potter, Perry, 7 ed., p. 655.)

After a client has recovered from a subtotal gastrectomy performed because of bleeding ulcers, he and his wife attend a discharge conference with the nurse. In addition to diet planning, they need to work together to plan: a) Methods of avoiding pernicious anemia after gastric surgery b) To maximize changes in his lifestyle c) To deal with long-term complications after surgery d) Ways of dealing with stress in their environment

d) Ways of dealing with stress in their environment Decreasing stress will promote a decrease in gastric acid secretion in the client with a duodenal ulcer. Even though the situation did not state duodenal ulcer, the other options are incorrect. He had a subtotal gastrectomy; therefore he should not have a problem with pernicious anemia or absorption of vitamin B12. The problem of pernicious anemia is treated, not avoided should it occur. Changes need to be minimized; and no long-term complications should occur. (Lewis, et al, 8 ed., p. 991.)

A client who is planning a trip to the beach is taking glipizide (Glucotrol). What would be important for the nurse to discuss with the client? a) The importance of eating night-time and between-meal snacks b) The problems associated with fluid retention in a warm climate c) Skin sensitivity resulting from exposure to saltwater d) Wearing sunscreen and avoiding direct sunlight

d) Wearing sunscreen and avoiding direct sunlight Orally hypoglycemic agents, such as the sulfonylureas, may increase sensitivity to sunlight, resulting in sunburn (photosensitivity). The nurse must teach the client to wear sunscreen and to avoid excessive exposure to sunlight. Fluid retention is a prominent side effect of the "glitazones," or oral hypoglycemic medications, such as rosiglitazone (Avandia). (Lehne, 7 ed., p. 1026.)

The nurse has placed a nasogastric (NG) tube in a client without complications. What is the best action by the nurse to validate placement of the tube? 1) Observe the posterior of the nasopharynx to see if tube is coiled in the throat. 2) Attach the tube to suction and observe for gastric drainage. 3) Connect a syringe to the tube and insert 30 mL of air and listen for gastric sounds. 4) Aspirate gastric contents and validate the pH is below 4 or less.

4) Aspirate gastric contents and validate the pH is below 4 or less. The best bedside method of validating placement is to aspirate the NG tube and test the fluid for pH; gastric secretions have a pH less than 4. Observing whether the tube in the throat is coiled should be done immediately after the insertion of the tube, and is not considered validating the placement. Injecting air through the tube and listening for gastric sounds is not a recommended method of validating placement. Presence of gastric drainage is a good indication of placement; however, the drainage should be tested for pH level to verify placement. (Potter, Perry, 7 ed., p. 1117.)

A client has had a long and difficult labor with the vaginal birth of a large baby. During the postpartum assessment, the nurse notes a cluster of external hemorrhoids. Which statement made by the client indicates a need for additional teaching? a) "I can give myself an enema every other day to reduce constipation." b) "I can take sitz baths for pain." c) "I can decrease the swelling by using a topical hydrocortisone cream." d) "I can take a stool softener to decrease the pain of a bowel movement."

a) "I can give myself an enema every other day to reduce constipation." An enema every other day to reduce constipation would negatively affect the normal bowel movement pattern and deplete the client's natural intestinal flora. Sitz baths, antiinflammatory and analgesic topical ointments or sprays, along with stool softeners and increased bulk in the diet would be indicated in the management of the external hemorrhoids. (Lewis, et al, 8 ed., p. 1053.)

Which statement by the client would be a priority concern for the nurse? a) "None of my friends with diabetes have amputations." b) "My wife will not let me have ice cream after dinner." c) "I take my metformin (Glucophage) with breakfast." d) "I keep candy in my briefcase."

a) "None of my friends with diabetes have amputations." Diabetes is a leading cause of amputations. This statement must be addressed to ensure the client understands the importance of foot inspection and reporting signs/symptoms of decreased sensation related to neuropathy. It is important for the client to try to moderate processed and high fat foods. Metformin (Glucophage) is administered with meals to minimize gastrointestinal effects. Candy is a suitable first-line intervention in the event of hypoglycemia but should be accompanied by complex carbohydrates (bread, crackers) and low-fat proteins (e.g., low-fat peanut butter). (Lewis, et al, 8 ed., p. 1249.)

The nurse is teaching a client with hypertension about his antihypertensive medications, hydrochlorothiazide (HCTZ) and enalapril (Vasotec). What is important to include in this teaching? a) "Stand up slowly to decrease problem with dizziness." b) "Increase fluid intake because of increased loss of body fluids." c) "When you begin to feel better, the doctor will decrease your medications." d) "Stay out of the sunshine and make sure you have adequate sodium intake."

a) "Stand up slowly to decrease problem with dizziness." A common side effect of a combination of antihypertensive (Vasotec) and diuretic (HCTZ) medications is postural hypotension. It is important to teach the client how to deal with it. The client should not increase intake of fluids because the diuretics are being given to decrease excess fluid. The client should decrease his intake of sodium. When the client is feeling better, the medication is working and will probably not be decreased. (Lehne, 7 ed., p. 510.)

A young client is postoperative for a total hysterectomy. The nurse is teaching the client regarding hormone replacement therapy. What comment by the client would indicate to the nurse the client understands the discharge teaching? a) "The hormone replacement will help to prevent hot flashes as well as osteoporosis." b) "I will need to take the hormone replacement therapy for the rest of my life." c) "I will decrease my fluid intake because the hormones will cause me to retain fluids." d) "Hormone replacement therapy will help to protect me against cardiovascular disease."

a) "The hormone replacement will help to prevent hot flashes as well as osteoporosis." Hormone replacement therapy (HRT) will help the woman to control the vasomotor symptoms that result in the discomfort of hot flashes. It will also help to prevent the development of osteoporosis. HRT should not be taken indefinitely. Studies have shown that women who take estrogen plus progestin have increased risk of breast cancer, stroke, heart disease, venous thrombosis, and pulmonary edema. In women who take only estrogen, studies show an increased risk of stroke and venous thrombosis. Estrogen will cause fluid retention, breast enlargement, nausea, and headache, but fluid intake should not be limited. Progesterone side effects are increased appetite, weight gain, irritability, depression, spotting, and breast tenderness. (Lehne, 7 ed., p. 726.)

The nurse is assessing clients at a weight-control clinic. Which client would be at the greatest risk for weight-related health complications? a) A 40-year-old client with an android shape and waist measurement of 36 in b) A 58-year-old client with a body mass index (BMI) of 23 kg/m2 c) A 35-year-old client who is 5′10″ tall and weighs 140 lb d) A 65-year-old client who is 6′ tall and weighs 200 lb and has large thighs and hips

a) A 40-year-old client with an android shape and waist measurement of 36 in The client who carries excess weight around the waist is considered to have an android shape and is at a higher risk for problems with cholesterol and hyperlipidemia. The client with a BMI of 23 kg/m2 is normal. A client who is 5′10″ tall and weighing 140 lb would have a BMI of 20 kg/m2, which is within normal range. A client who is 6′ tall and weighs 200 lb would have a BMI of 27 kg/m2, which is overweight, but not obese. This client is also android shape, carrying most of the weight in the thighs and hips. This shape carries less risk than a client who is overweight with an android shape. (Lewis, et al, 8 ed., p. 945.)

The nurse is providing preoperative care for a client who will have a gastric resection. What will the preoperative teaching include? a) A NG tube will be in place several days after surgery. b) The client will be started on a low-residue, bland diet about 2 days after the surgery. c) Explain the anticipated prognosis and implications that the client may have a malignancy. d) A urinary retention catheter will be in place for 1 week after surgery.

a) A NG tube will be in place several days after surgery. NG tubes are left in place for several days after gastric resection. It is important to prevent the stomach from becoming distended and putting pressure on the suture line. A diet will be started after there is evidence of good bowel function. Diet will be clear liquids until client tolerance is determined. It is not a nursing responsibility to advise the client regarding prognosis and status of malignancy. A urinary retention catheter may or may not be in place; preferably, the client will be voiding. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 998.)

The nurse is caring for a first-day postoperative surgical client. Prioritize the client's desired dietary progression by numbering the following from 1 to 4 (with 1 being the first step and 4 being the last step). _Full liquid _NPO _Clear liquid _Soft

1) NPO 2) Clear liquid 3) Full liquid 4) Soft The client's status is NPO immediately after surgery. Desired diet progression advances next to clear liquid. Desired diet progression then advances to full liquid. Desired diet progression next advances to a soft diet and then finally to a regular diet as tolerated by the client. (Potter, Perry, 7 ed., pp. 1404-1405.)

The nurse understands that which condition can result if hypersecretion of growth hormone (GH) occurs after epiphyseal closure? a) Acromegaly b) Congenital cretinism c) Dwarfism d) Gigantism

a) Acromegaly Acromegaly can occur because of excess growth hormone (GH) after closure of the epiphyseal plates. Congenital cretinism occurs with deficit thyroid hormone leading to hypothyroidism. Dwarfism is the description for a child being abnormally small. Gigantism occurs with hypersecretion of GH before the closure of the epiphyseal plates. (Hockenberry, Wilson, 9 ed., p. 1575.)

The nurse is teaching the mother of a child with diabetes how to recognize the signs and symptoms of hypoglycemia. Which signs and symptoms should the nurse discuss? a) Behavioral changes, increased heart rate, sweating, and tremors b) Nausea, fruity odor to breath, headache, and fatigue c) Polydipsia, polyuria, polyphagia, and weight loss d) Enlarged tongue, hypotonia, easy weight gain, and cool skin temperature

a) Behavioral changes, increased heart rate, sweating, and tremors The signs and symptoms of hypoglycemia include behavioral changes, increased heart rate, sweating, and tremors. Nausea, fruity odor to breath, headache, and fatigue are present with hyperglycemia. Polydipsia, polyuria, polyphagia, and weight loss are classic signs of diabetes. Enlarged tongue, hypotonia, easy weight gain, and cool skin temperature are associated with hypothyroidism. (Hockenberry, Wilson, 9 ed., p. 1602.)

A client arrives at the ER complaining that he has had several episodes of epistaxis. The client also states that he is taking warfarin (Coumadin), and his stools test positive for presence of blood. What medication would the nurse anticipate administering? a) Vitamin K b) Protamine sulfate c) Ascorbic acid d) Calcium chloride

a) Vitamin K Vitamin K is the antidote for the oral anticoagulant warfarin (Coumadin). Protamine sulfate is the antidote for heparin. The other two options do not affect the clotting of the blood. (Lehne, 7 ed., p. 605.)

The nurse is preparing discharge teaching for a client with a diagnosis of gastroesophageal reflux disease (GERD). What would be important for the nurse to include in this teaching plan? Select all that apply. a) Elevate the head of the b) Decrease intake of caffeine products. c) Discuss strategies for weight loss if overweight. d) Increase fluid intake with meals. e) Take ranitidine (Zantac) at bedtime. f) Eat a bedtime snack of milk and protein.

a, b, c, e Each of these actions will help either neutralize the acid in the stomach or decrease the physiologic reflux. Increased fluids with meals will exacerbate the problem, as will eating before going to bed. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 975.)

The nurse understands that the pain of intermittent claudication increases when a client walks: Select all that apply. a) Up an incline b) Fast c) In cold weather d) For an extended period e) In nonsupportive shoes f) Up stairs

a, b, d, f Intermittent claudication occurs when the leg muscles do not receive the oxygen-rich blood required during exercise, causing leg pain felt as cramping in the hips, thighs, or calves. It is affected or influenced by the speed or incline of the walk or by any condition in which the muscles' demand for oxygen is increased. The pain will be present from 1 day to the next during the same activity. The pain will resolve completely within 2 to 3 minutes of resting but will occur again when the same level of activity is resumed. (Lewis, 8 ed. pp. 1720-1721.)

What will the nurse teach the client with diabetes regarding exercise in the treatment program? Select all that apply. a) During exercise the body will use carbohydrates for energy production, which in turn will decrease the need for insulin. b) With an increase in activity, the body will use more carbohydrates; therefore, more insulin will be required. c) Exercise increases the HDL and decreases the chance of stroke and heart disease. d) The increase in activity results in an increase in the use of insulin; therefore, the client should decrease his or her carbohydrate intake. Exercise will improve pancreatic circulation and stimulate the islets of Langerhans to increase the production of intrinsic insulin.

a, c As carbohydrates are used for energy, insulin needs decrease. Therefore during exercise, carbohydrate intake should be increased to cover the increased energy requirements. The beneficial effects of regular exercise may result in a decreased need for diabetic medications in order to reach target blood glucose levels. Furthermore, it may help to reduce triglycerides, LDL cholesterol levels, increase HDLs, reduce blood pressure, and improve circulation. Increased HDLs have been associated with a decrease in syndrome x (Metabolic Syndrome). (Lewis, Dirksen, Heitkemper, et al, 8 ed., pp. 959, 1219, 1223.)

The nurse is caring for a client with Addison disease. Which of the following findings indicate the development of a complication of this condition? Select all that apply. a) Back and abdominal pain b) Hyperglycemia c) Extreme weakness d) Temperature of 101° F e) Increased blood pressure f) Confusion

a, c, d, f An Addisonian crisis is an acute episode of adrenal insufficiency, which can be a life-threatening emergency. It is characterized by weakness, often accompanied by pain in the back, abdomen, or legs, along with severe manifestations of glucocorticoid and mineralocorticoid deficiency, including hypotension (particularly postural), tachycardia, dehydration, hyponatremia, hyperkalemia, hypoglycemia, hyperpyrexia, and confusion. It is treated by administration of hydrocortisone and fluid replacement. (Lewis, et al, 8 ed., p. 1281.)

What are the best nursing actions in caring for a young client with appendicitis before surgery? Select all that apply. a) Maintain bed rest. b) Offer full liquids to maintain hydration. c) Position on side, legs flexed to the abdomen with the head slightly elevated. d) Position on left side, apply a warm K-Pad to the abdomen. e) Administer morphine intravenously to relieve pain. f) Maintain NPO and begin a peripheral IV for fluid replacement.

a, c, f The characteristic position of comfort for the client with appendicitis is on the side with the legs flexed against the abdomen; the head of the bed should remain slightly elevated to decrease the upward spread of infection in case the appendix ruptures. Keep the client NPO because of the impending surgery; initiate IV fluid replacement. Maintain the client on bed rest; do not apply any type of heat to the abdomen. Narcotics are given very carefully if at all since the analgesic may mask the symptoms of rupture. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 1021; Hockenberry, Wilson, 9 ed., p. 1311.)

Which of the following characteristics would be more indicative of an arterial leg ulcer rather than a venous leg ulcer? Select all that apply. a) Intermittent claudication b) Thick, hardened and indurated skin c) Frequent pruritis d) Capillary refill greater than 3 sec e) Irregularly shaped

a, d Intermittent claudication and capillary refill less than 3 seconds are indicative of arterial leg ulcers. Intermittent claudication is common because of lack of blood flow to muscle during movement and exercise, especially in early stages. As arterial circulation worsens, pain at night or at rest indicates an advanced stage. A delayed capillary refill is indicative of lack of oxygen-rich blood flow to an area seen in an arterial leg ulcer rather than a venous ulcer. Thick, hardened, and indurated skin is indicative of venous leg ulcers. Skin texture for arterial leg ulcers is thin, shiny, friable, and dry. Pruritis is very common with venous leg ulcers but rarely occurs with arterial ulcers. The ulcer margin of an arterial leg ulcer is usually rounded and smooth, whereas a venous leg ulcer margin is irregularly shaped. (Ignatavicius, Workman, 7 ed., p. 788; Lewis 8 ed. pp. 874-875.)

The nurse is conducting discharge dietary teaching for a client with diverticulosis who is recovering from an acute episode of diverticulitis. Which statement by the client would indicate to the nurse that the client understood his dietary teaching? a) "I will need to increase my intake of protein and complex carbohydrates to increase healing." b) "I need to eat foods that contain a lot of fiber to prevent problems with constipation." c) "I will not put any added salt on my food, and I will decrease intake of foods that are high in saturated fat." d) "Milk and milk products can cause a lactose intolerance. If this occurs, I need to decrease my intake of these products."

b) "I need to eat foods that contain a lot of fiber to prevent problems with constipation." Constipation increases problems with diverticula. A diet high in fiber is recommended. The other options do not have any specific relevance to diverticula disease. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 1047.)

The nurse should assess the client receiving heparin for which common untoward effect? a) Generalized dermatitis b) Hematuria c) Urinary retention d) Vitamin K deficiency

b) Hematuria Because of the increased clotting time, bleeding can occur anywhere, but especially in the mucus membranes, gums, and urine. The other options do not occur with heparin. (Lehne, 7 ed., p. 598.)

The nurse is caring for a client with pancreatic cancer. What would the nurse consider the highest priority for this client? a) Urinary and bowel program b) Nutritional support c) Self-image changes d) Skin integrity

b) Nutritional support Severe weight loss and anorexia occur with cancer of the pancreas, as with most cancers. Nutritional support is critical with this diagnosis. The pancreatic enzymes support the absorption of nutrients from the digestion of food products. (Lewis, et al, 8 ed., p. 1095.)

A client has a diagnosis of adrenocortical insufficiency. What would be an appropriate task to delegate to the certified nursing assistant? Select all that apply. a) Revise the client's nursing care b) Remind the client to change positions slowly. c) Assist the client out of bed. d) Evaluate the client for fatigue and muscle weakness. e) Explain to the client how to collect a 24-hour urine sample. f) Teach the client's spouse the importance of diet.

b, c Clients with adrenocortical insufficiency have neuromuscular weakness and hypotension, so explaining to the CNA to assist the client out of bed and to change positions slowly would be a safe nursing measure, especially after the nurse has initially explained to the client these nursing measures. Any type of assessment, teaching, or care planning is the function of the licensed professional nurse. (Ignatavicius, Workman, 7 ed., p. 1373, 1382.)

What complications should the nurse monitor for in a client who has had radical pancreatectomy surgery? Select all that apply. a) Diabetes insipidus b) Abdominal fistula c) Diabetes mellitus d) Peritonitis e) Hemorrhage f) Bowel obstruction

b, c, d, e, f A client who has radical pancreatectomy surgery would have complete removal of the pancreas and would have no insulin production. This would lead to diabetes mellitus, not diabetes insipidus. Abdominal fistula is the most common and serious complication following the surgery. Peritonitis, hemorrhage, and bowel obstruction are all complications that the nurse needs to monitor in the client postoperative a radical pancreatectomy. (Ignatavicius, Workman, 7ed., p. 1332)

The nurse is teaching a client with gastroesophageal reflux disease (GERD) and asks about his diet and the foods he regularly consumes. Which food choices would indicate the need for additional teaching? Select all that apply. a) Cottage cheese b) Carbonated soft drinks c) Raw vegetables d) Fried chicken e) Yogurt f) Chocolate cake

b, d, f Carbonated beverages, high fat, alcohol, and caffeine (chocolate) will stimulate belching and lead to increased gastric reflux. Raw vegetables and milk products are not restricted in the diet for clients with GERD. (Lewis, et al, 8 ed., p. 973.)

The nurse is caring for a client after a transsphenoidal resection of a pituitary tumor. Which finding(s) must be reported to the surgeon? Select all that apply. a) Presence of swelling at suture site b) Urine output of 350 mL for past 2 hours c) Increased crackles lower lobes d) Pulse oximetry 98%, BP 138/82 e) Serum osmolality of 302 mmol/kg

b, e After removal of the pituitary, the client may develop diabetes insipidus as a result of cerebral edema. It will be a priority to monitor urine output and urine specific gravity and to notify the surgeon of an increase in volume and decrease in specific gravity. The other major concern is related to the concentrated serum blood most likely related to hypernatremia. Swelling at the gum site in the mouth is possible, which would be expected and noted on the chart. Crackles are found with fluid volume overload, not dehydration, which is what this client is at risk of developing. The pulse oximetry is in the normal range, and BP is not critical. (Lewis, et al, 8 ed., p. 1261.)

A toddler is admitted to the hospital for surgical repair of an inguinal hernia. Which nursing observation on the initial assessment would be indicative of an inguinal hernia? a) Protrusion of the umbilicus b) Visible peristalsis c) A mass in the groin d) Abdominal distention

c) A mass in the groin The hernia is a visible mass in the groin. If the tube formed by a sac of peritoneum does not atrophy after the descent of the testis in utero, the intestine may descend into that sac and produce an inguinal hernia. (Hockenberry, Wilson, 9 ed., p. 448.)

A client with hypertension asks the nurse what type of exercise she should do each day. What is the nurse's best response? a) "Exercise for an hour, but only three times a week." b) "Walk on the treadmill for 45 minutes every morning." c) "Begin walking and increase your distance as you can tolerate it." d) "Exercise only in the morning and stop when you get tired."

c) "Begin walking and increase your distance as you can tolerate it." When any client begins exercising, it should be gradually with increasing activity as the client tolerates it. A complication of hypertension is heart failure, which may be first seen as dyspnea on exertion. The client should exercise as tolerated and stop when she gets tired or begins to have shortness of breath, regardless of the amount of time she has already exercised. (Lewis, Dirksen, Heitkemper et al, 8 ed., p. 746.)

The nurse is to administer an enema to an adult client. The tube should be inserted how many inches? a) 1 to 2 inches b) 2 to 3 inches c) 3 to 4 inches d) 4 to 6 inches

c) 3 to 4 inches Three to four inches are required for an adult to clear the rectal sphincters. (Potter, Perry, 7 ed., p. 1201.)

In preparing a pediatric client for an appendectomy, the nurse would question which doctor`s orders? a) Penicillin 600,000 units IVPB, now b) Obtain signed consent form from parents. c) Administer enemas until clear. d) 500 mL Ringer`s lactate solution at 50 mL/hr

c) Administer enemas until clear. Enemas or laxatives are not administered before surgery in clients with an acute abdomen. If gastric motility is stimulated, there is an increased danger of appendiceal rupture. All other orders are appropriate before an appendectomy. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 1021.)

A sexually active 17-year-old female is diagnosed with trichomoniasis through vaginal discharge analysis. The nurse explains which pharmacologic intervention to minimize symptoms and the risk for reoccurrence? a) Return to clinic each week for intramuscular injection of penicillin. b) Perform a daily vaginal douche with a weak iodine solution. c) Oral administration of metronidazole three times a day to client and partner. d) Application of trichloroacetic acid to lesions daily for 6 to 8 weeks.

c) Oral administration of metronidazole three times a day to client and partner. Trichomoniasis is a protozoal infection transmitted through sexual intercourse. All sexual partners need to be treated with the oral administration of metronidazole (Flagyl), a systemic antiprotozoal. Males may be asymptomatic. Intramuscular injection of penicillin is prescribed for syphilis. Douching should be avoided because it destroys the normal vaginal flora and increases the risk for developing the problem. Trichloroacetic acid (TCA) or podophyllin is topically applied to genital warts. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 1357.)

A client is admitted with hypothyroidism. What findings would be noted on the admission nursing assessment? Select all that apply. a) Diarrhea b) Tachycardia c) Brittle nails d) Intolerance to cold e) Hypotension f) Shiny, silky hair

c, d, e Brittle nails; intolerance to cold; hypotension; bradycardia; dry, coarse, brittle hair; and constipation are common findings with clients who have hypothyroidism. Tachycardia, diarrhea, and shiny, silky hair are common symptoms associated with hyperthyroidism. (Ignatavicius, Workman, 7 ed., p. 1401.)

The nurse is assessing a client who came into the office complaining of problems with gastric reflux and is diagnosed with gastroesophageal reflux disease (GERD). What comment by the client would indicate to the nurse that the client needs additional teaching? a) "I don't drink carbonated beverages anymore." b) "I have the head of my bed elevated on blocks." c) "I quit smoking and I keep a piece of hard candy in my mouth." d) "I always have a glass of milk and a little bit to eat before I go to bed."

d) "I always have a glass of milk and a little bit to eat before I go to bed." The problems with GERD are increased by eating before going to bed. The client should avoid eating or drinking for about 3 hours before going to bed. The other options are appropriate to prevent and or control the problems with GERD. (Lewis, et al, 8 ed., p. 975.)

The nurse is teaching a client how to care for his ileostomy. What comment by the client would indicate that he does not understand the teaching? a) "I will change the adhesive appliance around the stoma only if it is leaking." b) "I will clean the stoma with a nonirritating soap and rinse it good with water." c) "I will make sure there is no exposed skin when I place the appliance around the stoma." d) "I will irrigate daily so that I can establish a regular schedule of bowel evacuation."

d) "I will irrigate daily so that I can establish a regular schedule of bowel evacuation." Daily irrigations are not indicated for an ileostomy and would cause a loss of digestive enzymes, fluid, and electrolytes. In addition, the added fluid and stimulus from the irrigation would cause incontinence. The other options indicate that the client understands the principles of care of the ileostomy. (Lewis, et al, 8 ed., p. 1042.)

Place the following insulin medications in chronological order according to insulin peak times, with the earliest peak noted first and the slowest peak or no peak at all as last. (1-4). _Regular _Lantus _Lispro _NPH

1) Lispro 2) Regular 3) NPH 3) Lantus The earliest peaking insulin is insulin lispro (Humalog) at 0.5-2.5 hours, followed by regular (Humulin R) at 1-5 hours, and NPH at 6-14 hours. Insulin glargine (Lantus) has no pronounced peak. (Lehne, 7 ed., p. 665.)

The nurse is caring for a client currently under contact precautions. The nurse has changed a dressing on an infected wound and is now preparing to leave the room. Put the following actions in order in which the nurse performs them. _ Remove the gloves and dispose them in the room. _Wash hands after exiting the room. _Remove the gown and place it in the laundry hamper in the room. _Dispose of dressing before removing the gloves.

Dispose of the dressing gown before removing the gloves. Remove the gloves and dispose of them in the room. Remove the gown and place it in the laundry hamper in the room. Wash hands after exiting the room. (Potter, Perry, 7 ed., pp. 1314-1317.)

The nurse is discussing with a child and family the various sites used for insulin injections. The nurse would explain that the following site has the fastest rate of absorption: a) Abdomen. b) Thigh. c) Buttock. d) Arm.

a) Abdomen. The abdomen has the fastest rate of absorption but the shortest duration. The arm has a fast rate of absorption but short duration. The leg has a slow rate of absorption but a long duration. The buttock has the slowest rate of absorption and the longest duration. (Hockenberry, Wilson, 9 ed., p. 1610.)

The nurse is reviewing the health care provider's orders for a postoperative client. The client has just returned from surgery for aortic aneurysm repair. He is NPO, he has a nasogastric tube, and vital signs are stable. Which order would the nurse question? a) 20 mEq potassium IV push b) 1000 mL D51/2 NaCl to infuse at 125 mL per hour c) 1000 mL D5W with 40 mEq potassium to infuse at 100 mL per hour d) Cefoxitin (Mefoxin) 1g IV in 50 mL D5W over 15 minutes

a) 20 mEq potassium IV push Potassium should never be administered IV push. It is extremely irritating and painful at the catheter site and very dangerous to the client. It should be diluted in an IV solution and run over the time of the total infusion (1000 mL D5W with 40 mEq potassium over 8 hours), or small amounts should be given in less solution (potassium10 mEq in 250 mL D5W to run over 3 hours). The other orders listed are all within acceptable limits for a postoperative client. (Lehne, 7 ed., pp. 457-458.)

A nurse is caring for a client with type 1 diabetes mellitus. With a blood glucose level of 200 mg/dL, how many units of regular insulin will the nurse administer according to the sliding scale? a) Blood glucose at 200 mg/dL or less = no insulin b) Blood glucose 201 to 229 mg/dL = 2 units of insulin c) Blood glucose 230 to 259 mg/dL = 4 units of insulin d) Blood glucose 260 to 300 mg/dL = 6 units of insulin

a) Blood glucose at 200 mg/dL or less = no insulin With the blood sugar level at 200 mg/dL, no additional regular insulin must be given. Sliding scale insulin dosage is determined by the amount of glucose in the blood, which is based on glucometer readings. The sliding scale enables the client to receive appropriate amounts of insulin as the blood glucose level fluctuates throughout a 24-hour period. (Potter, Perry, 7 ed., p. 743.)

The nurse is administering metformin (Glucophage) to a client. Which observation indicates a therapeutic response to this medication? a) Blood sugar level maintained at 90 to 100 mg/dL b) Decrease in the serum uric acid levels c) Urine output increased to 60 mL/hr d) Blood pressure increased to 120/80 mm Hg

a) Blood sugar level maintained at 90 to 100 mg/dL This is an oral hypoglycemic medication used for the control of adult-onset (type 2) diabetes. The desired response is a normal blood sugar level, which is 70 to 120 mg/dL. (Lehne, 7 ed., p. 674; Lewis, 8 ed., p. 1219.)

The nurse understands that in an allergic reaction, the release of histamine results in: a) Bronchospasm, vasodilatation, and vascular permeability b) Bronchodilation, vasoconstriction, and vascular permeability c) Smooth muscle contraction, decreased vascular permeability, and vasoconstriction d) Pain, increased vascular permeability, and bronchodilation

a) Bronchospasm, vasodilatation, and vascular permeability The release of histamine results in bronchospasm, vasodilatation, and vascular permeability, leading to wheezing, increased mucus production in the lungs, and edema of the airway. Bronchodilation increases the diameter of the airway and facilitates breathing. No pain is involved with histamine release. Remember, for an option to be considered correct, all items must be correct in the listing, if the option is the answer to the question. (Lewis, et al, 8 ed., p. 218.)

Which medication will the nurse have available for emergency treatment of tetany in the client who has had a thyroidectomy? a) Calcium chloride b) Potassium chloride c) Magnesium sulfate d) Propylthiouracil (PTU)

a) Calcium chloride Calcium chloride or calcium gluconate should be available to treat tetany caused by accidental removal of the parathyroid glands during surgery. The parathyroid glands regulate calcium metabolism. Potassium chloride replaces the electrolyte potassium. Magnesium sulfate is used in the treatment of preeclampsia (pregnancy induced hypertension). Propylthiouracil is an antithyroid medication used to block production of thyroid hormone. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 1275.)

What is the primary action of insulin in the body? a) Enhances the transport of glucose across cell walls b) Aids in the process of gluconeogenesis c) Stimulates the pancreatic beta cells d) Decreases the intestinal absorption of glucose

a) Enhances the transport of glucose across cell walls Insulin acts to lower the blood sugar level, primarily by improving the transport of glucose into the cells. It is the principal regulator of the metabolism and storage of fats, carbohydrates, and proteins. It is a hormone produced in the beta cells in the islets of Langerhans of the pancreas. The rise in insulin after a meal stimulates the conversion of glucose to glycogen, inhibits gluconeogenesis, enhances fat deposition, and increases protein synthesis. It does not decrease intestinal absorption of glucose but works in the bloodstream to promote glucose transport across the cell membrane to the cytoplasm of the cell. (Lehne, 7 ed., p. 664.)

The nurse is administering metformin (Glucophage) to a client. What nursing observations would cause the nurse concern regarding side effects of the medication? a) Gastrointestinal upset b) Photophobia c) Hyperglycemia d) Skin eruptions

a) Gastrointestinal upset Anorexia, nausea, and a metallic taste in the mouth are common side effects, but can contribute to the client not taking the medication if unaware of the expected side effects. Over time, the gastrointestinal symptoms subside and can be relieved by taking the medication with food or by starting at a lower dose. (Lehne, 7 ed., p. 674.)

A pediatric client is hospitalized with AIDS. Which precautions are necessary for the nurse to implement? a) Gloves when in contact with any body fluids b) Mask, gloves, and gowns with any direct contact c) Sterile linens, mask, and gloves d) Disposable silverware and dishes

a) Gloves when in contact with any body fluids This situation calls for standard precautions, including the use of gloves when handling body fluids is part of standard precautions. Masks and gowns are not necessary all of the time. Sterile linens are used for protective isolation. Depending on the mode of transmission of the organism, disposable eating utensils may be used in cases that require contact isolation if the client is infected with an organism that is transmitted via oral secretions. (Hockenberry, Wilson, 8 ed., p. 941.)

The nurse is completing a preoperative assessment. What data from the assessment would cause the nurse the most concern? The client: a) Has been using herbal remedies for the past year b) Reports problems with infection when he had surgery 2 years ago c) Has a history of problems with pain control postoperatively d) Discontinued taking the aspirin for his arthritis about 3 weeks ago

a) Has been using herbal remedies for the past year Further assessment is necessary to determine what herbs he has been taking. Bleeding tendencies occur with many herbal remedies and could affect the anticipated surgery. Other information does not influence the current surgery. (Potter, Perry, 7 ed., pp. 1369-1389.)

A client with a diagnosis of type 2 diabetes has been ordered a course of prednisone for severe arthritic pain. An expected change that requires close monitoring by the nurse is: a) Increased blood glucose level b) Increased platelet aggregation c) Increased creatinine clearance d) Decreased white blood cell count

a) Increased blood glucose level An adverse reaction to corticosteroids is hyperglycemia. A client with type 2 diabetes must monitor blood glucose levels closely while taking steroids. Creatinine clearance measures renal function. Platelet aggregation is associated with hematologic disorders. Clients taking corticosteroids are at increased risk for infection due to suppressed immune response and not a decrease in WBCs. (Lehne, 7 ed., p. 850.)

The nurse is teaching a client about her medication. Which of the following will guide the nurse's explanation about glyburide (Micronase)? a) It is thought to stimulate insulin production and release from the pancreas. b) With prolonged use, it may decrease cellular sensitivity to insulin. c) It is an analog of insulin and acts by directly stimulating the beta cells of Langerhans. d) It reduces the blood sugar level by decreasing the rate of lipolysis, preventing gluconeogenesis.

a) It is thought to stimulate insulin production and release from the pancreas. Glyburide is a second-generation sulfonylurea whose primary action is to stimulate the release of insulin from the pancreatic islet cells. The second-generation sulfonylureas are more potent than first-generation ones, such as tolbutamide (Orinase), and with prolonged use, may increase cellular sensitivity to insulin. (Lehne, 7 ed., pp. 675-676.)

A client with diabetes is being admitted for abdominal surgery. What nursing actions would the nurse implement to promote wound healing for this client? a) Maintain the client's blood glucose within a normal range. b) Administer acetaminophen suppository for any temperature above 101° F. c) Monitor the client's calorie count to validate adequate carbohydrate intake for healing. d) Maintain a wet to dry dressing to facilitate wound granulation.

a) Maintain the client's blood glucose within a normal range. Elevated blood glucose levels will affect wound healing in clients with diabetes. A calorie count does not focus on increased protein the client may need for adequate healing. The fever needs to be controlled; however, a temperature of 101° F does not adversely impact healing. The dressing should be a dry, sterile dressing because the wound should be healing by primary intention. (Lewis, et al, 8 ed., pp. 1236-1239.)

The nurse is reviewing the client care assignment for the day. Several clients are at an increased risk for a problem with fluid balance. Which client would the nurse assess first? a) Older adult client who has been NPO for 6 hours and scheduled for surgery in 2 hours b) Client with a history of congestive heart failure c) An adolescent with superficial partial-thickness burns of his arms and hands d) A postoperative client who is on D5W with added KCl at 125 mL/hr

a) Older adult client who has been NPO for 6 hours and scheduled for surgery in 2 hours. The older adult client does not have any fluid intake and is scheduled for surgery. Clients going to surgery need to be well hydrated. The nurse should contact the surgeon regarding fluids for this client. The other clients are at risk; however, nothing indicates they are currently having any difficulty with fluid balance. (Lewis, et al, 8 ed., p. 340.)

Pancreatic enzymes are ordered for a 4-year-old child diagnosed with cystic fibrosis. The nurse understands that these enzymes will be given: a) Orally with meals b) At bedtime with water c) Orally after meals d) Intramuscularly on a monthly basis

a) Orally with meals Pancreatic enzymes are given orally with meals to assist in the absorption of nutrients. Every time the child has an intake of fat, the enzymes should be taken. (Lehne, 7 ed., p. 1256.)

The nurse is assessing a newborn. Before placing him on the scales to determine his weight, what would be important for the nurse to do? a) Place a waterproof protective barrier drape across the scales. b) Thoroughly wipe the scales clean with alcohol and cotton. c) Take no specific measures because the scales were cleaned after the last infant was weighed. d) Place a warm blanket on the scale to prevent excessive heat loss.

a) Place a waterproof protective barrier drape across the scales. Because the nurse is performing the initial assessment of the infant and weighing him, he has not been bathed since birth. Standard precautions indicate the necessity of placing a barrier across the scales to prevent contamination of the scales by amniotic fluid, as well as possible contamination by stool and urine. Wiping the scales with alcohol and cotton would not properly remove contaminated fluid from the scales. The scales should be clean, but that should not be assumed. A warm blanket would not be waterproof. (Hockenberry, Wilson, 8 ed., pp. 205, 224, 706.)

The nurse is caring for a client with a methicillin-resistant Staphylococcus aureus (MRSA) infection. What infection control procedure will the nurse implement when working with this client? a) Place specimens in a container that is clean and labeled on the outside for transport. b) Cleanse the blood pressure cuff before removing it from the room. c) Keep gloves on until out of the room and in an area in which they can be disposed. d) Remove any soiled linen from the room to prevent a reservoir for bacteria.

a) Place specimens in a container that is clean and labeled on the outside for transport. All specimens, whether infectious or noninfectious, should be transported to the laboratory in a container that is clean on the outside. The label should be on the outside of the bag or container. Linens should be placed in a bag and removed when necessary, not necessarily every time the nurse exits the room. When removed, linens should be placed in a waterproof linen bag and marked as contaminated. Blood pressure cuffs, stethoscopes, thermometers, dressing supplies, and irrigation fluids should remain in the client's room. Gloves should be removed before the nurse leaves the client's room. (Potter, Perry, 7 ed., pp. 661-663, 667-668.)

A client has been receiving inhalation desmopressin (DDAVP) therapy for hypothalamic diabetes insipidus. What will the nurse evaluate to determine the therapeutic response to this medication? a) Urine specific gravity b) Blood glucose c) Vital signs d) Oxygen saturation levels

a) Urine specific gravity Desmopressin (DDAVP) alleviates polyuria by acting as anti-diuretic hormone (ADH). In the case of diabetes insipidus, urine specific gravity should return to a normal level of 1.010 to 1.030. There is no effect on blood glucose or oxygen saturation levels. One adverse effect (not considered therapeutic for desmopressin) is the possibility of a change in vital signs related to peripheral vascular resistance (vasoconstriction). Another reason the vital signs may be affected is water intoxication, which is also a side effect of desmopressin. (Lehne, 7 ed., p. 706.)

If a child with hypoparathyroidism is receiving vitamin D therapy (calcitriol [Rocaltrol]), the parents should be advised to watch for which of the following signs of vitamin D toxicity? a) Weakness, fatigue, nausea, and vomiting b) Headache, irritability, and seizures c) Excessive thirst, diarrhea, and fatigue d) Bradycardia, insomnia, sweating

a) Weakness, fatigue, nausea, and vomiting Vitamin D therapy is somewhat difficult to regulate because the drug has a delayed onset of action and a long half-life. Vitamin D toxicity can be a serious consequence of therapy, because it is fat soluble and can cause irreversible renal impairment. Vitamin D toxicity can cause nausea, vomiting, poor appetite, constipation, weakness, and weight loss. It can also raise blood levels of calcium, causing mental status changes, such as confusion. High blood levels of calcium also can cause heart rhythm abnormalities. Calcinosis, the deposition of calcium and phosphate in the body's soft tissues, such as the kidneys, can also be caused by vitamin D toxicity. (Lehne, 7 ed. p. 872.)

A client does not want to remove a wedding band before surgery. What is the best nursing intervention? a) Wrap tape around it to secure it to the finger. b) Tell the client that the surgery cannot be performed if he does not remove the ring. c) Tell the operating room staff that the client refused to remove the ring. d) Remind the client that the hospital will not be liable for any loss.

a) Wrap tape around it to secure it to the finger. Dislodging a wedding band during surgery is the primary risk. If a client refuses to remove a band, it should be safely and securely held in place with tape and noted on the chart. (Potter, Perry, 7 ed., p. 1387.)

A child with newly diagnosed diabetes is in the emergency room and is unconscious. Glucagon has been prescribed for treatment of hypoglycemia. What would be important nursing management? Select all that apply. a) Watch for side effects of hypoglycemia. b) Child usually awakens within 20 minutes of receiving glucagon. c) Vomiting may occur after administration, so aspiration precautions should be taken. d) Do not rotate sites for administration, because even absorption in the abdomen is best. e) Give PO glucagon once the client has consciousness. f) Monitor blood values for increasing blood sugar.

a, b, c,f Glucagon is the medication of choice used to elevate blood sugar levels after insulin overdose. It does not correct hypoglycemia resulting from starvation. Rebound hypoglycemia is a potential adverse effect, which is why it is important for the client to have carbohydrates once consciousness returns. No significant side effects exist. If unconscious when administered, the child usually awakens in 5 to 20 minutes after receiving glucagon. Vomiting may occur after administration, so aspiration precautions should be taken by placing the child on the side. Blood work to monitor an increase in blood sugar (desired outcome) would be collected. IV is the preferred method of glucagon administration, although the medication is able to be given subQ and IM, not PO. When client is conscious, oral carbohydrates and protein should be given. (Lehne, 7 ed., p. 683.)

The nurse is performing a dressing change on a client who has a Staphylococcus infection in an abdominal incision. What infection control precautions will the nurse implement? Select all that apply. a) Wear clean gloves to remove old dressing. b) Put on a gown when entering the room. c) Wear a face shield. d) Dispose of the gown and mask in container outside the client's door. e) Leave all extra dressing supplies in the room. f) Carefully cleanse the stethoscope and scissors before taking them out of the room.

a, b, e Contact precautions would require the nurse to wear clean gloves to remove the old dressing, put on a gown when entering the room, and leave all extra dressing supplies in the room. A face shield is not necessary unless splattering of fluids is anticipated. The gown and mask should be disposed of in the client's room; they should not be removed from the room. The stethoscope and scissors should not be taken out of the client's room. (Potter, Perry, 7 ed., p. 663.)

The nursing staff is trying to reduce the rate of infections occurring on the nursing unit. What should the nursing staff include as potential sites and causes of infections? Select all that apply. a) A urinary retention catheter that disconnected for the client to ambulate b) Closed dirty linen hamper in the client's room c) Opened suction catheter lying next to the suction tubing on the bedside table d) Opened 4 × 4 dressing that has been secured with tape for next dressing change e) Opened nasogastric irrigation set lying on the bedside table f) Nearly full needle disposal unit on the wall next to the client's bed

a, c, d, f All urinary retention catheters should be maintained in a closed drainage system. The open suction catheter is a potential reservoir for bacteria; the bacteria would be introduced directly into the respiratory tract. The open dressing should be considered clean, not sterile and if it were placed in direct contact with a wound it could introduce pathogens into the wound. The nearly full needle disposal unit meets OSHA standards by containing sharps, and it should be replaced when two-thirds full to prevent injury in trying to insert a sharp into a full container. The major sites for infections related to health care include surgical or traumatic wounds and the urinary and respiratory tracts. The closed dirty linen hamper is the appropriate place for dirty linens and should be removed from the room as soon as possible. Irrigating a nasogastric tube is considered a clean procedure; the equipment is not sterile and is not usually the source of pathogens. (Potter, Perry, 7 ed., p. 648.)

The nurse is conducting discharge teaching for a client with Addison disease. What would the nurse advise the client to carry at all times? Select all that apply. a) Hydrocortisone b) Epinephrine c) An injectable diuretic agent d) The physician's phone number e) The client's medication schedule f) Documentation of the client's diagnosis

a, d, e, f A client with Addison disease should always wear a medical alert ID bracelet and should carry an emergency kit, which should include 100 mg of IM hydrocortisone and directions for its injection, the physician's phone number, and the client's diagnosis and medication schedule. (Lewis, et al, 8 ed, p. 1282.)

If dietary trays are usually brought to the nursing unit at 8:00 am, the nurse should plan to administer intermediate-acting insulin (Humulin N), 40 units, subcutaneously to a client between: a) 5:00 and 5:30 am b) 6:30 and 7:00 am c) 9:30 and 10:30 am d) 11:00 and 11:30 am

b) 6:30 and 7:00 am Intermediate-acting insulin, such as Humulin N, should be given 60 to 90 minutes before a meal. Therefore, if the breakfast tray arrived at 8:00 am, a client would need to receive the insulin between 6:30 and 7:30 am. Regular insulin usually is administered 30 minutes before a meal, and insulin lispro is given immediately (15 minutes) before or after meals. (Lehne, 7 ed., pp. 666-667.)

A client with diabetes receives a combination of regular and NPH insulin at 0700 hours. The nurse teaches the client to be alert for signs of hypoglycemia at: a) 12 pm to 1 pm (1200 to 1300 hours) b) 9 am and 5 pm (0900 and 1700 hours) c) 10 am and 10 pm (1000 and 2200 hours) d) 8 am and 11 am (0800 and 1100 hours)

b) 9 am and 5 pm (0900 and 1700 hours) Regular insulin (a short-acting insulin) peaks in 2 to 3 hours, and NPH (an intermediate-acting insulin) peaks in 4 to 10 hours. Hypoglycemia would most likely occur between 9 am and 5 pm (0900 to 1700 hours). (Lewis, Dirksen, Heitkemper et al, 8 ed., p. 1224.)

The nurse is assessing an older client during the immediate postoperative period after abdominal surgery. The nurse notes that the left foot is warm and pale and that there is no palpable pedal pulse. The best nursing action would be to: a) Elevate the left leg on a pillow and notify the doctor immediately. b) Check the chart to determine the status of the pulse before surgery. c) Assist the client to exercise the extremity to increase peripheral circulation. d) Place a warm pack on the leg to increase vasodilatation and circulation.

b) Check the chart to determine the status of the pulse before surgery. The client may not have had a pedal pulse before surgery. The foot is warm to touch, so the status of other peripheral pulses should be checked. It would be appropriate to get a Doppler evaluation of the pulse. Elevating the foot or advising the doctor is unnecessary unless other signs of impaired circulation occur. A warm pack should not be placed on the foot. (Lewis, et al, 8 ed., pp. 366-382.)

A client has been receiving corticosteroids for the past 5 years for treatment of rheumatoid arthritis. The client is now being admitted for a major surgical procedure. What would be important for the nurse to assess after the client returns from surgery? a) Development of a moon face, increased weight, and purple abdominal striations b) Continued orders for corticosteroids at or above level the client was receiving before surgery c) Discontinuation of the corticosteroids until after the incisional area has adequately healed d) Increasing problems with mobility secondary to withdrawal from the corticosteroids

b) Continued orders for corticosteroids at or above level the client was receiving before surgery Once a client has been on long-term corticosteroids, the body cannot adequately respond to stress. The client will continue to need the corticosteroids at the same level or frequently an increased level during the immediate postoperative period; hence the reason for ensuring the proper postoperative orders are in place. Potential difficulty with incisional healing should be monitored; however, this is not a reason to discontinue the steroids. The Cushingoid symptoms would already be present before the surgery. (Lehne, 7 ed., pp. 854-855.)

A postoperative patient says it hurts too much to deep breathe and cough every 2 hours and refuses to carry out the activity. What is the best initial nursing action? a) Respect the client's request and begin turning more frequently; plan to ambulate as soon as possible. b) Discuss with him how coughing and deep breathing will decrease the risk of respiratory complications. c) Advise the doctor about the problem and ask him to emphasize to the client the need to cough and deep breathe. d) Document on the chart the clients' refusal to participate in requested postoperative procedures.

b) Discuss with him how coughing and deep breathing will decrease the risk of respiratory complications. If a client understands why a treatment or procedure is important they are more likely to be compliant. Coughing and deep breathing are critical postoperatively and should not be ignored or referred to the doctor for follow-up. It would be appropriate for the nurse to encourage the coughing after the client has received a pain medication. The nurse should document the client's refusal, in addition to what actions were taken to educate the client and increase his participation and compliance with postoperative care. (Potter, Perry, 7 ed., pp. 1397-1404.)

The nurse is assessing a client's incision on the second postoperative day. There is warmth, tenderness, and inflammation present. The wound is well approximated with no drainage. What is the best nursing action? a) Irrigate the wound with cool normal saline. b) Document the status of the wound. c) Place warm packs on the incision to relieve the discomfort. d) Notify the surgeon and anticipate order for wound cultures.

b) Document the status of the wound. Inflammation, warmth, and tenderness are signs of normal wound healing. The nurse should document the appearance of the wound. Irrigation and warm packs are not appropriate for a clean healing wound. There is no need to notify the surgeon or for wound cultures to be obtained. (Potter, Perry, 7 ed., p. 1405.)

To prevent complications of immobility, what would be the most effective activities to implement for a client on the first postoperative day after a colon resection? a) Turn, cough, and deep-breathe every 30 minutes around the clock. b) Get the client out of bed and ambulate to a bedside chair. c) Provide passive range of motion three times a day. d) Immobility is not a concern on the first postoperative day.

b) Get the client out of bed and ambulate to a bedside chair. Weight bearing increases the vascular tone and decreases venous stasis, thereby preventing thrombi from developing; the increase in activity increases respiratory expansion and quality of breathing. Passive range of motion maintains joint mobility but is not as effective as weight bearing to prevent venous stasis and the complications of immobility. Turning and coughing every 30 minutes around the clock is too often—it would disrupt effective rest and sleep. Every 2 hours is the standard. Prevention of complications of immobility begins when the client becomes immobilized. (Potter, Perry, 7 ed., pp. 1225-1229, 1246-1261.)

The nurse understands the following about the correct administration of insulin lispro: a) It needs to be taken after the meals. b) It should be taken within 15 minutes of beginning a meal. c) It is to be taken once daily at the noon meal. d) It is taken only in the evenings with a snack before bedtime.

b) It should be taken within 15 minutes of beginning a meal. Rapid-acting insulins, such as insulin lispro (Humalog) and insulin aspart (Novolog), are able to more closely mimic the body's natural rapid insulin output after consumption of a meal, which is why both medications usually are administered within 15 minutes of beginning a meal. (Lehne, 7 ed., p. 665.)

While discussing a client's scheduled surgery, the nurse notices the client wringing her hands, moving around in her seat, and breathing rapidly. The nurse does a physical assessment and finds a rapid pulse of 128 beats/min with moist, clammy skin. The client states, "I'm so nervous." Which PRN order should the nurse consider administering to the client? a) Promethazine hydrochloride (Phenergan) 25 mg b) Lorazepam (Ativan) 0.5 to 1 mg c) Naproxen (Aleve) 275 mg d) Cefadroxil (Duricef) 500 mg

b) Lorazepam (Ativan) 0.5 to 1 mg Lorazepam (Ativan) is used for symptoms of moderate to severe anxiety: rapid pulse, diaphoresis, tightness in the chest, and inability to see connections between details. Moderate anxiety also involves tightness in the neck muscles, headaches, and inability to concentrate. Mild anxiety often occurs as a result of day-to-day stresses and is characterized by increased alertness, motivation, and attentiveness. Promethazine hydrochloride (Phenergan) is used to manage nausea. Naproxen (Aleve) is an NSAID and is commonly used for pain. Cefadroxil (Duricef) is a cephalosporin antibiotic. (Lewis, et al, 8 ed., pp. 344-347.)

The nurse is caring for a client in diabetic ketoacidosis. An order exists for insulin to be added to the current infusing IV. What type of insulin will the nurse use? a) Insulin detemir (Levemir). b) Regular insulin (Humulin R) c) NPH insulin (Novolin N) d) Insulin glargine (Lantus)

b) Regular insulin (Humulin R) Regular insulin and the rapid acting insulins (i.e., insulin lispro [Humalog], insulin aspart [Novolog], insulin glulisine [Apidra]) are the only forms of insulin recommended for IV use. The rapid acting and slower acting insulins are clear. All the other insulins are for subcutaneous injection or are cloudy. (Lehne, 7 ed., pp. 667; 669.)

Which of the following decreases the incidence of health care-associated infections (HAIs), also called nosocomial infections? a) Wearing of artificial fingernails by nurses b) Removing invasive devices as soon as possible c) Using broad-spectrum antibiotics as much as possible d) Reserving antibiotics for only life-threatening infections

b) Removing invasive devices as soon as possible Catheters and other invasive devices are some of the leading exogenous causes of HAIs and should be discontinued as soon as they are no longer needed. First-line antibiotics are preferred for treating infection because of greater efficacy, lower toxicity, and a narrow spectrum. Evidence-based research has indicated that artificial fingernails are more likely to harbor pathogens, especially gram-negative bacilli and yeast. Furthermore, the longer the artificial nails are worn, the more likely it is that a pathogen will be isolated. This would increase the risk and incidence of HAIs (nosocomial infections). (Potter, Perry, 7 ed., p. 648.)

Glipizide (Glucotrol) 10 mg bid PO has been ordered for an adult client with type 2 diabetes. The nurse would explain to the client that the medication reduces the blood sugar level by what process? a) Delays the cellular uptake of potassium and insulin b) Stimulates insulin release from the pancreas c) Decreases the body's need for and utilization of insulin at the cellular level d) Interferes with the absorption and metabolism of fats and carbohydrates

b) Stimulates insulin release from the pancreas The sulfonylureas reduce the blood glucose level by stimulating insulin release from the pancreas. Over a long period of time, sulfonylureas may actually increase insulin effects at the cellular level and decrease glucose production by the liver. This is the reason that sulfonylureas are prescribed for clients with type 2 diabetes who still have a functioning pancreas. (Lehne, 7 ed., pp. 675-676.)

The nurse is preparing the preoperative client for surgery. Which of the following statements indicate to the nurse that the client is knowledgeable about his impending surgery? Select all that apply. a) "After surgery, I will need to wear the pneumatic compression device while sitting in the chair." b) "The skin prep area is going to be longer and wider than the anticipated incision." c) "I cannot have anything to drink or eat after midnight on the night before the surgery." d) "To ensure my safety, a time-out for identification will be conducted in the operating room before surgery." e) "I will be given the consent form, and I will sign it after I get to the operating room."

b, c, d Having the skin prep area being longer and wider than the actual incision, maintaining NPO status after midnight, and performing the time-out identification indicate a correct understanding of the preoperative teaching. The pneumatic compression device is worn during bed rest and is removed when the client is out of bed or ambulating. The informed consent document should be signed before preoperative medication administration and before the client enters the operating room. Part of safety standards is to initiate a time-out in the operating room before the surgery is started. (Lewis, Dirksen, Heitkemper, et al, 8 ed., pp. 341-343.)

The nurse is admitting an 18-month-old infant with diarrhea, productive (sputum clear) cough, and a skin rash on the face. What would be important for the nurse to do on admission of this infant? Select all that apply. a) Determine from the parent if infant has had chickenpox. b) Place in a private room and initiate contact isolation. c) Obtain a culture and sensitivity of the sputum. d) Encourage increased intake of fluids. e) Obtain accurate weight. f) Encourage a parent to stay with the child.

b, d, e, f Diarrhea is the contagious element in this child; contact precautions should be initiated, and the child should be placed in a private room. Contact precautions would be used until stool cultures have been tested to rule out or to confirm the presence of a contagious condition. The child should have increased fluids. The skin rash is not characteristic of chickenpox. Developmentally, this is an age of separation anxiety, and the child will remain calmer if a parent stays. It is important to obtain an initial weight to monitor fluid balance. The productive cough is not a sufficient indicator to warrant a sputum culture. (Hockenberry, Wilson, 8 ed., pp. 677-678, 707, 822-823.)

The preoperative teaching plan for a client scheduled for a right lower lobe (RLL) lobectomy includes deep breathing and coughing. What should the nurse teach the client regarding coughing and deep breathing? a) "Coughing up large amounts of mucus indicates an effective cough." b) "Practice deep breathing and coughing from a supine position." c) "Take a deep breath, exhale through your mouth, and cough." d) "Take several short breaths, hold the last breath, and cough."

c) "Take a deep breath, exhale through your mouth, and cough." Preferably in the sitting position, the client will take a deep breath, exhale through the mouth, and cough from deep in the lungs. An incentive spirometry device helps the client measure the level of his deep breathing, but it is important for him to cough as well. Coughing promotes lung expansion and does not have to be productive. (Potter, Perry, 7 ed., pp. 1378-89.)

A client with type 1 diabetes calls the nurse because of nausea and not feeling well. What would be important for the nurse to tell the client? a) "Hold the oral hypoglycemics until he can begin eating again." b) "Take the insulin as scheduled, increase water intake, and continue to monitor the blood glucose." c) "Take his regular dose of insulin, replace food with fruit juices, and monitor his blood glucose." d) "Do not take any insulin as long as he is nauseous and cannot maintain intake."

c) "Take his regular dose of insulin, replace food with fruit juices, and monitor his blood glucose." This client is on insulin for his diabetic control. He should continue taking the regularly scheduled dose of insulin and eating the prescribed diet, as well as increasing the amount of low-calorie fluids (e.g., broth, water, decaffeinated tea). If the client is unable to consume solid foods or keep food down, then he can increase his caloric intake by drinking carbohydrate fluids (e.g., juices and soups). It is important for the client to check his blood glucose levels every 4 hours. Additionally, for the type 1 diabetic client with blood glucose levels greater than 240 mg/dL, urine testing for ketones every 3 to 4 hours is required, and findings should be reported to the healthcare provider. The blood sugar may continue to rise because of the illness, which is why it is important to continue medication. (Lewis, et al, 8 ed., p. 1236-1238.)

A client with an acute exacerbation of ulcerative colitis has type 2 diabetes that is controlled with diet and metformin (Glucophage). The health care provider orders prednisone to reduce inflammation in the colon. What would the nurse anticipate as part of the client's plan of care? a) Increase in fiber and calories in daily diet b) Increase in adverse side effects caused by the combination drug therapy c) Add insulin therapy while on prednisone d) More frequent monitoring of glycosolated hemoglobin levels

c) Add insulin therapy while on prednisone The addition of insulin to the client's diabetic medication regime would be required because of prednisone, which in high doses increases the blood sugar. More frequent monitoring of glycosolated hemoglobin is unnecessary, but rather more frequent glucose monitoring while on the insulin. Taking the two medications together should not increase the likelihood of adverse effects. Prednisone will increase the appetite, so calories and fluids should be monitored to avoid weight gain and fluid retention. (Lewis, et al, 8 ed., p. 1222.)

A 3-year-old child is admitted into day surgery for repair of an inguinal hernia. The child begins to cry when the nurse takes her favorite blanket from her before transferring from her room to the operating room. What is the best nursing action? a) Explain to the child the blanket will be waiting for her after surgery. b) Have the mother hold the child and tell her she cannot take her blanket to surgery. c) Allow the child to take the blanket until she receives the medication for anesthesia. d) Explain to the mother why the child cannot take the blanket into surgery.

c) Allow the child to take the blanket until she receives the medication for anesthesia. Allow the child to take the blanket. The blanket can be removed when the child receives the pre-anesthesia medications, and it will be less traumatic. Do not involve the mother in trying to explain information that the child cannot understand. (Hockenberry, Wilson, 9 ed., pp. 1005-1008.)

A patient is prescribed levothyroxine (Synthroid) daily. What is the most important instruction to teach for administration of this drug? a) Taper the dose and discontinue if mental and emotional problems stabilize. b) Take it at bedtime to avoid the side effects of nausea and flatus. c) Call the doctor immediately at the onset of palpitations or nervousness. d) Decrease the intake of juices and fruits with high potassium and calcium contents.

c) Call the doctor immediately at the onset of palpitations or nervousness. Levothyroxine (Synthroid) increases the metabolic rate of body tissues. Some serious side effects include cardiovascular collapse, dysrhythmias, and tachycardia. Because of these side effects, clients should be instructed not to take the medication if their pulse is greater than 100 beats/min and to notify their provider of headaches, nervousness, chest pain, palpitations, or any unusual symptoms. (Lehne, 7 ed., pp. 693-694.)

The nurse is monitoring a client who is receiving bedside conscious sedation with midazolam hydrochloride (Versed) during a colonoscopy. The nursing assessment reveals the client has nystagmus, slurred speech, and responds slowly to verbal commands. What is the best nursing action? a) Assess the adequacy of the airway. b) Administer naloxone (Narcan) to reverse sedation. c) Continue to monitor the client. d) Obtain an arterial blood gas to determine acid-base balance.

c) Continue to monitor the client. There is no indication of problems or complications, so continuing to monitor the client is appropriate. Slurred speech and nystagmus are normal occurrences as the client is coming out of conscious sedation. Naloxone (Narcan) is not indicated for benzodiazepine reversal; it reverses the effects of the opioids. There is no indication of respiratory difficulty or of acid-base imbalance. (Lehne, 7 ed., pp. 258-260.)

A child is receiving propylthiouracil (PTU) for treatment of hyperthyroidism. The parents and child should be taught to recognize and report immediately which of the following symptoms? a) Ear pain b) Headache c) Fever, sore throat d) Gastrointestinal infection

c) Fever, sore throat Sore threat and fever are the earliest indications of agranulocytosis, which is the most serious toxic effect of the medication. Because agranulocytosis may develop rapidly, periodic blood cell counts cannot guarantee early detection. Parents must be alert for any signs of infection, such as fever or sore throat, so that they can be promptly evaluated by a health care practitioner. Ear pain is not a sign of primary infection, but children with signs of upper respiratory tract infection and coughing would also require monitoring. (Lehne, 7 ed., p. 698.)

A postoperative patient receives a dinner tray with gelatin, pudding, and vanilla ice cream. Based on the foods on the client's tray, what would the nurse anticipate the client's current diet order to be? a) Bland diet b) Soft diet c) Full liquid diet d) Regular diet

c) Full liquid diet A full liquid diet includes liquids, as well as foods that are liquid at room temperature, such as ice cream, custards, puddings, and some refined cereals. A bland diet consists of foods that are soft, not very spicy, and low in fiber. A soft diet or low residue includes foods that are low fiber and easily digested, such as pastas, casseroles, canned fruits, and vegetables. A regular diet has no restrictions. (Potter, Perry, 7 ed., pp. 981-984.)

Which nursing action would be most likely to contribute to the development of health care-associated infection (HAIs) in a client? a) Cleansing hands with an antiseptic gel when leaving the client's room b) Providing the client with a plastic bag for disposal of tissues from coughing c) Having the client hold his urinary catheter bag in his lap when transferring him to a wheelchair d) Preparing the skin with an alcohol solution before administering an injection

c) Having the client hold his urinary catheter bag in his lap when transferring him to a wheelchair The urinary bag should always remain below the level of the client to prevent urine from draining back into the bladder. The draining back of urine into the bladder can cause a urinary tract infection, which would be a health care-associated infection (HAI) or nosocomial infection. Cleansing hands with antiseptic gel and preparing the skin with alcohol before injection are appropriate measures. The plastic bag is nonpermeable so that oral secretions would not leak through the bag to contaminate the area. (Potter, Perry, 7 ed., p. 1164.)

A client returns from surgery. Which data obtained during assessment would indicate the client is experiencing severe pain? a) Decreased heart rate, decreased blood pressure, decreased respirations b) Increased heart rate, decreased blood pressure, decreased respirations c) Increased heart rate, increased blood pressure, increased respirations d) Decreased heart rate, decreased blood pressure, increased respirations

c) Increased heart rate, increased blood pressure, increased respirations When a client is experiencing severe pain, all body functions are increased, as the sympathetic response in this instance is stimulated: increased heart rate, blood pressure, and respiratory rate. (Lewis, et al, 8 ed., pp. 374-375.)

The physician orders hydrocortisone daily for a client with Addison disease. The nurse explains to the client that the dosage may need to be adjusted because of which concern? a) Increased food intake b) An increase in blood glucose levels c) Increased stress levels d) Stomach discomfort

c) Increased stress levels Stress levels in the body will cause utilization of increased amounts of cortisol. With the lack of steroids caused by adrenal insufficiency associated with Addison disease, it would be important to maintain the level of cortisone in the body to keep the body functioning appropriately. (Lewis, et al, 8 ed., p. 1281.)

The nurse is caring for a client with postoperative repair of an aortic aneurysm. What is a nursing concern regarding a postoperative internal hemorrhage? a) Hypervolemia may occur when the sequestered blood returns to the vascular system. b) Signs of shock are more severe because the bleeding is arterial. c) Initial symptoms may be masked by the size of abdominal cavity and surgical pain. d) Signs of shock do not appear until permanent damage has occurred.

c) Initial symptoms may be masked by the size of abdominal cavity and surgical pain. Because the bleeding is internal, it is harder to detect, and consequently, the client can lose a lot of blood before the condition is identified. The accumulation of blood within a confined area can put pressure on vital organs. For example, 750 mL will occupy enough space in a limb to cause swelling and pain. With bleeding into the peritoneal cavity; however, the blood will usually spread throughout the cavity, causing little, if any, initial discomfort. (Lewis, et al, 8 ed., pp. 367-372, 869-870.)

It is important for the nurse to teach the client which of the following about metformin (Glucophage)? a) It may cause constipation. b) It should be taken at night. c) It should be taken with meals. d) It may increase the effects of aspirin.

c) It should be taken with meals. Metformin (Glucophage) is administered with meals to minimize gastrointestinal effects. These adverse effects are abdominal bloating, diarrhea, nausea, vomiting, and an unpleasant metallic taste. Metformin interacts with alcohol and cimetidine and is contraindicated in heart failure and liver disease and in clients with compromised renal function. (Lehne, 7 ed., pp. 674-675.)

A woman who is positive for the human immunodeficiency virus (HIV) gives birth in an uncomplicated delivery. The infant is admitted to the newborn nursery, where the nurse implements standard precautions. The next most important nursing activity would be to: a) Notify the laboratory for a stat enzyme immunoassay (EIA) test. b) Place the infant in protective isolation until status is determined. c) Maintain body temperature and assess vital signs. d) Place the infant under the bilirubin light to decrease red blood cell destruction.

c) Maintain body temperature and assess vital signs. After standard precautions have been initiated, the infant should be cared for as any other infant. The amniotic fluid is a source of contamination and the nurse should wear gloves until the infant is bathed and the fluid removed. No indication exists for a stat EIA or protective isolation. No indication exists that the infant does has a high bilirubin level; therefore a bilirubin light is not necessary. No special precautions are necessary if no transfer of body fluids occurs. (Hockenberry, Wilson, 8 ed., pp. 198-199, 305.)

A client with acquired immunodeficiency syndrome (AIDS) is admitted to the hospital for treatment of Pneumocystis jiroveci (formerly carinii) pneumonia. The nurse understands this is an opportunistic infection; therefore it will be important for the nurse to: a) Place the client in respiratory isolation to protect other clients. b) Maintain the client in protective isolation until the pneumonia resolves. c) Maintain good pulmonary hygiene and adequate hydration. d) Collect morning sputum specimens for analysis of bacteria.

c) Maintain good pulmonary hygiene and adequate hydration. An opportunistic infection is not a threat to people with a normal, healthy immune system, so isolation is not needed at this point. However, dyspnea and hypoxia are a problem. Good pulmonary hygiene is essential. The sputum does not need to be collected; this is commonly done in diagnosis of tuberculosis. (Lewis, et al, 8 ed., p. 254.)

An older adult client has a nursing diagnosis of risk for infection. What nursing intervention should be implemented to prevent an infection in caring for an older adult client, who has overflow urinary incontinence? a) Insert a urinary retention catheter. b) Initiate droplet-based precautions. c) Maintain standard precautions. d) Take the client to the bathroom every 2 hours.

c) Maintain standard precautions. Standard precautions require hand hygiene between clients, which is the most effective method to decrease infections in clients at high risk. Initiating droplet-based precautions is not appropriate unless the client has an infection. Inserting a urinary retention catheter will increase the risk of infection. Taking the client to the bathroom every 2 hours does not reduce the risk of infection, it only addresses incontinence. (Potter, Perry, 7 ed., pp. 649-651.)

In the recovery room, the postoperative client suddenly becomes restless with circumoral cyanosis. What is the first nursing action? a) Begin administration of oxygen through a nasal cannula. b) Call for assistance. c) Reposition the head and determine patency of airway. d) Insert an oral airway and suction the nasopharynx.

c) Reposition the head and determine patency of airway. It is important to determine whether the airway is patent and whether the client is breathing. If a significant amount of mucus and gurgling are noted in the upper airway, the client should be suctioned. Insertion of an oral airway may be necessary to maintain an open airway, but the airway must be assessed before determining a course of action. Inserting an airway will not solve the problem if the client is not breathing. (Lewis, Dirksen, Heitkemper et al, 8 ed., pp. 366-368.)

The nurse is teaching the parents of a child who is experiencing difficulty with control of his diabetes. Which of the following agents should the nurse teach the parents to administer if their child loses consciousness and has a severe hypoglycemic reaction? a) IV dextrose b) Subcutaneous insulin c) Subcutaneous glucagon d) Oral fast-acting carbohydrate

c) Subcutaneous glucagon If the child has a severe hypoglycemic episode, he frequently is neurologically compromised. It is important to administer subcutaneous or intramuscular glucagon. Subcutaneous insulin would further worsen the child's condition. IV dextrose would be given in the hospital. Oral administration of fast-acting carbohydrates is reserved for the conscious child who is not having a severe hypoglycemic reaction. (Lehne, 7 ed., p. 672.)

An adult with a diagnosis of hypothyroidism has been prescribed thyroid replacement therapy with levothyroxine (Synthroid). After 1 week, she calls to complain that she feels no better. The nurse's response should be based on the fact that: a) The client may require a different preparation of the medication b) The client did not take her medication as instructed c) Synthroid does not reach peak effect for at least a month d) The client's diet may be causing absorption problems

c) Synthroid does not reach peak effect for at least a month Clients should understand that it takes at least a month for thyroid replacement medication to cause plasma levels to reach a plateau and have therapeutic effects. This is because the hormone, levothyroxine, has a half-life of approximately 7 days. Because of the long half-life of the hormone, levels remain steady between doses, which makes this medication well suited for lifelong therapy with once-a-day dosing. (Lehne, 7 ed., p. 693.)

The nurse is teaching a client about taking a thyroid replacement hormone. Which should be included as symptoms to watch for associated with overdose? a) Dry skin, tremors, and weight gain b) Sneezing, coughing, and insomnia c) Tachycardia, angina, and nervousness d) Bradycardia, somnolence, and sweating

c) Tachycardia, angina, and nervousness The client should be taught signs of thyroid hormone overdose, which are tachycardia, chest pain, nervousness, insomnia, diaphoresis, tremor, and weight loss. If the dosage is especially large, then a thyrotoxic crisis may occur. (Lewis, et al, 8 ed., p. 1265.)

Which conditions would the nurse identify as requiring hand hygiene with soap and water? Select all that apply. a) After removal of gloves when an IV b) Before putting on gloves for insertion of a urinary catheter c) After accidentally contaminating hands with wound drainage d) After leaving one client's room and before going to another client's room e) After contaminating hands with drops of blood while starting an IV f) After a client unexpectedly vomited on the nurse's hands

c, e, f Soap and water (versus alcohol gel) should be used when the hands have been visibly contaminated with body fluids. Between clients and before and after using gloves, the nurse can use the antiseptic hand hygiene. (Potter, Perry, 7 ed., pp. 655-658.)

The nurse understands that which two cells in the immune system release histamine in an allergic reaction? a) Neutrophils and mast cells b) Monocytes and basophils c) Eosinophils and mast cells d) Basophils and tissue mast cells

d) Basophils and tissue mast cells Basophils and tissue mast cells secrete histamine and cause allergic reactions as severe as anaphylaxis. Neutrophils are granulocytes that respond to tissue injury and begin to engulf the bacteria and damaged cells. Eosinophils are released during an anaphylactic reaction to control the effects of the histamine released. Monocytes are similar to neutrophils and assist to remove the inflammatory debris to promote healing. (Lewis, et al, 8 ed., p. 219.)

When caring for a client in a thyroid crisis, the nurse would question an order for: a) IV fluids b) Propranolol (Inderal) c) Propylthiouracil (PTU) d) A hyperthermia blanket

d) A hyperthermia blanket Fever (hyperthermia) is a symptom of thyroid storm. The correct treatment would be a hypothermia blanket to cool the client. All other choices (IV fluids, Inderal, and PTU) are appropriate interventions for this diagnosis. (Lewis, Dirksen, Heitkemper, et al, 8 ed., pp. 1265-1266.)

The nurse is assisting an older adult client to get out of bed for the first time after surgery. What type of chair should the nurse have available? a) A soft chair with a low seat b) A rocking chair with a broad seat c) A straight chair with a high back d) An armchair with a firm, secure cushion

d) An armchair with a firm, secure cushion For the client to control his movements, he needs the arms on the armchair for support. This will provide some support getting in and out of the chair and will provide him with increased security while in the chair. The firm cushion provides support and makes it easier to get out of the chair. (Potter, Perry, 7 ed., pp. 793-794.)

A client is scheduled for major surgery. What is most important for the nurse to do before surgery? a) Remove all jewelry or tape wedding rings. b) Verify that all laboratory work is complete. c) Inform family or next of kin of recovery procedure. d) Check that consent forms are signed.

d) Check that consent forms are signed. Consent forms must be signed by the client, family, or guardian with medical power of attorney before any procedure can be done. Consent forms also must be signed before the client receives any narcotics or medications that would affect his reasoning. These medications are frequently in the preoperative medications ordered. (Lewis, Dirksen, Heitkemper, et al, 8 ed., pp. 344-346.)

The nurse is monitoring the fluid replacement during treatment of a client in an adrenal crisis. The nurse would question which of the following IV orders? a) D5 0.45% NS b) Isotonic saline solution c) Hydrocortisone d) D5W

d) D5W A client in adrenal, or Addisonian, crisis has hyponatremia. It would be inappropriate to administer a sodium-free IV solution such as D5W. Isotonic saline solution (normal saline), half strength (0.45%) saline with dextrose, and hydrocortisone are used in the treatment of adrenal crisis (Addisonian crisis). (Lehne, 7 ed., p. 713.)

A client is 1 day postoperative extensive abdominal surgery. He complains of abdominal pain at an 8 on a 10-point scale. He has a shallow cough and moves very little. The nurse observes he has not used his PCA. The client states he doesn't want to take narcotics because "I don't need it. I might get addicted." What would be the best nursing approach to this problem? a) Explain to the client that many pain medications exist and if one is addictive, then another one can be used. b) The nurse can leave him alone since he will ask for medication when he cannot tolerate the pain. c) Explain to him that in the hospital he should not be concerned with a problem of addiction. d) Discuss the adverse effects of pain and the importance of pain control to facilitate mobility as well as coughing and deep breathing.

d) Discuss the adverse effects of pain and the importance of pain control to facilitate mobility as well as coughing and deep breathing. The client's decreased mobility and poor coughing put him at increased risk for respiratory complications. Based on the client's statement, he does not understand the importance of management of postoperative pain. The statement to the nurse indicates a lack of understanding regarding the importance of postoperative pain management. The client does indicate a concern regarding addiction; however, the response that he should not be concerned is not sufficient to provide any reassurance. The client needs to understand the physical effects of pain and problem that occur with immobility. (Lewis, et al, 8 ed., pp. 375, 146.)

The nurse is reviewing the health care provider's orders for a postoperative client. The client has just returned from surgery for aortic aneurysm repair. He is NPO, he has a nasogastric tube, and vital signs indicate a pulse rate of 110, respirations 20, and BP 112/78. Which order would the nurse question? a) Determine adequacy of breath sounds bilaterally. b) Position the client in semi-Fowler's position and offer liquids. c) Increase fluid intake to made coughing more effective. d) Evaluate client for presence of pain.

d) Evaluate client for presence of pain. It is important to determine if the client's pain has caused the tachycardia. There is no indication of a respiratory compromise; the client's respiratory rate is within normal range (12-20 breaths/min). The pulmonary system can be further evaluated after assessing for level of pain and medicating the client. Hypoxia, pain, and anxiety can increase a client's pulse and respiratory rate. Positioning the client in semi-Fowler's and offering fluids does not address the tachycardia. Increasing fluid intake is important for respiratory hygiene but does not alleviate the current tachycardia. (Potter, Perry, 7 ed., pp. 1396-1404.)

A client comes into the clinic bringing her medication bottles and states she has been taking a sulfonylurea anti-diabetic medication and an ACE inhibitor. The nurse would recognize which of the following medications as the medications that client is taking? a) Metformin (Glucophage) and atenolol (Tenorim) b) Pioglitazone (Actos) and pramlintide (Symlin) c) Acarbose (Precose) and lisinopril (Zestril) d) Glyburide (Micronase) and captopril (Capoten)

d) Glyburide (Micronase) and captopril (Capoten) Glyburide (Micronase) and captopril (Capoten) are classified as a sulfonylurea and ACE inhibitor, respectively. Pioglitazone (Actos) is a thiazolidinediones (Glitazones). Metformin (Glucophage) is classified as a biguanide and acarbose (Precose) is an alpha-glucosidase inhibitor. Pramlintide (Symlin) is an amylin mimetic oral hypoglycemia medication. Atenolol (Tenorim) is a beta blocker used as an anti-hypertensive medication. (Lehne, 7 ed., p. 673.)

The nurse is assessing a group of clients who will be having surgery. Which client would be at the highest risk for postoperative complications? The client who: a) Has been taking birth control pills for the past 5 years b) Has had difficulty with constipation for the past 6 months c) Recently completed antibiotic therapy for a streptococcal throat infection d) Has been on a daily aspirin regimen for his arthritis

d) Has been on a daily aspirin regimen for his arthritis Aspirin can pose a problem with coagulation and increase the risk of bleeding. Aspirin regimens for arthritis clients may include a significant high dose of aspirin daily. The health care provider should be informed that the client is taking such drugs. The client who is on birth control pills is more susceptible to the development of an embolus, but it does not increase her surgical risk. The client who has completed antibiotic therapy and the client with problems of constipation do not pose an increased risk for postoperative complications. (Potter, Perry, 7 ed., pp. 1368-1374.)

The nurse is preparing a client for surgery. Which of the following items on the client's presurgery lab results would indicate a need to contact the surgeon? a) Platelet count of 325,000 mm3 b) Total cholesterol of 325 mg/dL c) Blood urea nitrogen (BUN) 17 mg/dL d) Hemoglobin 9.5 g/dL

d) Hemoglobin 9.5 g/dL The hemoglobin level is low, and the nurse needs to make sure the surgeon has the most recent laboratory values before surgery. This client may need a transfusion before surgery. The cholesterol is elevated but is not a concern before surgery. The platelets and the BUN are within normal limits. (Potter, Perry, 7 ed., pp. 1376-1377.)

If a child with growth hormone deficiency is receiving somatropin therapy, the nurse would monitor for what adverse effects? a)Hyperglycemia b) Early closure of the epiphyseal plates c) Hyperthyroidism d) Hypercalciuria

d) Hypercalciuria Common adverse effects from dosing of somatropin growth hormone are hyperglycemia, ketosis, hypothyroidism, hypercalciuria, nausea, and vomiting. Physiologic release is more normally stimulated as a result of pituitary release of growth hormone during the first 45 to 90 minutes after the onset of sleep. (Lehne, 7 ed., p. 705.)

A client receiving insulin asks if the disposable needles and syringes can be used more than once. The nurse's response should be based on what information? Needle reuse: a) Should not be practiced because of increased rate of infection b) Is appropriate once per day c) Is acceptable if the client has limited financial resources d) Is acceptable if there is no needle contamination

d) Is acceptable if there is no needle contamination It is acceptable practice for the client to reuse their disposable needles and syringes. Increases in rates of infection have not been documented in the research, and there is a considerable cost saving. A nurse should stress the importance of vigorous handwashing before handling any equipment, in addition to the importance of capping the syringe immediately after use. The needle should not be used indefinitely. Depending on number of injections, 1 to 3 days would be an acceptable guideline for reusing the needles. (Potter, Perry, 7 ed., p. 749.)

A client is learning to inject his own insulin. Which of the following nursing observations would indicate to the nurse that the client needs further teaching? a) Wipes the top of the insulin vial with alcohol b) Withdraws the prescribed amount of insulin within 0.2 mL c) Refers to the abdominal injection chart and chooses a previously unused site d) Keeps the insulin in the refrigerator and prepares and injects it immediately

d) Keeps the insulin in the refrigerator and prepares and injects it immediately Cold insulin increases the risk of lipodystrophy. All extra unopened bottles may be stored in the refrigerator, but the bottle currently being used should remain at room temperature, and the insulin should be injected at room temperature. Insulin should not be subjected to extreme temperatures, but it is stable at room temperature. (Lehne, 7 ed., p. 670; Lewis, et al, 8 ed., pp. 1226, 1227.)

The nurse is assessing the abdominal incision of a client who had a bowel resection 3 days ago. When the dressing is removed, the nurse observes an area of the incision where it appears stitches have broken, and there is a small loop of bowel protruding from the incision. The best nursing action would be to: a) Irrigate the area with antibacterial solution and reapply the sterile dressing. b) With a gloved finger, gently apply pressure to the bowel loop so that it can slip back inside. c) Pack the incisional area with sterile gauze soaked in an iodine solution. d) Place a sterile dressing soaked in normal saline solution over the incisional area.

d) Place a sterile dressing soaked in normal saline solution over the incisional area. With an evisceration, the nurse should place a sterile normal saline dressing over the bowel loop to keep it moist and then notify the physician. There should be no packing or irrigating of the incisional area, and the nurse should not apply any pressure on the protruding bowel. (Lewis, et al, 8 ed., p. 195.)

A client had a colon resection 3 days ago. She has been tolerating ice chips after having the nasogastric tube and IV removed. In planning the diet for this client, what food/fluid would the nurse give next? a) Iced tea, yogurt, and coffee b) Cherry gelatin, milk, and cream of pea soup c) Oatmeal, sherbet, and apple juice d) Plain gelatin, Popsicles, and apple juice

d) Plain gelatin, Popsicles, and apple juice Clear liquids are usually offered first to the postoperative client. Plain gelatin, Popsicles, and apple juice are clear and contain no residue. The other answers include a cream or milk product that causes residue and are included in the next progressive step of the diet, which is full liquids. (Potter, Perry, 7 ed., pp. 1404-1405.)

A client has been prescribed vasopressin subcutaneous. What would be important to teach the client? a) Watch for excessive bruising. b) Report any pallor changes in skin coloration. c) Notify health care provider if GI upset persists. d) Weigh daily at the same time each day.

d) Weigh daily at the same time each day. Water retention is a side effect of antidiuretic hormone (vasopressin), which could lead to weight gain. The client should monitor his weight to observe for this side effect. Clients experience flushing, not pallor, and should be monitored for clotting issues, not bleeding. GI issues such as flatus and gas are not potential side effects. (Lewis, et al, 8 ed., p. 1261.)

When should the nurse wash hands with soap and water? a) Before preparing medications b) After removing gloves c) Before entering a client's room d) When hands are visibly soiled

d) When hands are visibly soiled Hand hygiene may be performed with an antiseptic cleanser if there is no soiling visible. Thus soap-and-water handwashing would be required only when hands are visibly soiled. (Potter, Perry, 7 ed., p. 655.)

What would be important for the nurse to include in the teaching plan for clients who are taking insulin? a) The client should use only the injection sites that are most accessible. b) During times of illness, clients should increase their insulin dosage by 25%. c) When mixing insulins, the NPH insulin should be drawn up into the syringe first. d) When mixing insulins, regular insulin should be drawn up into the syringe first.

d) When mixing insulins, regular insulin should be drawn up into the syringe first. If mixing insulins, the regular insulin should always be drawn up into the syringe first. Remember: clear to cloudy; regular insulin first, followed by cloudy ones, such as NPH and Ultralente. Clients should always rotate injection sites (preferably in the abdomen) and should notify their physicians if they become ill. (Lehne, 7 ed., pp. 668, 685.)

The nurse understands that the following instruction should be included in a teaching plan for how a client should take pancreatic enzymes: a) At bedtime b) If meals are fatty c) In between meals d) With every meal and snack

d) With every meal and snack Because enzymes need to work with the food and nutrients, they should be taken with every meal and snack. Deficiency of pancreatic enzymes can compromise digestion, especially the digestion of fats. If the client has a bedtime snack, enzymes should be administered. (Lehne, 7 ed., p. 949.)