NUR 320: Exam #3 Review Questions

A client has a platelet count of 49,000/mL (40 × 10 9/L). The nurse should instruct the client to avoid which activity? Ambulation Blowing the nose Visiting with children The semi-Fowler position

Blowing the nose Rationale: Clients with thrombocytopenia are at a greater risk of excessive bleeding in response to minimal trauma. The nurse should instruct the client to avoid blowing the nose, because this activity can increase the risk of bleeding. Ambulation, visiting with children, and the semi-Fowler position are not contraindicated with thrombocytopenia.

The nurse is caring for a client who is admitted to the hospital with early heart failure. Which client statement indicates a clinical manifestation that is related to heart failure? I see spots before my eyes. I am tired at the end of the day. I feel bloated when I eat a large meal. I have trouble breathing when I climb a flight of stairs.

I have trouble breathing when I climb a flight of stairs. Rationale: Dyspnea on exertion occurs with heart failure because of the heart's inability to meet the oxygen needs of the body. Seeing spots before one's eyes, being tired at the end of the day, and feeling bloated are not specific to heart failure.

A client has a tentative diagnosis of Hodgkin disease. How does the nurse expect the diagnosis to be confirmed? Bone scan Lymph node biopsy Computed tomography (CT) scan Radioactive iodine ( 131I) uptake study

Lymph node biopsy Rationale: The diagnosis depends on the identification of characteristic histologic features of an excised lymph node. A bone scan is a diagnostic device to assess bony metastasis of cancers. CT scans identify the extent of the disease in the abdominal and thoracic cavities. A radioactive iodine ( 131I) uptake study is not indicated for Hodgkin disease; it is used for radiotherapy or diagnosis of thyroid diseases.

A client who is to receive external radiation for cancer says to the nurse, "My family and friends say that I will get a radiation burn." Which response by the nurse is best? "Daily application of an emollient will prevent the burn." "A localized skin reaction usually occurs." "It will be no worse than a sunburn." "They may be misinformed."

"A localized skin reaction usually occurs." Rationale: Localized skin reactions can occur with radiation. The word "burn" may increase the client's anxiety and should be avoided. Emollients are contraindicated; they may alter the calculated x-ray route and cause injury to healthy tissue. Some skin reactions can be quite severe. The response "They may be misinformed" does not answer the client's concern.

A client presents with bilateral leg pain and cramping in the lower extremities. The client has a history of cardiovascular disease, diabetes, and varicose veins. To guide the assessment of the pain and cramping, the nurse should include which question when completing the initial assessment? "Does walking for long periods of time increase your pain?" "Does standing without moving decrease your pain?" "Have you had your potassium level checked recently?" "Have you had any broken bones in your lower extremities?"

"Does walking for long periods of time increase your pain?" Rationale: Clients with a medical history of heart disease, hypertension, phlebitis, diabetes, or varicose veins often develop vascular-related complications. The nurse should recognize that the relationship of symptoms to exercise will clarify whether the presenting problem is vascular or musculoskeletal. Pain caused by a vascular condition tends to increase with activity. Musculoskeletal pain is not usually relieved when exercise ends. Low potassium levels can cause cramping in the lower extremities; however, given the client's health history, vascular insufficiency should be suspected. Previously healed broken bones do not cause cramping and pain.

A 5-year-old-child is undergoing chemotherapy. The mother tells the nurse that the child is not up to date on the required immunizations for school. What is the best response by the nurse? "By this time your child has developed sufficient antibodies to provide immunity." "Maintaining current immunizations is critical. Make sure the series is completed." "This isn't the best time to finish the immunizations, because your child's immune system is suppressed." "It's important to complete the immunizations because your child needs to be protected from childhood diseases that could be fatal."

"This isn't the best time to finish the immunizations, because your child's immune system is suppressed." Rationale: Chemotherapy compromises the immune system. The vaccines may be administered after the completion of the chemotherapy protocol, once the immune system has returned to its previous state. The child has not developed sufficient antibodies; booster immunizations are needed, but not at this time. Administering immunizations at this time could prove fatal.

A nurse identifies 12 mm of induration at the site of a Mantoux test when a client returns to the health office to have it read. Which explanation of this result should the nurse give to the client? Result is negative, and follow-up is not needed. The disease is active, and medication is required. Additional tests are needed, such as a chest x-ray. Outcome is inconclusive, and the test will be repeated in six weeks.

Additional tests are needed, such as a chest x-ray. Rationale: Induration of 10 mm or more is a positive result indicative of being infected with Mycobacterium tuberculosis organism; additional tests, including chest x-ray and sputum cultures, are now warranted to identify whether active disease is present. Test result is positive, not negative; further testing is necessary. A positive test indicates only exposure to and possible infection with tuberculosis. Waiting to do further testing is unsafe.

An adolescent with leukemia is to be given a chemotherapeutic agent that is known to cause nausea and vomiting. When is the best time for the nurse to administer the prescribed antiemetic? Before each dose of chemotherapy As nausea occurs 1 hour before meals Just before each meal is eaten

Before each dose of chemotherapy Rationale: The purpose of an antiemetic before chemotherapy is to prevent the child from experiencing nausea during and after the administration of the medication. Waiting until nausea has occurred is too late; the medication should be given before nausea occurs. The meals are not causing the nausea; the nausea is caused by the chemotherapy, and if nausea is not prevented, the child will not eat.

A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD). What complications are associated most commonly with COPD? Cardiac problems Joint inflammation Kidney dysfunction Peripheral neuropathy

Cardiac problems Rationale: COPD causes increased pressure in the pulmonary circulation. The right side of the heart hypertrophies (cor pulmonale)[1][2], causing right ventricular heart failure. The skeletal system is not directly related to the pulmonary system; joint inflammation does not occur because of COPD. Kidney dysfunction is not as closely related to the pulmonary system as is the cardiac system; kidney problems usually do not occur because of COPD. Peripheral nerves are not as closely related to the pulmonary system as to the cardiac system; peripheral neuropathy does not occur because of COPD.

Which cytokine medication is administered to treat chemotherapy-induced neutropenia? Filgrastim Oprelvekin Aldesleukin Darbepoetin alfa

Filgrastim Rationale: Colony-stimulating factors such as filgrastim are administered to treat chemotherapy-induced neutropenia. Oprelvekin is used to prevent thrombocytopenia. Aldesleukin is used to treat metastatic renal cell carcinoma. Darbepoetin alfa is administered to treat anemia related to chronic cancer and anemia related to chronic kidney disease.

A nurse administers oxygen at 2 L/min via nasal cannula to a client with emphysema. Which clinical indicators should the nurse closely observe in the client? Select all that apply. Anxiety Oxygenation Drowsiness Mental confusion Increased respirations

Oxygenation Drowsiness Mental confusion Rationale: Clients with chronic obstructive pulmonary disease (COPD) respond to the chemical stimulus of low oxygen levels. Administration of high concentrations of oxygen will decrease the stimulus to breathe, leading to decreased respirations, lethargy, and drowsiness. Oxygenation should be monitored to keep levels within a range to provide adequate oxygen without decreasing the client's drive to breathe. Clients with COPD experience the Haldane effect; as hemoglobin molecules become more saturated with oxygen, they are unable to transport carbon dioxide out of the body, leading to hypercapnia. Increased levels of carbon dioxide depress the central nervous system, causing mental confusion and a lowered level of consciousness. Rising carbon dioxide levels cause lethargy rather than anxiety.

A young child from a developing country is admitted to the pediatric unit for surgery to correct a congenital heart defect. The mother asks the nurse why her child squats after exertion. The nurse responds, in language that the mother understands, that this position does what? Decreases the number of muscle aches Improves walking capacity and hip mobility Reduces how hard the heart must work Helps more blood return to the heart

Reduces how hard the heart must work Rationale: When the child squats, blood pools in the lower extremities because of hip and knee flexion which causes less blood to return to the heart and reduces how hard the heart must work (cardiac workload). For this young child, squatting after exertion does not reduce muscle aches, it is unrelated to walking capacity and hip mobility, and it decreases (not increases) blood return to the heart.

The nurse is caring for a client with a platelet count of 50,000 cells per microliter. Which recommendation is inappropriate for the client? Walking with sturdy shoes Do not blow nose forcefully Using a soft-bristle toothbrush Shaving with a straight blade razor

Shaving with a straight blade razor Rationale: A client with platelet count of 50,000 cells per microliter has thrombocytopenia. The client should be encouraged to shave with an electric razor, rather than with a straight blade. Walking with sturdy shoes or slippers preserves foot skin tissue and helps to reduce the chances of cuts. Forceful blowing of the nose can result in bleeding. The use of a soft-bristle toothbrush helps to prevent injury to the gums.

A nurse is teaching a client with a diagnosis of pulmonary tuberculosis about recovery after discharge. What is the most important intervention for the nurse to include in this plan? Ensuring sufficient rest Changing lifestyle routines Breathing clean outdoor air Taking medications as prescribed

Taking medications as prescribed Rationale: Tubercle bacilli are particularly resistant to treatment and can remain dormant for long periods. Drugs must be taken consistently, or more drug-resistant forms may recolonize and flourish. Although a balance between activity and rest is desirable, it is not the priority. A change in lifestyle is not necessary. Although clean, fresh air is desirable, it is not the priority.

The nurse instructs the client admitted for an acute exacerbation of chronic obstructive pulmonary disease (COPD) about the importance of assessing for right-sided heart failure after discharge. What does the nurse instruct the client to assess for? Increased appetite Clubbing of the nail beds Hypertension Weight gain

Weight gain Rationale: The most common signs and symptoms of right-sided heart failure are hepatomegaly, weight gain, jugular vein distention, and peripheral edema. Clients with right-sided heart failure often have decreased appetites. Clubbing is indicative of hypoxemia. Hypertension is associated with left-sided heart failure.

A nurse is caring for an infant with Down syndrome. What does the nurse recall as the most common serious anomaly associated with this disorder? Renal disease Hepatic defects Congenital heart disease Endocrine gland malfunction

Congenital heart disease Rationale: Many children with Down syndrome have cardiac anomalies, most often ventricular septal defects, which can be life threatening. Renal disease, hepatic defects, and endocrine gland malfunction are not characteristic findings in children with Down syndrome.

When an older client with heart failure is transferred from the emergency department to the medical service, what should the nurse on the unit do first? Interview the client for a health history. Assess the client's heart and lung sounds. Monitor the client's pulse and temperature. Obtain the client's blood specimen for electrolytes.

Assess the client's heart and lung sounds. Rationale: With heart failure, the left ventricle is not functioning effectively, which is evidenced by an increased heart rate and crackles associated with pulmonary edema. The health history interview is done after vital signs and breath sounds are obtained and the client is stabilized. Although an infection would complicate heart failure, there are no signs that indicate this client has an infection. Obtaining the client's blood specimen for electrolytes is inappropriate for immediate monitoring; it should be done after vital signs and clinical assessments have been completed.

A nurse is caring for a client who has developed dysphagia and is unable to swallow. The client is receiving around-the-clock opioid pain medications for cancer pain, and hospice has recently begun caring for the client. What is the best nursing intervention in preparing for the client's discharge? Contact the client's healthcare provider to ask to substitute a liquid form of medications for the pill form. Teach the client and family members to crush the pills and administer them with applesauce. Contact the client's healthcare provider to discuss use of transdermal medications for pain control. Teach the client and family members about addiction that may occur as a result of regular opioid use.

Contact the client's healthcare provider to discuss use of transdermal medications for pain control. Rationale: The client will be discharged home with hospice and therefore there is no chance that dysphagia will be relieved by surgery or will improve by other measures. Considering that the client is approaching death and the client's condition is deteriorating, the transdermal route of administration of the pain medications is less invasive and provides comfort. The liquid form of pain medication or crushing the pills and administering them with applesauce is not possible because the client has dysphagia. The client is approaching the end of life and requires comfort measures; therefore opioid addiction is not a nursing concern for the dying client.

The nurse provides discharge teaching to a client with a history of angina. The nurse instructs the client to call for emergency services immediately if the client's pain exhibits which characteristic? Causes mild perspiration Occurs after moderate exercise Continues after rest and nitroglycerin Precipitates discomfort in the arms and jaw

Continues after rest and nitroglycerin Rationale: When neither rest nor nitroglycerin relieves the pain, the client may be experiencing an acute myocardial infarction. Angina may cause mild diaphoresis; acute myocardial infarction causes profuse diaphoresis, which should be reported. Chest pain after exercise is expected; activity increases cardiac output, which can cause angina. Anginal pain can, and often does, radiate.

A client with bronchial pneumonia is having difficulty maintaining airway clearance because of retained secretions. To decrease the amount of secretions retained, what should the nurse do? Administer continuous oxygen Increase fluid intake to at least 2 L a day Place the client in a high-Fowler position Instruct the client to gargle deep in the throat using warmed normal saline

Increase fluid intake to at least 2 L a day Rationale: Increased fluid intake helps to liquefy respiratory secretions, which promotes expectoration. Oxygen may dry the mucous membranes, which may thicken secretions; oxygen should be administered only when necessary. Placing the client in a high-Fowler position promotes retention of secretions; supine, prone, and Trendelenburg positions promote removal of secretions via gravity. Retained secretions are in the bronchi and trachea; gargling lubricates only the oropharynx.

A nurse is caring for a school-aged child with acute lymphoid leukemia. While examining the child's laboratory results, the nurse notes that the child is neutropenic. What does the nurse recognize as the cause of the neutropenia? Internal bleeding Overwhelming infection Increased immature cell growth Decreased intake of iron-rich nutrients

Increased immature cell growth Rationale: Extensive growth of lymphoblasts suppresses the usual growth of red cells, white cells, and platelets. Internal bleeding does not cause neutropenia. Infection is a risk result, not the cause, of neutropenia. An iron-intake deficit will not result in neutropenia.

What is the nurse primarily attempting to prevent when caring for a client in the initial stages of chronic lymphocytic leukemia (CLL)? Injury Fatigue Infection Cachexia

Infection Rationale: Although lymphocytosis is always present, defects in humoral and cellular immunity increase the risk for infection. Injury becomes an issue later in the disease when thrombocytopenia may develop. Fatigue becomes an issue later in the disease when anemia may develop. Although excessive weight loss is a concern, it does not pose the same threat as infection for clients with CLL.

A client is taking furosemide and digoxin for heart failure. Why does the nurse advise the client to drink a glass of orange juice every day? Maintaining potassium levels Preventing increased sodium levels Limiting the drugs' synergistic effects Correcting the associated dehydration

Maintaining potassium levels Rationale: Orange juice is an excellent source of potassium. Furosemide promotes excretion of potassium, which can result in hypokalemia. Digoxin toxicity can occur in the presence of hypokalemia. Neither drug increases sodium levels. Digoxin does not potentiate the action of furosemide; therefore, the client should not experience dehydration. Orange juice will not prevent an interaction between digoxin and furosemide.

A client is diagnosed with acute lymphoid leukemia and is receiving chemotherapy. The nurse should monitor what thrombocytopenic side effects of chemotherapy? Select all that apply. Nausea Melena Purpura Diarrhea Hematuria

Melena Purpura Hematuria Rationale: Black, tarry feces caused by the action of intestinal secretions on blood are associated with bleeding in the gastrointestinal tract; bleeding is related to a reduced number of thrombocytes, which are part of the coagulation process. Hemorrhages into the skin and mucous membranes (purpura) may occur with reduced numbers of thrombocytes, which are part of the coagulation process. Blood in the urine (hematuria) may occur with a reduced number of thrombocytes, which are part of the coagulation process. Nausea and vomiting are not related to thrombocytopenia; they occur because of the effect of chemotherapy on the rapidly dividing cells of the mucous membranes of the gastrointestinal system. Diarrhea may be a side effect of chemotherapy, but it is not a thrombocytopenic side effect.

The nurse is caring for a client hospitalized with a myocardial infarction. Which analgesic is the drug of choice for this client? Diazepam Meperidine Flurazepam Morphine sulfate

Morphine sulfate Rationale: For myocardial infarction, morphine sulfate is the drug of choice because it relieves pain quickly and reduces anxiety while decreasing cardiac workload. Diazepam is a muscle relaxant that may be used for its sedative effect; it is not effective for the pain of a myocardial infarction. Although meperidine is effective, it is not the drug of choice. Flurazepam is a hypnotic that may be used to reduce fear and restlessness; it is not effective for the pain of a myocardial infarction.

A client with cancer develops pancytopenia during the course of chemotherapy. The client asks the nurse why this has occurred. What explanation will the nurse provide? Steroid hormones have a depressant effect on the spleen and bone marrow. Lymph node activity is depressed by radiation therapy used before chemotherapy. Noncancerous cells also are susceptible to the effects of chemotherapeutic drugs. Dehydration caused by nausea, vomiting, and diarrhea results in hemoconcentration.

Noncancerous cells also are susceptible to the effects of chemotherapeutic drugs. Rationale: Chemotherapy destroys erythrocytes, white blood cells, and platelets indiscriminately along with the neoplastic cells because these are all rapidly dividing cells that are vulnerable to the effects of chemotherapy. Stating that steroid hormones have a depressant effect on the spleen and bone marrow is not a true description of the side effects of steroids. Depressed lymph node activity as a result of radiation therapy used before chemotherapy is not the cause for fewer erythrocytes, white blood cells, and platelets. Although it is true that dehydration caused by nausea, vomiting, and diarrhea results in hemoconcentration, this does not explain pancytopenia.

What are the priority nursing interventions for a client with neutropenia in an emergency department? Select all that apply. Monitor for rashes and pruritus. Prepare an appropriate diet plan. Obtain blood cultures immediately. Teach hygiene measures to be followed. Administer antibiotic STAT as prescribed.

Obtain blood cultures immediately. Administer antibiotic STAT as prescribed. Rationale: Identifying the causative agent for neutropenia is important for starting treatment. Therefore the priority nursing intervention is to obtain blood cultures immediately and administer antibiotic STAT as prescribed to the client. The nurse can monitor for rashes and pruritus after administering the medication. The nurse can prepare a diet plan and teach hygiene measures after stabilizing the client.

A woman is exposed to indomethacin during the third trimester of pregnancy. Which teratogenic effect of the medication is expected in the newborn? Neural tube defects Neonatal hypoglycemia Cleft lip with cleft palate Premature closure of the ductus arteriosus

Premature closure of the ductus arteriosus Rationale: Indomethacin is a nonsteroidal antiinflammatory drug that may cause premature closure of the ductus arteriosus in newborns receiving long-term maternal dosing. Neural tube defects cannot be expected since the medication is taken in the third trimester. Neonatal hypoglycemia is caused only by oral hypoglycemic drugs. Cleft lip with cleft palate is expected by the medications administered within 8 weeks of gestation.

Metoprolol is prescribed for a client. Which condition in the client's electronic medical record will cause the nurse to question the prescription? Hypertension Angina pectoris Sinus bradycardia Myocardial infarction

Sinus bradycardia Rationale: Metoprolol is a beta blocker; it decreases the heart rate and thus is contraindicated with bradycardia. Metoprolol is an antihypertensive agent and is given for hypertension. By reducing cardiac output, metoprolol reduces myocardial oxygen consumption, which helps prevent ischemia from anginal pain and myocardial infarction.

A client with Hodgkin disease is started on chemotherapy. The nurse teaches the client to notify the healthcare provider to seek treatment for which adverse response to chemotherapy? Hair loss Sores in the mouth Moderate diarrhea after treatment Nausea for 6 hours after treatment

Sores in the mouth Rationale: Stomatitis is a common response to chemotherapy and should be brought to the healthcare provider's attention because a swish-and-swallow anesthetic solution can be prescribed to make the client more comfortable. Hair loss is also anticipated with some chemotherapeutic drugs; the effects are temporary and reversible. Moderate diarrhea is expected and is not a cause for concern unless dehydration results. Nausea is expected but should be reported if it lasts more than 24 hours.

A nurse is caring for a client with a diagnosis of right ventricular heart failure. The nurse expects what assessment findings associated with right-sided heart failure? Select all that apply. Dependent edema Swollen hands and fingers Collapsed neck veins Right upper quadrant discomfort Oliguria

Dependent edema Swollen hands and fingers R upper quadrant discomfort Rationale: With right-sided heart failure, signs of systemic congestion occur as the right ventricle fails; key features include dependent edema and swollen hands and fingers. Upper right quadrant discomfort is expected with right ventricular failure because venous congestion in the systemic circulation results in hepatomegaly. Jugular venous collapse and oliguria are key features of left-sided heart failure. Left-sided heart failure is associated with decreased cardiac output.

When assessing the client with peripheral arterial disease, the nurse anticipates the presence of which clinical manifestations? Select all that apply. Dependent rubor Warm extremities Ulcers on the toes Thick, hardened skin Delayed capillary refill

Dependent rubor Ulcers on the toes Delayed cap refill Rationale: Peripheral arterial disease affects arterial circulation and results in delayed and impaired circulation to the extremities. As a result, the extremities exhibit rubor while in the dependent position and pallor while elevated, ulcers on the feet and toes, cool skin, and capillary refill longer than three seconds. Warm extremities and thick, hardened skin occur in the presence of venous disease.

A nurse is caring for a client with pulmonary tuberculosis. What must the nurse determine before discontinuing airborne precautions? Client no longer is infected. Tuberculin skin test is negative. Sputum is free of acid-fast bacteria. Client's temperature has returned to normal

Sputum is free of acid-fast bacteria. Rationale: The absence of bacteria in the sputum indicates that the disease can no longer be spread by the airborne route. Treatment is over an extended period; eventually the client may not have an active disease, but still remains infected. Once an individual has been infected, the test will always be positive. The client's temperature returning to normal is not evidence that the disease cannot be transmitted.

A client is admitted to the hospital with a diagnosis of lower extremity arterial disease (LEAD) or peripheral arterial disease. Which is the most beneficial lifestyle modification the nurse should teach this client? Stop smoking Control blood glucose Start a walking program Eat a low-fat, low-cholesterol diet

Stop smoking Rationale: Smoking is the single most important risk factor for peripheral arterial diseases, and cessation should be encouraged. Although hyperglycemia is a contributing factor, it is not the primary risk factor for LEAD. Although a sedentary lifestyle is a contributing factor, it is not the primary risk factor for LEAD. Although a high-fat, high-cholesterol diet is a contributing factor, it is not the primary risk factor for LEAD.

A client with chronic obstructive pulmonary disease (COPD) states, "I have had steady weight loss, and I am often too tired to eat." Which nursing diagnosis would be most appropriate for this client? Fatigue related to weight loss secondary to COPD Imbalanced nutrition: less than body requirements, related to fatigue Imbalanced nutrition: less than body requirements, related to COPD Ineffective breathing pattern, related to alveolar hypoventilation

Imbalanced nutrition: less than body requirements, related to fatigue Rationale: The response portion of the nursing diagnosis is Imbalanced nutrition: less than body requirements, and the etiology is fatigue associated with the disease process of COPD. Interventions should be planned to deal with the breathing problem and the fatigue associated with it while implementing actions to combat the weight loss. Weight loss related to COPD is not a NANDA-approved nursing diagnosis. Fatigue associated with the COPD disease process is the cause of the weight loss, not COPD in itself. Altered breathing pattern is also a problem, but does not specifically relate to the weight loss problem.

The nurse provides discharge teaching to a client who has received prescriptions for digoxin, furosemide, and a 2-gram sodium diet. Which statement from the client indicates that further teaching is needed? "I must check my pulse every day." "I can gradually increase my exercise as long as I take rest periods." "I should call my healthcare provider if I have difficulty breathing when I am lying flat." "I can use a little table salt on my food as long as I do not use it when cooking food."

"I can use a little table salt on my food as long as I do not use it when cooking food." Rationale: The response "I can use a little table salt on my food as long as I do not use it when cooking" demonstrates that the client did not understand the discharge teaching. Table salt and foods high in sodium should be avoided. Sodium intake causes fluid retention, which can precipitate a fluid volume excess, which contributes to heart failure. Digoxin should be withheld if the client's pulse is less than a preset rate (i.e., 60 beats per minute) because this is a sign of digoxin toxicity; the risk of digoxin toxicity is increased if the client develops hypokalemia as a result of receiving furosemide. Slowly increasing activities while ensuring rest periods limits the stress on the heart and is desirable. Orthopnea is a sign of pulmonary edema related to heart failure, and the healthcare provider should be notified.

A client is diagnosed with heart failure and is admitted for medical management. Which statement made by the client may indicate worsening heart failure? "I am unable to run a mile (1.6 kilometers) now." "I wake up at night short of breath." "My wife says I snore very loudly." "My shoes seem larger lately."

"I wake up at night short of breath." Rationale: Increased shortness of breath is often an indicator of fluid overload in the heart failure client. Being unable to run a mile (1.6 kilometers), snoring loudly, and shoes seeming larger are not as related to heart failure as waking up at night with shortness of breath.

A nurse is caring for a child with newly diagnosed acute lymphoblastic leukemia. What clinical findings does the nurse anticipate when assessing the child? Select all that apply. Pallor Fatigue Jaundice Multiple bruises Generalized edema

Pallor Fatigue Multiple bruises Rationale: Pallor is the result of anemia associated with leukemia. Fatigue is the result of anemia associated with leukemia. Multiple bruises are the result of thrombocytopenia associated with leukemia. Jaundice usually indicates liver damage or excessive hemolysis and is not an early sign of leukemia. Edema is not a manifestation of the disease because the pathophysiology does not involve transport of fluids.

A client has been admitted with severe edema and hypertension. Intravenous furosemide has been prescribed. Which subjective clinical manifestations lead the nurse to suspect that the furosemide is infusing too rapidly? Select all that apply. Hunger Tinnitus Weakness Leg cramps Excess salivation

Tinnitus Weakness Leg cramps Rationale: Tinnitus is a central nervous system side effect of furosemide. Weakness and leg cramps result from hypokalemia caused by an overload of furosemide. Nausea and anorexia, not hunger, are side effects of dehydration that may occur with an overload of furosemide. Dry mouth, not salivation, results from dehydration caused by an overload of furosemide.

A client is diagnosed with cancer of the pancreas and is apprehensive and restless. Which nursing action should be included in the plan of care? Encouraging expression of concerns Administering antibiotics as prescribed Teaching the importance of getting rest Explaining that everything will be all right

Encouraging expression of concerns Rationale: Open communication helps to decrease anxiety. Antibiotics will have no direct effect on the client's anxiety. Knowledge does not always reduce anxiety and promote rest. Explaining that everything will be all right is false reassurance.

A client is admitted to the emergency department with a possible myocardial infarction. Three hours after admission, the client experiences a new onset of severe chest pain. The client is diaphoretic with a pulse rate of 110 beats per minute. Which action should the nurse take immediately? Decrease the oxygen amount Obtain an electrocardiogram (ECG) Administer the prescribed morphine Offer acetaminophen until the pain subsides

Administer the prescribed morphine Rationale: The client requires immediate relief of pain by administering morphine. The client needs increased oxygen, not less. ECG monitoring is continuous in the ED, so the nurse does not need to obtain an ECG. Acetaminophen does not relieve the pain associated with a myocardial infarction.

A client being treated for hypertension reports having a persistent hacking cough. What class of antihypertensive should the nurse identify as a possible cause of this response when reviewing a list of this client's medications? Thiazide diuretics Calcium channel blockers Angiotensin receptor blockers Angiotensin-converting enzyme (ACE) inhibitors

Angiotensin-converting enzyme (ACE) inhibitors Rationale: ACE increases the sensitivity of the cough reflex, leading to the common adverse effect sometimes referred to as an ACE cough. A cough is not a side effect of thiazide diuretics, calcium channel blockers, or angiotensin receptor blockers.

The nurse obtains a laboratory report that shows acid-fast rods in a client's sputum. Which disorder should the nurse consider may be related to these results? Influenza virus Diphtheria bacillus Bordetella pertussis Mycobacterium tuberculosis

Mycobacterium tuberculosis Rationale: Mycobacterium tuberculosis is the acid-fast causative organism of tuberculosis. Acid-fast rods are not related to influenza viruses. The diphtheria bacillus is not an acid-fast rod. The microorganism that causes pertussis is not an acid-fast rod.

When obtaining a health history, the nurse is informed that a client has been taking digoxin. What therapeutic effect of digoxin does the nurse expect? Decreased cardiac output Decreased stroke volume of the heart Increased contractile force of the myocardium Increased electrical conduction through the atrioventricular (AV) node

Increased contractile force of the myocardium Rationale: Digoxin produces a positive inotropic effect that increases the strength of myocardial contractions and thus cardiac output. The positive inotropic effect of digoxin increases, not decreases, cardiac output. Digoxin increases the strength of myocardial contractions (positive inotropic effect) and slows the heart rate (negative chronotropic effect); these effects increase the stroke volume of the heart. Digoxin decreases the refractory period of the AV node and decreases conduction through the sinoatrial (SA) and AV nodes.

A nurse is caring for several clients in the intensive care unit. Which is the greatest risk factor for a client to develop acute respiratory distress syndrome (ARDS)? Aspirating gastric contents Getting an opioid overdose Experiencing an anaphylactic reaction Receiving multiple blood transfusions

Aspirating gastric contents Rationale: Aspirating gastric contents is a common cause of ARDS. Gastric enzymes injure alveolar-capillary membranes, which release inflammatory mediators; the process progresses to pulmonary edema, vascular narrowing and obstruction, pulmonary hypertension, and impaired gas exchange. Getting an opioid overdose is not as common a cause of ARDS as is aspiration pneumonia; this more likely will cause depressed respirations. Although anaphylaxis may cause ARDS, it is not a common cause. Although multiple blood transfusions have been known to precipitate ARDS, they are not a common cause.

A client is admitted with thrombocytopenia. Which specific nursing actions are appropriate to include in the plan of care for this client? Select all that apply. Avoid intramuscular injections Institute neutropenic precautions Monitor the white blood cell count Administer prescribed anticoagulants Examine the skin for ecchymotic areas

Avoid intramuscular injections Examine the skin for ecchymotic areas Rationale: Intramuscular injections should be avoided because of the increased risk of bleeding and possible hematoma formation. Decreased platelets increase the risk of bleeding, which leads to ecchymoses. Neutropenic precautions are for clients with decreased white blood cells (WBCs), not platelets. Thrombocytopenia refers to decreased platelets, not WBCs. Anticoagulants are contraindicated because of the increased bleeding risk.

While a nurse is conducting an initial assessment on a client, which classic sign would alert the nurse that the client has chronic obstructive pulmonary disease (COPD)? Barrel chest Cyanosis Hyperventilation Lordosis

Barrel chest Rationale: Clients with COPD often develop a barrel chest over time because of air being trapped, thus resulting in enlarged lungs and thoracic cavity. This also causes the lungs to have less flexibility. Cyanosis is a bluish discoloration, especially of the skin and mucous membranes, caused by excessive concentration of deoxyhemoglobin in the blood caused by deoxygenation. COPD sufferers can exhibit this, but barrel chest is the most obvious sign, as other respiratory/cardiovascular disorders can cause cyanosis as well. Hyperventilation is the act of breathing faster or deeper than normal, which causes excessive expulsion of circulating carbon dioxide. This causes the arterial concentration of carbon dioxide (PaCO 2) to fall below normal, raising blood pH, and results in alkalosis. COPD sufferers can experience hyperventilation, but barrel chest is the classic sign of COPD. Lordosis is an unusual inward curving of the spine in the lower part of the back. It can be considered medically significant; however, it is not associated with classic signs of COPD.

A client is admitted with a tentative diagnosis of pneumonia. On admission the client is not in respiratory distress, but later develops chest pain and a fever of 103° F (39.4° C). A productive cough produces rust-colored sputum. How should the nurse interpret these findings? Onset of pulmonary edema Expected course of pneumonia Presence of a pulmonary embolus Insidious onset of tuberculosis (TB)

Expected course of pneumonia Rationale: Chest pain, fever, productive cough, and rust-colored sputum are cardinal signs of pneumonia[1][2]. Chest pain results from excessive coughing; fever, increased sputum, and rust-colored sputum result from the infectious process. Dependent edema, respiratory distress, and crackles on auscultation of the lungs are associated with pulmonary edema. Although chest pain is expected with a pulmonary embolus, rust-colored sputum and a high fever are not. Pulmonary TB is associated with a low-grade fever, nonproductive or mucopurulent blood-tinged sputum, night sweats, and fatigue.

During a client's routine physical examination, a chest x-ray film reveals a lesion in the right upper lobe. Which information in the client's history supports the healthcare provider's diagnosis of pulmonary tuberculosis? Select all that apply. Fever Dry cough Night sweats Frothy sputum Engorged neck veins Blood-tinged sputum

Fever Night sweats Blood-tinged sputum Rationale: Tuberculosis is an infectious disease in which recurrent fevers are present, usually in the late afternoon. Profuse diaphoresis at night (night sweats) is a classical sign of tuberculosis. Blood-tinged sputum (hemoptysis) results from pathophysiological trauma to mucous membranes. The cough is productive, not dry, because the inflammatory process causes purulent mucus. Frothy sputum is present with pulmonary edema, not tuberculosis. Engorged neck veins are symptomatic of heart failure or fluid overload.

A client who was admitted with a diagnosis of acute lymphoblastic leukemia is receiving chemotherapy. Which assessment findings would alert the nurse to the possible development of thrombocytopenia? Select all that apply. Fever Diarrhea Headache Hematuria Ecchymosis

Headache Hematuria Ecchymosis Rationale: Thrombocytopenia is a condition characterized by abnormally low levels of thrombocytes, also known as platelets, in the blood. This reduction in platelet activity impairs blood clotting, so any assessment finding associated with potentially abnormal bleeding would alert the nurse to the possibility of thrombocytopenia. This includes headache (bleeding into brain tissue), hematuria (bleeding within the renal system) and ecchymosis (bleeding into skeletal soft tissue). Fever and diarrhea are common side effects of chemotherapy, but are not findings specifically attributed to thrombocytopenia.

A client is experiencing a myocardial infarction. What should the nurse identify as the primary cause of the pain experienced by a client with a coronary occlusion? Arterial spasm Heart muscle ischemia Blocking of the coronary veins Irritation of nerve endings in the cardiac plexus

Heart muscle ischemia Rationale: Ischemia causes tissue injury and the release of chemicals, such as bradykinin, that stimulate sensory nerves and produce pain. Arterial spasm, resulting in tissue hypoxia and pain, is associated with angina pectoris. Arteries, not veins, are involved in the pathology of a myocardial infarction. Tissue injury and pain occur in the myocardium.

The nurse should refer a client to the pulmonary clinic for suspected tuberculosis based on which clinical indicators reported during the initial client interview? Select all that apply. Vomiting Weight gain Hemoptysis Night sweats Bilateral crackles

Hemoptysis Night sweats Rationale: Erosion of lung tissue causes blood in the sputum, a classic sign of tuberculosis. Increased body temperature causes profuse diaphoresis, a classic sign of tuberculosis. Vomiting is associated with a gastrointestinal (GI) obstruction or cancer. Weight loss, not weight gain, is a sign of tuberculosis. Bilateral crackles are associated with excess fluid volume.

A client with a history of heart failure on daily weights has a 2-pound (0.9 kilogram) weight gain and pitting edema in lower extremities bilaterally. Which action should the nurse take next? Check the record to ascertain the code status. Encourage increased intake of favorite drink. Perform a head-to-toe assessment, including vital signs. Continue to monitor daily weights and edema and to document findings.

Perform a head-to-toe assessment, including vital signs. Rationale: Performing a head-to-toe assessment, including vital signs, would indicate symptoms, such as jugular distention with right-sided heart failure, or pulmonary issues (crackles) associated with left-sided heart failure. Checking the record for code status is not a priority and should have been established and known on an elderly client. Increasing intake will make the problem of fluid retention worse. Continuing to monitor daily weights without an assessment may miss worsening symptoms.

A young child with acute nonlymphoid leukemia is admitted to the pediatric unit with a fever and neutropenia. What are the most appropriate nursing interventions to minimize the complications associated with neutropenia? Placing the child in a private room, restricting ill visitors, and using strict hand washing techniques Encouraging a well-balanced diet, including iron-rich foods, and helping the child avoid overexertion Avoiding rectal temperatures, limiting injections, and applying direct pressure for 5 minutes after venipuncture Offering a moist, bland, soft diet; using toothettes rather than a toothbrush; and providing frequent saline mouthwashes

Placing the child in a private room, restricting ill visitors, and using strict hand washing techniques Rationale: Children with leukemia most often die of infection; a low neutrophil count is associated with myelosuppressant therapy. Placing the child in a private room, restricting ill visitors, and using strict hand washing techniques are the best ways to minimize complications. Encouraging a well-balanced diet, including iron-rich foods, and helping the child avoid overexertion are not appropriate measures to prevent infection resulting from neutropenia; they are appropriate for treating the anemia. Avoiding rectal temperatures, limiting injections, and applying direct pressure for 5 minutes after venipuncture are not appropriate measures to prevent infection resulting from neutropenia; they are more appropriate for preventing bleeding. Offering a moist, bland, soft diet; using toothettes rather than a toothbrush; and providing frequent saline mouthwashes are not appropriate measures to prevent infection resulting from neutropenia; they are used to ease and treat stomatitis.

What is a nurse's most important consideration when formulating a plan of care for a school-aged child undergoing chemotherapy? Preventing infection Increasing caloric intake Limiting nausea and vomiting Monitoring hematoma formation

Preventing infection Rationale: Chemotherapy suppresses the immune system; the child is in danger of contracting an overwhelming infection. Although increasing caloric intake is important, it is not the priority. Although nausea and vomiting are side effects of chemotherapy, they can be minimized with appropriate pharmacological therapy. Although it is important to check for hematomas, it is not as important as preventing infection; gentle handling helps prevent hematomas.

During chemotherapy, altered nutrition is a common side effect. Knowing that compromised nutrition can contribute to an increased risk of infection and other problems, what can the nurse do to offset nutritional deficiencies? Provide oral supplements. Offer the patient's favorite foods. Restrict intake from dairy products. Encourage the client to drink low-protein shakes.

Provide oral supplements Rationale: The patient with cancer may experience protein and calorie malnutrition characterized by fat and muscle depletion. Soft, nonirritating high-protein and high-calorie foods should be eaten throughout the day. Foods suggested for increasing the protein intake and high-calorie foods that provide energy and minimize weight loss are recommended. Teach the patient to avoid extremes of temperature of food, spicy or rough foods, and other irritants. Encourage nutritional supplements like Ensure as an adjunct to meals and fluid intake. Teach the patient to use nutritional supplements in place of milk when cooking or baking. Foods to which nutritional supplements can be easily added include scrambled eggs, pudding, custard, mashed potatoes, cereal, and cream sauces. Packages of instant breakfast can be used as indicated or sprinkled on cereals, desserts, and casseroles. Families are an integral part of the healthcare team. As symptom severity increases, the family's role in helping the patient eat becomes increasingly critical. If the malnutrition cannot be treated with dietary intake, it may be necessary to use enteral or parenteral nutrition. Favorite foods are not offered during chemotherapy because the client's sense of taste has changed. Dairy products are a necessary part of a balanced diet and do not affect chemotherapy. High-protein shakes are used to encourage healing and protein intake.

A child is admitted to the hospital with pneumonia. What is the priority need that must be included in the nursing plan of care for this child? Rest Exercise Nutrition Elimination

Rest Rationale: Rest reduces the need for oxygen and minimizes metabolic needs during the acute, febrile stage of the disease. The child requiring hospitalization for pneumonia is usually confined to bed and needs to reduce activity to conserve oxygen. Nutrition is not a priority; the child is expected to be anorectic during the febrile phase. Elimination is usually not a problem, except as a result of immobility.

A nurse is developing a teaching plan for a client with lower extremity arterial disease (LEAD). Which information will the nurse include in the teaching plan? Trimming toenails so that they are short and rounded Checking bathwater temperature by putting the toes in first Using alcohol to rub hands, feet, legs, and arms at least two times a day Seeking professional treatment for any minor injuries to the extremities

Seeking professional treatment for any minor injuries to the extremities Rationale: Because diminished circulation leads to inadequate healing, early treatment of injuries is essential. Toenails should not be too short and should be trimmed straight across. Bathwater should be checked with a bath thermometer; toes of persons with peripheral artery disease (PAD) may be less sensitive to temperature change, and a burn may occur. These clients develop trophic skin changes; the drying action of alcohol will contribute to dryness and skin breakdown.

A client that has a diagnosis of bone cancer is being prepared for the first radiation treatment. As the nurse begins the treatment, the client starts crying, stating, "I'm so discouraged." What is the nurse's best response? Tell the client, "It's difficult to deal with your diagnosis and treatment." Complete the preparation and tell the client, "We can talk about this later." Explain the therapy and reinforce that it will only cause a little discomfort. Allow the client to be alone for a few minutes so the client can regain composure.

Tell the client, "It's difficult to deal with your diagnosis and treatment." The correct response focuses on the client's feelings of despair and provides the opportunity to talk about them. Leaving the client alone abandons the client and leaves the client with no support. Avoiding a pressing problem misses an opportunity for discussion of feelings. Explaining the therapy and saying it will only cause a little discomfort focuses on the nurse's interpretation of the problem, not the client's.

The nurse providing care for a client with a diagnosis of neutropenia reviews isolation procedures with the client's spouse. The nurse determines that the teaching was effective when the spouse states that protective environment isolation helps prevent the spread of infection in which direction? To the client from outside sources From the client to others From the client by using special techniques to destroy infectious fluids and secretions To the client by using special sterilization techniques for linens and personal items

To the client from outside sources Rationale: Protective environment isolation implies that the activities and actions of the nurse will protect the client from infectious agents because the client's own immune defense ability is compromised (neutropenia). Protective environment isolation is also referred to as reverse isolation. "From the client to others," "From the client by using special techniques to destroy infectious fluids and secretions," and "To the client by using special sterilization techniques for linens and personal items" are incorrect concepts related to protective environment isolation.

The nurse observes a client with chronic obstructive pulmonary disease (COPD) breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs and hears crackles and wheezes. What action should the nurse take? Encourage the client to take slow, deep breaths and administer 5 L/min oxygen per nasal cannula. Place the client in a side-lying position and perform chest physiotherapy using clapping and vibration. Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula. Assist the client in assuming a position of comfort and perform postural drainage.

Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula. Rationale: Sitting facilitates breathing by increasing lung expansion; 2 L of oxygen promotes respirations while preventing carbon dioxide narcosis. However, the results of one recent study of clients with stable COPD indicate that the hypercarbic drive is preserved with oxygen higher than 2 L. More research is needed before this theory is applied clinically. Five liters of oxygen may cause respiratory depression and carbon dioxide narcosis in a client with COPD. Chest physiotherapy may be done later after the client's condition improves. Delaying intervention likely will worsen the respiratory distress.

A client complaining of fatigue is admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD). What should the nurse do to prevent fatigue? Provide small, frequent meals Encourage pursed-lip breathing Schedule nursing activities to allow for rest Encourage bed rest until energy level improves

Schedule nursing activities to allow for rest Rationale: Rest limits muscle contractions, which diminishes oxygen needs and decreases fatigue. Although small, frequent meals may decrease pressure on the diaphragm and facilitate breathing, this precaution does not address the client's fatigue. Although pursed-lip breathing facilitates gas exchange, it does not reduce the metabolic demand for oxygen. Bed rest promotes pooling of pulmonary secretions, which may aggravate the client's respiratory status.

A nurse is performing a respiratory assessment of an 8-month-old child with the diagnosis of viral pneumonia. The nurse identifies bronchial breath sounds over areas of consolidation, mild substernal retractions, profuse mucus production, pallor, and a temperature of 102° F (38.9° C). What is the priority nursing action? Suctioning the nasopharynx so a patent airway can be maintained Starting an intravenous infusion to provide necessary fluids and electrolytes Calling the respiratory therapist to start preparations for oxygen administration Notifying the practitioner of the fever so a prescription for an antipyretic can be issued

Suctioning the nasopharynx so a patent airway can be maintained Rationale: Establishment and maintenance of a patent airway is always the priority. This intervention follows the ABCs (airway, breathing, circulation) of emergency care. An intravenous infusion will likely be started; however, this is not essential right away. The practitioner, not the respiratory therapist, should be asked for a prescription to begin oxygen administration; this action is not the priority. Taking the time to obtain a prescription for an antipyretic will delay attention to the immediate problem of respiratory distress.

A 50-year-old client being seen for a routine physical asks why a stool specimen for occult blood testing has been prescribed when there is no history of health problems. What is an appropriate nursing response? "You will need to ask your healthcare provider; it is not part of the usual tests for people your age." "There must be concern of a family history of colon cancer; that is a primary reason for an occult blood stool test." "It is performed routinely starting at your age as part of an assessment for colon cancer." "There must have been a positive finding after a digital rectal examination performed by your healthcare provider."

"It is performed routinely starting at your age as part of an assessment for colon cancer." Rationale: The primary reason for a stool specimen for guaiac occult blood testing is that it is part of a routine examination for colon cancer in any client over the age of 40. Age, family history of polyps, and a positive finding after a digital rectal examination are factors related to colon cancer and secondary reasons for the occult blood test (guaiac test).

A client comes to the ambulatory surgery unit on the morning of an elective surgical procedure. The client reports shortness of breath, dizziness, and palpitations. The nurse observes profuse diaphoresis and is concerned that the client may be having either a panic attack or a myocardial infarction. Which assessments support the conclusion that the client may be experiencing a myocardial infarction? Select all that apply. Anxiety Chest pain Irregular pulse Fear of losing control Feelings of depersonalization

Anxiety Chest pain Irregular pulse Rationale: Anxiety is associated with both myocardial infarctions and panic attacks. The overwhelming chest pain that usually accompanies a myocardial infarction, due to myocardial ischemia, precipitates a feeling of impending death. Most people who have panic attacks eventually recognize that they are not going to die as a result of the attack. Chest pain is associated with both myocardial infarctions and panic attacks. Chest pain is associated with a myocardial infarction because of myocardial ischemia. It is often described as "viselike" or "crushing" in nature. The chest discomfort during a panic attack usually is not as severe as the pain associated with a myocardial infarction. Fear of losing control usually is not a characteristic associated with a myocardial infarction. Fear of losing control or of going crazy is among the criteria for the diagnosis of panic attacks. A feeling of depersonalization is not a characteristic associated with a myocardial infarction. Depersonalization (feeling detached from the self) and derealization (feelings of unreality) are among the criteria for the diagnosis of panic attacks.

A client is hospitalized with pneumococcal pneumonia. Which drug will the nurse most likely administer? Penicillin G Ceftriaxone Vancomycin Meropenem

Ceftriaxone Rationale: Streptococcus pneumoniae causes pneumococcal pneumonia. The drug preferred for the disease caused by this bacterium is ceftriaxone. Streptococcus pneumoniae is resistant to penicillin G. Vancomycin is preferred for the treatment of the infections caused by Staphylococcus aureus. Meropenem is used for treating the infections caused by Klebsiella pneumoniae.

A nurse identifies that clients with cancer often lose weight and may become cachectic. What common response do clients with cancer experience, regardless of the site of the cancer, that accounts for this weight loss? Depression precipitates anorexia. Changes in taste and food aversions. Decreased saliva impedes chewing and swallowing. Nutrients are not absorbed through the gastrointestinal mucosa.

Changes in taste and food aversions. Rationale: This problem may occur even when nutritional intake appears adequate. Changes in taste resulting from the cancer or the treatment can reduce appetite and cause food aversions. Some patients experience early satiety or a sense of fullness and inability to eat even though they have eaten only a small volume of food. Depression does not occur in all clients with cancer, and when it does, it does not necessarily cause anorexia. Decreased saliva impeding chewing and swallowing is not a commonality associated with all clients with cancer; it may occur in clients who receive treatment to the head and neck. Nutrients not being absorbed through the gastrointestinal mucosa is not a commonality associated with all clients with cancer; it may occur in clients who receive treatment that affects the gastrointestinal tract.

A nurse is caring for a client with the diagnosis of right ventricular failure. Which condition unrelated to cardiac disease is the major cause of right ventricular failure? Renal disease Hypovolemic shock Severe systemic infection Chronic obstructive pulmonary disease (COPD)

Chronic obstructive pulmonary disease (COPD) Rationale: COPD causes destruction of capillary beds around the alveoli, interfering with blood flow to the lungs from the right side of the heart. As the heart continues to strain against this resistance, heart failure eventually results. Renal disease causes stress on the left side of the heart. Hypovolemic shock will not cause stress on the right side of the heart. Severe systemic infection probably will produce greater stress on the left side of the heart.

Which client care can be safely delegated to the unlicensed nursing personnel (UNP) to provide oral hygiene? 1. Dental caries 2. Oral cancer 3. Jaw fracture 4. Thrombocytopenia

Client 1 Rationale: Client A with dental caries is least likely to have any complications during oral hygiene. Oral care in clients with oral cancer has associated risks; therefore, it should be performed by a registered nurse (RN). Since client C with a jaw fracture has limited ability to open the mouth, care cannot be safely delegated to the UNP. In client D with thrombocytopenia, small bruises that could occur during oral care may result in persistent bleeding. This complication prevents delegation of oral hygiene for client D to UNPs.

A nurse reviews the chest examination reports of four clients with respiratory disorders. Which client's findings indicate atelectasis? (Palpation - percussion - auscultation) 1. Decreased chest wall movement/hyper-resonance/wheezes 2. Increased vibrations over chest wall above effusion/dull/diminished or absent over effusion 3. Decreased from fremitus/dull over affected area/crackles 4. Increased fremitus over affected area/dull over affected area/bronchial sounds

Client 3 Rationale: A client suffering from atelectasis may have decreased fremitus, dull percussion over the affected area, and crackle sounds upon auscultation like Client C. Decreased chest wall movements, hyperresonance, and wheezing indicate asthma in Client A. Client B with increased vibrations over the chest wall above effusion, dull percussion, and diminished or absent breath sounds over the affected area may have a pleural effusion. Client D with increased fremitus over the affected area, dull percussion over the affected area, and bronchial sounds upon auscultation may have pneumonia.

Which client would the nurse consider to have the highest risk of pneumonia? 1. 16 years/has a poor nutritional status/received vaccination in the last 3 months 2. 28 years/uses tobacco/received vaccination 2 years ago 3. 45 years/consumes alcohol regularly/received vaccine a year ago 4. 67 years/chronic lung disease/received vaccine more than 5 years ago

Client 4 Rationale: Client 4, who is an older adult with chronic lung disease and has received the pneumococcal vaccination more than 5 years ago, has the highest risk of pneumonia. An infection may occur because older adults with chronic lung disease are at a higher risk of infection. Client 1 received the pneumococcal vaccination in the last 3 months and thus has a lower risk of pneumonia. Client 2 received a pneumococcal vaccination in the last 2 years and may not have an elevated risk of pneumonia. Client 3 may have a lower risk of pneumonia due to receiving the pneumococcal vaccine a year ago.

An infant who has a congenital heart defect with left-to-right shunting of blood is admitted to the pediatric unit. What early sign of heart failure should the nurse identify? Cyanosis Restlessness Decreased heart rate Increased respiratory rate

Increased respiratory rate Rationale: Because the lungs are stressed by pulmonary edema, a quicker respiratory rate is the first and most reliable indicator of early heart failure in infants. Cyanosis is a late sign of heart failure; with early failure there is still adequate perfusion of blood. Infants with early heart failure do not move about; they become fatigued quickly, especially when feeding, because of a decrease of oxygen to body cells. The heart rate of an infant in early heart failure increases, not decreases, in an attempt to increase oxygen to body cells.

A client with an inferior myocardial infarction has a heart rate of 120 beats per minute. Which goal achievements are priority? Increase left ventricular filling and improve cardiac output Decrease oxygen needs of the vital organs and prevent cardiac dysrhythmias Decrease the workload on the heart and promote maximum coronary artery filling Increase venous return to the right atrium and increase pulmonary arterial blood flow

Decrease the workload on the heart and promote maximum coronary artery filling Rationale: With a myocardial infarction, circulation of blood to cardiac muscle is reduced, depriving it of oxygen; therefore the oxygen demands of the body need to be decreased to reduce stress on the heart and reduce cardiac output. Increased coronary artery filling allows more blood and therefore oxygen to reach cardiac muscle; this increases myocardial efficiency. Increasing left ventricular filling increases the workload of the heart. Oxygenation of vital organs must be maintained. Decreasing oxygen to vital organs of the body may interfere with their ability to function. Increasing venous return to the right atrium increases the workload of the heart.

A primary healthcare provider decides to omit a treatment that was part of a course of chemotherapy for a client because the client demonstrates myelosuppression. What information would be appropriate for the nurse to give to the client regarding myelosuppression? Calcium carbonate and vitamin D must be increased in the diet because of the effects of myelosuppression. Eating a balanced diet, resting, and trying to prevent bleeding and infections are appropriate at this time. The development of myelosuppression explains why the client has nausea, vomiting, anorexia, and alopecia. Frequent testing for restlessness, muscle control, and pupillary response is necessary because the meninges may be irritable.

Eating a balanced diet, resting, and trying to prevent bleeding and infections are appropriate at this time. Rationale: Myelosuppression involves a decreased number of red blood cells (anemia), resulting in a reduced oxygen-carrying capacity of the blood and fatigue. A decreased number of white blood cells (leukopenia) results in a potential for infection. A decreased number of platelets (thrombocytopenia) results in a potential for bleeding. Myelosuppression is not related directly to calcium carbonate and vitamin D; myelosuppression, a reduction in bone marrow activity, results in decreased numbers of red blood cells (RBCs), white blood cells (WBCs), and platelets. Myelosuppression is not related to nausea, vomiting, anorexia, or alopecia. Myelosuppression is related to bone marrow activity, not the nervous system.

When caring for a client with pneumonia, which nursing intervention is the highest priority? Increase fluid intake. Employ breathing exercises and controlled coughing. Ambulate as much as possible. Maintain a nothing-by-mouth (NPO) status.

Employ breathing exercises and controlled coughing. Rationale: For most clients, the most effective means of preventing fluid consolidation in the lungs with a diagnosis of pneumonia is to keep active by deep breathing and controlled coughing exercises. Increased fluid intake and ambulation are important aspects of care if not contraindicated, but they are secondary to deep breathing and coughing. Keeping the client NPO is not necessary; unless contraindicated, the client with pneumonia is usually offered the regular diet as tolerated.

A client is admitted to the hospital for surgery for rectosigmoid colon cancer, and the nurse is obtaining a health history as part of the admission process. What clinical findings associated with rectosigmoid colon cancer does the nurse expect the client to report? Select all that apply. Feeling tired Rectal bleeding Inability to digest fat Change in the shape of stools Feeling of abdominal bloating

Feeling tired Rectal bleeding Change in the shape of stools Feeling of abdominal bloating Rationale: Anemia may manifest as fatigue, feeling tired, and/or generalized weakness. Anemia is common with rectosigmoid colon cancer from the loss of blood rectally. Passage of red blood (hematochezia) is one of the cardinal signs of rectosigmoid colon cancer; ulceration of the tumor and straining to pass stool precipitate this clinical finding. A cancerous mass can grow into the lumen of the sigmoid colon, altering the shape of stool; stools may be ribbonlike or pencil thin. Tumors in the rectosigmoid colon cause partial and eventually complete obstruction of the intestinal lumen. Stool in the descending and sigmoid colon is more formed, and thus straining to pass stools, gas pains, cramping, and incomplete evacuation commonly occur. An inability to digest fat is not specific to rectosigmoid colon cancer.

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with acute bronchopneumonia. The client is in moderate respiratory distress. The nurse should place the client in what position to enhance comfort? Side-lying with head elevated 45 degrees Sims with head elevated 90 degrees Semi-Fowler with legs elevated High-Fowler using the bedside table to rest the arms

High-Fowler using the bedside table to rest the arms Rationale: The high-Fowler position elevates the clavicles and helps the lungs to expand, thus easing respirations. The side-lying, Sims, and semi-Fowler positions do not promote more comfortable breathing.

A nurse is caring for an infant with heart failure. What treatment does the nurse most likely anticipate in the care of this infant? Open heart surgery Cardiac stress test Aggressive intravenous fluid infusions Medications that are prescribed for both children and adults

Medications that are prescribed for both children and adults Rationale: Because the mechanism of heart failure is the same in children and adults, the same medications (e.g., cardiac glycosides, angiotensin-converting enzyme [ACE] inhibitors, and diuretics) are used, although the dosage will be adjusted for the infant and for the child. Open heart surgery may or may not be necessary; other treatments may be successful. A cardiac stress test is not an anticipated treatment for an infant. Also, a stress test is a diagnostic test, not a treatment. Aggressive fluid infusions are usually not ordered for clients in heart failure. Excessive fluid increases the workload of the heart.

An older client with hypertension is admitted to the hospital. Which data from the client's history and diagnostic workup represent risk factors for hypertension? Select all that apply. Taking an aspirin a day Occasional cocaine use Reduced hemoglobin level African-American heritage Increased high-density lipoprotein (HDL)

Occasional cocaine use African-American heritage Rationale: Cocaine is a stimulant that causes tachycardia and hypertension. Hypertension is more prevalent in African-Americans in the United States. Aspirin decreases platelet aggregation, thus reducing the risk for cardiovascular disease. Lowered hemoglobin may increase the heart rate, not the blood pressure. Increased HDL reduces the risk for cardiovascular disease because it helps to remove excess cholesterol from the blood, thereby preventing atheromas.

An older client with a history of congestive heart failure expresses concern about potential exposure to tuberculosis. The client states that a roommate at the extended care facility where the client resides sleeps a lot, coughs a great deal, and sometimes spits up blood. What is the primary reason that the nurse pursues more information about the roommate? Death from tuberculosis is on the increase The roommate is causing the client to be anxious Older adults with chronic illness are affected adversely by tuberculosis The roommate most likely is preventing the client from getting proper sleep

Older adults with chronic illness are affected adversely by tuberculosis Rationale: The client's cardiac condition and age make the client vulnerable to communicable diseases. In the United States, death from tuberculosis is declining because of improved drug therapy. (Canada: According to the Public Health Agency of Canada, 1,607 new active and re-treatment (latent) TB cases were reported to the Canadian Tuberculosis Reporting System in 2011, but TB is no longer common in the overall Canadian population.) The nurse's primary concern is to prevent the spread of infection. The issues of client anxiety and potential sleep disturbance should be addressed later; they are not the greatest concern at this time.

During the assessment of a client who was admitted to the hospital because of a productive cough, fever, and chills, the nurse percusses an area of dullness over the right posterior lower lobe of the lung. Which medical diagnosis will the nurse most likely observe documented in the client's electronic records? Pleurisy Bronchitis Pneumonia Emphysema

Pneumonia Rationale: The data presented indicate an infectious process within the lung. The classic clinical findings associated with pneumonia are a productive cough (sputum is purulent, blood-tinged, or rust-colored), fever, chills, pleuritic chest discomfort, and dyspnea. Percussion is dulled over areas of consolidation. The cardinal clinical findings associated with pleurisy are pain in the lower lobe at the height of inspiration and a pleural friction rub. Although fever and chills can occur later in bronchitis, the cardinal clinical findings associated with bronchitis are irritating productive cough, chest pain, and shortness of breath. The cardinal clinical findings associated with emphysema are barrel chest, resonance on percussion, and air trapping.

A client with an acute emphysema episode is dyspneic and anxious. To decrease the dyspnea, what is the nurse's first action? Increase the client's oxygen intake. Have the client breathe into a paper bag. Teach the client to do pursed-lip breathing. Check the client's vital signs.

Teach the client to do pursed-lip breathing. Rationale: The purpose of pursed-lip breathing (PLB) is to prolong exhalation and thereby prevent bronchiolar collapse and air trapping. PLB is simple and easy to teach and learn, and it gives the patient more control over breathing, especially during exercise and periods of dyspnea. Table 28-13 gives step-by-step instructions on how to teach the client to perform pursed-lip breathing techniques. Increasing the client's oxygen intake is contraindicated. It is believed that the client should receive low amounts of oxygen to prevent CO2 intoxication (CO2 narcosis). However, the results of one recent study of clients with stable chronic obstructive pulmonary disease (COPD) indicate that the hypercarbic drive is preserved. More research is needed before this theory is applied clinically. Having the client breathe into a paper bag is contraindicated because it increases carbon dioxide retention. Checking the client's vital signs, including the blood pressure, should be part of assessment, but assessment does not decrease dyspnea.

Serum cardiac marker studies are prescribed for a client after a myocardial infarction. Which laboratory test is most important for the nurse to monitor? Troponin Myoglobin Homocysteine Creatine kinase (CK)

Troponin Rationale: Troponin is the biomarker of choice for a myocardial infarction. Troponin, specifically subtypes cardiac-specific troponin T (cTnT) and cardiac-specific troponin I (cTnI), reflects myocardial muscle protein released into circulation soon after injury. Troponin increases as quickly as CK and remains increased for 2 weeks. Although myoglobin is one of the first cardiac markers to increase after a myocardial infarction (MI), it lacks cardiac specificity. Homocysteine is produced when proteins break down, but it is more indicative of cardiovascular disease than a myocardial infarction. CK isoenzyme levels, especially the creatine phosphokinase (MB) subunit, begin to increase in 3 to 6 hours, peak in 12 to 24 hours, and are increased for 48 hours after the occurrence of the infarct. Although reliable in assisting with an early diagnosis of MI, it is not as sensitive or specific as the troponin test.

When supporting vasodilation by the use of warmth for a client with peripheral arterial insufficiency, what should the nurse caution the client to avoid? <p>When supporting vasodilation by the use of warmth for a client with peripheral arterial insufficiency, what should the nurse caution the client to avoid?</p> Applying a hot water bottle to the abdomen Using a heating pad to warm the extremities Drinking a warm cup of tea when feeling chilly Turning the room thermostat above 72° F (23.3° C)

Using a heating pad to warm the extremities Rationale: The client's extremities are less sensitive to thermal stress because of peripheral vascular problems, and burns may occur. Applying heat to the abdomen causes reflex dilation of the arteries in the extremities and increases blood flow without untoward effects. Raising the internal temperature by drinking warm fluid prevents vascular constriction and warms the extremities. Increasing heat of the external environment is an effort to prevent cold, chilling, and further constriction of peripheral vasculature.

The nurse is making rounds on a client who has developed severe bone marrow depression after receiving chemotherapy for cancer. Which of these actions by the nurse is appropriate? Select all that apply. Monitor for signs of alopecia. Encourage an increase in fluids. Wash hands before entering the client's room. Advise use of a soft toothbrush for oral hygiene. Report an elevation in temperature immediately. Encourage the client to eat raw, fresh fruits and vegetables.

Wash hands before entering the client's room. Advise use of a soft toothbrush for oral hygiene. Report an elevation in temperature immediately. Rationale: It is essential to prevent infection in a client with severe bone marrow depression; thorough handwashing before touching the client or client's belongings is important. Thrombocytopenia occurs with most chemotherapy treatment programs; using a soft toothbrush helps prevent bleeding gums. Any temperature elevation in a client with neutropenia must be reported to the primary healthcare provider immediately because it may be a sign of infection. Although alopecia does occur with chemotherapy, it is not related to bone marrow suppression. Increasing fluids will neither reverse bone marrow suppression nor stimulate hematopoiesis. This is not related to bone marrow suppression. Clients who have severe bone marrow depression must avoid eating raw fruits and vegetables and undercooked meat, eggs, and fish to prevent possible exposure to microbes.

The nurse instructs the client admitted for an acute exacerbation of chronic obstructive pulmonary disease (COPD) about the importance of assessing for right-sided heart failure after discharge. What does the nurse instruct the client to assess for? Increased appetite Clubbing of the nail beds Hypertension Weight gain

Weight gain Rationale: The most common signs and symptoms of right-sided heart failure are hepatomegaly, weight gain, jugular vein distention, and peripheral edema. Clients with right-sided heart failure often have decreased appetites. Clubbing is indicative of hypoxemia. Hypertension is associated with left-sided heart failure.

A client with laryngeal cancer is receiving chemotherapy. Which laboratory report is most important for the nurse to monitor when considering the effects of chemotherapy? Platelets Hemoglobin level Red blood cell count White blood cell count

White blood cell count Rationale: Antineoplastic drugs depress bone marrow, which results in leukopenia; the client must be protected from infection, which is a primary cause of death in the patient with cancer. Platelets may decrease rapidly, but complications may be limited by infusions of platelets. Although the hemoglobin level diminishes, a transfusion with packed red blood cells (RBCs) will alleviate the anemia. RBCs diminish slowly and may be replaced with a transfusion of packed red blood cells.