Practice Adaptive Quiz MED SURG (Term 2)

A nurse must administer streptomycin 1 g intramuscularly (IM) to a client with tuberculosis. The vial contains 500 mg/mL. How much solution must the nurse administer? Record your answer using a whole number. ____ mL

2 ML Rationale First convert 1 g to its equivalent of 1000 mg and then use the "Desire over Have" formula of ratio and proportion to solve the problem. Desire 1000 mg x mL ------------------ = ------- Have 500 mg 1 mL 500x = 1000 x = 1000 ÷ 500 x = 2 mL

Which condition may cause respiratory alkalosis? Asthma Atelectasis Poliomyelitis Cystic fibrosis

Asthma Rationale Asthma causes respiratory alkalosis. Atelectasis, poliomyelitis, and cystic fibrosis cause respiratory acidosis, not respiratory alkalosis.

Which clinical manifestation occurs in a client with vasopressin deficiency? Impotence Hypotension Amenorrhea Decreased libido

Hypotension Rationale Vasopressin regulates fluid level and blood pressure. A vasopressin deficiency causes hypotension. Impotence, amenorrhea, and decreased libido in both men and women are clinical manifestations of luteinizing and follicle-stimulating hormone deficiencies.

Which is a clinical manifestation of respiratory acidosis? Tetany Tremors Bradycardia Hypertension

Tremors Rationale Tremors are a clinical manifestation of respiratory acidosis. Tetany is a clinical manifestation of respiratory alkalosis. Tachycardia, not bradycardia, is a clinical manifestation of respiratory acidosis. Hypotension, not hypertension, may manifest in respiratory acidosis.

A nurse provides smoking cessation education to a client with chronic obstructive pulmonary disease (COPD). The nurse concludes that the client is ready to quit smoking when the client makes which statement? "I'll just finish the carton that I have at home." "I'll cut back to a half pack a day." "I find that smoking is the only way I can relax." "I should find this easy because I don't smoke when I drink."

"I'll cut back to a half pack a day." Rationale The response "I'll cut back to a half pack a day" is a positive step in reducing smoking; it is the first step toward stopping. The response "I'll just finish the carton that I have at home" is postponing the decision to quit. The response "I find that smoking is the only way I can relax" is rationalizing why quitting smoking is too difficult. The response "I should find this easy" is unrealistic because giving up smoking is difficult regardless of if the client smokes when alcoholic beverages are consumed.

A client has a persistent productive cough that becomes blood tinged. A needle biopsy is scheduled. The client tells the nurse, "During the procedure, a needle will be inserted into my back to collapse my lung." Which is the most appropriate response by the nurse? "Your perception of the diagnostic test is incorrect." "I will ask the primary health care provider to clarify the diagnostic procedure." "Tell me more about the conversation you had with your health care provider." "The procedure will be fast so that you will experience minimal discomfort."

"Tell me more about the conversation you had with your health care provider." Rationale Exploration and collection of data are important parts of the therapeutic process; anxiety, fear, and depression can influence understanding. The response "Your perception of the diagnostic test is incorrect" will put the client on the defensive. Instructing the client to ask the health care provider to clarify the procedure is not the priority; at this point, the nurse should collect more data. The response "The procedure will be fast so that you will experience minimal discomfort" is false reassurance.

A client is admitted with a diagnosis of chronic adrenal insufficiency. Which roommate should be avoided when assigning a room for this client? A young adult client with pneumonia An adolescent client with a fractured leg An older adult client who had a brain attack A middle-aged client who has cholecystitis

A young adult client with pneumonia Rationale Circulatory collapse can be caused by exposure to an infection, cold, or overexertion of a client with chronic adrenocortical insufficiency (Addison disease). Roommates with a fractured leg, a brain attack, or cholecystitis are appropriate room assignments because they do not have communicable infections.

Which statement regarding menopause is true? Hot flashes are a result of an increase in estrogen Menopause usually occurs in women between 18 and 22 years of age During menopause, menstrual flow ceases and hormone levels decrease Cigarette smoking, family history, and surgical interventions are all associated with delayed menopause

During menopause, menstrual flow ceases and hormone levels decrease Rationale During menopause, menstruation ceases and estrogen and progesterone hormone levels decrease. The reduction in estrogen results in hot flashes. Menopause usually occurs in women between 42 and 58 years of age. Cigarette smoking, family history, and surgical intervention are all associated with early menopause.

Which statements are true regarding type I diabetes mellitus? Select all that apply. It causes weakness and fatigue. It decreases libido and disturbs body image. It is usually observed in overweight individuals. It results in frequent incidence of complications. It usually occurs in individuals older than 35 years of age.

It causes weakness and fatigue. It decreases libido and disturbs body image. It results in frequent incidence of complications. Rationale Type I diabetes mellitus causes weakness and fatigue. It decreases libido and disturbs body image. It results in frequent incidence of complications. It is usually observed in underweight individuals. It usually occurs in individuals younger than 35 years of age.

A client is admitted to the hospital with a diagnosis of cancer of the larynx, and a total laryngectomy is scheduled. Which nursing action is most important in the immediate postoperative management of this client? Instructing the client to whisper Placing the client in the orthopneic position Suctioning the tracheostomy tube whenever necessary Changing the outer tracheostomy tube at least once a day

Suctioning the tracheostomy tube whenever necessary Rationale Secretions are increased because of alterations in structure and function; a patent airway must be maintained. The client cannot whisper because air no longer exits the lungs by passing through the vocal cords. Initially nonverbal and written forms of communication are encouraged. The orthopneic position may cause neck flexion and block the airway. The outer tracheostomy tube is not removed because the stoma may close.

A female client has a history of recurrent urinary tract infections. What should the nurse include in the teaching plan when teaching the client about health practices that may help decrease future urinary tract infections? Wear cotton underpants. Void at least every 6 hours. Increase alkaline ash foods in the diet. Wipe from back to front after toileting.

Wear cotton underpants. Rationale Cotton allows air to circulate and does not retain moisture the way synthetic fabrics do; microorganisms multiply in warm, moist environments. Drinking 3 L of fluids a day and voiding every 2 hours help to flush ascending microorganisms from the bladder, thereby reducing the risk for urinary tract infections. Foods high in acid, not alkaline, ash help to acidify urine; this urine is less likely to support bacterial growth. Wiping from back to front after toileting may transfer bacteria from the perianal area toward the urinary meatus, which will increase the risk for urinary tract infection.

What is the manifestation of Cushing syndrome? "Moon face" Weight loss Short stature Skin hyperpigmentation

"Moon face" Rationale The manifestation of Cushing syndrome is "moon face" and weight gain. Short stature is a sign of dwarfism. Skin hyperpigmentation is a feature of Addison's disease.

The nurse is providing care for a client who had an endarterectomy one month ago. The nurse explains the reason that clopidogrel (Plavix) is being prescribed. The nurse concludes that the teaching is understood when the client says what? "The medication will limit inflammation around my incision." "The medication will help prevent further clogging of my arteries." "The medication will lower the slight fever I have had since surgery." "The medication will reduce the discomfort I feel at the surgical incision."

"The medication will help prevent further clogging of my arteries." Rationale Clopidogrel interferes with platelet aggregation, thus impeding the formation of thrombi, which clog arteries. Clopidogrel is a platelet aggregation inhibitor, not an anti-inflammatory, antipyretic, or analgesic.

The nurse is providing care to a client being treated for bacterial cystitis. What is the goal before discharge for this client? Understand the need to drink 4 L of water per day, an essential measure to prevent dehydration Be able to identify dietary restrictions and plan menus Achieve relief of symptoms and maintain kidney function Recognize signs of bleeding, a complication associated with this type of procedure

Achieve relief of symptoms and maintain kidney function Rationale Relief of symptoms and continued urine output are measurable responses to therapy and are the desired outcomes. Four liters of water per day is too much fluid; 2 to 3 liters a day is recommended to flush the bladder and urethra. Dietary restrictions are not necessary with cystitis. Bleeding is not a complication associated with this procedure.

Which assessment should the nurse obtain before administering digoxin (Lanoxin) to a client? Apical heart rate Radial pulse on the left side Radial pulse in both right and left arms Difference between apical and radial pulses

Apical heart rate Rationale Because digoxin (Lanoxin) slows the heart rate, the apical pulse should be counted for one minute before administration. If the apical rate is below a preset parameter (usually 60 bpm), digoxin should be withheld because its administration may further decrease the heart rate. Some protocols permit waiting for one hour and retaking the apical rate; the result determines if it is administered or the health care provider is notified. Obtaining the radial pulse on the left side is not as accurate as an apical pulse; the client also may have an atrial dysrhythmia, which cannot be detected through a radial rate alone. Obtaining the radial pulse in both right and left arms is not as accurate as an apical pulse; the client also may have an atrial dysrhythmia, which cannot be detected through a radial rate alone. Obtaining the difference between apical and radial pulses is a pulse deficit, not a pulse rate.

A hospitalized client puts the call light on and reports a sudden onset of chest pain that feels like a pressure or weight on the chest. The client also states, "I feel nauseated and very weak." What action should the nurse take? Call the rapid response team Perform a nutritional assessment Discuss possible sources of stress with the client Provide reassurance while helping the client to focus on pleasant topics

Call the rapid response team Rationale These are classic symptoms of a myocardial infarction; further medical evaluation and intervention are needed immediately. Performing a nutritional assessment presumes a dietary problem when a more serious situation may exist. Discussing possible sources of stress with the client considers only an emotional source of the reported symptoms and ignores a potential medical emergency. Providing reassurance while helping the client to focus on pleasant topics provides false reassurance and ignores a potential medical emergency.

A client is receiving doxorubicin as part of a chemotherapy protocol. The nurse should assess the client for which major life-threatening side effect of doxorubicin? Anemia Cardiotoxicity Pulmonary fibrosis Ulcerative stomatitis

Cardiotoxicity Rationale Heart failure and dysrhythmias are the primary life-threatening toxic effects unique to doxorubicin. When bone marrow is depressed to precarious levels, the dose is altered or blood components administered. Pulmonary fibrosis is not an adverse effect of doxorubicin or of any of the other antineoplastic agents. Ulcerative stomatitis is an uncomfortable side effect of doxorubicin, but it is not life threatening as are the primary life-threatening toxic effects unique to doxorubicin.

A nurse instructs a client with a history of frequent urinary tract infections to drink cranberry juice to do what? Decrease the urinary pH Exert a bactericidal effect Improve glomerular filtration Relieve the symptoms of dysuria

Decrease the urinary pH Rationale Cranberry juice is excreted as hippuric acid, which helps acidify the urine (decrease the pH) and inhibit bacterial growth. Although bacterial growth may be inhibited, bacteria are not destroyed. Glomerular filtration is unaffected by cranberry juice. Cranberry juice acidifies the urine and may increase the burning sensation associated with urination when an infection is present.

A nurse is caring for a newborn with a diaphragmatic hernia and impaired gas exchange. What does the nurse identify as the cause of the infant's decreased gas exchange? Incarcerated hernia Decreased oxygen intake Increased basal metabolic rate Excessive respiratory secretions

Decreased oxygen intake Rationale The presence of abdominal viscera in the thoracic cavity impinges on the lungs and affects their ability to expand, thus limiting the amount of air that can enter the lungs and alveoli. In addition, these newborns tend to have underdeveloped lungs. An incarcerated hernia, although a medical emergency, does not impair gas exchange on a long-term basis. The basal metabolic rate is not increased with a diaphragmatic hernia. Excessive secretions do not occur with a diaphragmatic hernia.

A client with emphysema experiences shortness of breath and uses pursed-lip breathing and accessory muscles of respiration. What does the nurse determine as the cause of the dyspnea? Spasm of the bronchi that traps the air Increase in the vital capacity of the lungs Too rapid expulsion of the air from the alveoli Difficulty in expelling the air trapped in the alveoli

Difficulty in expelling the air trapped in the alveoli Rationale Emphysema involves destructive changes in the alveolar walls, leading to dilation of the air sacs; there is subsequent air trapping and difficulty with expiration. Bronchospasm is characteristic of asthma, not emphysema. The vital capacity is decreased because of restriction of the diaphragm and thoracic movement. Expiration is slowed by pursed-lip breathing to keep the airways open so less air is trapped.

A client with hypertension has received a prescription for metoprolol (Lopressor). Which information should the nurse include when teaching this client about metoprolol? Consume alcoholic beverages in moderation Do not abruptly discontinue the medication Increase the medication dosage if chest pain occurs Report a heart rate of less than 70 beats per minute

Do not abruptly discontinue the medication Rationale Abrupt discontinuation of metoprolol may cause rebound hypertension and an acute myocardial infarction. Alcohol is contraindicated for clients taking beta-adrenergic blockers such as metoprolol. Clients should never increase medications without medical direction. The pulse rate can go lower than 70 beats per minute as long as the client feels well and is not dizzy.

A nurse teaches the signs of organ rejection to a client who had a kidney transplant. What should be included in the education? Weight loss Subnormal temperature Elevated blood pressure Increased urinary output

Elevated blood pressure Rationale Hypertension is caused by hypervolemia because of the failure of the new kidney. Weight gain, not loss, occurs with a rejection of the kidney because of fluid retention. The client will have an elevated temperature exceeding 100° F with kidney rejection. Urine output will be decreased or absent, depending on the degree of kidney rejection.

Which intervention should the nurse implement to help prevent atelectasis in a client with fractured ribs as a result of chest trauma? Apply a thoracic binder for support. Encourage coughing and deep breathing. Defer pain medication the first day after injury. Position the client face-down on a soft mattress.

Encourage coughing and deep breathing. Rationale Atelectasis with impaired gas exchange is a major complication when clients use shallow breathing to avoid pain; coughing and deep breathing help mobilize secretions. Applying a thoracic binder for support may impede deep breathing and coughing, which help prevent atelectasis. Analgesics are essential to diminish pain caused by breathing and help motivate the client to cough and deep breathe. The prone position may diminish breathing for both lungs and is contraindicated.

A client with respiratory disorder complains of fatigue. Which nursing intervention will be beneficial for this client? Assessing the degree of dyspnea Encouraging adequate periods of rest Instruction in effective breathing techniques Monitoring for nasal flaring and sternal retractions

Encouraging adequate periods of rest Rationale A client with fatigue should be encouraged to get adequate rest to conserve energy and reduce fatigue. The degree of dyspnea should be assessed in a client with an ineffective breathing pattern but won't matter in reducing fatigue. Effective breathing techniques should be taught to the client with an ineffective breathing pattern, but it is unlikely to improve fatigue. Nasal flaring and sternal retractions should be noted in a client with ineffective breathing pattern but won't help fatigue.

The most essential nursing intervention for a client with a nephrostomy tube is to do what? Ensure free drainage of urine Milk the tube every two hours Instill 2 mL of normal saline every eight hours Keep an accurate record of intake and output

Ensure free drainage of urine Rationale The tube must be kept patent to prevent urine backup, hydronephrosis, and kidney damage. Milking the tube every two hours is unnecessary unless the tube is not functioning. Instilling 2 mL of normal saline every eight hours is a dependent function and requires a health care provider's prescription. Although keeping an accurate record of intake and output is important, it will not ensure free drainage of urine, which is the priority.

A client is admitted to the hospital with diabetic ketoacidosis. The nurse identifies that the elevated ketone level present with this disorder is caused by the incomplete oxidation of what? Fats Protein Potassium Carbohydrates

Fats Rationale Incomplete oxidation of fat results in fatty acids that further break down to ketones. Protein metabolism results in nitrogenous waste production, causing elevated blood urea nitrogen (BUN). Potassium is not oxidized. Ketones do not result when there are alterations in potassium levels. Carbohydrates do not contain fatty acids that are broken down into ketones.

A nurse assesses a newly admitted client with renal colic to determine the signs and symptoms that are present. The nurse assesses the client for which primary subjective symptom? Uremia Nausea Voiding at night Flank discomfort

Flank discomfort Rationale A subjective symptom must be experienced and described by the client; flank pain, pain on the side of the body between the ribs and the ileum, accompanies renal colic. Uremia and voiding at night are objective signs that can be verified by observation or measurement. Although nausea is a subjective symptom and can occur with the severe pain associated with renal colic, it is not as significant as flank pain.

During a yearly physical examination a complete blood count (CBC) is performed to determine a client's hematological status. The nurse recalls that the CBC is composed of several tests, one of which is the level of what? Blood glucose Hemoglobin (Hb) C-reactive protein Blood urea nitrogen (BUN)

Hemoglobin (Hb) Rationale A CBC includes red blood cell (RBC) count and RBC indices, white blood cell (WBC) count and WBC differential count, hemoglobin (Hb), hematocrit (Hct), and platelet count. A blood glucose level is not part of a CBC. The C-reactive protein level is not part of a CBC. BUN is not part of a CBC.

A nurse is assessing a female client with Cushing syndrome. Which clinical findings can the nurse expect to identify? Select all that apply. Hirsutism Menorrhagia Buffalo hump Dependent edema Migraine headaches

Hirsutism Buffalo hump Rationale Excessive hairiness, especially a male pattern of hair distribution on a woman (hirsutism), occurs with Cushing syndrome because of an androgen excess. Cushing syndrome results from excess adrenocortical activity. Hypercortisolism causes fat redistribution, resulting in "buffalo hump"; it also contributes to slow wound healing, hirsutism, weight gain, hypertension, acne, thin arms and legs, and behavioral changes. Menorrhagia (excessive menstrual bleeding) does not occur; menses may cease or be scanty because of virilization. Edema does not occur except when severe heart failure is present. Headaches do not occur with this syndrome.

A client experiences angina and is admitted to the telemetry unit for observation. Sublingual nitroglycerin tablets are prescribed to control periodic episodes of chest pain. Which instruction should the nurse include when teaching the client about the correct use of sublingual nitroglycerine? Plan to take the tablet between meals. Take the tablet with a full glass of juice. Dissolve the tablet in water before swallowing it. Hold the tablet under the tongue until it is dissolved.

Hold the tablet under the tongue until it is dissolved. Rationale A rich vascular supply is present under the tongue; this ensures quick delivery of medication into the blood. Usually, relief of pain will occur within 5 minutes. Sublingual nitroglycerine is taken during an episode of anginal chest pain, not at preset intervals. The prescribed nitroglycerine is administered sublingually, not orally.

A client with a history of hemoptysis and cough for the last six months is suspected of having lung cancer. A bronchoscopy is performed. Two hours after the procedure the nurse identifies an increase in the amount of bloody sputum. What is the nurse's priority? Immediately contact the primary health care provider Document the amount of sputum Monitor vital signs every hour Increase the frequency of coughing and deep breathing

Immediately contact the primary health care provider Rationale The observation may be indicative of bleeding and the health care provider should be notified. Overlooking the first signs of hemorrhage may permit the client to go into shock. Continuing only to monitor the client is unsafe. Monitoring vital signs every hour for four hours is a potentially life-threatening situation; the health care provider should be notified immediately. Increasing the coughing and deep breathing regimen can precipitate bleeding because of an increase in intrathoracic pressure.

Which structure extends from the mons pubis to the perineal floor? Rugae Hymen Vestibule Labia majora

Labia majora Rationale The labia majora are two large folds that extend from the mons pubis to the perineal floor. The walls of the vagina normally lie in folds called rugae. The external opening of the vagina is covered by a fold of mucus membrane, skin, and fibrous tissue called a hymen. The vestibule is the space enclosing the structures located beneath the labia minora.

The nurse provides education about signs and symptoms of hypoglycemia to a client with newly diagnosed type 1 diabetes. The nurse concludes that the teaching was effective when the client states that she will drink orange juice and eat a slice of bread when she feels what? Nervous and weak Flushed and short of breath Thirsty and has a headache Nauseated and has abdominal cramps

Nervous and weak Rationale These are the most commonly reported symptoms of hypoglycemia and are related to increased sympathetic nervous system activity. Feeling flushed and short of breath are adaptations of hyperglycemia. Being thirsty, having a headache, being nauseated, or having abdominal cramps are symptoms of hyperglycemia.

Which carcinoma is the most common type of thyroid cancer and is most often found in younger women? Papillary carcinoma Follicular carcinoma Medullary carcinoma Anaplastic carcinoma

Papillary carcinoma Rationale Papillary carcinoma is the most common type of thyroid cancer; it is most often seen in younger women. Follicular carcinoma occurs most often in older adults. Medullary carcinoma is seen mostly in clients older than 50 years. Anaplastic carcinoma is a rapid-growing, aggressive tumor.

A client receives a prescription for nitroglycerin (Nitrostat) sublingual as needed for anginal pain. What should the nurse include in the teaching about this medication? To facilitate absorption, drink a large glass of water after taking the medication Place the tablet under the tongue or between the cheek and gum It takes 30 to 45 minutes for the nitroglycerin to achieve its effect If dizziness occurs, take a few deep breaths and lean the head back

Place the tablet under the tongue or between the cheek and gum Rationale Nitroglycerin sublingual tablets should not be chewed, crushed, or swallowed. They work much faster when absorbed through the lining of the mouth. Clients are instructed to place the tablet under the tongue or between the cheek and gum, and let it dissolve. The client should not eat, drink, smoke, or use chewing tobacco while a tablet is dissolving; this will decrease the effectiveness of the drug. If taken with water, the tablet is washed away from the site of absorption or may be swallowed. Nitroglycerin sublingual tablets usually give relief in one to five minutes. If a client experiences dizziness or lightheadedness, the client is instructed to take several deep breaths and bend forward with the head between the knees. This position promotes blood flow to the head.

When obtaining a health history from a client recently diagnosed with type 1 diabetes, the nurse expects the client to report what clinical manifestations? Irritability, polydipsia, and polyuria Polyuria, polydipsia, and polyphagia Nocturia, weight loss, and polydipsia Polyphagia, polyuria, and diaphoresis

Polyuria, polydipsia, and polyphagia Rationale Excessive thirst (polydipsia), excessive hunger (polyphagia), and frequent urination (polyuria) are caused by the body's inability to metabolize glucose adequately. Although polydipsia and polyuria occur with type 1 diabetes, lethargy occurs because of a lack of metabolized glucose for energy. Although polydipsia and weight loss occur with type 1 diabetes, frequent urination occurs throughout a 24-hour period because glucose in the urine pulls fluid with it. Although polyphagia and polyuria occur with type 1 diabetes, diaphoresis occurs with severe hypoglycemia, not hyperglycemia.

A client with laryngeal cancer has a partial laryngectomy and tracheostomy. What should the nurse do to best facilitate communication postoperatively? Provide a means for the client to write. Allow the client more time for articulation. Use visual clues, such as gestures and objects. Face the client and speak slowly and distinctly.

Provide a means for the client to write. Rationale The client will be unable to speak because a tracheostomy tube is in place to prevent edema. The client cannot speak with a tracheostomy tube in place. The client's ability to see and hear is not affected. The client can receive information but cannot speak. The client's ability to hear or understand is not affected.

A client who is taking an oral hypoglycemic daily for type 2 diabetes develops the flu and is concerned about the need for special care. What should the nurse advise the client? Select all that apply. Avoid solid food. Take the oral medication. Drink fluids throughout the day. Monitor capillary glucose levels. Do not take medication until tolerating food.

Take the oral medication. Drink fluids throughout the day. Monitor capillary glucose levels. Rationale Physiologic stress increases gluconeogenesis, requiring continued pharmacologic therapy despite an inability to eat; fluids prevent dehydration; monitoring of glucose levels permits early intervention if necessary. Skipping the oral hypoglycemic agent may precipitate hyperglycemia. Food intake should be attempted to prevent acidosis. Delaying an oral hypoglycemic agent may precipitate hyperglycemia.

A client hospitalized for heart failure is receiving digoxin (Lanoxin) and will continue taking the drug after discharge. What should be included in the plan of care for the next few days? Monitoring vital signs and encouraging a vigorous aerobic exercise program. Taking the apical pulse before drug administration and teaching the client how to count the pulse. Contacting Social Services for a home health nursing consultation. Providing written material on the adverse effects of the medication.

Taking the apical pulse before drug administration and teaching the client how to count the pulse. Rationale Adverse effects of digoxin include many types of dysrhythmias. If the patient's apical pulse rate is less than 60, the medication is "held" and the health care provider is notified. Because the client will be taking the medication at home, the client should be taught how to take an accurate pulse and to contact the health care provider if the rate falls outside predetermined parameters. The client will be assuming responsibility for drug administration at home; teaching is the priority. Vigorous exercise is not recommended for clients who have heart failure. There is nothing in the question to suggest the client requires home health care. Providing written material on the adverse effects may not meet all of the client's learning needs.

After thoracic surgery a client has a chest tube connected to a water-seal drainage system that is attached to suction. When excessive bubbling is observed in the water-seal chamber, what should the nurse do? Strip the chest tube catheter Check the system for air leaks Decrease the amount of suction pressure Recognize that the system is functioning correctly

Check the system for air leaks Rationale Excessive bubbling indicates an air leak, which must be eliminated to permit lung expansion. Striping the chest tube catheter is contraindicated because it can increase the pressure in the pleural space and cause a pneumothorax. Decreased suction pressure results in limiting bubbling in the suction control, not the water-seal chamber. Excessive bubbling in the water-seal chamber is not expected; the system is malfunctioning.

Four days after the client's total hip arthroplasty, the nurse is preparing to transfer the client to a rehabilitation center. Before admission the client took warfarin sodium (Coumadin) daily for a history of pulmonary embolus. While hospitalized, the client received subcutaneous heparin two times a day. The nurse does not see any anticoagulant therapy listed on the client's transfer prescriptions. What should the nurse do? Contact the health care provider to determine what anticoagulant therapy should be prescribed for this client Arrange for a supply of heparin for the client to take to the rehab center Explain to the client that anticoagulant therapy will no longer be needed Instruct the client to talk about anticoagulant needs with the health care provider at the rehabilitation center

Contact the health care provider to determine what anticoagulant therapy should be prescribed for this client Rationale Failure to clarify this omission can be life threatening because of the potential for an embolus. Waiting until the client is in the new facility to discuss the administration of an anticoagulant may jeopardize the client's status. Because anticoagulant therapy was not included in the transfer prescriptions, the nurse cannot legally supply the client with medications to take to the rehabilitation center. It is unclear what the anticoagulant needs are for this client; it is unsafe to tell the client that anticoagulants are no longer required. It is the nurse's, not the client's, responsibility to discuss this situation with the health care provider.

A nurse is caring for a client who had an open abdominal cholecystectomy because of biliary colic. Which nursing action is most important during the postoperative period? Maintaining T-tube drainage Ensuring a pain-free experience Encouraging coughing and deep breathing Providing a heating pad for shoulder pain for 15 minutes hourly

Encouraging coughing and deep breathing Rationale Because of the high abdominal surgical incision clients often avoid deep breathing and coughing and therefore need support and encouragement to accomplish these actions. Monitoring oxygen saturation allows the nurse to identify an ineffective gas exchange so that more intensive support and encouragement can be implemented. Although maintaining T-tube drainage is important, encouraging coughing and deep breathing supports effective gas exchange, which is essential to prevent serious respiratory complications. Ensuring a pain-free experience may not be possible; some discomfort is expected. The nursing goal is to keep the client's pain at least at a tolerable level. Providing a heating pad for shoulder pain for 15 minutes hourly is employed for the shoulder pain caused by retained carbon dioxide after a laparoscopic cholecystectomy, not for an abdominal cholecystectomy.

A client with a 30-year history of smoking has several episodes of blood in the sputum. A bronchoscopy with a lung biopsy is performed. After the procedure, what is the most important nursing intervention? Assess for signs of hemoptysis Have the client rest in the supine position Check the client's level of consciousness frequently Ensure nothing by mouth (NPO) until the gag reflex returns

Ensure nothing by mouth (NPO) until the gag reflex returns Rationale Ensuring nothing by mouth until the gag reflex returns prevents aspiration. Although assessing for signs of hemoptysis is important because hemoptysis can occur after these procedures, it is not the priority. The supine position can promote aspiration. Checking for level of consciousness is unnecessary after this procedure.

Which part of the upper respiratory system is involved in equalizing the pressure within the middle ear while swallowing? Glottis Paranasal sinus Palatine tonsils Eustachian tubes

Eustachian tubes Rationale The Eustachian tubes connect the nasopharynx to the middle ears; these tubes open during swallowing to equalize pressure within the middle ear. The glottis is the opening between true vocal cords. The paranasal sinuses are air-filled cavities within the bones that surround the nasal passages. Palatine tonsils are a part of the immune system and are located on the sides of the oropharynx. These tonsils protect against invading organisms.

A client would benefit from diaphragmatic breathing. What should the nurse advise the client to do? Take rapid, deep breaths Breathe with hands on the hips Expand the abdomen on inhalation Perform exercises leaning forward while in a sitting position

Expand the abdomen on inhalation Rationale Expanding the abdomen on inhalation aids descent of the diaphragm so that more air can enter and fill the lungs. Rapid breathing promotes respiratory alkalosis; diaphragmatic breathing includes slow deep breathing. The hands should be placed lightly on the abdomen to verify abdominal excursion. Diaphragmatic breathing may be performed in any position other than the prone or Trendelenburg; usually the semi-Fowler position is used.

A client responds well after extensive pulmonary surgery for lung cancer and is discharged. A week after discharge the home care nurse observes the client's downcast eyes and lack of interest in the environment. The client's family states that this behavior started a few days after discharge. The nurse understands that the client's response is what? Normal, and no follow-up is required Expected, but needs to be addressed Unusual, indicating mental illness Serious, needing immediate acute care

Expected, but needs to be addressed Rationale Depression is an expected part of grieving that requires supportive care. Although depression is a normal response, intervention is necessary because it cannot be assumed that the depression will be of short duration. Depression is an expected response to the diagnosis of cancer; it does not indicate mental illness. Unless the client is suicidal, immediate acute care is not indicated.

A client is to be transferred from the coronary care unit to a progressive care unit. The client asks the nurse, "Are you sure I'm ready for this move?" From this statement the nurse determines that the client most likely is experiencing what? Fear Depression Dependency Ambivalence

Fear Rationale Fear of a recurrent myocardial infarction or sudden death is common when the client's environment is to be changed to one that appears less vigilant. Depression is exhibited by withdrawal, crying, anorexia, and apathy, and it usually becomes more evident after discharge from the hospital. Dependency is exhibited by an unwillingness to increase exercise or perform tasks. Ambivalence is exhibited by contrasting emotions; the client's statement does not demonstrate this.

The parent of a 5-month-old infant with heart failure questions the necessity of weighing the baby every morning. What does the nurse say to explain the importance this information to the infant's condition? Fluid retention Kidney function Nutritional status Medication dosage

Fluid retention Rationale Fluid retention is reflected by an excessive weight gain in a short period. Inadequate cardiac output decreases blood flow to the kidneys and thus leads to increased intracellular fluid and hypervolemia. Although this assessment may add information to the data regarding kidney function, other assessments, such as hourly urine output, blood urea nitrogen concentration, and creatinine level more significantly reflect kidney function. Weight gain resulting from nutritional intake is gradual and will not vary greatly on a day-to-day basis. Although weight is used to determine medication dosages, dosages do not need to be recalculated according to changes in daily weights.

An older adult client states, "I walk 2 miles a day for exercise, but now that the weather is hot, I am worried about becoming dehydrated." What should the nurse teach the client? Drink fruit juices if you start to feel dehydrated. Thirst is a good guide to use to determine fluid intake. Fluids should be increased if the urine is getting darker. Water should be consumed when the skin becomes dry.

Fluids should be increased if the urine is getting darker. Rationale In hot weather, dark-colored urine indicates dehydration. The amount of fluid to be excreted is less, and the body is attempting to conserve fluid. Fruit juices should be avoided during rehydration because of their high sugar content. By the time people become thirsty, they already are dehydrated, especially older adults. Dry skin in older adults may be related to aging rather than to dehydration. Water intake should be adequate (in hot weather, dark-colored urine indicates dehydration. The amount of fluid to be excreted is less, and the body is attempting to conserve fluid. Approximately 2000 mL daily is needed) and spaced throughout the day.

While caring for a client who had an open reduction and internal fixation of the hip, the nurse encourages active leg and foot exercises of the unaffected leg every two hours. The nurse explains that these exercises will help do what? Prevent clot formation Reduce leg discomfort Maintain muscle strength Limit venous inflammation

Prevent clot formation Rationale Active range-of-motion (ROM) exercises increase venous return in the unaffected leg, preventing complications of immobility, including thrombophlebitis. These isotonic exercises are being performed on the unaffected extremity; there should be no discomfort. Although isotonic exercises do promote muscle strength, that is not the purpose of these exercises at this time. Active ROM exercises help prevent, not limit, venous inflammation.