Practice Custom 3 banks Med Surge 2

A nurse is caring for a client who has a prescription for 3,000 mL of dextrose 5% in 0.45% sodium chloride to infuse IV over 24 hr. The nurse initiates an IV infusion of 1,000 mL of this fluid at 0800. At what time should the nurse prepare to initiate the second 1,000 mL bag? 1600 2400 1200 1800

1600 3000 mL is going to be infused over 24 hr. Each 1000 mL will hang for 8 hr. The first 1000 mL bag was initiated at 0800, so the second 1000 mL bag will be initiated in 8 hr, or at 1600.

A nurse is preparing to administer 0.45% sodium chloride (NaCl) 1000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero) mL/hr

The nurse should set the IV pump 125 mL/hr.

A nurse is providing dietary teaching for a client who has a new prescription for a monoamine oxidase inhibitor (MAOI). When the client develops a sample lunch menu, which of the following items requires intervention by the nurse? Glass of whole milk Celery sticks Bologna sandwich Sliced apples

Bologna sandwich Clients who are receiving an MAOI should avoid foods containing a high tyramine content. Bologna has a high tyramine content and should be avoided.

A nurse is caring for a client who has a prescription for potassium chloride (KCL) 20 mEq PO daily. The nurse reviews the client's most recent laboratory results and finds the client's potassium level is 5.2 mEq/L. Which of the following actions should the nurse take? Give the ordered KCL as prescribed. Omit the KCL dose and document it was not given. Call the prescribing physician and inform her of the client's serum potassium level results. Call the lab to verify the client's results.

Call the prescribing physician and inform her of the client's serum potassium level results. As a potassium level of 5.2 mEq/L is above the expected reference range, the nurse should hold the medication and notify the provider of the client's serum potassium level.

A nurse is caring for a client who is taking sucralfate. Which of the following outcomes indicates a therapeutic effect of the medication? Alleviate Helicobacter pylori Relief of gastrointestinal pain Prevention of opportunistic infections Improvement of impaired vision

Relief of gastrointestinal pain Sucralfate, an antiulcer medication, is prescribed for acute or maintenance therapy of duodenal ulcers. A therapeutic effect of the medication is relief of gastrointestinal pain associated with gastric ulcers. Sucralfate also promotes ulcer healing.

A nurse is caring for a 20-year-old client who has a fever and reports severe headache. Temperature 38.9° C (102° F); Tympanic Apical pulse 118/min; strong and regular Respirations 20/min; even and unlabored Blood pressure 114/78 mm Hg Oxygen saturation 97% on room air Nurses notes 0800: Client reports missing classes at a local community college the last two days due to fever and headache. Rates pain with headache as a 9 on a scale of 0 to 10. Verbalizes that headache was not relieved by acetaminophen or ibuprofen taken at home. Client awake, alert, and oriented to person, place, and time. Pupils equal, round, and reactive to light. Temperature elevated. Skin warm and dry, face flushed. Petechiae noted on trunk. Reports nausea and vomiting for the last 24 hr. Bowel sounds positive x 4 quadrants. Abdomen soft and nontender to light palpation. Photophobia present. Nuchal rigidity noted. Brudzinski's sign positive. Respirations easy and unlabored. Lungs clear to auscultation. 0815: Provider notified of client's current vital signs and assessment findings. New prescriptions received A nurse is preparing the client for a lumbar puncture. Which of the following actions should the nurse take? Select all that apply. Obtain coagulation studies. Administer IV sedation as prescribed. Ensure informed consent is obtained. Place the client in a lateral position with the knees drawn to the abdomen. Administer a soapsuds enema. Assess for allergies to contrast dyes. Provide education about the procedure. Place client NPO for 4 to 6 hr.

Administer a soapsuds enema is incorrect. To help prevent discomfort during the procedure, the client should empty the bowel and bladder prior to the procedure. However, the administration of a soapsuds enema is not required. Place the client in a lateral position with the knees drawn to the abdomen is correct. The client should be placed in a side-lying position with the knees drawn to the abdomen and the chin touching the chest. This position separates the lumbar vertebrae and allows for easier needle insertion. Assess for allergies to contrast dyes is incorrect. Contrast dyes are not used for a lumbar puncture; they are used for cerebral angiography. Obtain coagulation studies is correct. Systemic inflammation caused by meningitis can cause coagulopathy to occur. To decrease the risk of bleeding during and after the procedure, the nurse should obtain coagulation studies prior to the procedure. Place client NPO for 4 to 6 hr is incorrect. Aspiration is not a concern with a lumbar puncture. Clients undergoing a cerebral angiography would be placed on NPO status. Ensure informed consent is obtained is correct. A lumbar puncture is an invasive procedure. The nurse should ensure that informed consent has been obtained before the procedure occurs. Administer IV sedation as prescribed is incorrect. The client who is undergoing a lumbar puncture receives a local anesthetic agent at the injection site. IV sedation is not performed. Provide education about the procedure is correct. To decrease the clients fears and misconceptions about the procedure, the nurse should educate the client about what to expect before, during, and after the procedure.

A nurse is assessing a client who received IV conscious sedation for a colonoscopy. Which of the following findings indicated that the client is ready for discharge? The client is restless. The client is cooperative and oriented. The client shows a brisk response to stimulus. The client shows a sluggish response to stimulus.

The client is cooperative and oriented. A client who is cooperative, oriented, and calm will have a Ramsay Sedation score of 2, which indicates the client has recovered adequately to go home with a responsible adult.

A nurse is caring for a client who is exhibiting signs of alcohol withdrawal. Which of the following medications should the nurse plan to administer? Methadone Disulfiram Diazepam Buprenorphine

Diazepam Diazepam is prescribed to treat the symptoms and prevent complications of alcohol withdrawal.

A nurse is providing nutritional teaching to a client who has osteoporosis. Which of the following foods should the nurse recommend as being the highest in calcium? 1 cup carrot strips 3 oz canned salmon 1 cup chopped chicken breast 1 plain baked potato

3 oz canned salmon The nurse should recommend canned salmon as a food to increase calcium intake. A 3 oz serving of canned salmon contains 197 mg of calcium

A nurse is caring for a male client who has chronic glomerulonephritis. Which of the following findings should the nurse expect? Urine specific gravity 1.035 Creatinine clearance 120 mL/min Serum creatinine 7 mg/dL BUN 15 mg/dL

Serum creatinine 7 mg/dL A serum creatinine of 7 mg/dL is a critical value that indicates serious impairment of renal function. Clients who have chronic glomerulonephritis usually develop the disease over 20 to 30 years. Gradual changes occur in the kidney resulting in atrophy and a decreased number of functioning nephrons.

A nurse is collecting data on a client who has a new prescription for ampicillin. The nurse should recognize which of the following findings is a priority? Nausea Vomiting Wheezing Moniliasis

Wheezing When using the airway, breathing, circulation approach to client care, the nurse should determine the priority finding is wheezing. Wheezing is a manifestation of an anaphylactic allergic reaction due to bronchospasm and edema in the airway. Wheezing indicates a constriction of the airway and requires immediate intervention to support respiratory function. The nurse should advise the client to wear identification to indicate an allergy to this medication.

A nurse is providing discharge teaching to a client following an abdominal hysterectomy. Which of the following information should the nurse include in the teaching? "You should refrain from sexual intercourse for at least 4 weeks." "You should expect to have burning with urination for the first week." "You should soak in a warm tub bath to ease incisional pain." "You should limit lifting to objects of 20 pounds or less.

""You should refrain from sexual intercourse for at least 4 weeks." The nurse should instruct the client to refrain from engaging in sexual intercourse for 4 to 6 weeks.

A nurse is teaching a client who has bipolar disorder and a prescription for lithium to recognize the manifestations of toxicity. Which of the following statements by the client indicates an understanding of the teaching? "I will report any loss of appetite." "Increased flatulence is an indication of toxicity." "Vomiting is an indication of toxicity." "I will call my provider if I experience any headaches."

"Vomiting is an indication of toxicity." Since vomiting and diarrhea are early signs of lithium toxicity, the client should omit the next dose of lithium and call the provider.

A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider? A change in the Glasgow Coma Scale score from 13 to 11 Diplopia A drop in heart rate from 76 to 70/min Ataxia

A change in the Glasgow Coma Scale score from 13 to 11 In a client who has mild TBI, a decrease of 2 points on the Glasgow Coma Scale indicates a decrease in level of consciousness and that the client is risk of a deteriorating neurologic status. Therefore, this finding is the priority to report to the provider

A nurse is preparing to administer blood to a client. The unit of blood on hand is type B, and the client has type AB blood. Which of the following actions should the nurse take? Administer the blood as ordered. Contact the provider for further orders. Notify the blood bank of the discrepancy. Complete an incident report.

Administer the blood as ordered. The nurse should administer the blood as ordered. Type B blood is compatible with type AB. Type AB blood is considered a universal recipient, as it contains no antibodies to react to transfused blood.

A nurse is caring for a client who has developed gout. Which of the following medications should the nurse prepare to administer? Zolpidem Alprazolam Spironolactone Allopurinol

Allopurinol Allopurinol is a xanthene oxidase inhibitor that reduces uric acid synthesis. The medication is prescribed to treat gout.

A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first? Stop the infusion of blood. Inform the provider. Obtain a urine specimen. Notify the laboratory.

Stop the infusion of blood. This client is experiencing an acute intravascular hemolytic transfusion reaction. The greatest risk to this client is injury from receiving additional blood; therefore, the first action the nurse should take is to stop the infusion of blood.

A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions by the client indicates an understanding of the teaching? The client holds his breath for 10 seconds after inhaling the medication. The client takes a quick inhalation while releasing the medication from the inhaler. The client exhales as the medication is released from the inhaler. The client waits 10 min between inhalations.

The client holds his breath for 10 seconds after inhaling the medication. The medication should be retained in the lungs for a minimum of 10 seconds so the maximum amount of the dosage can be delivered properly to the airways. To use the inhaler, the client exhales normally just prior to releasing the medication, inhales deeply as the medication is released, then holds the medication in the lungs for approximately 10 seconds prior to exhaling.

A nurse is completing a medical interview with a client who has elevated cholesterol levels and takes warfarin. The nurse should recognize that which of the following actions by the client can potentiate the effects of warfarin? The client follows a low-fat diet to reduce cholesterol. The client drinks a glass of grapefruit juice every day. The client sprinkles flax seeds on food 1 hr before taking the anticoagulant. The client uses garlic to lower cholesterol levels.

The client uses garlic to lower cholesterol levels. The nurse should recognize that garlic can potentiate the action of the warfarin.

A nurse is preparing to care for an 84-year-old male client who is being admitted to a medical unit from a provider's office. The nurse reviews the client's medical records to prepare the client's plan of care. Diagnostic Results HbA1C 6.2% (less than 7%) Blood glucose 102 mg/dL (82 to 115 mg/dL)Hemoglobin 14.2 g/dL (14.2 to 18 g/dL)Hematocrit 42.6% (42% to 52%)Total WBC count 6,000/mm3 (5,000 to 10,000/mm3)HDL 35 mg/dL (greater than 45 mg/dL)LDL 142 mg/dL (less than 130 mg/dL)Brain natriuretic peptide (BNP) 352 pg/mL (less than 100 pg/mL)Chest x-ray: Shows cardiomegaly and bibasilar pleural congestion. UrinalysisResultsExpected Reference RangeAppearanceClearClearColorYellowYellowpH5.84.6 to 8.0Specific gravity1.0121.005 to 1.030Leucocyte esteraseNegativeNegativeNitratesNoneNoneCrystalsNoneNoneCastsNoneNoneGlucoseNoneNoneWBC0 to 4 per lower-power fieldNoneRBCLess than or equal to 2None Medication Administration Record Metformin 850 mg PO q amDigoxin 0.25 mg PO q amCarvedilol 25 mg PO bidFurosemide 40 mg IV bolus once now Vital Signs BP 146/98 mm HgTemperature 36.8º C (98.2º F)Pulse rate 106/minRespirations 24/minO2 saturation 94% on 2 L/min nasal cannula Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

The nurse should elevate the head of the bed and encourage an intake of a low-sodium diet because the client is most likely experiencing heart failure because the BNP level, blood pressure, pulse, and respiratory rate are elevated and the chest x-ray indicates an enlarged heart and bibasilar fluid accumulation in the lungs. The nurse should monitor urinary output and blood pressure because the administration of furosemide should result in diuresis/increased urinary output and might lower blood pressure. Teaching the client signs of hyperglycemia, assessing feet for sensation, and encouraging a diet that includes iron-rich foods do not address the condition the client is most likely experiencing, which is congestive heart failure. White blood cell count, fingerstick blood glucose, and hemoglobin are not necessary for the nurse to monitor because they do not directly affect congestive heart failure.

A nurse is caring for a client who experienced an open, right femur fracture following a motor-vehicle crash. Medical History Type 1 diabetes mellitus Diagnostic Results 0300: Hemoglobin 10 g/dL (12 to 16 g/dL; critical value less than 7 g/dL) Hematocrit 34% (37% to 47%) WBC count 10,500/mm3 (5,000 to 10,000/mm3) Glucose 270 mg/dL (74 to 106 mg/dL) 1200: Glucose 244 mg/dL (74 to 106 mg/dL) Nurses' Notes 0700: Client admitted to the orthopedic unit following surgery to reduce the femur fracture and stabilize it through external fixation. Splint to right leg clean, dry, and intact. Client rates pain as 5 on a scale of 0 to 10. Right foot is pink and warm to touch, no edema noted, able to plantar flex and dorsiflex foot when asked, posterior tibial and dorsalis pedis pulses palpable, and capillary refill to toes on right foot less than 2 seconds. Lactated ringers (LR) infusing at 100 mL/hr to left arm intravenous (IV) site. Lung sounds clear. Hypoactive bowel sounds x 4 quadrants. Diagnostic results and medical history noted. 1200: Client reports pain as 10 on a scale of 0 to 10 and numbness to the right foot. Upon assessment, the foot and leg is cool to touch, capillary refill is greater than 2 seconds, and the client is unable to move the foot when asked to do so. 4+ edema noted. Provider notified of the client's condition. Vital Signs 0700: Temperature 36° C (96.8° F) Heart rate 68 /min Respiratory rate 16 /min Blood pressure 110/68 mm Hg SaO2 97 % on 2 L of oxygen via nasal cannula 1200: Temperature 37.3° C (99.1° F) Heart rate 92/min Respiratory rate 22 /min Blood pressure 126/78 mm Hg SaO2 95 % on room air Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

The nurse should identify that the client is most likely experiencing compartment syndrome. Compartment syndrome occurs following a fracture due to increased edema of the extremity or restriction by a cast or splint. It is identified by the five Ps: pain, pallor, pulselessness, paresthesia, and paralysis. Compartment syndrome is a medical emergency. The nurse's priorities are to loosen the dressing to the splint and assess the client's peripheral pulses. A pulse volume recorder may be necessary to detect the peripheral pulses. The nurse should frequently monitor the client's neurovascular function to detect any changes that may indicate further progression of compartment syndrome. The nurse should also monitor and treat the client's pain using prescribed opioids.

A nurse is caring for a client who is 1 day postoperative following a thyroidectomy and reports severe muscle spasms of the lower extremities. Which of the following actions should the nurse take? Check the pedal pulses. Verify the most recent calcium level. Request prescription for a relaxant. Administer an oral potassium supplement.

Verify the most recent calcium level. A client who has had a thyroidectomy is at risk of hypocalcemia due to the possible disruption of the parathyroid gland during surgery. The parathyroid glands are four small glands located inside the thyroid gland that are responsible for calcium regulation. If they are damaged during a thyroidectomy, there is a risk of hypocalcemia. Low calcium levels can be manifested as numbness and tingling of the fingers and around the mouth, muscle spasms (particularly of the hands and feet), and hyperactive reflexes. If a client develops any of these manifestations following a thyroidectomy, the nurse should check the client's latest calcium level. The expected reference range for calcium is 8.5 to 10.5 mg/dL. If the calcium level is low, the provider should be notified, and oral or intravenous calcium replacement should be administered

A nurse on a medical-surgical unit is caring for a newly admitted client with a diagnosis of R/O tuberculosis. Nurses' Notes Day 1: 0900: Client admitted from emergency department with hemoptysis, dull chest pain, increasing fatigue, anorexia, nausea, chest tightness, and 3.2 kg (7 lb) weight loss in 2 weeks. Heart rate regular, lung sounds with crackles in bilateral upper lobes. No edema. Airborne precautions initiated upon admission. Day 2: 1100: Client reports shortness of breath, nausea, and fatigue. Crackles auscultated bilaterally throughout lung fields. Productive cough, with thick, blood-streaked sputum. Bowel sounds active, no edema. Day 3: 0900: Client reports some improvement in dyspnea. Client coughing up thick, yellow, blood-streaked sputum. Crackles auscultated in bilateral upper lobes of lungs. Sclera noted to be yellow. Client's weight is 0.7 kg (1.6 lb) less than at admission. Encouraged to increase intake of oral fluids. Client reports urine appears reddish orange in color. Vital Signs Day 1: Temperature 38.6°C (101.4°F) Heart rate 96/min Respiratory rate 26/min Blood pressure 158/88 mm Hg Oxygen saturation 91% on room air Day 2: Temperature 38.4°C (101.2°F) Heart rate 88/min Respiratory rate 24/min Blood pressure 152/82 mm Hg Oxygen saturation 92% on O2 at 4L/min via nasal cannula Day 3: Temperature 37.8°C (100.1°F) Heart rate 82/min Respiratory rate 22/min Blood pressure 130/78 mm Hg Oxygen saturation 96% on O2 at 4L/min via nasal cannula Provider Prescriptions Day 1: Purified protein derivative 0.1 mL intradermal to right forearm Isoniazid 300 mg PO daily Rifampin 600 mg PO daily Acetaminophen 500 mg 1-2 tablets PO every 4 to 6 hr PRN fever, pain Medical History Client has no chronic illnesses. Traveled out of the country 2 months ago. Diagnostic Results Day 1 ALT 36 SI/L (4 - 36 SI/L) AST 35 units/L (0-35 units/L) Alkaline phosphatase 118 units/L (30-120 units/L) Chest x-ray caseation with inflammation throughout upper lobes Day 3: Mantoux Test: 12 mm induration (negative, reaction less than 5 mm) ALT 38 SI/L (4 - 36 SI/L) AST 36 units/L (0-35 units/L) Alkaline phosphatase 129 units/L (30-120 units/L) Which of the following findings should the nurse report to the provider? Yellow sclera Increasing AST level Weight loss Mantoux test result Increasing ALT level Reddish-orange urine color

When analyzing assessment findings, it is imperative to report yellow sclera, increasing AST and ALT levels, weight loss, and positive Mantoux test. The nurse should identify that yellowed sclera can indicate jaundice, which can be caused by hepatotoxic effects of isoniazid and rifampin. An elevated AST and ALT level can indicate liver disease or damage, which can be caused by hepatotoxic effects of isoniazid and rifampin. Clients who have tuberculosis suffer from anorexia and weight loss. An induration greater than 10 mm in a client who has recently travelled out of the country indicates infection with or expose to tuberculosis.

A nurse is caring for a client receiving hemodialysis. Medical History Client has a history of type 2 diabetes mellitus, chronic kidney disease, and hemodialysis with Arteriovenous fistula. Nurses' Notes Day 1: 1000: Client alert and oriented x3. Lung fields clear, heart rhythm regular; bowel sounds normoactive x4; ate 75% of morning meal. Denies pain. Left forearm arteriovenous (AV) fistula, skin warm, brachial and radial pulses 2+. 1600: Client returned from dialysis, lethargic, not hungry, tried to eat a few crackers but vomited them up. Capillary blood glucose 134 mg/dL. AV fistula site skin warm, bruit and thrill noted, brachial and radial pulses palpable. Day 2: 0700: Client reports not sleeping well last night; capillary blood glucose 75 mg/dL; crackles in left lower lobe; unproductive cough; AV fistula site ecchymotic, warm, bruit and thrill noted. Oriented to person, place, and time. Vital Signs Day 1: 1000: Temperature 36.3°C (97.3°F) Heart rate 70/min Respiratory rate 16/min Blood pressure 144/72 mm Hg Oxygen saturation 94% on room air Weight 90 kg (198 lb) 1600: Temperature 37.1 °C (98.7°F) Heart rate 62/min Respiratory rate 16/min Blood pressure 112/54 mm Hg Oxygen saturation 95% on room air Day 2: 0700: Temperature 36.7°C (98.1°F) Heart rate 62/min Respiratory rate 12/min Blood pressure 118/52 mmHg Oxygen saturation 95% on room air Weight 86.4 kg (190 lb) A nurse is caring for a client who has received hemodialysis. Which of the following assessment findings require follow-up? Vital signs Weight Blood glucose level Presence of bruit and thrill Lung sounds AV fistula site assessment

When analyzing cues, it is appropriate to follow up with the lung and AV fistula site assessments. There has been in a change in the client's lung sounds accompanied by a non-productive cough. The client experienced an episode of nausea with emesis at 1600 the evening prior and could have aspirated or may be retaining fluid related to decreased kidney function. The nurse should assess the site further for evidence of bleeding due to the use of anticoagulants during dialysis.

A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The nurse should anticipate that the client will report that her earliest manifestation was dysphagia. hoarseness. dyspnea. weight loss.

hoarseness. Laryngeal cancer, a malignant tumor of the larynx, is most often caused by long exposure to tobacco and alcohol. Hoarseness that does not resolve for several weeks is the earliest manifestation of cancer of the larynx because the tumor impedes the action of the vocal cords during speech. The voice may sound harsh and lower in pitch than normal.

A nurse is teaching a client who has a new prescription for fluoxetine to treat depression. Which of the following statements by the client indicates an understanding of the teaching? "I should expect to feel better after 24 hours of starting this medication." "I should not take this medicine with grapefruit juice." "I'll take this medicine with food." "I'll take this medicine first thing in the morning."

"I'll take this medicine first thing in the morning." The client should take fluoxetine in the morning to reduce the risk for insomnia

A nurse is caring for a client who has nausea and a prescription for metoclopramide intermittent IV bolus every 4 hr as needed. The client asks the nurse how metoclopramide will relieve her nausea. Which of the following explanations should the nurse provide? "The medication relieves nausea by promoting gastric emptying." "The medication works by decreasing gastric acid secretions." "The medication relieves nausea by slowing peristalsis." "The medication works by relaxing gastric muscles."

"The medication relieves nausea by promoting gastric emptying." Reglan is a gastrointestinal stimulant used to relieve nausea, vomiting, heartburn, stomach pain, bloating, and a persistent feeling of fullness after meals. Reglan works by promoting gastric emptying.

A nurse is teaching a client who has a new prescription for cyclobenzaprine. Which of the following information should the nurse include in the teaching? Discontinue medication if nausea occurs. Expect urine to turn orange. Monitor for increased muscle spasms. Avoid driving until effects are known.

Avoid driving until effects are known. Cyclobenzaprine can cause drowsiness and dizziness. Instruct the client to avoid driving if these effects occur.

A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority? Positive Western blot test CD4-T-cell count 180 cells/mm3 Platelets 150,000/mm3 WBC 5,000/mm3

CD4-T-cell count 180 cells/mm3 A CD4-T-cell count of less than 180 cells/mm3 indicates that the client is severely immunocompromised and is at high risk for infection. Therefore, this value is the priority for the nurse to report to the provider.

A nurse is assessing a client who has a puncture wound on his foot. Which of the following findings is a manifestation of acute osteomyelitis? Numbness of toes on the affected foot Hypothermia Localized erythema Bradycardia

Localized erythema Swelling and localized erythema are manifestations of acute osteomyelitis

A nurse is providing discharge teaching to a client who has a new prescription for lithium. Which of the following information should the nurse include in the teaching? Follow a low-sodium diet. Limit daily fluid intake. Obtain a daily weight. Avoid foods that have a high tyramine content.

Obtain a daily weight. Clients who are taking lithium should monitor their daily weight due to the risk of fluid imbalance.

A nurse is preparing to administer a rectal suppository to a client. In which of the following positions should the nurse place the client for insertion of the suppository? Sim's position Prone position Lying on the right side Supine

Sim's position The nurse should assist the client to the Sim's position by lying on the left side, left hip and lower extremity straight, and right hip and knee bent. This position exposes the anus and helps the client relax the external sphincter, allowing for easier insertion of the suppository.

A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.)

A primary survey is an organized system to rapidly identify and manage immediate threats to life. The mnemonic "ABCDE" is a reminder of the steps of the primary survey. The first step is "airway," during which the nurse should establish a patent airway using the jaw-thrust maneuver. The second is "breathing," during which the nurse should assess the client's ventilator efforts to determine effectiveness of breaths. During the third step, "circulation," the nurse should establish IV access for fluids and blood administration as needed. The fourth step is "disability," during which the nurse should determine a baseline neurologic status by completing a GSC assessment. And the fifth step is "exposure," during which the nurse should remove the client's clothing to complete a thorough assessment of the client's injuries.

A nurse is caring for a client who has cirrhosis of the liver. Medical History Cirrhosis of the liver, hepatitis C, type 2 diabetes mellitus, hypertension, and coronary artery disease. Surgical history: liver biopsy 2 years ago, paracentesis last done 4 months ago, and endoscopic variceal ligation 2 months ago. Client reports feeling well until approximately 3 days ago. Client describes loss of appetite, fatigue, weight gain of approximately 3 kg (6.6 lb) in 4 days, and itching all over their body with increased abdominal distention and course tremor of both hands. Diagnostic Results Total bilirubin 8 mg/dL (0.3 to 1.0 mg/dL) Alanine aminotransferase (ALT) 220 units/L (4 to 36 units/L) Ammonia 95 mcg/dL (10 to 80 mcg/dL) Platelets 90,000/mm3 (150,000 to 400,000/mm3) Hematocrit 42% (37% to 47% female; 42% to 52% male) Hemoglobin 14 g/dL (14 to 18 g/dL) Albumin 2.1 g/dL (3.5 to 5 g/dL) Vital Signs Temperature 36° C (96.9° F) Heart rate 101/min Respiratory rate 24/min Blood pressure 82/58 mm Hg Oxygen saturation 92% Which of the following assessment findings require immediate follow-up? Select all that apply. Ammonia level Scattered ecchymosis on the upper limbs Bilirubin Pruritis Temperature Abdominal girth Blood pressure Asterixis

Blood pressure is correct. The client's blood pressure is below the expected reference range and could indicate hypovolemia. Abdominal girth is correct. Abdominal distention, in combination with hypotension, suggests ascites or third-spacing of fluid in the abdomen. Bilirubin is incorrect. Although the bilirubin is above the expected reference range, this is an expected finding with hepatitis. The nurse should report a level greater than 12 mg/dL as a critical value. Pruritis is incorrect. The nurse should recognize that itching is an expected finding of late cirrhosis. Scattered ecchymosis on the upper limbs is correct. The scattered ecchymosis, along with the client's platelet count, indicate that the client has thrombocytopenia. Temperature is incorrect. The client's temperature is within the expected reference range of 36° to 38° C (96.8° to 100.4° F). Ammonia level is correct. The client's ammonia level is above the expected reference range. An increased ammonia level indicates that the client's liver is not effectively detoxifying protein by-products and that the client may be experiencing hepatic encephalopathy. Asterixis is correct. Asterixis is a course tremor that results in hand and finger flapping and can indicate worsening hepatic encephalopathy.

A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention? Daily weight Sodium level Tissue turgor Intake and output

Daily weight Obtaining a client's daily weight and comparing it to previous weights is a reliable method for measuring a client's fluid volume over time.

A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority? Defibrillation Airway management Epinephrine administration Amiodarone administration

Defibrillation The greatest risk to the client is death from a lack of cardiac output. Ventricular fibrillation is a lethal rhythm in which the ventricles are in a quivering pattern and there is no atrial activity. Defibrillation is essential to resolve ventricular fibrillation promptly and convert the rhythm to restore cardiac output. The nurse should follow defibrillation with cardiopulmonary resuscitation and repeated defibrillation, if necessary, to convert the ventricular fibrillation into a sustainable rhythm.

A nurse witnesses a motor vehicle crash and finds a client who is not breathing. The nurse suspects the client has a cervical vertebrae fracture. Which of the following actions should the nurse take first? Place the client in a rigid cervical collar. Open the client's airway using the jaw-thrust maneuver. Evaluate the client for other injuries. Complete a neurological check on the client.

Open the client's airway using the jaw-thrust maneuver. When using the airway, breathing, circulation approach to client care, the nurse determines that the priority action is opening the client's airway using the jaw-thrust maneuver to protect the client's cervical spine. The priorities of care at an accident scene, and when using the ABC approach to client care, are airway, breathing, and circulation

A nurse is providing teaching for a client who is on diuretic therapy and has a new prescription for potassium chloride (KCL) 20 mEq extended release PO daily. Which of the following instructions should the nurse provide about the new prescription? Take the extended release tablets on an empty stomach. Add an antacid if the medication causes indigestion. Take the extended release tablets whole. Expect urinary output to decrease while on this medication.

Take the extended release tablets whole. The nurse should teach the client that extended release tablets should be taken whole and should not be broken, crushed, or chewed.

A nurse is teaching a client who has a new prescription for ibuprofen to treat hip pain. Which of the following instructions should the nurse include in the teaching? Expect ringing in your ears. Take the medication with food. Store the medication in the refrigerator. Monitor for weight loss.

Take the medication with food. To minimize gastric irritation, the client should take ibuprofen with food or immediately after a meal.

A nurse is instructing the caregiver of a toddler who has bacterial conjunctivitis and a new prescription for an ophthalmic ointment. Which of the following instructions should the nurse provide? "Apply the ointment in a thin line into the conjunctival sac." "Ask the child to look down before applying the ointment." "Always wipe from the outer to the inner canthus when wiping away secretions." "Use a sterile glove and applicator to apply the antibiotic ointment."

"Apply the ointment in a thin line into the conjunctival sac." The medication should be administered (in a thin line) into the conjunctival sac, rather than being placed directly on the globe of the eye. This ensures that more of the medication comes in contact with the surfaces of the eye when the child blinks. If applied to the globe of the eye, most of the medication will end up in the child's lashes when the child closes her eye.

A nurse is preparing to administer medications to four clients. The nurse should administer medications to which of the following clients first? A client who has pneumonia, a WBC count of 11,500/mm3, and is prescribed piperacillin. A client who has anemia, hemoglobin of 11 g/dL, and is prescribed epoetin alfa A client who has renal failure, a serum potassium of 5.8/mEq/L, and is prescribed sodium polystyrene sulfonate A client who is post-coronary artery bypass graft (CABG), has total cholesterol of 318 mg/dL, and is prescribed atorvastatin

A client who has renal failure, a serum potassium of 5.8/mEq/L, and is prescribed sodium polystyrene sulfonate The expected reference range for serum potassium is 3.5 to 5 mEq/L. A serum potassium level of 5.8/mEq/L indicates that this client is at greatest risk for bradycardia, hypotension, and ECG changes; therefore, this client is the nurse's priority for medication administration. Elevated potassium can cause tall, tented T waves on ECG and can lead to ventricular dysrhythmias. Sodium polystyrene sulfonate is a potassium excreting agent that exchanges potassium for sodium and allows for excretion of potassium through the stool.

A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority? Provide the client with antipyretic therapy. Administer antibiotics to the client. Increase the client's protein intake. Teach relaxation breathing to reduce the client's pain.

Administer antibiotics to the client. The greatest risk to this client is bacteremia caused by the infection which can lead to septic shock; therefore, the priority intervention is antibiotic therapy. The client might require multiple antibiotics for an extended time.

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention? Airway obstruction Infection Fluid imbalance Paralytic ileus

Airway obstruction When using the airway, breathing, circulation approach to client care, the nurse determines that the priority risk is airway obstruction. Burns of the head, neck, and chest often involve damage to the pulmonary tree due to heat as well as smoke and soot inhalation. This can result in severe respiratory difficulty. Nursing measures to maintain a patent airway should take priority in this client's care.

A nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first? Pain severity Wound drainage Tissue integrity Airway patency

Airway patency When using the airway, breathing, circulation approach to client care, the nurse determines that the priority assessment is airway patency. After head and neck surgery, a major, life-threatening complication is airway obstruction. The priority actions involve airway maintenance and gas exchange.

Blood pressure 180/90 mm Hg Heart rate 105/min Temperature 37.1º C (98.8º F) Respirations 18min; labored Pulse oximetry 94 on 2L nasal cannula% History of coronary artery disease Type 2 diabetes mellitus Renal failure Renal transplant 6 weeks ago The client reports worsening fatigue over the last 3 days. The client also reports loss of appetite, denies nausea or vomiting. On assessment, the client appears pale, lung and heart sounds within defined limits. Abdomen is tender in area of incision from transplant. Bowel sounds are hypoactive in all 4 quadrants. Bilateral pedal pulses +2. +1 edema in bilateral lower extremities. Client reports that for the last 2 days they have only urinated twice per 24-hour period. BUN 25 mg/dL (10 to 20 mg/dL) Creatine 2.0 mg/dL (0.5 to 1.3 mg/dL) Hemoglobin 15 mmoL/L (12 to 18 mmoL/L) Hematocrit 45% (37% to 52%) Potassium 5.2 mEq/L (3.5 to 5.0 mEq/L) Sodium 145 mEq/L (136 to 145 mEq/L) Which of the following findings indicate that the client may be experiencing transplant rejection? (Select all that apply). Creatinine level Lung sounds Bowel sounds Assessment of incision site Assessment of lower extremities Sodium level Blood pressure

Blood pressure is correct. The client's blood pressure is above the defined limits and increased blood pressure is an indication of renal transplant rejection. Bowel sounds is incorrect. The client's bowel sounds are not an indication of organ rejection. Assessment of the incision site is correct. Tenderness at the incision site can indicate an enlarged or tender kidney, which indicates renal transplant rejection. Creatinine level is correct. The client's creatinine level is increased, which can be an indication of renal transplant rejection. Lung sounds is incorrect. The client's lung sounds are within defined limits and do not indicate transplant rejection. Sodium level is incorrect. The client's sodium level is within the expected reference range. Assessment of lower extremities is correct. The assessment of the client's lower extremities indicate edema, which is an indication of fluid retention caused by renal transplant rejection.

A nurse is caring for a client who has heart failure. Nurses' Notes Day 1: Bilateral breath sounds clear and present throughout.Weight 80 kg (176 lb)Urine output 480 mL/8 hr Day 4: Breath sounds scattered, crackles heard bilaterally.Apical heart rate rapid and irregular. Audible S3 gallop.Weight 82.1 kg (181 lb)Urine output 320 mL/8 hr Vital Signs Day 1: Temperature 37.6º C (99.7º F)Blood pressure 108/50 mm HgPulse 98/minRespiratory rate 20/minPulse oximetry 95% on room air Day 4: Temperature 36.8º C (98.2º F)Blood pressure 138/80 mm HgPulse 112/minRespiratory rate 28/minPulse oximetry 88% on room air A nurse is reviewing the assessment finding for the client on day 4. Which of the following findings requires further action? (Select all that apply.) Oxygen saturation Temperature Weight Urine output Breath sounds Blood pressure

Breath sounds are correct. The client's breath sounds indicate pulmonary congestion. The nurse should report this finding to the provider and prepare to administer a diuretic to promote excretion of pulmonary fluid. Weight is correct. The client has gained 2.1 kg (5 lb) within 1 week indicating fluid retention. The nurse should report this finding to the provider and prepare to administer a diuretic to promote excretion of pulmonary fluid. Temperature is incorrect. The client's temperature is within the expected reference range. Therefore, this finding does not require follow-up. Urine output is incorrect. The client's urine output is greater than 30 mL/hr which indicates adequate perfusion to the kidneys. Oxygen saturation is correct. The client's oxygen saturation is below the expected reference range of 95% to 100%, indicating decreased gas exchange and placing the client at risk for dysrhythmias. Blood pressure is correct. The client's blood pressure is significantly increased indicating the presence of fluid overload.

A nurse is caring for a client Diagnostic Results 0900: Hct 27% (37% to 47%)Hgb 8 g/dL (12 g/dL to 16 g/dL)WBC 7,000/mm³ (5000 to 10,000/mm³)Potassium 4.2 mEq/L (3.5 mEq/L to 5 mEq/L) Nurses' Notes 1000: 1 unit of packed RBCs started through a #18 g IV in right hand as prescribed. Unit of blood infusing well. IV site dry and intact, without redness or swelling. 1015: Client appears anxious and reports a headache and low back pain. Client voided 100 mL of brown-colored urine. Bilateral breath sounds clear and present throughout. Vital Signs 1000: Temperature 37.2º C (99º F)Blood pressure 106/56 mm HgHeart rate 104/minRespiratory rate 20/minPulse oximetry 96% on room air 1015: Temperature 39.6º C (103.3º F)Blood pressure 74/50 mm HgHeart rate 124/minRespiratory rate 28/minPulse oximetry 95% on room air Which of the following findings at 1015 requires further action? (Select all that apply.) Oxygen saturation Respiratory rate Urine color Blood pressure Low back pain

Blood pressure is correct. The client's blood pressure is less than the expected reference range. Hypotension is a manifestation of an acute transfusion reaction. The nurse should stop the transfusion and notify the provider. Oxygen saturation is incorrect. The client's oxygen saturation is within the expected reference range of 95% to 100%. Low back pain is correct. Low back or flank pain is a manifestation of a transfusion reaction and requires interventions to reduce the risk for further injury. The nurse should stop the transfusion and notify the provider. Urine color is correct. Reddish or dark brown urine is a manifestation of a transfusion reaction and requires interventions to reduce the risk for further injury. The nurse should stop the transfusion, notify the provider, and send a urine sample to the laboratory. Respiratory rate is correct. Tachypnea is a manifestation of a transfusion reaction and requires intervention to reduce the risk for further injury. The nurse should stop the transfusion and notify the provider. The client's WBC count is within the expected reference range.

A client who is receiving magnesium sulfate has a urine output of 20 mL/hr. Which of the following medications should the nurse expect to administer? Calcium gluconate Flumazenil Naloxone Protamine

Calcium gluconate Magnesium sulfate is used to manage clients who have preeclampsia and require close monitoring for signs of excessive administration. Central nervous system and respiratory depression, depression of deep tendon reflexes, hypotension, diaphoresis, and decreased or loss of urinary output are signs of excessive magnesium administration. Calcium gluconate is administered intravenously over several minutes as the antidote for magnesium sulfate toxicity.

A nurse is caring for a client is receiving hydromorphone HCL via PCA pump and reports continuous pain of 6 on a scale from 0 to 10. Which of the following actions should the nurse take first? Administer a bolus of medication. Check the display on the PCA pump. Obtain an order for another pain medication for breakthrough pain. Encourage the client to administer a demand dose.

Check the display on the PCA pump. The first action the nurse should take using the nursing process is to assess the client; therefore, the nurse should assess the display on the PCA pump to determine the amount of medication administered. Some clients are fearful of developing an addiction to narcotics and may be reluctant to use the PCA

A nurse is caring for a client who is 1 day postoperative following a transsphenoidal hypophysectomy. While assessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the following should be the nurse's initial action? Document the amount of drainage. Obtain a culture of the drainage. Check the drainage for glucose. Notify the client's provider.

Check the drainage for glucose. A potential complication of hypophysectomy is cerebral spinal fluid (CSF) leakage. Fluid leakage from the nose is a sign that this complication has occurred. The first action the nurse should take using the nursing process is to assess the drainage for the presence of glucose, which would indicate that the drainage is CSF.

A nurse is caring for a client who has a cast in place for a fractured tibia. Which of the following nursing actions is the priority immediately after the provider has applied the cast? Checking capillary refill distal to the cast Teaching the client about cast care Managing pain Performing range of motion

Checking capillary refill distal to the cast The priority action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to check capillary refill. Musculoskeletal injuries can cause changes in the neurovascular system, usually distal to the injury from the pressure of the cast. Capillary refill provides data about the client's circulation.

A nurse is teaching a client who has a new prescription for disulfiram. Which of the following information should the nurse include in the teaching? "Avoid grapefruit juice while taking this medication." "Do not crush this medication before swallowing." "Do not drink alcohol while taking this medication." "Take this medication with food."

Do not drink alcohol while taking this medication." Disulfiram is a type of aversion therapy that helps maintain abstinence from alcohol. Drinking alcohol while taking disulfiram can produce a life-threatening response that can include palpitations, headache, and hypotension. Therapy must not begin until the client has abstained from alcohol for at least 12 hr. The client should avoid all forms of alcohol including cough syrups and after-shave lotions.

A nurse finds radioactive pellets on the floor of the surgical. Which of the following actions should the nurse take first? Follow safety data sheet (SDS) instructions. Place pellets in the biohazard area. Contact environmental services. Notify the surgical department director.Follow safety data sheet (SDS) instructions.

Follow safety data sheet (SDS) instructions. The Occupational Safety and Health Administration requires SDS to be available in all health care facilities. The SDS gives specific information about the potential hazards, first aid guidelines, and precautions for safe handling and use for each substance. Finding and following the SDS instructions is the first action the nurse should take.

A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first? Measure the circumference of both upper arms. Notify the provider who inserted the PICC line. Remove the PICC line. Apply a cold pack to the client's upper arm.

Measure the circumference of both upper arms. The first action the nurse should take using the nursing process is to assess the client. The nurse should measure the arm and compare the result with the circumference of the other arm. If the arm is swollen, the nurse should notify the provider who inserted the PICC line. Swelling could indicate formation of a clot above the site or even catheter rupture.

A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis? Oral mucosa Conjunctivae Ear lobes Soles of the feet

Oral mucosa According to evidence-based practice, the nurse should first monitor the client's tongue and lips for manifestations of central cyanosis because cyanosis is most evident in areas with minimal pigmentation.

A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first? Review the client's electrolyte values. Check the client's perianal skin integrity. Investigate the client's emotional concerns. Obtain a dietary history from the client.

Review the client's electrolyte values. The greatest risk to this client is injury from impaired function of cardiac or respiratory muscles; therefore, the first action the nurse should take is to review the client's electrolyte values. The client might have low sodium, potassium, and chloride from frequent diarrhea.

A nurse is preparing to administer imipramine 200 mg PO daily divided equally every 12 hr. The amount available is imipramine 25 mg tablets. How many tablets should the nurse administer with each dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

X = 8 STEP 7: Round if necessary. STEP 8: Reassess to determine whether the amount to administer makes sense. If there are 25 mg/tablet and the amount prescribed is 200 mg, it makes sense to administer 8 tablets, or 4 tablets PO every 12 hr. The nurse should administer imipramine 4 tablets PO every 12 hr.

A nurse is preparing to titrate morphine 6 mg via IV bolus to a client. The amount available is morphine 8 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest hundredth. Use a leading zero if it applies. Do not use a trailing zero.) mL

X mL = 0.75 mL Step 5: Round if necessary. Step 6: Reassess to determine whether the amount to administer makes sense. If there are 8 mg/mL and the prescription reads 6 mg, it makes sense to administer 0.75 mL. The nurse should titrate morphine 0.75 mL via IV bolus.

A nurse is providing teaching for a client who has a new prescription for alprazolam to treat insomnia. Which of the following instructions should the nurse include? "Take this medication every night before sleep." "Take this mediation with a high-fat meal." "Avoid activities that require alertness, such as driving." "Monitor for peripheral edema."

"Avoid activities that require alertness, such as driving." The client should avoid activities that require alertness. Alprazolam is a benzodiazepine that causes sedation and dizziness.

A nurse at an ophthalmology clinic is providing teaching to a client who has open-angle glaucoma and a new treatment regimen of timolol and pilocarpine eye drops. Which of the following instructions should the nurse provide? Administer the medications by touching the tip of the dropper to the sclera of the eye. Hold pressure on the conjunctiva sac for 2 min following application of drops. Administer the medications 5 min apart. It is not necessary to remove contact lenses before administering medications.

Administer the medications 5 min apart. The nurse should instruct the client that, if more than one ophthalmic medication is to be administered, they should be given 5 min apart.

A nurse is teaching a client who has been taking prednisone to treat asthma and has a new prescription to discontinue the medication. The nurse should explain to the client to reduce the dose gradually to prevent which of the following adverse effects? Hyperglycemia Adrenocortical insufficiency Severe dehydration Rebound pulmonary congestion

Adrenocortical insufficiency Prednisone, a corticosteroid, is similar to cortisol, the glucocorticoid hormone produced by the adrenal glands. It relieves inflammation and is used to treat certain forms of arthritis, severe allergies, autoimmune disorders, and asthma. Administration of glucocorticoids can suppress production of glucocorticoids, and an abrupt withdrawal of the drug can lead to a syndrome of adrenal insufficiency.

A nurse is assessing a client who is African-American and has jaundice. Which of the following areas is the most reliable for the nurse to inspect the client for jaundice? Palms of the hands Hard palate Conjunctiva Back of the neck

Hard palate According to evidence-based practice, inspecting the client's oral mucous membrane and hard palate are the most reliable methods to determine jaundice for a client who is African-American.

A nurse is caring for a client who has heart failure and is receiving IV furosemide. The nurse should monitor the client for which of the following electrolyte imbalances? Hypernatremia Hyperuricemia Hypercalcemia Hyperchloremia

Hyperuricemia The nurse should monitor the client who is receiving IV furosemide for hyperuricemia. The nurse should instruct the client to notify the provider for any tenderness or swelling of the joints.

A nurse is teaching a client who has chronic kidney disease and a new prescription for epoetin alfa. The nurse should instruct the client to increase dietary intake of which of the following substances? Iron Protein Potassium Sodium

Iron Epoetin alfa is a synthetic form of erythropoietin, a substance produced by the kidneys that stimulates the bone marrow to produce red bloo

A nurse is caring for a client who receives furosemide to treat heart failure. Which of the following laboratory values should the nurse monitor for this client due to this medication? Potassium Albumin Cortisol Bicarbonate

Potassium Furosemide is a loop diuretic that promotes the excretion of potassium. The nurse should monitor the client's potassium level to watch for hypokalemia.

A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first? Test the drainage for glucose. Suction the nostril. Notify the physician. Ask the client to blow his nose.

Test the drainage for glucose. This is the priority nursing action. Because of the high risk of cerebral spinal fluid (CSF) leak in clients with basal skull fractures, the nurse should realize there is a possibility that the clear fluid coming from the client's nostril is CSF, which will test positive for glucose.

A nurse is caring for a newly admitted client Medical History Cirrhosis Type 2 diabetes mellitus Hypertension Partner reports client drinks 12 cans of beer daily Diagnostic Results 0700: Hemoglobin 11 g/dL (12 to 16 g/dL) Hematocrit 34% (37% to 47%) Aspartate aminotransferase (AST) 135 units/L (0 to 35 units/L) Alanine aminotransferase (ALT) 150 units/L (4 to 36 units/L) Alkaline phosphatase (ALP) 301 units/L (30 to 120 units/L) Ammonia 236 mcg/dL (10 to 80 mcg/dL) Total bilirubin 9.7 mg/dL (0.3 to 1.0 mg/dL) Albumin 2.5 g/dL (3.5 to 5 g/dL) Total protein 5.0 g/dL (6.4 to 8.3 g/dL) Prothrombin time 12.4 seconds (11.0 to 12.5 seconds) Glucose 180 mg/dL (74 to 106 mg/dL) Vital Signs 0800: Temperature 37.2o C (98.9o F) Heart rate 92/min Respiratory rate 22/min Blood pressure 140/92 mm Hg SaO2 94% on 2 L oxygen via nasal cannula Physical Examination 0800: Client is difficult to arouse and is disoriented to person, place, and time Lung sounds clear, no shortness of breath noted Bowel sounds active in all 4 quadrants, abdomen soft and slightly distended Skin intact, no petechiae or bruising noted. 2+ edema to legs bilaterally Jaundice to sclerae bilaterally Client denies pain Nurse's Notes 0830: Client refuses breakfast; is agitated and disoriented. Assisted to commode. Had large soft stool, urine is dark yellow. A nurse notes the client's condition and initiates the following action. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

The nurse should identify that the client is most likely experiencing encephalopathy related to cirrhosis. Encephalopathy can lead to seizures and coma and is life-threatening if not treated. Increased ammonia levels lead to encephalopathy, which can cause alterations in mental status and motor disturbances, including asterixis, an involuntary flapping of hands. Lactulose is given to decrease ammonia by expelling it in the stool. The nurse should expect two to three soft stools per day from the lactulose and should notify the provider if liquid stools develop. The nurse should frequently monitor the client's neurological status to promptly recognize any further progression of confusion. The nurse should also ensure appropriate safety measures are in place to keep the client safe from injury.

A nurse is caring for a client who has cancer and is undergoing chemotherapy. Physical Examination January: Weight 70.5 kg (155 lb)BMI 24 February: Weight 69 kg (152 lb)BMI 23 Diagnostic Results January: Complete Blood Count:WBC count 5,500/mm³ (5,000 to 10,000/mm³)RBC count 4.2 (4.2 to 5.4)Hgb 12 g/dL (12 g/dL to 16 g/dL)Hct 37% (37% to 47%)Platelet count: 150,000/mm³ (150,000 to 400,000/mm³) February: Complete Blood Count:WBC count: 4,500/mm³ (5,000 to 10,000/mm³)RBC count 4 (4.2 to 5.4)Hgb: 14 g/dL (15 g/dL to 16 g/dL)Hct: 36% (37% to 47%)Platelet count: 140,000/mm³ (150,000 to 400,000/mm³) Nurses' Notes January: Client reports fatigue and nausea following chemotherapy treatments. States, "It just makes me not want to eat. When I do eat, the food taste funny." Client teaching: Instructed client to attempt to eat small meals several times daily, to eat food cold or at room temperature, to avoid fried foods. Encourage client to rest before eating meals. Oral mucosa is inflamed. Client teaching: Instructed client to avoid mouthwashes that contain alcohol, to increase water intake to 2 or more liters daily, and to avoid hot foods. Reviewed laboratory findings and stressed the need to protect self from illness due to immunosuppression. Client teaching: Instructed client to not eat raw or undercooked meat, to drink only pasteurized milk, and to boil water before drinking it; take temperature daily and report fever, avoid crowds, wash hands frequently with antimicrobial soap. Reviewed laboratory findings and stressed need for bleeding precautions. Client states, "I've had bleeding from these ulcers in my mouth." Client teaching: Use an electric razor, take a stool softener if constipation occurs, avoid coarse-textured foods. February: Client has experienced weight loss of 1.5 kg (3 lb), has experienced decrease in hct and hgb, WBC, and platelet count. Client reports still not able to consume much food; has increased intake of water. Oral mucosa with less inflammation. Client reports no bleeding episodes. Which of the following assessments indicates an improvement in the client's condition?

WBC count is incorrect. The client's WBC count has decreased over the month. Therefore, it is not an improvement in the client's condition. A decreased WBC count places the client at increased risk of infection. Oral health is correct. The nurse's assessment and the client's report of increase in water intake indicate an improvement in the client's condition. Platelet count is incorrect. The client's platelet count has decreased over the month. Therefore, is not an improvement in their condition. A decreased platelet count places the client at an increased risk of bleeding. Weight change is incorrect. The client's weight has decreased. Therefore, it is not an improvement in their condition. Bleeding episodes is correct. Despite a decreasing platelet count, the client reports no further bleeding episodes. Therefore, this indicates an improvement in the client's condition.

A clinic nurse is giving instructions to a mother on the proper technique of applying ophthalmic ointment to her preschool-age child who has conjunctivitis. Which of the following should the nurse include in the instructions? "Warm the ointment by placing the tube in glass of hot tap water." "Cleanse the eye with a wet cotton ball in a direction towards the inner canthus before applying the ointment." "Discard the first bead of ointment before each application." "Instruct your child to squeeze his eyes shut following application."

"Discard the first bead of ointment before each application." The parent should discard the first bead of ointment from the tube because it is considered contaminated.

A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following statements by the client indicates an adverse effect of the medication? "I can walk a mile a day." "I've had a backache for several days." "I am urinating more frequently." "I feel nauseated and have no appetite."

"I feel nauseated and have no appetite." Anorexia, nausea, vomiting, and abdominal discomfort are early signs of digoxin toxicity.

A nurse is providing teaching to a client who has gout and a new prescription for allopurinol. Which of the following statements by the client indicates an understanding of the teaching? "If I get a rash from this medication, I will take my usual antihistamine." "I need to increase my fluid intake while taking this medication." "I should take this medicine on an empty stomach." "If I get a fever while taking this medication, I will take some aspirin."

"I need to increase my fluid intake while taking this medication." Clients who have gout should increase their fluid intake to 2 to 3L per day to prevent toxicity of allopurinol and decrease uric acid levels.

A nurse is teaching a client who has a new prescription for amoxicillin-clavulanate to treat pharyngitis. Which of the following statements by the client indicates an understanding of the teaching? "I will take this medication until my sore throat goes away." "I should take this medication on an empty stomach between meals." "I will stop taking this medication if I develop itching." "I will double my dose, if I miss one."

"I will stop taking this medication if I develop itching." Penicillin-derived medications are a common cause of medication allergic reactions. Manifestations of allergic reactions include rashes, hives, itchy and watery eyes, and swollen lips, tongue, or face. Anaphylactic reactions can develop within 1 hr of taking the dose, and include difficulty breathing, shortness of breath, stridor, and angioedema. The client should discontinue the medication and notify the provider if these manifestations occur.

A nurse in the emergency department is assessing a newly admitted client who has facial trauma. Which of the following assessments is the nurse's priority? Soft-tissue edema Facial asymmetry Active bleeding Altered respirations

Altered respirations When using the airway, breathing, circulation approach to client care, the nurse determines that the priority is to assess the client's respirations, because edema from the client's injuries could cause airway obstruction. The nurse should assess the client's airway for stridor, shortness of breath, and dyspnea.

A nurse is caring for a client who is postoperative following abdominal surgery. The nurse discovers a loop of bowel through an opening in the surgical incision. Which of the following actions should the nurse take? Place the head of the client's bed in the flat position. Gently reinsert the bowel back into the client's wound. Apply moistened sterile gauze to the site. Position the client on his left side.

Apply moistened sterile gauze to the site. The nurse should apply moistened sterile gauze to the site to reduce the risk for further injury and infection.

A nurse is teaching a client who has a new prescription for transdermal nitroglycerin to treat angina pectoris. Which of the following instructions should the nurse include in the teaching? Apply a new transdermal patch once a week. Apply the transdermal patch in the morning. Apply the transdermal patch in the same location as the previous patch. Apply a new transdermal patch when chest pain is experienced.

Apply the transdermal patch in the morning. The client should apply the patch every morning and leave it in place for a 12 to 14 hr, then remove it in the evening.

A nurse is caring for a client admitted who reports increased urination and thirst. Medical History Physical Examination Diagnostic Results Nurses' Notes Vital Signs Medical History Client admitted with report of polyuria and polydipsia. Notable muscle twitching of upper extremities. Past medical history: Varicella as a child. No other health issues. Current medications: Occasional ibuprofen for pain. Family history: Father had history of nephrogenic diabetes insipidushysical Examination Alert and oriented x 3. Client states that they have had difficulty concentrating lately and are irritable. Client reports occasional dizziness. Skin is warm, dry, and scaly. Mucous membranes dry and pink. Lungs clear to auscultation bilaterally. Abdomen soft, nondistended with active bowel sounds x 4. Denies nausea, vomiting, or diarrhea. Peripheral pulses +1. Twitching noted in upper extremities, client states they have had twitching "for some time." Diagnostic Results Nurses' Notes Vital Signs Diagnostic Results Basic metabolic profile Sodium 157 mEq/L (136 to 145 mEq/L) Potassium 4.0 mEq/L (3.5 to 5 mEq/L) Chloride 102 mEq/L (98 to 106 mEq/L) Magnesium 1.8 mEq/L (1.3 to 2.1 mEq/L) Total calcium 9.7 mg/dL (9.0 to 10.5 mg/dL) CBC with differential Total WBCs 6,500/mm3 (5,000 to 10,000/mm3) Neutrophils 60% (55% to 70%) Lymphocytes 30% (20% to 40%) Monocytes 5% (2% to 8%) Eosinophils 2.5% (1% to 4%) Basophils 0.7% (0.5% to 1%) Hemoglobin 21 g/dL (Male: 14 to 18 g/dL; Female: 12 to 16 g/dL) Hematocrit 55% (Male: 42% to 52%; Female: 37% to 47%) RBCs 5.7 x 106µL (Male: 4.7 to 6.1 x 106µL; Female: 4.2 to 5.4 x 106µL Nurses' Notes 0845: Needed assistance to the bathroom, reports dizziness. Urine output 1,500 mL. Assisted client to bed. Vitals taken. Vital Signs 0800: Temperature 37.4° C (99.4° F) Heart rate 100/min Respiratory rate 22/min Blood pressure 108/78 mm Hg Oxygen saturation 98% on room air 0900: Temperature 37.4° C (99.4° F) Heart rate 104/min Respiratory rate 22/min Blood pressure 96/70 mm Hg Complete the following sentence by using the lists of options. The nurse has assisted the client back to bed. The nurse should first address the client's Select... followed by the client's Select... .

Drop Down 1 Heart rate is incorrect. The heart rate increases with fluid volume deficits to help maintain blood pressure with less volume. This is an expected finding for a client who is dehydrated. Respiratory rate is incorrect. The respiratory rate increases in a client who has fluid volume deficit due to decreased blood volume that reduces perfusion and gas exchange. An increase in the respiratory rate is a compensatory mechanism. This is an expected finding. Blood pressure is correct. A decreased blood pressure can indicate that this client is at risk for hypovolemia due to the client's polyuria and decrease in fluid volume; therefore, this is the priority finding. Drop Down 2 Hemoglobin level is incorrect. Hemoglobin levels are elevated in clients who are experiencing fluid volume deficits. This is due to hemoconcentration and is an expected finding. Polyuria is incorrect. Polyuria is a manifestation of diabetes insipidus. Management of this disorder focuses on controlling the manifestations using drug therapy with desmopressin. Sodium level is correct. After the nurse has addressed the client's blood pressure, the nurse should then address client's elevated sodium level. With increased sodium levels, more sodium is able to move rapidly across cell membranes during depolarization, causing tissues to be easily excited. Actions need to be taken to decrease the client's sodium level. Therefore, this finding is the nurse's priority to address.

Custom: PRACTICE0310 CLOSE Question 6 loaded Question: 6 of 50 Time Remaining: 07:53:10 Pause Remaining: 00:05:00 PAUSE FLAG A nurse is caring for a client who reports fatigue and had a syncopal episode at home. Medical History Vital Signs Nurses' Notes Diagnostic Results Medical History 30-year-old female admitted with reports of increased fatigue x 6 months. States they needs to rest frequently and is unable to participate in many activities due to reduced energy level. Reports dyspnea on exertion. Experienced syncopal episode at home without injuries. BMI: 21 Height: 62 inches Weight: 128.5 lb Denies recent weight loss. Denies anorexia. Past medical history: Has routine well health check-ups. Regular menses cycles, with heavy menstrual bleeding over the last year. Placed on ethinyl estradiol/drospirenone, one tablet PO daily 1 month ago. Denies sexual activity. No other health issues. Family history: Mother has hypertension, father has diabetes mellitus, no siblings. The nurse has completed an assessment on the client after the syncopal episode. Complete the following sentence by using the list of options. The nurse should first address the client's Select... , fSelect... . glossitis oxygen saturation increased fatigue hemoglobin paresthesia of the feet followed by the client's heart murmur pale and cool skin wound on heel decreased energy level hypotension

Dropdown 1 Hemoglobin is incorrect. A hemoglobin within the expected reference range for a female client is 12 to16 g/dL. A hemoglobin less than 12 g/dL is indicative of anemia. The nurse should anticipate the hemoglobin level to be less than 12 g/dL ; therefore, the client's hemoglobin is the not the priority for the nurse to address. Oxygen saturation is correct. The first action the nurse should take when using the airway, breathing, circulation approach to client care is client's oxygen saturation. Anemia is a reduction in the number of RBCs and the amount of hemoglobin or hematocrit. Hemoglobin carries oxygen to the tissues. When a client's hemoglobin level is low, the delivery of oxygen is decreased, which results in hypoxia. Increased fatigue is incorrect. Fatigue is a manifestation of anemia and is caused by the decreased RBCs. The client's increased fatigue is not the priority for the nurse to address. Paresthesia of the feet is incorrect. Paresthesia of the feet and hands are a symptom of vitamin B12 deficiency anemia. Vitamin B12 helps maintain nerve function. Clients who have vitamin B12 deficiency anemia have decreased vitamin B12 levels. The client's paresthesia of the feet is not the priority for the nurse to address. Glossitis is incorrect. Glossitis, a beefy red smooth tongue, is a manifestation of vitamin B12 deficiency anemia. Although it can cause decreased oral intake, it is not the priority for the nurse to address. Dropdown 2 Pale and cool skin is incorrect. Clients who have anemia have decreased levels of RBCs, hemoglobin, and hematocrit. Decreased hemoglobin causes decreased oxygenation and perfusion. Cool pale skin is a manifestation of anemia and is not the priority finding for the nurse to address. Hypotension is correct. After the nurse had addressed the client's oxygen saturation level, the nurse should address the client's hypotension. Anemia reduces oxygen delivery causing the heart to work harder to maintain tissue perfusion. Pulses become weak and thready and blood pressure decreases. Decreased energy level is incorrect. Reduced energy level is a normal finding in anemia due to decreased RBCs. This is not the priority finding for the nurse to address. Heart murmur is incorrect. Abnormal heart sounds, such as murmurs and gallops, can be auscultated in clients who have severe anemia. This is an expected finding and is not the priority finding for the nurse to address. Wound on heel is incorrect. Decreased tissue perfusion occurs with anemia due to decreased RBCs, hemoglobin, and hematocrit. This is not the priority fin

A nurse is caring for an older adult client who reports taking bisacodyl tablets daily. Which of the following responses should the nurse make? "Irregular bowel movements are an indication of poor intestinal health." "Excessive laxative use may cause an electrolyte imbalance." "Chronic use of laxatives can lead to a tear in the rectal mucosa." "Decrease your intake of foods high in fiber."

Excessive laxative use may cause an electrolyte imbalance." Bisacodyl is a stimulant laxative that acts by stimulating intestinal motility and increasing the amount of water and electrolytes within the intestines; therefore, chronic use of laxatives can lead to fluid and electrolyte imbalance

A nurse is caring for a client who is postoperative following a left corneal transplant. The nurse observes purulent drainage from the affected eye. Which of the following actions is the nurse's priority? Notify the surgeon. Instill an antibiotic solution in both eyes. Clean eye from inner to outer canthus. Apply a non-pressure patch to the affected eye.

Notify the surgeon. Purulent draining is a manifestation of infection and should be reported to the surgeon immediately.

FLAG A nurse in a clinic is collecting a history from a client who reports that a member of his family just received a diagnosis of pulmonary tuberculosis. The nurse should expect that the provider will prescribe which of the following diagnostic tests first? Sputum culture for acid-fast bacillus (AFB) Nucleic acid amplification test (NAAT) CT scan Chest x-ray

Nucleic acid amplification test (NAAT) The CDC recommends that the NAAT test replace other diagnostic screening tests for tuberculosis. The test is performed on a client's sputum.

A nurse is assessing a client who is being admitted from the PACU following an abdominal hysterectomy. Which of the following assessments is the nurse's priority? Oxygen saturation Abdominal dressing Urinary output Pain level

Oxygen saturation The priority action the nurse should take when using the airway, breathing, circulation approach to client care, is to assess the client's oxygen saturation to determine adequate gas exchange.

A nurse is caring for a client who has streptococcal pneumonia and a prescription for penicillin G by intermittent IV bolus. 10 minutes into the infusion of the third dose, the client reports that the IV site itches and that he feels dizzy and short of breath. Which of the following actions should the nurse take first? Stop the infusion. Call the client's provider. Elevate the head of the bed. Auscultate the client's breath sounds.

Stop the infusion. When using the airway, breathing, circulation approach to client care, the nurse should place the priority on stopping the infusion. The client is exhibiting signs of penicillin anaphylaxis and the first action that should be taken is to withdraw the medication.

A nurse is assessing a client who is receiving a unit of packed RBCs. The client appears flushed and reports low-back pain. Which of the following actions is the nurse's priority? Stop the transfusion. Collect a urine specimen. Notify the blood bank. Begin an infusion of 0.9% sodium chloride through new tubing.

Stop the transfusion. The greatest risk to the client is injury due to further hemolysis; therefore, the priority action is to stop the transfusion. When a hemolytic reaction is suspected, the priority action by the nurse is to immediately stop the transfusion to prevent further hemolysis.

A nurse is caring for a 64-year-old client in an emergency department. Nurses Notes Client presents with report of sudden onset of dyspnea and sharp chest pain. Respirations labored with crackles auscultated throughout lung fields. Dry cough present. Skin is cool and moist. Heart sounds are moderate and regular. Jugular vein distention noted. Abdomen is soft, nondistended with active bowel sounds in all four quadrants. 1+ peripheral edema noted. Peripheral pulses are moderate. Client is restless and anxious. Vital Signs Temperature 38° C (100.4° F) Apical pulse rate 116/min Respiratory rate 26/min Blood pressure 100/64 mm Hg Oxygen saturation 90% on room air Medical History Client states that they just returned from trip to Hawaii with family. Client reports experiencing gastrointestinal influenza-like symptoms for 1 day on the trip. No known drug allergies. Diagnosed with type 2 diabetes mellitus 10 years ago; takes glyburide 2.5 mg PO daily Myocardial infarction 9 months ago and had angioplasty. Prescribed aspirin 325 mg PO daily. Noncompliant; client states the medication "hurts my stomach. The nurse is reviewing the client's data to prepare the client's plan of care. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

The nurse should request a D-dimer and apply oxygen because the client is most likely experiencing a pulmonary embolism because the client has had a sudden onset of dyspnea with pleuritic (sharp) chest pain along with hypotension after returning from a trip. Due to a decreased gas exchange, the client needs oxygen applied. A D-dimer needs to be drawn to assist with diagnosing a pulmonary embolism. The nurse should monitor the client's pulse oximetry and partial thromboplastin time because a client who has a pulmonary embolism display manifestations of decreased gas exchange and decreased tissue perfusion. Treatment for a pulmonary embolism includes drug therapy with an anticoagulant, such as unfractionated heparin, low-molecular-weight heparin, or fondaparinux. The client's partial thromboplastin time is drawn before anticoagulant therapy is started and throughout therapy per facility policy.

A nurse is caring for a client who is on warfarin therapy for atrial fibrillation. The client's INR is 5.2. Which of the following medications should the nurse prepare to administer? Epinephrine Atropine Protamine Vitamin K

Vitamin K Vitamin K reverses the effects of warfarin.

A nurse is reviewing the medical record of a client who has hypertension and a new prescription for metoprolol. Which of the following findings should the nurse investigate further? Diet-controlled Type 2 diabetes mellitus A history of left-sided heart failure A concurrent prescription for tadalafil Recently treated bilateral pneumonia

A history of left-sided heart failure The nurse should further investigate the client's history of heart failure. Although metoprolol can be used to treat heart failure, it can also cause heart failure, so this medication should be used with great caution with a client who has a history of heart failure. The nurse should teach the client to watch for signs of increasing left-sided heart failure, such as shortness of breath and weight gain indicating fluid retention, and report these findings to the provider.

A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first? Notify the provider. Check the tubing for kinks. Adjust the rate of the bladder irrigant. Irrigate the catheter.

Check the tubing for kinks. When providing client care, the nurse should first use the least restrictive intervention; therefore, the nurse should check the catheter tubing for kinks. The nurse must ensure constant flow of the bladder irrigant into the catheter and outward drainage from the catheter to prevent clotting, which could occlude the catheter lumen.

A nurse is caring for a client who is 4 days postoperative following a right radical mastectomy. Which of the following activities should the nurse anticipate being the most difficult for this client to perform with her right hand? Buttoning her blouse Eating her breakfast Combing her hair Brushing her teeth

Combing her hair Abduction of the arm is the most difficult, and usually the last, type of movement to be regained by a client following a mastectomy.

A nurse is teaching a client who has diabetes mellitus and receives 25 units of NPH insulin every morning if her blood glucose level is above 200 mg/dL. Which of the following information should the nurse include? Discard the NPH solution if it appears cloudy. Shake the insulin vigorously before loading the syringe. Expect the NPH insulin to peak in 6 to 14 hr. Freeze unopened insulin vials.

Expect the NPH insulin to peak in 6 to 14 hr. NPH insulin is an intermediate-acting insulin. Its onset of action is 1 to 2 hr, peaking at 6 to 14 hr. Its duration of action is 16 to 24 hr. The client is at risk for hypoglycemia during the peak time.

While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care? Impaired tissue perfusion Alteration in body image Alteration in activity tolerance Impaired skin integrity

Impaired tissue perfusion When using the airway, breathing, and circulation (ABC) priority-setting framework, the nurse should identify impaired perfusion of tissues as the priority finding. The presence of varicose veins indicates venous reflux is present which inhibits perfusion to all the tissues. The nurse should note the client has signs of chronic venous insufficiency as well which include edema, a feeling of heaviness in the legs, and the presence of venous stasis ulcers.

A nurse in an emergency department is caring for a client who has abdominal pain. Nurses' Notes 0800: Client reports abdominal pain that began the previous evening. Client is two weeks postoperative from a right knee replacement. Reports taking 3 to 4 hydrocodone tablets daily for postoperative pain. Has not had bowel movement in 4 days. Reports not drinking many fluids to avoid having "to get up and go to the bathroom so often because it hurts to walk." 0830: Client taken for abdominal x-ray. Partner reports that client has not been following physical therapist's exercise regimen of walking several times daily. 0915: Fecal mass of hard, dry stool removed digitally from client per provider's order. 1015: Provided teaching to client and partner about constipation and methods to avoid further impaction. Diagnostic Results 0900:Abdominal x-ray: Large amount of fecal material throughout the colon with rectal impaction. No evidence of small bowel obstruction. A nurse is providing teaching to a client who has constipation. Which of the following information should the nurse include? (Select all that apply.) Increase intake of low fiber foods. Avoid drinking hot liquids. Increase daily exercise. Include probiotic foods in the daily diet. Increase fluid intake to 1500 mL daily.

Increase fluid intake to 1500 mL daily is correct. Drinking at least 1500 mL of fluid daily will help to soften the stool. Include probiotic foods in the daily diet is correct. Probiotic foods, such as yogurt, contain live bacterial cultures that aid in digestion by promoting regularity in bowel elimination. Increase daily exercise is correct. Lack of exercise decreases the muscle tone of the lower digestive tract. Even minimal exercise can increase peristalsis.

A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications should the nurse identify as most important for the client's recovery? It decreases the client's level of anxiety. It facilitates the client's deep breathing. It enhances the client's ability to sleep. It reduces the client's blood pressure.

It facilitates the client's deep breathing. When using the airway, breathing, circulation approach to client care, the nurse should identify facilitation of deep breathing as the most important desired effect of opioids aside from pain relief. Following thoracic type surgeries, the client's has increased pain with moving, deep breathing and coughing. Opioid medications help minimize the discomfort experienced with deep breathing and coughing which prevents the development of postoperative pneumonia. The nurse should also encourage the client to splint his incision to help minimize pain.

A nurse is caring for client whose throat culture is positive for group A streptococcus 24 hr after a rapid strep test (RST) was negative. Which of the following actions is the nurse's priority? Notify the client to return to the clinic for initiation of antibiotic therapy. Ask the client to identify friends and family who have been in close contact. Reinforce teaching about gargling with warm saline several times daily. Instruct the client to take antipyretics as directed for elevated temperature.

Notify the client to return to the clinic for initiation of antibiotic therapy. An RST can produce a false negative result. A throat culture that is positive for streptococcus indicates a bacterial infection that is often associated with enlarged red tonsils, exudate, nasal discharge, and local lymph node involvement. A streptococcal infection can lead to serious complications, including glomerulonephritis, rheumatic fever, and endocarditis, so it is imperative and the highest priority for the nurse to start the client on antibiotic therapy to prevent complications.

A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take? Perform a neurovascular assessment. Explain the discharge instructions to the client and parents. Provide reassurance to the client and parents. Apply an ice pack to the casted leg.

Perform a neurovascular assessment. The greatest risk to the client is neurovascular injury. Therefore, the priority action is to perform a neurovascular assessment. This consists of assessing the involved extremity (the lower leg) at the most distal point (the foot) for circulation (color), motion (movement), and sensation, and can be remembered by the acronym "C-M-S check."

A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first? Check the client for a fecal impaction. Examine the client for areas of skin breakdown. Check the client's bladder for distention. Place the client in a sitting position.

Place the client in a sitting position. The nurse should use the least invasive intervention first. Therefore, the nurse should place the client in a sitting position to decrease the manifestation of hypertension

A nurse in the emergency department is caring for a client who has an elevated temperature and reports fatigue and muscle aches. Medical History The client was sent to the ED by their provider The client was in the office for an appointment and the provider believes that the client has pneumonia. Client has elevated temperature, fatigue, muscle aches, chills, dyspnea, and a productive cough with yellow-greenish sputum. Client also reports nausea and diarrhea for the last 24 hours. Past medical history: Asthma and diabetes mellitus type 2. Current medications: Albuterol 2 inhalations per metered dose inhaler every 6 hr. Metformin 500 mg PO BID. Vital Signs Temperature: 39.7º C (103.4º F)Apical Pulse: 110/minRespiratory Rate: 26/minBlood Pressure: 100/54 mm HgPulse Oximetry: 90% on room air Nurses' Notes (1200) Skin warm and dry, face flushed. Skin turgor poor. Mucous membranes pink and dry. Heart sounds regular and moderate. Lung sounds crackles. (1300) Sitting at bedside, reports of increased shortness of breath. Respiratory rate irregular at 28/min. Oxygen saturation 90%. Apical Pulse 108/min. Reports loss of taste. Provider notified. Which of the following actions should the nurse take? (Select all that apply.) Obtain a chest x-ray. Prepare the client for intubation. Request a prescription for isoniazid. Place the client on supplemental oxygen. Request a prescription for dexamethasone. Place the client in a negative pressure room.

Place the client on supplemental oxygen is correct. The nurse should place the client on supplemental oxygen to increase their oxygen saturation and improve their gas exchange. Place the client in a negative air pressure room is incorrect. The nurse does not need to place the client is an airborne infection room that has negative air pressure. Negative air pressure rooms are used for clients who have illnesses that are transmitted by airborne droplet nuclei smaller than 5 microns, such as measles, varicella, and tuberculosis. Obtain a chest x-ray is correct. A chest x-ray is often the most common diagnostic test for a client who has pneumonia. Prepare the client for intubation is incorrect. The client does not require intubation at this time. The nurse should apply supplemental oxygen to increase the client's gas exchange. Request a prescription for isoniazid is incorrect. Isoniazid is a medication used to treat tuberculosis. Request a prescription for dexamethasone is correct. Dexamethasone and other IV steroids are often administered to clients with pneumonia.

A nurse is caring for a client who has a new prescription for propranolol. The nurse should monitor the client for which of the following adverse reactions to this medication? Ototoxicity Tachycardia Postural hypotension Hypokalemia

Postural hypotension Propranolol can cause postural hypotension. The client should change positions slowly and the nurse should monitor the client's blood pressure from a lying to sitting to standing position.

A nurse is planning to administer digoxin to a client who has heart failure. Which of the following laboratory results is the priority for the nurse to review prior to administering the medication? Potassium Hemoglobin Creatinine Blood urea nitrogen

Potassium Digoxin is a cardiac glycoside medication used to improve myocardial contractility, increasing stroke volume and cardiac output in a client who has heart failure. During therapy, the nurse should closely monitor the client's potassium level as hypokalemia increases the risk of digitalis toxicity and cardiac arrhythmias.

A nurse is reviewing the laboratory results of a client who takes furosemide. Which of the following results should the nurse identify as the priority finding? Potassium 2.9 mEq/L Phosphorous 4.5 mEq/L Sodium 145 mEq/L Calcium 8.2 mg/dL

Potassium 2.9 mEq/L Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is the client's potassium level. The client's level is below the expected reference range of 3.5 to 5.0 mEq/L. Hypokalemia can be a life-threatening condition if left untreated. Potassium is the primary electrolyte vital for cell metabolism and cardiac and neuromuscular function.

A nurse is caring for a client who has thrombophlebitis and is receiving a continuous heparin infusion. Which of the following medications should the nurse have available to reverse heparin's effects? Vitamin K Protamine sulfate Acetylcysteine Deferasirox

Protamine sulfate Protamine sulfate reverses the effects of heparin by binding with heparin to form a heparin-protamine complex that has no anticoagulant properties.

A nurse is teaching a client who has a pelvic fracture about manifestations of fat embolism syndrome. The nurse should include which of the following findings as an early manifestation? Tachypnea Hypertension Bradycardia Swollen calf

Tachypnea Tachypnea, dyspnea, and hypoxemia are early manifestations of fat emboli syndrome.

A nurse is caring for a client who requires a medication that is packaged in a single dose glass ampule. Which of the following techniques should the nurse use when opening the glass ampule? Wear sterile gloves and break off the neck of the glass ampule with a single snap to the right side. Wear sterile gloves and break off the neck of the glass ampule with a single snap in a downward motion. Tap the bottom of the ampule, place a gauze pad around the ampule neck, and break off the bottom with a forward motion away from the body. Tap the top of the ampule, place a sterile gauze pad around the ampule neck, and break off the top by bending it toward the body.

Tap the top of the ampule, place a sterile gauze pad around the ampule neck, and break off the top by bending it toward the body. The nurse should tap the top of the ampule, place a sterile gauze pad around the ampule neck, and break off the top by bending it toward the body. The sterile gauze prevents broken glass coming in contact with the fingers, and bending the ampule top toward the body allows glass fragments to spray away from the nurse.

A hospice nurse is caring for a client who has terminal cancer and takes PO morphine for pain relief. The client reports that he had to increase the dose of morphine this week to obtain pain relief. Which of the following scenarios should the nurse document as the explanation for this situation? The client not been taking the medication properly. The client is experiencing episodes of confusion. The client has become addicted to the medication. The client developed a tolerance to the medication.

The client developed a tolerance to the medication. The nurse should document that the client has developed a tolerance to the medication. Morphine is a narcotic analgesic used for the treatment of severe pain. Tolerance is an adverse effect of narcotic analgesics in which a larger dose is needed to produce the same response.

A nurse is caring for a client who has atrial fibrillation and is receiving heparin. Which of the following findings is the nurse's priority? The client's ECG tracing shows irregular heart rate without P waves. The client has an aPTT of 80 seconds. The client experiences sudden weakness of one arm and leg. The client's urine output is cloudy and odorous.

The client experiences sudden weakness of one arm and leg. Sudden weakness or numbness of the face and one arm or leg and can indicate that the client is at greatest risk for stroke; therefore, this is the nurse's priority finding. In addition to these findings, the client may appear confused, have slurred speech, loss of balance, dizziness, or sudden severe headache.

A nurse is reviewing the health history for a client who has angina pectoris and a prescription for propranolol hydrochloride PO 40 mg twice daily. Which of the following findings in the history should the nurse report to the provider? The client has a history of hypothyroidism. The client has a history of bronchial asthma. The client has a history of hypertension. The client has a history of migraine headaches.

The client has a history of bronchial asthma. Beta-adrenergic blockers can cause bronchospasm in clients who have bronchial asthma; therefore, this is a contraindication to its use and should be reported to the provider.

A nurse is caring for a client who is 1 day postoperative following a right-sided thoracotomy with a chest tube insertion. Nurses Notes 0800: Chest tube is patent to client's right side, dressing is dry and intact, connected to a disposable three-chamber drainage system. Suction at prescribed -20 cm H2O. Tidaling noted in the water seal chamber along with continuous bubbling. Client reports pain as 3 on a scale of 0 to 10. 50 mL of sanguineous drainage noted in the collection chamber since 0700. Productive cough with clear sputum. Physical Examination 0800: Lung sounds diminished in the bases bilateral, no adventitious sounds noted Bowel sounds active x 4 quadrants, abdomen soft Capillary refill less than 2 seconds Skin dry and intact, 1+ edema noted to legs bilaterally Diagnostic Results 0500: Hemoglobin 15 g/dL (12 to 16 g/dL; critical value less than 7 g/dL) Hematocrit 35% (37 to 47%) WBC count 9,500/mm3 (5,000 to 10,000/mm3) Vital Signs 0800: Temperature 37.2° C (99° F) Heart rate 92/min Respiratory rate 20/min Blood pressure 128/68 mm Hg SaO2 96% on 2 L of oxygen via nasal cannula A nurse prioritizes care after completing the assessment and initiates the following action. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

The nurse should identify that the client is potentially experiencing an air leak because there is continuous bubbling in the water seal chamber of the chest drainage system. The nurse should assess for subcutaneous emphysema by palpating around the dressing site. If subcutaneous emphysema is present, the nurse will hear a cracking sound with palpation, and the provider should be notified. The nurse should also check the drainage system and tubing for the source of the air leak. If a leak is found in the drainage system, the unit should be replaced. If the nurse cannot find the source of the air leak within the drainage unit, the provider should be notified. The nurse should monitor the client for their ability to perform lung expansion exercises, such as deep breathing, the use of an incentive spirometer, and coughing. These activities will help to maximize the client's lung inflation, open closed airways, and remove secretions. The nurse should also monitor the client's respiratory status. If the client is experiencing an air leak, a pneumothorax is possible. The client will exhibit tachycardia, tachypnea, and increasing shortness of breath. A pneumothorax is a medical emergency, and the provider should be notified immediately.

A nurse is caring for a client on the medical-surgical unit. Nurses' Notes 09/12/xx 1300: Client presented to the emergency department with reports of fever and heart palpitations for two days. Client states they do not have a thermometer, but "I can tell my temperature is high." Client states "I also have these small red spots all over." Client reports fatigue and anorexia. Client reports alcohol use of "a couple of beers and spirits a few nights a week". Client also admits using recreational IV cocaine at least once per month with last use being one week ago. Alert and oriented, answers questions appropriately. Petechiae observed in conjunctiva. Breath sounds clear, respirations even and unlabored. Grade III/VI systolic murmur auscultated, heart rate tachycardic. Purple macules observed on the client's fingers and hands and splinter hemorrhages observed on the fingernails and toenails. 1400: Initiated IV of 0.9% Sodium Chloride to left hand infusing at 125 mL/hr. 1800: Client admitted to the medical-surgical unit with possible diagnosis of infective endocarditis. 09/13/xx 0800: Client states they are feeling better "now that my fever has come down." Client denies abdominal pain and states appetite has improved slightly from yesterday. Reports headache as 3 on a pain scale of 0 to 10 as dull. Labs drawn as prescribed. 0845: Client reports feeling dizzy and nauseated when they got up to go to the bathroom. The client also reported hearing ringing in their ears while they were feeling dizzy, but it has since gone away. The client was instructed to request assistance to the bathroom and to remain in bed. Vital Signs 09/12/xx 1300: Temperature 39 °C (102.1 °F) Respiratory Rate 20/min Heart Rate 112/min Blood Pressure 169/89 mm Hg 09/13/xx 0800: Temperature 37.8 °C (100.1 °F) Respiratory Rate 18/min Heart Rate 100/min Blood Pressure 139/81 mm Hg 0845: Blood Pressure 126/70 mm Hg Respirations 20/min Heart rate 96/min Laboratory Results 09/12/xx 1300: WBC count 15,300 mm3 (5000-10,00mm3) Blood cultures (set 1) gram positive cocci in clusters (negative) Blood cultures (set 2) gram positive cocci in clusters (negative) ALP (alkaline phosphatase) 119 U/L (30-120 U/L) ALT (Alanine Aminotransferase) 30 U/L (4-36 U/L) AST (Aspartate Aminotransferase) 20 U/L (0-35 U/L) 09/13/xx 0900: WBC count 13,200 mm3 (5000-10,00mm3) Gentamicin peak 20 mcg/mL (<10mcg/mL) ALT (Alanine Aminotransferase) 37 U/L (4-36 U/L) AST (Aspartate Aminotransferase: 36 U/L (0-35 U/L) BUN 23 mg/dL (10-20 mg/dL) Creatinine 1.4 mg/dL (0.5-1.1 mg/dL) Provider Prescriptions 09/12/xx 1400: Losartan 100mg PO daily Gentamicin 1 mg/kg IV every 8 hours Acetaminophen 650mg PO every 8 hours PRN temperature greater than 38° C (100.4° F) Diagnostic Results 09/12/xx 1500: Transesophageal echocardiogram: vegetations noted to mitral valve and tricuspid valve Medication Administration Record 09/12/xx 1415: Gentamicin 1 mg/kg IV Acetaminophen 650mg PO 1700: Losartan 100mg PO 2215: Gentamicin 1 mg/kg IV 09/13/xx 0615: Gentamicin 1 mg/kg IV 0900: Losartan 100mg PO Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at greatest risk for developing Select... due to Select... .

The nurse should identify that the priority hypothesis is that the greatest risk for the client is developing hearing loss due to antibiotics. The client was admitted with a possible diagnosis of infective endocarditis and prescribed gentamicin which is an aminoglycoside. The client is exhibiting signs of headache, dizziness, nausea, and tinnitus. Ototoxicity may occur in clients who are receiving aminoglycosides. The client's diagnostic lab results also indicate an increase in BUN, creatinine, gentamicin peak level, ALT, and AST all which place the client at risk for ototoxicity and hearing loss. Hearing loss is generally in the high frequency range and is associated with peak aminoglycoside levels that continue to remain elevated.

A nurse is caring for a client who is receiving hemodialysis. Nurses Notes 0600: Client transferred to hemodialysis room. Client is alert oriented to person, place, and time. Denies discomfort. 1030: Client returns to client room from hemodialysis room. Alert and oriented to person and place, but client has episodes of confusion. Client reports nausea and headache. Restless along with fatigue. 1100: Client ambulates to bathroom with the assist of one, gait unsteady. Vomits 300 mL of undigested food. Returns to bed Vital Signs 0600: Temperature 37.2° C (99° F) Pulse rate 86/min Respiratory rate 22/min Blood pressure 120/74 mm Hg Oxygen saturation 98% on room air 1030: Temperature 37.6° C (99.7° F) Pulse rate 92/min Respiratory rate 20/min Blood pressure 106/62 mm Hg Oxygen saturation 98% on room air Diagnostic Results 0600: Sodium 148 mEq/L (136 to 145 mEq/L) Potassium 5.8 mEq/L (3.5 to 5 mEq/L) Chloride 102 mEq/L (98 to 106 mEq/L) Magnesium 3.1 mEq/L (1.3 to 2.1 mEq/L) Phosphorus 6.2 mg/dL (3.4 to 4.5 mg/dL) Glucose 86 mg/dL (74 to 106 mg/dL) WBC count 7,500/mm3 (5,000 to 10,000/mm3) Medical History Chronic kidney disease; hemodialysis three times per week Type 1 diabetes mellitus The nurse is reviewing the client's data to report to the provider. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

The nurse should implement seizure precautions and obtain an electrolyte panel to be drawn because the client is most likely experiencing disequilibrium syndrome. Disequilibrium syndrome can occur during or after hemodialysis has been completed as a result of the rapid decrease in electrolytes and other particles. Disequilibrium syndrome is caused by cerebral fluid shifts. The nurse should monitor the client's neurological status along with the presence of nausea and vomiting. Manifestations for disequilibrium syndrome include headache, nausea, vomiting, fatigue, restlessness, seizures, and coma.

A nurse is caring for a client in the emergency department (ED) Nurse's Notes The client arrives to the ED and reports a "fluttering" and "racing" heartbeat. The client also reports dizziness and shortness of breath. Client placed on telemetry, cardiac rhythm is irregular, tachycardic and has unclear P waves. Vital Signs Blood pressure 165/88 mm Hg Pulse rate126/min Respiratory rate 22/min Oxygen Saturation 94% on room air Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress

The nurse should obtain a 12-lead ECG and administer an anticoagulant as prescribed because the client is most likely experiencing atrial fibrillation. Atrial fibrillation is characterized by manifestations of a fast, irregular heart rate that appears as a chaotic rhythm with unclear P waves. The nurse should monitor for manifestations of stroke as well as the client's PTT and INR because clients who have atrial fibrillation are at risk for the formation of clots.

A nurse is caring for a client in the provider's office. Nurses' Notes 6 months ago: 0900: A client presents to the office today for a routine check-up. They report that they saw their ophthalmologist recently and were told "I have diabetes in my eyes, so I need to make sure my blood sugar and blood pressure stay well controlled. They said I don't need eye surgery yet." The client is now wearing new glasses. Client has no complaints. Today: 1000: The client called the provider's office with reports of loss of vision in right eye. Client sates "It's like there is a curtain closing across the right eye." They have also noticed a sudden increase in the number of floaters. The client also reports seeing "bright flashing lights." Client denies eye pain, burning, redness, exudate, or lens cloudiness. Client denies headache or halos around lights. Vital Signs 6 months ago 0900: Temperature 98.2˚F (36.8˚C) Heart Rate 82/min Respiratory Rate 18/min Blood Pressure 128/86 mm Hg Laboratory Results 6 months ago: 0900: Hemoglobin A1c 6.8% to 7% Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Upon recognizing and analyzing the client's cues of sudden loss of vision, increase in the number of floaters, seeing "bright flashing lights" and "a curtain coming down" in the right eye, the nurse's priority hypotheses is that this client is most likely experiencing a retinal detachment. It is important to generate solutions and take actions to prevent further detachment. The nurse should advise the client to have someone drive them to their eye doctor immediately and anticipate emergency eye surgery to repair the client's retina. Following surgery, the nurse should monitor the client for sudden eye pain and change in pupil size which can indicate complications and should notify the provider immediately.

A nurse is caring for a client in the emergency department (ED). Nurses' Notes 0930: The client arrives to the ED and reports a "fluttering" and "racing" heartbeat. The client also reports dizziness and shortness of breath. 0945: Client placed on telemetry, cardiac rhythm is irregular, tachycardia and has unclear P waves. 0955: Doctor in to assess patient. Orders received Vital Signs 0940: Blood pressure 165/88 mm Hg Pulse rate 126/min Respiratory rate 22/min Oxygen saturation 94% on room air Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress

The nurse should obtain a 12-lead ECG and administer an anticoagulant as prescribed because the client is most likely experiencing atrial fibrillation. Atrial fibrillation is characterized by manifestations of a fast, irregular heart rate that appears as a chaotic rhythm with unclear P waves. The nurse should monitor for manifestations of stroke as well as the client's PTT and INR because clients who have atrial fibrillation are at risk for the formation of clots.

A nurse is caring for a 50-year-old client in the emergency department. Medical History 50-year-old client presented to emergency department reporting fever, chills, night sweats, and fatigue for the past several days. Yesterday, client became short of breath and has been unable to complete ADLs. Client has history of hypertension, hyperlipidemia, myocardial infarction at age 48, and osteoarthritis. Treated with penicillin 3 weeks ago for abscessed molar. History of smoking for 10 years, hasn't smoked for past 20 years. Client reports no alcohol or substance abuse. Vital Signs Temperature 38.9° C (102° F) Heart rate 86/min Respiration rate 24/min BP 130/84 mm Hg Oxygen saturation 95% room air Nurses' Notes Alert and oriented x3. Client reports shortness of breath. Denies chest pain. Apical pulse regular with murmur present. Respirations slightly labored with occasional nonproductive cough. Crackles auscultated throughout lung fields. Flat, reddened macules noted on palms of hands bilaterally. Denies discomfort in hands. No peripheral edema noted. Abdomen soft and nondistended, active bowel sounds x4. The nurse is reviewing the client's data to initiate a plan of care. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

The nurse should obtain blood cultures and request an antibiotic because the client is most likely experiencing infective endocarditis due to their previous abscessed tooth. The client is experiencing fever, chills, night sweats, fatigue, Janeway lesions, and heart murmur. These are manifestations of infective endocarditis. The nurse should monitor the client's temperature and neurological status. An elevated temperature can indicate that a change in the antibiotic or surgical intervention is needed. In addition, the nurses should monitor the client's neurological status. A complication of endocarditis is an arterial embolization in which clots break off and travel through the body. This can affect the major organs, such as the brain and heart.

A nurse is assisting with the care for a client who has been admitted to the emergency department (ED) Nurses Notes The client presents to the ED stating that they had a sudden onset of dyspnea while taking a shower. The client appears restless, pale, and diaphoretic and keeps stating, "I think I'm going to die." Client is alert and orientated x 4. Heart sounds are clear, pulse is tachycardic. Crackles in bilateral lower bases are auscultated as well as a pleural friction rub. Bowel sounds are normoactive in all four quadrants. Bilateral pedal pulses are +2. Vital Signs Temperature 99.5°F (37.5°C) Heart rate 109/min Respiratory rate 28/min Blood pressure 176/78 mm Hg Oxygen saturation 90% on room air Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to determine the client's progress.

The nurse should place the client in high-Fowler's position and obtain venous access because the client is most likely experiencing a pulmonary embolism (PE). Placing the client in high-Fowler's promotes optimal gas exchange and obtaining venous access allows for medications to treat the PE or complications to be administered. The nurse should monitor for petechiae on the chest and cardiac dysrhythmias which can occur with PE and can be life threatening. The nurse should also monitor the client's aPTT prior to the administration of an anticoagulants and then while receiving treatment, as prescribed.

A nurse is caring for a for a client who has been admitted to the emergency department (ED). Nurse's Notes The client presents to the ED stating that they had a sudden onset of dyspnea while taking a shower. The client appears restless, pale and diaphoretic, and keeps stating "I think I'm going to die." Client is alert and orientated x 4. Heart sounds are clear, pulse is tachycardic. Crackles in bilateral lower bases are auscultated as well as a pleural friction rub. Bowel sounds are normoactive in all 4 quadrants. Bilateral pedal pulses are +2. Vital Signs Temperature 37.5° C (99.5° F) Pulse rate 109/min Respiratory rate 28/min Blood pressure 176/78 mm Hg Oxygen Saturation 90% on room air Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition and two parameters the nurse should monitor to assess the client's progress.

The nurse should place the client in high-Fowler's position and obtain venous access because the client is most likely experiencing a pulmonary embolism (PE). Placing the client in high-Fowler's promotes optimal gas exchange and obtaining venous access allows for medications to treat the PE or complications to be administered. The nurse should monitor for petechiae on the chest and cardiac dysrhythmias, which can occur with a PE and can be life threatening. The nurse should also monitor the client's aPTT prior to the administration of anticoagulants and also while the client is receiving treatment, as prescribed.

Nurses' Notes 1310: A&O x 3. Skin cool, clammy, pale. Respirations labored at 30/min, shallow. Coarse crackles throughout bilateral lung fields. O2 saturation 88% on room air. Jugular vein distention (JVD) present bilaterally. Heart sounds moderate and regular, rate 98/min. BP 114/78 mm Hg. Temperature 37.8º C (99.9º F). Denies pain. Medical History 1000: 74-year-old female who is obese admitted with increased weight gain of 4.5 kg (10 lb) over the last 4 days. Diet has consisted of canned soup and cold meat sandwiches. Denies shortness of breath at rest, dyspnea on exertion. Respirations slightly labored at 22/min. O2 saturation 95% on room air. Few fine rales auscultated bilateral bases. Heart sounds moderate and regular. 3+ pitting edema present bilateral lower extremities. Skin cool, dry, and intact. Abdomen distended, denies discomfort on palpation. Alert and oriented x 3. PERRLA. Past medical history: hypertension x 20 years that is controlled with medication, coronary artery disease (CAD), left ventricular hypertrophy and right-sided heart failure, COPD. History of smoking 2 packs of cigarettes a week. Current medications: Losartan/Hydrochlorothiazide 50/12.5 mg PO daily Aspirin 81 mg PO daily Nitroglycerin 0.3 mg sublingual PRN chest pain Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

The nurse should take action by apply O2 at 2 L/min via nasal cannula and elevate the head of the client's bed because the client's condition is worsening related to their congestive heart failure . The nurse should continue to monitor the parameters of the client's respiratory rate and oxygen saturation to assess the client's progress. The client's respirations have increased in rate and are more labored. The client's oxygen saturation level has decreased and their lung sounds have deteriorated from a few fine crackles in bilateral bases to coarse crackles throughout.

A nurse is caring for a client who is being admitted to the medical-surgical unit from the emergency department. The nurse is reviewing the client's medical records. Diagnostic Results HbA1c 8.4% (less than 7% for diabetics) Blood glucose 235 mg/dL (74 to 106 mg/dL) Hemoglobin 14.2 g/dL (12 to 18 g/dL) Hematocrit 42.6% (37 to 52%) Total WBC count 6000/mm3 (5000 to 10,000/mm3) HDL 75 mg/dL (greater than 55 mg/dL) LDL 124 mg/dL (less than 130 mg/dL) BNP 52 pg/ml (less than 100 pg/mL) Chest x-ray: Clear. No evidence of infiltrates. UrinalysisResultExpected Reference RangeAppearanceClearClearColorAmberYellowpH5.84.6 to 8.0Specific gravity1.0121.005 to 1.030Leucocyte esteraseNegativeNegative NitratesNoneNoneCrystalsNoneNoneCastsNoneNoneGlucose0NegativeWBC00 to 4 per low-power fieldRBC0less than or equal to 2 Medication Administration Record Glargine U 100 25 units subcutaneous at bedtimeFingerstick/random blood glucose before breakfast & bedtime with regular insulin subcutaneous sliding scale coverage: Less than 160 mg/dL: no coverage160 to 220 mg/dL: 2 units221 to 280 mg/dL: 3 units281 to 340 mg/dL: 6 units341to 400 mg/dL: 8 unitGreater than 400: call physician Aldactone 50 mg PO twice dailyDigoxin 0.25 mg PO every morningCarvedilol 25 mg PO twice daily Vital Signs BP 120/72 mm HgTemperature 36.8º C (98.2º F)Pulse rate 88/minRespirations 20/min Nurses' Notes Client received to emergency department from home via private vehicle. Reports fatigue, blurred vision, dizziness, and headache x 2 days. Reports running out of blood glucose strips and Humulin regular insulin due to lack of financial means. States that they are afraid of possible falls from fatigue and dizziness. Lives at home alone. Orders received; will increase glargine from 20 units to 25 units at bedtime. Other meds taken at home remain the same at this time. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

The nurse should teach the client signs of hyperglycemia and assess their feet for sensation because the client is most likely experience type 1 diabetes mellitus because the HgA1c is elevated to a level indicating only fair diabetic control and the fingerstick blood glucose level is high, which is indicative of diabetes. The nurse will need to assess for the potential diabetic complication of peripheral neuropathy in the feet. The nurse should monitor urinary output and fingerstick blood glucose. This will allow the nurse to determine whether the medication and diet are effective in controlling the client's glucose levels.

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first? Turn the client's head to the side. Check the client's motor strength. Loosen the clothing around the client's waist. Document the time the seizure began.

Turn the client's head to the side. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to turn the client's head to the side. This action keeps the client's airway clear of secretion to prevent aspiration.