RQ 9

11. The client has developed atrial fibrillation, with a ventricular rate of 150 beats per minute. Which associated findings would the nurse anticipate in the assessment? Select all that apply.

1. Syncope 2. Dizziness 3. Palpitations

8. A client has been started on long-term therapy with rifampin. The nurse would provide which information to the client about the medication?

3. Causes orange discoloration of sweat, tears, urine, and feces

14. The nurse has just administered the first dose of omalizumab to a client with asthma. Which statement by the client alerts the nurse of a life-threatening effect?

4. "My lips and tongue are swollen." Anaphylactic reaction

7. A client is to begin a 6-month course of therapy with isoniazid. The nurse would plan to teach the client to take which action?

2. Report yellow eyes or skin immediately. Isoniazid is hepatotoxic; therefore, the client is taught to immediately report signs and symptoms of hepatitis, which include yellow skin and sclera

8. The nurse has conducted discharge teaching with a client diagnosed with tuberculosis who has been receiving medication for 2 weeks. The nurse determines that the client has understood the information if the client makes which statement?

4. "I won't be contagious after 2 to 3 weeks of medication therapy."

16. The nurse is caring for a client receiving an albuterol/ipratropium nebulized breathing treatment. Which report from the client would the nurse note as an expected side effect of this combination medication?

1. "I feel as though my heart is racing." Common side and adverse effects include headache, dizziness, dry mouth, tremors, nervousness, and tachycardia.

15. The nurse is teaching a client who is beginning antiviral therapy for influenza. Which statement by the client indicates an understanding of the instructions?

1. "I must take the medication exactly as prescribed."

3. The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions would the nurse include on the list? Select all that apply.

1. Activities should be resumed gradually. 2. Avoid contact with other individuals, except family members, for at least 6 months. 3. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4. Respiratory isolation is not necessary, because family members already have been exposed. 5. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags.

3. The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles. The nurse immediately asks another nurse to contact the primary health care provider and prepares to implement which priority interventions? Select all that apply.

1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide 4. Administering morphine sulfate intravenously

2. A client with chronic kidney disease being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious, and the nurse suspects air embolism. What are the priority nursing actions? Select all that apply.

1.Administer oxygen to the client. 3.Notify the primary health care provider (PHCP) and Rapid Response Team. 4.Stop dialysis, and turn the client on the left side with head lower than feet.

12. A client's cardiac rhythm suddenly changes on the monitor. There are no P waves; instead, there are fibrillatory waves before each QRS complex. How would the nurse interpret the rhythm?

1. Atrial fibrillation Atrial fibrillation is characterized by a loss of P waves and fibrillatory waves before each QRS complex. The atria quiver, which can lead to thrombus formation.

11. The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. Which actions would the nurse take? Select all that apply.

1. Check the level of the drainage bag. 2. Reposition the client to the side. 3. Place the client in good body alignment. 4.Check the peritoneal dialysis system for kinks.

13. A client begins therapy with theophylline. The nurse plans to teach the client to limit the intake of which items while taking this medication?

1. Coffee, cola, and chocolate The nurse teaches the client to limit the intake of xanthine-containing foods while taking this medication.

12. A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. The nurse would assess the client for which expected finding?

1. Dyspnea The infection begins as a respiratory infection

16. The community health nurse is conducting an educational session with community members regarding the signs and symptoms associated with tuberculosis. The nurse informs the participants that tuberculosis is considered as a diagnosis if which signs and symptoms are present? Select all that apply.

1. Dyspnea 3. Night sweats 4. A bloody, productive cough 5. A cough with the expectoration of mucoid sputum

13. The nurse is reviewing a client's record and notes that the primary health care provider has documented that the client has chronic kidney disease. On review of the laboratory results, the nurse most likely would expect to note which finding?

1. Elevated creatinine level The creatinine level is the most specific laboratory test to determine renal function. The creatinine level increases when at least 50% of renal function is lost.

1. The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client?

2. Diminished breath sounds

4. The nurse discusses plans for future treatment options with a client with symptomatic polycystic kidney disease. Which treatment(s) would be included in this discussion? Select all that apply.

1. Hemodialysis 3.Kidney transplant 4.Bilateral nephrectomy

9. A client has frequent bursts of ventricular tachycardia on the cardiac monitor. Which factor is highest priority with regard to this dysrhythmia?

1. It can develop into ventricular fibrillation at any time. Ventricular tachycardia is a life-threatening dysrhythmia that results from an irritable ectopic focus that takes over as the pacemaker for the heart. Ventricular tachycardia can deteriorate into ventricular fibrillation with cardiac arrest at any time. Clients frequently experience a feeling of impending doom. The low cardiac output that results can lead quickly to cerebral and myocardial ischemia.

14. The nurse is taking the history of a client with occupational lung disease (silicosis). The nurse would ask the client whether the client wears which item during periods of exposure to silica particles?

1. Mask Silicosis results from chronic, excessive inhalation of particles of free crystalline silica dust. The client needs to wear a mask to limit inhalation of this substance, which can cause restrictive lung disease after years of exposure

5. A client is admitted to the emergency department following a fall from a horse, and the primary health care provider (PHCP) prescribes insertion of a urinary catheter. While preparing for the procedure, the nurse notes blood at the urinary meatus. The nurse would take which action?

1. Notify the PHCP before performing the catheterization. The presence of blood at the urinary meatus may indicate urethral trauma or disruption. The nurse notifies the PHCP, knowing that the client would not be catheterized until the cause of the bleeding is determined by diagnostic testing.

6. The nurse is assessing the patency of a client's left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent?

1. Palpation of a thrill over the fistula The nurse assesses the patency of the fistula by palpating for the presence of a thrill or auscultating for a bruit. The presence of a thrill and bruit indicates patency of the fistula. Enlarged visible blood vessels at the fistula site are a normal observation but are not indicative of fistula patency.

11. A client who is human immunodeficiency virus (HIV)-positive has had a tuberculin skin test (TST). The nurse notes a 7-mm area of induration at the site of the skin test and interprets the result as which finding?

1. Positive The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client.

12. Rifabutin is prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. The nurse would monitor for which side and adverse effects of rifabutin? Select all that apply.

1. Signs of hepatitis 2. Flulike syndrome 3. Low neutrophil count 5. Ocular pain or blurred vision

17. A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats per minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How would the nurse interpret this rhythm?

1. Sinus tachycardia Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and normal-width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia, the atrial and ventricular rates are greater than 100 beats per minute.

14. A client receiving thrombolytic therapy with a continuous infusion of alteplase suddenly becomes extremely anxious and reports itching. The nurse hears stridor and notes generalized urticaria and hypotension. Which interventions would the nurse take? Select all that apply.

1. Stop the infusion. 4. Administer diphenhydramine. 5. Call for the Rapid Response Team (RRT).

8. The nurse is monitoring a client for adverse effects of medications. Which findings are characteristic of adverse effects of hydrochlorothiazide? Select all that apply.

1. Sulfa allergy 3. Hypokalemia 5. Hyperglycemia 6. Hypercalcemia

18. The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable. How would the nurse interpret the client's neurovascular status?

1. The neurovascular status is expected because of increased blood flow through the leg. An expected outcome of aortoiliac bypass graft surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. The remaining options are incorrect interpretations

1. A client with acute kidney injury has a serum potassium level of 7.0 mEq/L (7.0 mmol/L). The nurse would plan which actions as a priority? Select all that apply.

1.Place the client on a cardiac monitor. 2.Notify the primary health care provider (PHCP). 4.Review the client's medications to determine whether any contain or retain potassium.

2. The nurse provides discharge instructions to a client with atrial fibrillation who is taking warfarin sodium. Which statement by the client reflects the need for further teaching?

2. "I will take coated aspirin for my headaches."

2. The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? Select all that apply.

2. A hyperinflated chest noted on the chest x-ray 3. Decreased oxygen saturation with mild exercise

16. The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. Which assessment is the nursing priority

2. Activation status and settings of the device The nurse who is caring for the client after insertion of an automatic internal cardioverter-defibrillator needs to assess device settings, similar to care after insertion of a permanent pacemaker. Specifically, the nurse needs to know whether the device is activated, the heart rate cutoff above which it will fire, and the number of shocks it is programmed to deliver.

15. The nurse is evaluating a client's response to cardioversion. Which assessment would be the priority?

2. Airway patency Nursing responsibilities after cardioversion include maintenance first of a patent airway, and then oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection.

3. The nurse is providing discharge instructions to a client receiving trimethoprim-sulfamethoxazole. Which instruction would be included in the list?

2. Drink 8 to 10 glasses of water per day.

7. A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action?

2. Check the client's status. Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Accurate assessment of the client is necessary to determine the cause and identify the appropriate intervention.

6. A client with valvular heart disease who has a clot in the right atrium is receiving a heparin sodium infusion at 1000 units/hr and warfarin sodium 7.5 mg at 1600 daily. The morning laboratory results are as follows: activated partial thromboplastin time (aPTT), 32 seconds; international normalized ratio (INR), 1.3. Which action would the nurse take based on the client's laboratory results?

2. Collaborate with the PHCP to obtain a prescription to increase the heparin infusion and continue the warfarin sodium as prescribed. When a client is receiving warfarin for clot prevention due to atrial fibrillation, an INR of 2 to 3 is appropriate for most clients. Until the INR has achieved a therapeutic range, the client should be maintained on a continuous heparin infusion with the aPTT ranging between 60 and 80 seconds.

4. A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds?

2. Crackles Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles.

5. The nurse is monitoring a client with hypertension who is taking propranolol. Which assessment finding indicates a potential adverse complication associated with this medication?

2. Development of expiratory wheezes Audible expiratory wheezes may indicate a serious adverse reaction, bronchospasm. Beta blockers may induce this reaction, particularly in clients with chronic obstructive pulmonary disease or asthma. Normal decreases in blood pressure and heart rate are expected.

10. The nurse is monitoring a client with heart failure who is taking digoxin. Which findings are characteristic of digoxin toxicity? Select all that apply.

2. Diarrhea 4. Blurred vision 5. Nausea and vomiting

17. The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication?

2. Hyperglycemia An extended dwell time increases the risk of hyperglycemia in the client with diabetes mellitus as a result of absorption of glucose from the dialysate and electrolyte changes. Diabetic clients may require extra insulin when receiving peritoneal dialysis. Peritonitis is a risk associated with breaks in aseptic technique

1. A client with a history of type 2 diabetes is admitted to the hospital with chest pain and scheduled for a cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure?

2. Metformin Metformin needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because of the injection of contrast medium during the procedure. If the contrast medium affects kidney function, with metformin in the system the client would be at increased risk for lactic acidosis.

9. The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse would wear which items when performing this care?

2. Particulate respirator, gown, and gloves

6. A client has been taking isoniazid for 2 months. The client complains to the nurse about numbness, paresthesias, and tingling in the extremities. The nurse interprets that the client is experiencing which problem?

2. Peripheral neuritis

13. Intravenous heparin therapy is prescribed for a client with atrial fibrillation. While implementing this prescription, the nurse ensures that which medication is available on the nursing unit?

2. Protamine sulfate The antidote to heparin is protamine sulfate; it needs to be readily available for use if excessive bleeding or hemorrhage occurs.

11. The nurse has a prescription to give a client salmeterol, 2 puffs, and beclomethasone dipropionate, 2 puffs, by metered-dose inhaler. The nurse would administer the medication using which procedure?

2. Salmeterol first and then the beclomethasone Salmeterol is an adrenergic type of bronchodilator, and beclomethasone dipropionate is a glucocorticoid. Bronchodilators are always administered before glucocorticoids when both are to be given on the same time schedule. This allows for widening of the air passages by the bronchodilator, which then makes the glucocorticoid more effective.

6. Bethanechol chloride is prescribed for a client with urinary retention. The nurse would contact the prescriber if which disorder, a contraindication to the medication, was documented in the client's record?

2. Urinary strictures Bethanechol chloride can be hazardous to clients with urinary tract obstruction or weakness of the bladder wall. The medication has the ability to contract the bladder and thereby increase pressure within the urinary tract. Elevation of pressure within the urinary tract could damage or rupture the bladder in clients with these conditions

5. Phenazopyridine is prescribed for a client with a urinary tract infection. The nurse evaluates that the medication is effective based on which observation?

2. Urination is not painful. Phenazopyridine is a urinary analgesic. It is effective when it eliminates pain and burning with urination. It does not eliminate the bacteria causing the infection, so it would not make the urine clear amber.

12. The nurse administered intravenous bumetanide to a client being treated for heart failure. Which outcome indicates that the medication has achieved the expected effect?

2. Urine output increases from 10 mL/hr to greater than 50 mL hourly.

5. A client with myocardial infarction is developing cardiogenic shock. Which potential condition would the nurse anticipate and monitor the client for to detect cardiogenic shock?

2. Ventricular dysrhythmias Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium. Classic signs of cardiogenic shock as they relate to myocardial ischemia include low blood pressure and tachycardia

1. A client with atrial fibrillation is receiving a continuous heparin infusion at 1000 units/hr. Which result would indicate to the nurse that the client is receiving a therapeutic dose?

3. Activated partial thromboplastin time of 60 seconds Because the aPTT should be 1.5 to 2.5 times the normal value, the client's aPTT would be considered therapeutic if it was 60 seconds. Prothrombin time assesses response to warfarin therapy.

4. A client is being treated with procainamide for a cardiac dysrhythmia. Following intravenous administration of the medication, the client complains of dizziness. Which intervention would the nurse implement first?

3. Auscultate the client's apical pulse and blood pressure. If the client complains of dizziness, the nurse would assess the vital signs first.

10. A client is having frequent premature ventricular contractions. The nurse would place priority on assessment of which information?

3. Blood pressure and oxygen saturation Premature ventricular contractions can cause hemodynamic compromise. Therefore, the priority is to monitor the blood pressure and oxygen saturation. The shortened ventricular filling time can lead to decreased cardiac output. The client may be asymptomatic or may feel palpitations. Premature ventricular contractions can be caused by cardiac disorders; states of hypoxemia; any number of physiological stressors, such as infection, illness, surgery, or trauma; and intake of caffeine, nicotine, or alcohol.

15. The nurse would report which assessment finding to the primary health care provider (PHCP) before initiating thrombolytic therapy in a client with pulmonary embolism?

3. Blood pressure of 198/110 mm Hg Thrombolytic therapy is contraindicated in severe uncontrolled hypertension because of the risk of cerebral hemorrhage.

9. Following kidney transplantation, cyclosporine is prescribed for a client. Which laboratory result would indicate an adverse effect from the use of this medication?

3. Blood urea nitrogen level of 25 mg/dL (8.8 mmol/L)

7. The nurse, who is administering bethanechol chloride, is monitoring for cholinergic overdose associated with the medication. The nurse would check the client for which sign of overdose?

3. Bradycardia Cholinergic overdose of bethanechol chloride produces manifestations of excessive muscarinic stimulation

10. A client has experienced pulmonary embolism. The nurse would assess for which symptom, which is most commonly reported?

3. Chest pain that occurs suddenly

4. Terbutaline is prescribed for a client with bronchitis. Which disorder in the client's medical history requires caution by the nurse?

3. Diabetes mellitus The medication may increase blood glucose levels.

8. The nurse is assessing a client with epididymitis. The nurse anticipates which findings on physical examination?

3. Fever, nausea, vomiting, and painful scrotal edema Typical signs and symptoms of epididymitis include scrotal pain and edema, which often are accompanied by fever, nausea and vomiting, and chills. Epididymitis most often is caused by infection, although sometimes it can be caused by trauma.

10. The nurse is providing dietary instructions to a client who has been prescribed cyclosporine. Which food item would the nurse instruct the client to exclude from the diet?

3. Grapefruit juice As a result, consumption of grapefruit juice can raise cyclosporine levels by 50% to 100%, thereby greatly increasing the risk of toxicity. Red meats, orange juice, and green, leafy vegetables do not interact with the cytochrome P450 system.

1. A client has a prescription to take guaifenesin. The nurse determines that the client understands the proper administration of this medication if the client states that they will perform which action?

3. Increase water intake when taking the medication Guaifenesin is an expectorant and needs to be taken with a full glass of water to decrease the viscosity of secretions.

10. A client with tuberculosis is starting antituberculosis therapy with isoniazid. Before giving the client the first dose, the nurse would ensure that which baseline study has been completed?

3. Liver enzyme levels Isoniazid therapy can cause an elevation of hepatic enzyme levels and hepatitis.

5. Zafirlukast is prescribed for a client with bronchial asthma. Which laboratory test does the nurse expect to be prescribed before the administration of this medication?

3. Liver function tests

9. The home health care nurse is visiting a client with coronary artery disease with elevated triglyceride levels and a serum cholesterol level of 398 mg/dL (10 mmol/L). The client is taking cholestyramine, and the nurse teaches the client about the medication. Which statement by the client indicates the need for further teaching?

4. "I'll continue my nicotinic acid from the health food store." Nicotinic acid, even an over-the-counter form, needs to be avoided because it may lead to liver abnormalities. All lipid-lowering medications also can cause liver abnormalities, so a combination of nicotinic acid and cholestyramine resin needs to be avoided.

6. The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64 beats per minute. Which action would the nurse take?

3. Monitor for any rhythm change. The PR and QRS measurements are normal, measuring between 0.12 and 0.20 seconds and 0.04 and 0.10 seconds, respectively. There are no irregularities in this rhythm currently, so there is no immediate need to check vital signs or laboratory results, or to notify the primary health care provider. Therefore, the nurse would continue to monitor the client for any rhythm change

7. A client is diagnosed with an ST segment elevation myocardial infarction (STEMI) and is receiving a tissue plasminogen activator, alteplase. Which action is a priority nursing intervention?

3. Monitor for signs of bleeding. Tissue plasminogen activator is a thrombolytic. Hemorrhage is a complication of any type of thrombolytic medication. The client is monitored for bleeding

14. A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client's temperature is 101.2° F (38.5° C ). Which nursing action is most appropriate?

3. Notify the primary health care provider. A temperature of 101.2° F (38.5° C) is significantly elevated and may indicate infection. The nurse would notify the primary health care provider (PHCP). Dialysis clients cannot have fluid intake encouraged.

6. A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest?

3. Paradoxical chest movement Flail chest results from multiple rib fractures. This results in a "floating" section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement.

3. A client arrives at the emergency department with complaints of low abdominal pain and hematuria. The client is afebrile. The nurse next assesses the client to determine a history of which condition?

3. Recent trauma to the bladder or abdomen Bladder trauma or injury needs to be considered or suspected in the client with low abdominal pain and hematuria.

2. The nurse is preparing to administer a dose of naloxone intravenously to a client with an opioid overdose. Which supportive medical equipment would the nurse plan to have at the client's bedside?

3. Resuscitation equipment

17. The nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse would check the results of which diagnostic test that will confirm this diagnosis?

3. Sputum culture

8. The nurse is watching the cardiac monitor and notices that a client's rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140 beats per minute. The nurse determines that the client is experiencing which dysrhythmia?

3. Ventricular tachycardia Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (longer than 0.12 seconds), and typically a rate between 140 and 180 impulses per minute. The rhythm is regular.

16. The nurse provides instructions to the client about nicotinic acid prescribed for hyperlipidemia. Which statement by the client indicates understanding of the instructions?

4. "Ibuprofen taken 30 minutes before the nicotinic acid may decrease the flushing." Flushing is an adverse effect of this medication. Aspirin or a nonsteroidal antiinflammatory drug, as prescribed, can be taken 30 minutes prior to taking the medication to decrease flushing.

20. A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which statement by the client indicates the need for further teaching?

4. "My spouse told me that since I have this problem, we are going to stop walking in the mall every morning." Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, most often at rest. The pain is a result of coronary artery spasm.

3. A client who is receiving digoxin daily has a serum potassium level of 3 mEq/L (3 mmol/L) and reports anorexia. The cardiologist prescribes a serum digoxin level to be done. Which level would the nurse recognize as being outside of the therapeutic range?

4. 2.2 ng/mL (2.8 nmol/L) If the client is experiencing symptoms such as anorexia and is experiencing hypokalemia as evidenced by a low potassium level, digoxin toxicity is a concern.

14. A client in ventricular fibrillation is about to be defibrillated. Which energy level (in joules, J) would the nurse set on the monophasic defibrillator machine for the first delivery?

4. 360 J The energy level used for all defibrillation attempts with a monophasic defibrillator is 360 joules.

19. A client is admitted to the hospital with a diagnosis of benign prostatic hyperplasia, and a transurethral resection of the prostate is performed. Four hours after surgery, the nurse takes the client's vital signs and empties the urinary drainage bag. Which assessment finding indicates the need to notify the primary health care provider (PHCP)?

4. Blood pressure, 100/50 mm Hg; pulse, 130 beats per minute A rapid pulse with a low blood pressure is a potential sign of excessive blood loss. The PHCP needs to be notified.

3. A cromolyn sodium inhaler is prescribed for a client with allergic asthma. The nurse provides instructions regarding the adverse effects of this medication and would tell the client that which undesirable effect is associated with this medication?

4. Bronchospasm

19. The nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an intravenous (IV) infusion at a rate of 150 mL/hr, unchanged for the last 10 hours. The client's urine output for the last 3 hours has been 90, 50, and 28 mL (28 mL is most recent). The client's blood urea nitrogen level is 35 mg/dL (12.6 mmol/L), and the serum creatinine level is 1.8 mg/dL (159 mcmol/L), measured this morning. Which nursing action is the priority?

4. Call the primary health care provider.

13. The nurse is assisting to defibrillate a client in ventricular fibrillation. Which intervention is a priority after placing the pads on the client's chest and before discharging the device?

4. Confirm the cardiac rhythm. Until the defibrillator is attached and charged, the client is resuscitated by using cardiopulmonary resuscitation. Once the defibrillator has been attached, the electrocardiogram is checked to verify that the rhythm is ventricular fibrillation or pulseless ventricular tachycardia. Leads also are checked for any loose connections.

1. A client who has a cold is seen in the emergency department with an inability to void. Because the client has a history of benign prostatic hyperplasia, the nurse determines that the client would be questioned about the use of which

4. Decongestants In the client with benign prostatic hyperplasia, episodes of urinary retention can be triggered by certain medications, such as decongestants, anticholinergics, and antidepressants. These medications lessen the voluntary ability to contract the bladder.

10. The nurse is collecting data from a client. Which symptom described by the client is characteristic of an early symptom of benign prostatic hyperplasia?

4. Decreased force in the stream of urine Decreased force in the stream of urine is an early symptom of benign prostatic hyperplasia. The stream later becomes weak and dribbling. The client then may develop hematuria, frequency, urgency, urge incontinence, and nocturia. If untreated, complete obstruction and urinary retention can occur.

9. The nurse has given a client taking ethambutol information about the medication. The nurse determines that the client understands the instructions if the client states that they will immediately report which finding?

4. Difficulty in discriminating the color red from green Ethambutol causes optic neuritis, which decreases visual acuity and the ability to discriminate between the colors red and green. This poses a potential safety hazard when a client is driving a motor vehicle. The client is taught to report this symptom immediately.

7. A client has a tentative diagnosis of urethritis. The nurse would assess the client for which manifestation of the disorder?

4. Dysuria and penile discharge Urethritis often results from chlamydial infection and is characterized by dysuria, which is accompanied by a clear to mucopurulent discharge.

20. The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse would assess the client during dialysis for which associated manifestations?

4. Headache, deteriorating level of consciousness, and twitching At the same time, the blood-brain barrier interferes with the efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic gradient, causing increased intracranial pressure and onset of symptoms. The syndrome most often occurs in clients who are new to dialysis and is prevented by dialyzing for shorter times or at reduced blood flow rates.

18. A week after kidney transplantation, a client develops a temperature of 101° F (38.3° C), the blood pressure is elevated, and there is tenderness over the transplanted kidney. The serum creatinine is rising, and urine output is decreased. The x-ray indicates that the transplanted kidney is enlarged. Based on these assessment findings, the nurse anticipates which treatment?

4. Increased immunosuppression therapy Treatment consists of increasing immunosuppressive therapy. Acute rejection most often occurs within 1 week after transplantation but can occur any time post-transplantation.

7. The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse would assess for which earliest sign of acute respiratory distress syndrome?

4. Increased respiratory rate

16. A client with severe back pain and hematuria is found to have hydronephrosis due to urolithiasis. The nurse anticipates that which treatment will be done to relieve the obstruction? Select all that apply.

4. Insertion of a nephrostomy tube 5. Placement of a ureteral stent with ureteroscopy

15. The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action?

4. Notify the primary health care provider (PHCP). Disequilibrium syndrome may be caused by rapid removal of solutes from the body during hemodialysis. These changes can cause cerebral edema that leads to increased intracranial pressure. The client is exhibiting early signs and symptoms of disequilibrium syndrome, and appropriate treatments with anticonvulsive medications and barbiturates may be necessary to prevent a life-threatening situation. The PHCP must be notified

5. The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse would expect to note which finding?

4. Pain, especially with inspiration

12. A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse would assess for which manifestations of this complication?

4. Pallor, diminished pulse, and pain in the left hand Steal syndrome results from vascular insufficiency after creation of a fistula. The client exhibits pallor and a diminished pulse distal to the fistula.

2. A client in sinus bradycardia, with a heart rate of 45 beats per minute and blood pressure of 82/60 mm Hg, reports dizziness. Which intervention would the nurse anticipate will be prescribed?

4. Prepare for transcutaneous pacing. This rhythm becomes a concern when the client becomes symptomatic. Hypotension and dizziness are signs of decreased cardiac output. Transcutaneous pacing provides a temporary measure to increase the heart rate and thus perfusion in the symptomatic client.

8. Oxybutynin chloride is prescribed for a client with urge incontinence. Which sign would indicate a possible toxic effect related to this medication?

4. Restlessness Toxicity (overdosage) of oxybutynin produces central nervous system excitation

11. Prior to administering a client's daily dose of digoxin to treat heart failure, the nurse reviews the client's laboratory data and notes the following results: serum calcium, 9.8 mg/dL (2.45 mmol/L); serum magnesium, 1.0 mEq/L (0.4 mmol/L); serum potassium, 4.1 mEq/L (4.1 mmol/L); serum creatinine, 0.9 mg/dL (79.5 mcmol/L). Which result would alert the nurse that the client is at risk for digoxin toxicity?

4. Serum magnesium level

13. The nurse provides discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client indicates to report which early sign of exacerbation?

4. Shortness of breath

15. The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position would the nurse instruct the client to assume?

4. Sitting up and leaning on an overbed table Positions that will assist the client with emphysema with breathing include sitting up and leaning on an overbed table,

4. Trimethoprim-sulfamethoxazole is prescribed for a client. The nurse would instruct the client to report which symptom if it develops during the course of this medication therapy?

4. Sore throat Clients taking trimethoprim-sulfamethoxazole need to be informed about early signs and symptoms of blood disorders that can occur from this medication.

11. Tacrolimus is prescribed for a client who underwent a kidney transplant. Which instruction would the nurse include when teaching the client about this medication?

4. Take the oral medication every 12 hours at the same times every day. It is important that the medication be taken at 12-hour intervals to maintain a stable blood level to prevent organ rejection.

9. A client complains of fever, perineal pain, urinary urgency, frequency, and dysuria. To assess whether the client's problem is related to bacterial prostatitis, the nurse reviews the results of the prostate examination for which characteristic of this disorder?

4. Tender, indurated prostate gland that is warm to the touch The client with bacterial prostatitis has a swollen and tender prostate gland that is also warm to the touch, firm, and indurated. Systemic symptoms include fever with chills, perineal and low back pain, and signs of urinary tract infection, which often accompany the disorder.

2. Nitrofurantoin is prescribed for a client with a urinary tract infection. The client contacts the nurse and reports a cough, chills, fever, and difficulty breathing. The nurse would make which interpretation about the client's complaints?

4. The client is experiencing a pulmonary reaction requiring cessation of the medication. Nitrofurantoin can induce two kinds of pulmonary reactions: acute and subacute. Acute reactions, which are most common, manifest with dyspnea, chest pain, chills, fever, cough, and alveolar infiltrates. These symptoms resolve 2 to 4 days after discontinuing the medication. Acute pulmonary responses are thought to be hypersensitivity reactions. Subacute reactions are rare and occur during prolonged treatment. Symptoms (e.g., dyspnea, cough, malaise) usually regress over weeks to months following nitrofurantoin withdrawal. However, in some clients, permanent lung damage may occur.

4. The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, would the nurse immediately report to the primary health care provider?

Bronchospasm