SAUNDERS - INCORRECT Questions W/ Rationales Part 1

A nursing student who is researching a medication at the nurses' station asks the registered nurse (RN) what the function of an alpha-adrenergic receptor is, and where the receptors are primarily found. The RN educates the nursing student. Which statement by the nursing student indicates that teaching has been effective? 1"The peripheral arteries and veins; when stimulated they cause vasoconstriction." 2"Arterial and bronchial walls; when stimulated they cause vasodilation and bronchodilation." 3"The heart; when stimulated it causes an increase in heart rate, atrioventricular node conduction, and contractility." 4"Several tissues; when stimulated they cause contraction of smooth muscle, inhibition of lipolysis, and promotion of platelet aggregation."

1"The peripheral arteries and veins; when stimulated they cause vasoconstriction." Rationale: Found in the peripheral arteries and veins, alpha-adrenergic receptors cause a powerful vasoconstriction when stimulated. The remaining options are incorrect statements.

The nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. The nurse is planning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. Which nursing action is required before plugging the tube? 1. Deflate the cuff on the tube. 2.Place the inner cannula into the tube. 3. Ensure that the client is able to speak. 4. Ensure that the client is able to swallow.

1. Deflate the cuff on the tube Rationale: Plugging a tracheostomy tube is usually done by inserting the tracheostomy plug (decannulation stopper) into the opening of the outer cannula. This closes off the tracheostomy, and airflow and respiration occur normally through the nose and mouth. When plugging a cuffed tracheostomy tube, the cuff must be deflated. If it remains inflated, ventilation cannot occur, and respiratory arrest could result. A tracheostomy plug could not be placed in a tracheostomy if an inner cannula was in place. The ability to swallow or speak is unrelated to weaning and plugging the tube

A client recovering from pulmonary edema is preparing for discharge. What would the nurse plan to teach the client to do to manage or prevent recurrent symptoms after discharge? 1. Weigh self on a daily basis. 2. Sleep with the head of the bed flat. 3. Take a double dose of the diuretic if peripheral edema is noted. 4. Withhold prescribed digoxin if slight respiratory distress occurs.

1. Weigh self on a daily basis.1. Weigh self on a daily basis. Rationale: The client can best determine fluid status at home by weighing himself or herself on a daily basis. Increases of 2 to 3 lb (0.9 to 1.4 kg) in a short period are reported to the primary health care provider (PHCP). The client needs to sleep with the head of the bed elevated. During recumbent sleep, fluid (which has seeped into the interstitium with the assistance of the effects of gravity) is rapidly reabsorbed into the systemic circulation. Sleeping with the head of the bed flat is therefore avoided. The client does not modify medication dosages without consulting the PHCP.

The registered nurse (RN) is educating a new nurse on mitral stenosis. Which statement by the new nurse indicates that the teaching has been effective? "Left ventricle to aorta narrowing will impede flow of blood." 2. "Left atrium to left ventricle narrowing will impede flow of blood." 3. "Right atrium to right ventricle narrowing will impede flow of blood." 4. "Right ventricle to pulmonary artery narrowing will impede flow of blood."

2. "Left atrium to left ventricle narrowing will impede flow of blood." Rationale: Mitral Stenosis is the narrowing of the valve between the two LEFT heart chambers. This causes angina/dyspnea and reduces blood flow. It also causes a heart murmur. The mitral valve separates the left atrium from the left ventricle. The remaining options describe impeded flow due to aortic, tricuspid, and pulmonic stenosis, respectively.

The home health nurse is visiting a client who has had a mechanical valve replacement for severe mitral valve stenosis. Which statement by the client reflects an understanding of specific postoperative care after this surgery? 1. "I need to count my pulse every day." 2. "I have to do deep-breathing exercises every 2 hours." 3. "I need to throw away my straight razor and buy an electric razor." 4. "I have to go to the bathroom frequently because of my medication."

3. "I need to throw away my straight razor and buy an electric razor." Rationale: Mechanical valves require long-term anticoagulation to prevent clots from forming on the "foreign" object implanted in the client's body. Anticoagulation therapy requires clients to avoid any trauma or potential means of causing bleeding, such as the use of straight razors. Counting pulse, deep-breathing exercises, and going to the bathroom frequently are not specifically related to postoperative care after prosthetic mechanical valve replacement.

A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit. What activity level would the nurse encourage for the client immediately after transfer? 1. Ad lib activities as tolerated 2. Strict bed rest for 24 hours after transfer 3. Bathroom privileges and self-care activities 4. Unsupervised hallway ambulation for distances up to 200 feet (60 meters)

3. Bathroom privileges and self-care activities Rationale: On transfer from CCU to an intermediate care or general medical unit, the client is allowed self-care activities and bathroom privileges. Activities ad lib as tolerated is premature at this time and potentially harmful for this client. It is unnecessary and possibly harmful to limit the client to bed rest. The client would ambulate with supervision in the hall for brief distances, with the distances being gradually increased to 50, 100, and 200 feet (15, 30, and 60 meters).

Normal Cardiac Output Range:

4-8 L/min

The nurse teaches skin care to a client receiving external radiation therapy. Which client statement indicates the need for further instruction? 1. "I will handle the area gently." 2. "I will wear loose-fitting clothing." 3. "I will avoid the use of deodorants." 4. "I will limit sun exposure to 1 hour daily."

4. "I will limit sun exposure to 1 hour daily." Rationale: The client needs to be instructed to avoid exposure to the sun. Because of the risk of altered skin integrity, options 1, 2, and 3 are accurate measures in the care of a client receiving external radiation therapy.

Metformin is prescribed for a client with type 2 diabetes mellitus. What is the most common side effect that the nurse would include in the client's teaching plan? 1. Weight gain 2. Hypoglycemia 3. Flushing and palpitations 4. Gastrointestinal disturbances

4. Gastrointestinal disturbances Rationale: The most common side effect of metformin is gastrointestinal disturbances, including decreased appetite, nausea, and diarrhea. These generally subside over time. This medication does not cause weight gain; clients lose an average of 7 to 8 lb (3.2 to 3.6 kg) because the medication causes nausea and decreased appetite. Although hypoglycemia can occur, it is not the most common side effect. Flushing and palpitations are not specifically associated with this medication.

The nurse is performing an initial assessment on a newborn infant. When assessing the infant's head, the nurse notes that the ears are low-set. Which nursing action is most appropriate? 1. Document the findings. 2. Arrange for hearing testing. 3. Notify the pediatrician. 4. Cover the ears with gauze pads

Answer: 3. Notify the pediatrician. Rationale: Low or oddly placed ears are associated with various congenital (abnormal) defects and need to be reported immediately. Although the findings need to be documented, the most appropriate action would be to notify the pediatrician. Options 2 and 4 are inaccurate and inappropriate nursing actions.

A client with a complete heart block has had a permanent demand ventricular pacemaker inserted. The nurse assesses for proper pacemaker function by examining the electrocardiogram (ECG) strip for the presence of pacemaker spikes at what point? 1. Before each P wave 2. Just after each P wave 3. Just after each T wave 4.Before each QRS complex

4.Before each QRS complex Rationale: If a ventricular pacemaker is functioning properly, there will be a pacer spike followed by a QRS complex. An atrial pacemaker spike precedes a P wave if an atrial pacemaker is implanted.

The nurse is planning care for a client with deep vein thrombosis of the right leg. Which interventions would the nurse anticipate the physician to most likely prescribe? Select all that apply. 1. Strict bed rest 2. Elevation of the right leg 3. Administration of acetaminophen 4. Application of moist heat to the right leg 5. Monitoring for signs of pulmonary embolism

Answer: 2. Elevation of the right leg 3. Administration of acetaminophen 4. Application of moist heat to the right leg 5. Monitoring for signs of pulmonary embolism Rationale: Standard management for the client with DVT includes maintaining the activity level as prescribed by the physician; limb elevation; relief of discomfort with warm, moist heat; and analgesics as needed. Strict bed rest is not likely to be prescribed; recent research is showing that ambulation does not cause pulmonary embolism and does not cause the existing DVT to worsen. Additionally, bed rest can cause complications such as skin integrity problems, weakness due to immobility, and respiratory problems.

A client with tuberculosis whose status is being monitored in an ambulatory care clinic asks the nurse when it is permissible to return to work. What factor would the nurse include when responding to the client? 1. Five blood cultures are negative. 2. Three sputum cultures are negative. 3. A blood culture and a chest x-ray are negative. 4. A sputum culture and a tuberculin skin test are negative.

Answer: 2. Three sputum cultures are negative. Rationale: The client with tuberculosis must have sputum cultures performed every 2 to 4 weeks after initiation of antituberculosis medication therapy. The client may return to work when the results of three sputum cultures are negative, because the client is considered noninfectious at that point. Options 1, 3, and 4 are not reliable determinants of a noninfectious status.

A client has been diagnosed with thromboangiitis obliterans (Buerger's disease). The nurse is identifying measures to help the client cope with lifestyle changes needed to control the disease process. The nurse plans to refer the client to which member of the health care team? 1. Dietitian 2. Medical social worker 3. Pain management clinic 4. Smoking cessation program

Answer: 4. Smoking cessation program Rationale: Buerger's disease is a vascular occlusive disease that affects the medium and small arteries and veins. Smoking is highly detrimental to the client with Buerger's disease, so stopping smoking completely is recommended. Because smoking is a form of chemical dependency, referral to a smoking cessation program may be helpful for many clients. For many clients with Buerger's disease, symptoms are relieved or alleviated once smoking stops. A dietitian, a medical social worker, and a pain management clinic are not specifically associated with the lifestyle changes required in this disorder, although they may be needed if secondary problems arise.

The community health nurse is creating a poster for an educational session for a group of community members and will be discussing the risk factors associated with breast cancer. Which risk factors for breast cancer would the nurse list on the poster? Select all that apply. 1. Multiparity 2. Early menarche 3. Early menopause 4. Family history of breast cancer 5. High-dose radiation exposure to chest 6. Previous cancer of the breast, uterus, or ovaries

Answer: 2. Early menarche 4. Family history of breast cancer 5. High-dose radiation exposure to chest 6. Previous cancer of the breast, uterus, or ovaries Rationale: Risk factors for breast cancer include nulliparity or first child born after age 30 years; early menarche; late menopause; family history of breast cancer; high-dose radiation exposure to the chest; and previous cancer of the breast, uterus, or ovaries. In addition, specific inherited mutations in Breast Cancer (BRCA)1 and BRCA2 increase the risk of female breast cancer; these mutations are also associated with an increased risk for ovarian cancer.

The nurse is participating in a class on rhythm strip interpretation. Which statement by the nurse indicates an understanding of a PR interval of 0.20? 1. "This is a normal finding." 2."This is indicative of atrial flutter." 3."This is indicative of atrial fibrillation." 4."This is indicative of impending reinfarction."

Answer: 1. "This is a normal finding." Rationale: The PR interval represents the time it takes for the cardiac impulse to spread from the atria to the ventricles. The normal range for the PR interval is 0.12 to 0.20 seconds. The remaining options are incorrect and indicate that further education is needed.

The nurse is assessing the client's condition after cardioversion. Which observation would be of highest priority to the nurse? 1. Heart rate 2. Skin color 3. Status of airway 4. Peripheral pulse strength

Answer: 3. Status of airway Rationale: Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Airway, however, is always the highest priority,

The registered nurse (RN) is educating a new nurse about aortic regurgitation. Which statement by the new nurse indicates that the teaching has been effective? 1"Failure of the aortic valve to close completely allows blood to flow retrograde through the aorta to the left ventricle." 2"Failure of the aortic valve to close completely allows blood to flow retrograde through the left ventricle to the left atrium." 3"Failure of the aortic valve to close completely allows blood to flow retrograde through the right ventricle to the right atrium." 4"Failure of the aortic valve to close completely allows blood to flow retrograde through the pulmonary artery to the right ventricle."

Answer: 1"Failure of the aortic valve to close completely allows blood to flow retrograde through the aorta to the left ventricle." Rationale: Aortic valve regurgitation is a condition that occurs when your heart's aortic valve doesn't close tightly. As a result, some of the blood pumped out of your heart's main pumping chamber (left ventricle) leaks backward. The leakage may prevent your heart from efficiently pumping blood to the rest of your body. As a result, you may feel fatigued and short of breath. The aortic valve separates the aorta from the left ventricle. The statements in the remaining options are inaccurate.

The new registered nurse (RN) is orienting on the cardiac unit. Which statement by the new RN indicates an understanding of an early indication of fluid volume deficit due to blood loss? 1"Pulse rate will increase." 2"Blood pressure will decrease." 3"Edema will be present in the legs." 4"Crackles in the lungs will be present."

Answer: 1"Pulse rate will increase." Rationale: The cardiac output is determined by the volume of the circulating blood, the pumping action of the heart, and the tone of the vascular bed. Early decreases in fluid volume are compensated for by an increase in the pulse rate. Although the blood pressure will decrease, it is not the earliest indicator. Edema and crackles in the lungs indicate an increase in fluid volume.

The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse would make which statement to the client? 1. "Take a deep breath when I tell you, and hold it while I remove the tube." 2. "Take a deep breath when I tell you, and bear down while I remove the tube." 3. "Take a deep breath when I tell you, and slowly exhale while I remove the tube." 4. "Take a deep breath when I tell you, and breathe normally while I remove the tube."

Answer: 1. "Take a deep breath when I tell you, and hold it while I remove the tube." Rationale: The client would take a deep breath, because the client's airway will be temporarily obstructed during tube removal. The client is then told to hold the breath and the tube is withdrawn slowly and evenly over the course of 3 to 6 seconds (coil the tube around the hand while removing it) while the breath is held. Bearing down could inhibit the removal of the tube. Exhaling is not possible during removal because the airway is temporarily obstructed during removal. Breathing normally could result in aspiration of gastric secretions during inhalation.

The nurse is performing an admission assessment on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain at home. During the assessment the client complains of chest pain. The nurse would immediately ask the client which question? 1. "Where is the pain located?" 2. "Are you having any nausea?" 3. "Are you allergic to any medications?" 4. "Do you have your nitroglycerin with you?" Correct Answer

Answer: 1. "Where is the pain located?" Rationale: If a client complains of chest pain, the initial assessment question is to ask the client about the pain intensity, location, duration, and quality. Although the questions in the remaining options all may be components of the assessment, none of these questions is the initial assessment question for this client.

A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder? 1. Cardiovascular disease 2. Frequent urinary tract infections 3. A history of migraine headaches 4. Frequent upper respiratory infections

Answer: 1. Cardiovascular disease Rationale: Hypertension, cardiovascular disease, diabetes mellitus, and obesity are associated with the development of glaucoma. Options 2, 3, and 4 do not identify risk factors associated with this eye disorder.

The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which piece of assessment data would alert the nurse to this occurrence? 1. Inability to pass flatus 2. Loss of anal sphincter control 3. Severe, constant pain with rapid onset 4.Firm, nontender mass palpable at the lower right costal margin

Answer: 1. Inability to pass flatus Rationale: An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the most common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Loss of sphincter control is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually manifests as a more constant generalized discomfort. Option 4 is the description of the physical finding of liver enlargement. The liver may be enlarged in cases of cirrhosis or hepatitis. Although this client may have an enlarged liver, an enlarged liver is not a sign of paralytic ileus or intestinal obstruction.

The ambulatory care nurse is working with a client who has been diagnosed with Prinzmetal's (variant) angina. What would the nurse plan to teach the client about this type of angina? 1. It is most effectively managed by beta-blocking agents. 2. It has the same risk factors as stable and unstable angina. 3. It can be controlled with a low-sodium, high-potassium diet. 4. Generally it is treated with calcium channel-blocking agents.

Answer: 1. It is most effectively managed by beta-blocking agents. Rationale: Prinzmetal's angina results from spasm of the coronary vessels and is treated with calcium channel blockers. Beta blockers are contraindicated because they may actually worsen the spasm. The risk factors are unknown, and this type of angina is relatively unresponsive to nitrates. Diet therapy is not specifically indicate

The nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse would include which intervention in the plan? 1. Maintain activity level as prescribed. 2. Maintain the affected leg in a dependent position. 3. Administer an opioid analgesic every 4 hours around the clock. 4. Apply cool packs to the affected leg for 20 minutes every 4 hours.

Answer: 1. Maintain activity level as prescribed. Rationale: Standard management for the client with DVT includes maintaining the activity level as prescribed by the PHCP; limb elevation; relief of discomfort with warm, moist heat; and analgesics as needed. Recent research is showing that ambulation, unlike as previously thought, does not cause pulmonary embolism and does not cause the existing DVT to worsen. Therefore, the nurse needs to maintain the prescribed activity level. Opioid analgesics are not required to relieve pain, and pain normally is relieved with acetaminophen.

The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client that which positions alleviate dyspnea? Select all that apply. 1. Sitting up and leaning on a table 2. Standing and leaning against a wall 3. Lying supine with the feet elevated 4. Sitting up with the elbows resting on knees 5. Lying on the back in a low-Fowler's position

Answer: 1. Sitting up and leaning on a table 2. Standing and leaning against a wall 4. Sitting up with the elbows resting on knees Rationale:The client would use the positions outlined in options 1, 2, and 4. These allow for maximal chest expansion. The client would not lie on the back because this reduces movement of a large area of the client's chest wall. Sitting is better than standing, whenever possible. If no chair is available, leaning against a wall while standing allows accessory muscles to be used for breathing and not posture control.

A client with no history of heart disease has experienced acute myocardial infarction and has been given thrombolytic therapy with tissue plasminogen activator. What assessment finding would the nurse identify as an indicator that the client is experiencing complications of this therapy? 1. Tarry stools 2. Nausea and vomiting 3. Orange-colored urine 4. Decreased urine output

Answer: 1. Tarry stools Rationale: Thrombolytic agents are used to dissolve existing thrombi, and the nurse would monitor the client for obvious or occult signs of bleeding. This includes assessment for obvious bleeding within the gastrointestinal (GI) tract, urinary system, and skin. It also includes Hematest testing of secretions for occult blood. The correct option is the only one that indicates the presence of blood.

After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse would expect to note which finding? 1. Waves of loud gurgles auscultated in all four quadrants 2. Low-pitched swishing auscultated in one or two quadrants 3. Relatively high-pitched clicks or gurgles auscultated in all four quadrants 4. Very high-pitched, loud rushes auscultated especially in one or two quadrants

Answer: 1. Waves of loud gurgles auscultated in all four quadrants Rationale: Although frequency and intensity of bowel sounds vary, depending on the phase of digestion, normal bowel sounds are relatively high-pitched clicks or gurgles. Loud gurgles (borborygmi) indicate hyperperistalsis and are commonly associated with nausea and vomiting. A swishing or buzzing sound represents turbulent blood flow associated with a bruit. Bruits are not normal sounds. Bowel sounds are very high-pitched and loud (hyperresonance) when the intestines are under tension, such as in intestinal obstruction. Therefore, options 2, 3, and 4 are incorrect.

A client who has had a myocardial infarction asks the nurse why it is not advised to bear down or strain to ensure having a bowel movement. The nurse provides education to the client based on which physiological concept? 1.Vagus nerve stimulation causes a decrease in heart rate and cardiac contractility. 2Vagus nerve stimulation causes an increase in heart rate and cardiac contractility. 3Sympathetic nerve stimulation causes a decrease in heart rate and cardiac contractility. 4Sympathetic nerve stimulation causes an increase in heart rate and cardiac contractility.

Answer: 1.Vagus nerve stimulation causes a decrease in heart rate and cardiac contractility. Rationale: Bearing down as if straining to have a bowel movement can stimulate a vagal reflex. Stimulation of the vagus nerve causes a decrease in heart rate and cardiac contractility. Stimulation of the sympathetic nervous system has the opposite effect. These two branches of the autonomic nervous system oppose each other to maintain homeostasis.

The nurse educator is lecturing new registered nurses (RNs) about serum calcium levels. Which statement by one of the new RNs indicates that teaching has been effective? 1"Calcium has no effect on the risk for stroke." 2"Low calcium levels can lead to cardiac arrest." 3"Low calcium levels cause high blood pressure." 4"Calcium has no effect on urinary stone formation."

Answer: 2"Low calcium levels can lead to cardiac arrest." Rationale: The normal calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A low calcium level could lead to severe ventricular dysrhythmias, prolonged QT interval, and ultimately cardiac arrest. Calcium is needed by the heart for contraction. Calcium ions move across cell membranes into cardiac cells during depolarization and move back during repolarization. Depolarization is responsible for cardiac contraction. Option 1 is unrelated to calcium levels. A low calcium level is unrelated to hypertension. Elevated calcium levels can lead to urinary stone formation. The nurse would take action and contact the health care provider when a calcium level is abnormal.

A sexually active young adult client has developed viral hepatitis. Which client statement indicates the need for further teaching? 1. "I would avoid drinking alcohol." 2. "I can go back to work right away." 3. "My partner needs to get the vaccine." 4. "A condom would be used for sexual intercourse."

Answer: 2. "I can go back to work right away." Rationale: To prevent transmission of hepatitis, vaccination of the partner is advised. In addition, a condom is advised during sexual intercourse. Alcohol needs to be avoided because it is detoxified in the liver and may interfere with recovery. Rest is especially important until laboratory studies show that liver function has returned to normal. The client's activity is increased gradually, and the client would not return to work right away.

The nurse has provided dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions? 1. "I'll need to become a strict vegetarian." 2. "I should use polyunsaturated oils in my diet." 3. "I need to substitute eggs and whole milk for meat." 4. "I should eliminate all cholesterol and fat from my diet."

Answer: 2. "I should use polyunsaturated oils in my diet." Rationale:The client with coronary artery disease needs to avoid foods high in saturated fat and cholesterol such as eggs, whole milk, and red meat. These foods contribute to increases in low-density lipoproteins. The use of polyunsaturated oils is recommended to control hypercholesterolemia. It is not necessary to eliminate all cholesterol and fat from the diet. It is not necessary to become a strict vegetarian.

A client with severe coronary artery disease who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse would anticipate that the client is at risk for which problem? 1. Hypovolemia 2. Acute kidney injury 3. Glomerulonephritis 4.Urinary tract infection

Answer: 2. Acute kidney injury Rationale: The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal injury is signaled by decreased urine output and increased blood urea nitrogen (BUN) and creatinine levels. Normal reference levels are BUN, 10 to 20 mg/dL (3.6 to 7.1 mmol/L), and creatinine, male 0.6 to 1.2 mg/dL (53 to 106 mcmol/L) and female 0.5 to 1.1 mg/dL (44 to 97 mcmol/L). The client may need medications to increase renal perfusion and possibly could need peritoneal dialysis or hemodialysis. No data in the question indicate the presence of hypovolemia, glomerulonephritis, or urinary tract infection.

The nurse is concerned about the adequacy of peripheral tissue perfusion in the post-cardiac surgery client. Which action would the nurse include in the plan of care for this client? 1. Use the knee gatch on the bed. 2. Cover the legs lightly when sitting in a chair. 3. Encourage the client to cross the legs when sitting in a chair. 4. Provide pillows for the client to place under the knees as desired.

Answer: 2. Cover the legs lightly when sitting in a chair. Rationale: Covering the legs with a light blanket during sitting promotes warmth and vasodilation of the leg vessels. The nurse plans postoperative measures to prevent venous stasis. These include applying elastic stockings or leg wraps, use of pneumatic compression boots, and discouraging crossing of the legs. Clients would be encouraged to perform passive and active range-of-motion exercises. The knee gatch on the bed and pillows under the knees would be avoided because they place pressure on the blood vessels in the popliteal area, impeding venous return.

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action? 1. Check for an air leak. 2. Document the findings. 3. Notify the primary health care provider. 4. Change the chest tube drainage system.

Answer: 2. Document the findings. Rationale: Bubbling in the water seal chamber is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent (not constant) bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space. Continuous bubbling during inspiration and expiration indicates that an air leak exists. If this occurs, it must be corrected. Notifying the primary health care provider and changing the chest tube drainage system are not indicated at this time.

The nurse is developing a plan of care for a client with varicose veins in whom skin breakdown occurred over the varicosities as a result of secondary infection. Which is a priority intervention? 1. Keep the legs aligned with the heart. 2. Elevate the legs higher than the heart. 3. Clean the skin with alcohol every hour. 4. Position the client onto the side during every shift.

Answer: 2. Elevate the legs higher than the heart. Rationale: In the client with a venous disorder, the legs are elevated above the level of the heart to assist with the return of venous blood to the heart. Alcohol is very irritating and drying to tissues and would not be used in areas of skin breakdown. Option 4 specifies infrequent care intervals, so it is not the priority intervention.

A client complains of calf tenderness, and thrombophlebitis is suspected. The nurse would next assess the client for which finding? 1. Bilateral edema 2. Increased calf circumference 3. Diminished distal peripheral pulses 4. Coolness and pallor of the affected limb

Answer: 2. Increased calf circumference Rationale: The client with thrombophlebitis, also known as deep vein thrombosis, exhibits redness or warmth of the affected leg, tenderness at the site, possibly dilated veins (if superficial), low-grade fever, edema distal to the obstruction, and increased calf circumference in the affected extremity. Peripheral pulses are unchanged from baseline because this is a venous, not an arterial, problem. Often thrombophlebitis develops silently; that is, the client does not present with any signs and symptoms unless pulmonary embolism occurs as a complication.

The nurse is caring for a teenage client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis? 1. Leukopenia with a shift to the left 2. Leukocytosis with a shift to the left 3. Leukopenia with a shift to the right 4. Leukocytosis with a shift to the right

Answer: 2. Leukocytosis with a shift to the left Rationale: Laboratory findings do not establish the diagnosis of appendicitis, but there is often an elevation of the white blood cell count (leukocytosis) with a shift to the left (an increased number of immature white blood cells). Options 1, 3, and 4 are incorrect because they are not associated findings in acute appendicitis.

The nurse is preparing a list of home care instructions regarding stoma and laryngectomy care for a client with laryngeal cancer who had a laryngectomy. Which instructions would be included in the list? Select all that apply. 1. Restrict fluid intake. 2. Obtain a MedicAlert bracelet. 3. Keep the humidity in the home low. 4. Prevent debris from entering the stoma. 5. Avoid exposure to people with infections. 6.Avoid swimming and use care when showering.

Answer: 2. Obtain a MedicAlert bracelet. 4. Prevent debris from entering the stoma. 5. Avoid exposure to people with infections. 6.Avoid swimming and use care when showering. Rationale: The nurse would teach the client how to care for the stoma, depending on the type of laryngectomy performed. Most interventions focus on protection of the stoma and the prevention of infection. Interventions include obtaining a MedicAlert bracelet, preventing debris from entering the stoma, avoiding exposure to people with infections, and avoiding swimming and using care when showering. Additional interventions include wearing a stoma guard or high-collared clothing to protect the stoma, increasing the humidity in the home, and increasing fluid intake to 3000 mL/day to keep the secretions thin.

The post-myocardial infarction client is scheduled for a technetium-99m ventriculography (multigated acquisition [MUGA] scan). The nurse ensures that which item is in place before the procedure? 1. A urinary catheter 2. Signed informed consent 3. A central venous pressure (CVP) line 4. Notation of allergies to iodine or shellfish

Answer: 2. Signed informed consent Rationale:MUGA is a radionuclide study used to detect myocardial infarction and decreased myocardial blood flow and to determine left ventricular function. A radioisotope is injected intravenously; therefore, a signed informed consent is necessary. A urinary catheter and CVP line are not required. The procedure does not use radiopaque dye; therefore, allergies to iodine and shellfish are not a concern.

The nurse is creating a plan of care for a client in skin traction. The nurse would monitor for which priority finding in this client? 1. Urinary incontinence 2, Signs of skin breakdown 3. The presence of bowel sounds 4. Signs of infection around the pin sites

Answer: 2. Signs of skin breakdown Rationale: Skin traction is achieved by Ace wraps, boots, or slings that apply a direct force on the client's skin. Traction is maintained with 5 to 8 lb (2.3 to 3.6 kg) of weight, and this type of traction can cause skin breakdown. Urinary incontinence is not related to the use of skin traction. Although constipation can occur as a result of immobility and monitoring bowel sounds may be a component of the assessment, this intervention is not the priority assessment. There are no pin sites with skin traction.

The nurse is assigned the care of a client with a diagnosis of heart failure who is receiving intravenous doses of furosemide. The client is attached to cardiac telemetry, and the nurse is monitoring the client's cardiac status. The nurse notes that the client's cardiac rhythm has changed to this pattern. The nurse determines that the most likely cause of this cardiac rhythm in the client is which problem? Refer to figure. 1. Pacemaker dysfunction 2. The presence of hypokalemia 3. The effectiveness of the furosemide 4. An impending myocardial infarction (MI)

Answer: 2. The presence of hypokalemia Rationale: This cardiac rhythm is normal sinus rhythm with unifocal premature ventricular complexes (PVCs). PVCs may be insignificant, or they may occur with myocardial ischemia or MI; heart failure; hypokalemia; hypomagnesemia; medications; stress; nicotine, caffeine, or alcohol intake; infection; trauma; or surgery. This client is receiving furosemide, a diuretic that causes the excretion of potassium. The most likely cause of the PVCs in this client is hypokalemia. Option 3 is an incorrect interpretation. The question presents no data indicating that this client has a pacemaker or has signs or symptoms of an impending MI.

A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client? 1. Begin to teach relaxation techniques. 2. Encourage the client to discuss the assault. 3. Remain with the client until the anxiety decreases. 4.Place the client in a quiet room alone to decrease stimulation.

Answer: 3. Remain with the client until the anxiety decreases Rationale: This client is in a severe state of anxiety. When a client is in a severe or panic state of anxiety, it is crucial for the nurse to remain with the client. The client in a severe state of anxiety would be unable to learn relaxation techniques. Discussing the assault at this point would increase the client's level of anxiety further. Placing the client in a quiet room alone may also increase the anxiety level.

The home care nurse has taught a client with heart failure and a problem of inadequate cardiac output about helpful lifestyle adaptations to promote health. Which statement by the client best demonstrates an understanding of the information provided? "I will try to exercise vigorously to strengthen my heart muscle." 2."I will eat enough daily fiber to prevent straining during bowel movement." 3."I will drink 3000 to 3500 mL of fluid daily to promote good kidney function." 4."Drinking 2 to 3 oz of liquor each night will promote blood flow by enlarging blood vessels."

Answer: 2."I will eat enough daily fiber to prevent straining during bowel movement." Rationale: Standard home care instructions for a client with this problem include, among others, lifestyle changes such as avoiding alcohol intake, avoiding activities that increase the demands on the heart, instituting a bowel regimen to prevent straining and constipation, and maintaining fluid and electrolyte balance. Consuming 3000 to 3500 mL of fluid and exercising vigorously will increase the cardiac workload.

A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage would the nurse expect? 1.Serous 2.Bloody 3.Serosanguineous 4.Bloody, with frequent small clots

Answer: 2.Bloody Rationale: In the first few hours after surgery, the drainage from the chest tube is bloody. After several hours, it becomes serosanguineous. The client would not experience frequent clotting. Proper chest tube function would allow for drainage of blood before it has the chance to clot in the chest or the tubing.

The nurse teaches a client newly diagnosed with type 1 diabetes about storing Humulin N insulin. Which statement indicates to the nurse that the client understood the discharge teaching? 1. "I would keep the insulin in the cabinet during the day only." 2. "I know I have to keep my insulin in the refrigerator at all times." 3."I can store the open insulin bottle in the kitchen cabinet for 1 month." 4. "The best place for my insulin is on the windowsill, but in the cupboard is just as good."

Answer: 3. "I can store the open insulin bottle in the kitchen cabinet for 1 month." Rationale: An insulin vial in current use can be kept at room temperature for 1 month without significant loss of activity. Direct sunlight and heat must be avoided. Therefore, options 1, 2, and 4 are incorrect.

A client received 20 units of Humulin N insulin subcutaneously at 08:00. At what time would the nurse plan to assess the client for a hypoglycemic reaction? 1. 10:00 2. 11:00 3. 17:00 4. 24:00

Answer: 3. 17:00 Rationale: Humulin N is an intermediate-acting insulin. The onset of action is 60 to 120 minutes, it peaks in 6 to 14 hours, and the duration of action is 16 to 24 hours. Hypoglycemic reactions most likely occur during peak time.

A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to the touch. The nurse would document that these findings identify which type of ulcer? 1. A stage 1 ulcer 2. A vascular ulcer 3. An arterial ulcer 4. A venous stasis ulcer

Answer: 3. An arterial ulcer Rationale: Arterial ulcers have a pale deep base and are surrounded by tissue that is cool with trophic changes such as dry skin and loss of hair. Arterial ulcers are caused by tissue ischemia from inadequate arterial supply of oxygen and nutrients. A stage 1 ulcer indicates a reddened area with an intact skin surface. A venous stasis ulcer (vascular) has a dark red base and is surrounded by brown skin with local edema. This type of ulcer is caused by the accumulation of waste products of metabolism that are not cleared, as a result of venous congestion.

The nurse is providing instructions to a client with a diagnosis of hypertension regarding high-sodium items to be avoided. The nurse instructs the client to avoid consuming which item? 1. Bananas 2.Broccoli 3. Antacids 4. Cantaloupe

Answer: 3. Antacids Rationale: The sodium level can increase with the use of several types of products, including toothpaste and mouthwash; over-the-counter medications such as analgesics, antacids, laxatives, and sedatives; and softened water and mineral water. Clients are instructed to read labels for sodium content. Water that is bottled, distilled, deionized, or demineralized may be used for drinking and cooking. Fresh fruits and vegetables are low in sodium.

A client has experienced an episode of pulmonary edema. The nurse determines that the client's respiratory status is improving after this episode if which breath sounds are noted? 1. Rhonchi 2. Wheezes 3. Crackles in the bases 4. Crackles throughout the lung fields

Answer: 3. Crackles in the bases Rationale: Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. As the client's condition improves, the amount of fluid in the alveoli decreases, which may be detected by crackles in the bases. (Clear lung sounds indicate full resolution of the episode.) Rhonchi and wheezes are not associated with pulmonary edema. Auscultation of the lungs reveals crackles throughout the lung fields.

A hospitalized client has been diagnosed with heart failure as a complication of hypertension. In explaining the disease process to the client, the nurse identifies which chamber of the heart as primarily responsible for the symptoms? 1. Left atrium 2. Right atrium 3. Left ventricle 4. Right ventricle

Answer: 3. Left ventricle Rationale: Hypertension increases the workload of the left ventricle because the ventricle has to pump the stroke volume against increased resistance (afterload) in the major blood vessels. Over time this causes the left ventricle to fail, leading to signs and symptoms of heart failure. The remaining options are not the chambers that are primarily responsible for this disease process, although these chambers may be affected as the disease becomes more chronic.

The nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which assessment finding indicates the presence of this complication? 1. Flat neck veins 2. A pulse rate of 60 beats/minute 3. Muffled or distant heart sounds 4. Wheezing on auscultation of the lungs

Answer: 3. Muffled or distant heart sounds Rationale: Assessment findings associated with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention with clear lung sounds, and a falling blood pressure accompanied by pulsus paradoxus (a drop in inspiratory blood pressure greater than 10 mm Hg). The other options are not signs of cardiac tamponade.

A 6-year-old child has just been diagnosed with localized Hodgkin's disease, and chemo therapy is planned to begin immediately. The parent of the child asks the nurse why radiation therapy was not prescribed as a part of the treatment. The nurse would plan to make which best response? 1. "It's very costly, and chemotherapy works just as well." 2."I'm not sure. I'll discuss it with the primary health care provider." 3."Sometimes age has to do with the decision for radiation therapy." 4."The primary health care provider would prefer that you discuss treatment options with the oncologist.

Answer: 3."Sometimes age has to do with the decision for radiation therapy." Rationale: Radiation therapy is usually delayed, whenever possible, until a child is 8 years old to prevent retardation of bone growth and soft tissue development. Options 1, 2, and 4 are inappropriate responses to the parent and place the parent's question on hold.

A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse would assess the client for which signs and symptoms characteristic of this disorder? 1.Bradycardia and hyperactivity 2.Decreased respiratory rate and depth 3.Headache, restlessness, and confusion 4.Bradypnea, dizziness, and paresthesias

Answer: 3.Headache, restlessness, and confusion Rationale: When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache; restlessness; mental status changes, such as drowsiness and confusion; visual disturbances; diaphoresis; cyanosis as the hypoxia becomes more acute; hyperkalemia; rapid, irregular pulse; and dysrhythmias. Options 1, 2, and 4 are not specifically associated with this disorder.

The nurse is reinforcing instructions to a hospitalized client with heart block about the fundamental concepts regarding the cardiac rhythm. The nurse plans to explain to the client that the normal site in the heart responsible for initiating electrical impulses is which site? 1.Bundle of His 2.Purkinje fibers 3.Sinoatrial (SA) node 4.Atrioventricular (AV) node

Answer: 3.Sinoatrial (SA) node Rationale: The SA node is responsible for initiating electrical impulses that are conducted through the heart. The impulse leaves the SA node and travels down through internodal and interatrial pathways to the AV node. From there, impulses travel through the bundle of His to the right and left bundle branches and then to the Purkinje fibers. This group of specialized cardiac cells is referred to as the cardiac conduction system. The ability of this specialized tissue to generate its own impulses is called automaticity.

A client with an acute respiratory infection is admitted to the hospital with a diagnosis of sinus tachycardia. Which nursing action would be included in the client's plan of care? 1. Limiting oral and intravenous fluids 2. Measuring the client's pulse each shift 3. Providing the client with short, frequent walks 4. Eliminating sources of caffeine from meal trays

Answer: 4. Eliminating sources of caffeine from meal trays Rationale: Sinus tachycardia often is caused by fever, physical and emotional stress, heart failure, hypovolemia, certain medications, nicotine, caffeine, and exercise. Fluid restriction and exercise will not alleviate tachycardia. Measuring the pulse each shift will not decrease the heart rate. In addition, the pulse needs to be taken more frequently than each shift.

The nurse is teaching a client with cardiomyopathy about home care safety measures. The nurse would address with the client which most important measure to ensure client safety? 1. Assessing pain 2. Administering vasodilators 3. Avoiding over-the-counter (OTC) medications 4. Moving slowly from a sitting to a standing position

Answer: 4. Moving slowly from a sitting to a standing position Rationale: Orthostatic changes can occur in the client with cardiomyopathy as a result of venous return obstruction. Sudden changes in blood pressure may lead to falls. Vasodilators normally are not prescribed for the client with cardiomyopathy. Although important, pain assessment and avoiding OTC medications are not directly related to the issue of safety.

The nurse is caring for a client scheduled for a transsphenoidal hypophysectomy. The preoperative teaching instructions would include which statement? 1. "Your hair will need to be shaved." 2. "You will receive spinal anesthesia." 3. "You will need to ambulate after surgery." 4. "Brushing your teeth needs to be avoided for at least 2 weeks after surgery."

Answer: 4."Brushing your teeth needs to be avoided for at least 2 weeks after surgery." Rationale: A transsphenoidal hypophysectomy is a surgical approach that uses the nasal sinuses and nose for access to the pituitary gland. Based on the location of the surgical procedure, spinal anesthesia would not be used. In addition, the hair would not be shaved. Although ambulating is important, specific to this procedure is avoiding brushing the teeth to prevent disruption of the surgical site.

A client with coronary artery disease is scheduled to undergo cardiac catheterization for the first time, and the nurse provides instructions to the client. Which client statement indicates an understanding of the instructions? 1. "It will really hurt when the catheter is first put in." 2. "I will receive general anesthesia for the procedure." 3."I will have to go to the operating room for this procedure." 4."I probably will feel tired after the test from lying on a hard x-ray table for a few hours."

Answer: 4."I probably will feel tired after the test from lying on a hard x-ray table for a few hours." Rationale: It is common for the client to feel fatigued after the cardiac catheterization procedure. A local anesthetic is used, so little to no pain is experienced with catheter insertion. General anesthesia is not used. Other preprocedure teaching points include the fact that the procedure is done in a darkened cardiac catheterization room. The x-ray table is hard and may be tilted periodically, and the procedure may take 1 to 2 hours. The client may feel various sensations with catheter passage and dye injection.

During a routine prenatal visit, a client complains of gums that bleed easily with brushing. The nurse performs an assessment and teaches the client about proper nutrition to minimize this problem. Which client statement indicates an understanding of the proper nutrition to minimize this problem 1. "I will drink 8 oz of water with each meal." 2."I will eat three servings of cracked wheat bread each day." 3."I will eat two saltine crackers before I get up each morning." 4."I will eat fresh fruits and vegetables for snacks and for dessert each day."

Answer: 4."I will eat fresh fruits and vegetables for snacks and for dessert each day." Rationale: Fresh fruits and vegetables provide vitamins and minerals needed for healthy gums. Drinking water with meals has no direct effect on gums. Cracked wheat bread may abrade the tender gums. Eating saltine crackers can also abrade the tender gums.

A client with myocardial infarction is experiencing new multiform premature ventricular contractions and short runs of ventricular tachycardia. The nurse plans to have which medication available for immediate use to treat the ventricular tachycardia 1.Digoxin 2.Verapamil 3.Acebutolol 4.Amiodarone

Answer: 4.Amiodarone Rationale: Amiodarone is an antidysrhythmic that may be used to treat ventricular dysrhythmias. Digoxin is a cardiac glycoside; verapamil is a calcium channel-blocking agent; acebutolol is a beta-adrenergic blocking agent. Digoxin can be used to treat supraventricular dysrhythmias but is inactive against ventricular dysrhythmias. Verapamil is used to slow the ventricular rate for a client with atrial fibrillation or atrial flutter, or to terminate supraventricular tachycardia. Acebutolol is a beta blocker used to treat dysrhythmias.

A client is about to undergo a lumbar puncture. The nurse describes to the client that which position will be used during the procedure? 1. Side-lying with a pillow under the hip 2. Prone with a pillow under the abdomen 3. Prone in slight Trendelenburg's position 4. Side-lying with the legs pulled up and the head bent down onto the chest Submit

Answer: 4.Side-lying with the legs pulled up and the head bent down onto the chest Submit Rationale:A client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen and the head bent down onto the chest. This position helps open the spaces between the vertebrae and allows for easier needle insertion by the primary health care provider. The nurse remains with the client during the procedure to help the client maintain this position. The other options identify incorrect positions for this procedure.

Levothyroxine is prescribed for a client diagnosed with hypothyroidism. Upon review of the client's record, the nurse notes that the client is taking warfarin. Which modification to the plan of care would the nurse review with the client's primary health care provider? 1. A decreased dosage of levothyroxine 2. An increased dosage of levothyroxine 3. A decreased dosage of warfarin sodium 4. An increased dosage of warfarin sodium

Answer: A decreased dosage of warfarin sodium Rationale: Levothyroxine accelerates the degradation of vitamin K-dependent clotting factors. As a result, the effects of warfarin are enhanced. If thyroid hormone replacement therapy is instituted in a client who has been taking warfarin, the dosage of warfarin would be reduced.

The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management? 1. Engaging in immoral acts 2. Always reinforcing self-approval 3. Observing rigid rules and regulations 4. Having the need always to make the right decision

Answer: Having the need always to make the right decision Rationale: Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help these clients manage their anxiety

The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The primary health care provider has now prescribed that the nasogastric tube be removed. What is the priority nursing assessment prior to removing the tube? 1. Checking for normal serum electrolyte levels 2. Checking for normal pH of the gastric aspirate 3. Checking for proper nasogastric tube placement 4. Checking for the presence of bowel sounds in all four quadrants

Answer:4. Checking for the presence of bowel sounds in all four quadrants Rationale: Distention, vomiting, and abdominal pain are a few of the symptoms associated with intestinal obstruction. Nasogastric tubes may be used to remove gas and fluid from the stomach, relieving distention and vomiting. Bowel sounds return to normal as the obstruction is resolved and normal bowel function is restored. Discontinuing the nasogastric tube before normal bowel function may result in a return of the symptoms, necessitating reinsertion of the nasogastric tube. Serum electrolyte levels, pH of the gastric aspirate, and tube placement are important assessments for the client with a nasogastric tube in place but would not assist in determining the readiness for removing the nasogastric tube.

The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select all that apply. 1. Set the room temperature at a comfortable level. 2. Remove distracting objects from the interviewing area. 3. Place a chair for the client across from the nurse's desk. 4. Ensure comfortable seating at eye level for the client and nurse. 5. Provide seating for the client so that the client faces a strong light. 6. Ensure that the distance between the client and nurse is at least 7 feet (2.1 meters).

Answers: 1. Set the room temperature at a comfortable level. 2. Remove distracting objects from the interviewing area. 4.. Ensure comfortable seating at eye level for the client and nurse. Rationale: When preparing the physical environment for an interview, the nurse would set the room temperature at a comfortable level. The nurse would provide sufficient lighting for the client and nurse to see each other. The nurse would avoid having the client face a strong light because the client would have to squint into the full light. Distracting objects and equipment need to be removed from the interview area. The nurse would arrange seating so that the nurse and client are seated comfortably at eye level, and the nurse avoids facing the client across a desk or table, because this creates a barrier. The distance between the nurse and the client would be set by the nurse at 4 to 5 feet (1.2 to 1.5 meters). If the nurse places the client any closer, the nurse will be invading the client's private space and may create anxiety in the client. If the nurse places the client farther away, the nurse may be seen as distant and aloof by the client.

The nurse is conducting an interview of an older client and is concerned about the possibility of benign prostatic hyperplasia (BPH). Which are characteristics of this disorder? Select all that apply. 1. Nocturia 2. Incontinence 3. Enlarged prostate 4. Nocturnal emissions 5. Decreased desire for sexual intercourse

Answers: 1. Nocturia 2. Incontinence 3. Enlarged prostate Rationale: Nocturia, incontinence, and an enlarged prostate are characteristics of BPH and need to be assessed for in clients over 50 years of age. Nocturnal emissions are commonly associated with prepubescent individuals. Low testosterone levels (not BPH) may be associated with a decreased desire for sexual intercourse.

Key indication of first-degree heart block

Prolonged and equal PR intervals

Define the following: - Stable Angina -Variant Angina - Unstable Angina - Intractable Angina

Rationale: Stable angina is triggered by a predictable amount of effort or emotion and is a chronic condition. Variant angina is triggered by coronary artery spasm; the attacks are of longer duration than in classic angina and tend to occur early in the day and at rest. Unstable angina is triggered by an unpredictable amount of exertion or emotion and may occur at night; the attacks increase in number, duration, and severity over time. Intractable angina is chronic and incapacitating and is refractory to medical therapy.

A client is scheduled for elective cardioversion to treat chronic high-rate atrial fibrillation. Which finding indicates that further preparation is needed for the procedure? 1. The client's digoxin has been withheld for the last 48 hours. 2. The client is wearing a nasal cannula delivering oxygen at 2 L/min. 3. The defibrillator has the synchronizer turned on and is set at 120 joules (J). 4. The client has received an intravenous dose of a conscious sedation medication

Rationale: During the procedure, any oxygen is removed temporarily because oxygen supports combustion, and a fire could result from electrical arcing. Digoxin may be withheld for up to 48 hours before cardioversion because it increases ventricular irritability and may cause ventricular dysrhythmias after the countershock. The defibrillator is switched to synchronizer mode to time the delivery of the electrical impulse to coincide with the QRS and avoid the T wave, which could cause ventricular fibrillation. Energy level typically is set at 120 to 200 J for a biphasic machine. The client typically receives a dose of an intravenous sedative or antianxiety agent.

A client is being discharged from the hospital after being treated for infective endocarditis. The nurse would provide the client with which discharge instruction? 1. Take acetaminophen if the chest pain worsens. 2. Take antibiotics until the chest pain is fully resolved. 3. Use a firm-bristle toothbrush and floss vigorously to prevent cavities. 4. Notify all physicians' of the history of infective endocarditis before any invasive procedures.

Take acetaminophen if the chest pain worsens.2Take 4. Answers: 4. Notify all physicians' of the history of infective endocarditis before any invasive procedures. Rationale: Infective endocarditis (IE), also called bacterial endocarditis, is an infection caused by bacteria that enter the bloodstream and settle in the heart lining, a heart valve or a blood vessel. The client needs to alert any physician about the history of infective endocarditis before invasive dental, oral, or upper respiratory procedures. The physician would place the client with a history of infective endocarditis on prophylactic antibiotics if one of these procedures is needed. Antibiotics need to be taken for the full course of therapy. The client needs to notify the physician if chest pain worsens or if dyspnea or other symptoms occur. The client would use a soft toothbrush and floss carefully to avoid any trauma to the gums, which could provide a portal of entry for bacterial infection.