That time of day

A nurse teaches a client with type 2 diabetes mellitus who is prescribed glipizide (Glucotrol). Which statement would the nurse include in this client's teaching?

"Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs)."

The nurse is planning teaching for a client who is starting acarbose for diabetes mellitus type 2. Which statement will the nurse include in the teaching?

"Be sure to take the drug with each meal."

After teaching a young adult client who is newly diagnosed with type 1 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the need for eye examinations?

"Diabetes can cause blindness, so I should see the ophthalmologist yearly."

A nurse teaches a patient about self-monitoring of blood glucose levels. Which statement would the nurse include in this client's teaching to prevent bloodborne infections?

"Do not share your monitoring equipment."

After teaching a client who is newly diagnosed with type 2 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?

"I should decrease my intake of protein and eliminate carbohydrates from my diet."

After teaching a client who has diabetes mellitus with retinopathy, nephropathy, and peripheral neuropathy, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching?

"I should look into swimming or water aerobics to get my exercise."

After teaching a patient with type 2 diabetes mellitus who is prescribed nateglinide, the nurse assesses the client's understanding. Which statement made by the patient indicates a correct understanding of the prescribed therapy?

"I will take this medicine immediately before I eat."

After teaching a client who is recovering from pancreas transplantation, the nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching?

"If I develop an infection, I should stop taking my corticosteroid."

A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement would the nurse include in this client's plan of care to delay the onset of microvascular and macrovascular complications?

"Maintain tight glycemic control and prevent hyperglycemia."

A nurse teaches a client with diabetes mellitus about sick-day management. Which statement would the nurse include in this client's teaching?

"Monitor your blood glucose levels at least every 4 hours while sick."

When teaching a client recently diagnosed with type 1 diabetes mellitus, the client states, "I will never be able to stick myself with a needle." How would the nurse respond?

"Tell me what it is about the injections that are concerning you."

After teaching a client with diabetes mellitus to inject insulin, the nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching?

"The lower abdomen is the best location because it is closest to the pancreas."

A nurse teaches a client with diabetes mellitus who is experiencing numbness and reduced sensation. Which statement would the nurse include in this client's teaching to prevent injury?

"Use a bath thermometer to test the water temperature."

A nurse teaches a client with type 1 diabetes mellitus. Which statement would the nurse include in this client's teaching to decrease the client's insulin needs?

"Walk at a moderate pace for 1 mile daily."

A nurse is teaching a client with diabetes mellitus who asks, "Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL (3.3 mmol/L)?" How would the nurse respond?

"Your brain needs a constant supply of glucose because it cannot store it."

A nurse cares for a client who has a family history of diabetes mellitus. The client states, "My father has type 1 diabetes mellitus. Will I develop this disease as well?" How would the nurse respond?

"Your risk of diabetes is higher than the general population, but it may not occur."

A nurse reviews the laboratory test values for a client with a new diagnosis of diabetes mellitus type 2. Which A1C value would the nurse expect?

7.4%

31-32 After calling for help, when the nurse finds a client in his or her room without a pulse, apneic and unconscious, which action should be taken next? A. Begin cardiac compressions B. Establish IV access C. Give supplemental oxygen D. Defibrillate the patient

A

The nurse is teaching a client a client about taking elbasvir for hepatitis C. What information in the client's history would the nurse need prior to drug administration? a. History of hepatitis B b. History of kidney disease c. History of cardiac disease d. History of rectal bleeding

A

Which piece of equipment would the nurse recommend for a client to manage hypertension at home? A. Blood pressure monitoring device B. Stationary exercise bicycle C. Blood glucose monitoring device D. Kitchen food scale

A The nurse would teach the client to obtain an ambulatory BP monitoring (ABPM) device for use at home so the pressure can be checked daily. The nurse would also evaluate the client's and family's ability to use this device accurately and instruct the client to keep a record of blood pressure readings and report very low or high readings to the primary health care provider.

What is the nurse's priority action when a client with AAA suddenly exhibits decreased level of consciousness, blood pressure 82/48 mm Hg, irregular apical pulse, and perfuse diaphoresis? A. Alert the Rapid Response Team. B. Establish IV access. C. Place the client on a cardiac monitor. D. Auscultate for bruit and palpate for a mass.

A These findings indicate a ruptured AAA which means that the client is critically ill and at risk for hypovolemic shock caused by hemorrhage. Signs and symptoms include hypotension, diaphoresis, decreased level of consciousness, oliguria (scant urine output), loss of pulses distal to the rupture, and dysrhythmias. The priority action is to notify the Rapid Response Team to intervene and save the client's life.

A nurse assesses clients who are at risk for diabetes mellitus. Which client is at greatest risk?

A 58-year-old American Indian

"It produces an enzyme that alters the acidity of the stomach."

A patient asks the nurse how an infection such as Helicobacter pylori causes gastric ulcers. Which information would the nurse provide about this organism?

Contact the health care provider to report these symptoms.

A patient experiences regular epigastric discomfort that usually goes away after eating. Which action would the nurse take?

Decompression of the stomach

A patient with peptic ulcer disease has developed a pyloric obstruction, and the health care provider orders placement of a nasogastric (NG) tube. For which purpose would the nurse place a NG tube in this patient?

A nurse assesses a client who is recovering from a myocardial infarction. The clients pulmonary artery pressure reading is 25/12 mm Hg. Which action should the nurse take first? a. Compare the results with previous pulmonary artery pressure readings. b. Increase the intravenous fluid rate because these readings are low. c. Immediately notify the health care provider of the elevated pressures. d. Document the finding in the clients chart as the only action.

A- Normal pulmonary artery pressures range from 15 to 26 mm Hg for systolic and from 5 to 15 mm Hg for diastolic. Although this clients readings are within normal limits, the nurse needs to assess any trends that may indicate a need for medical treatment to prevent complications. There is no need to increase intravenous fluids or notify the provider.

The emergency department manager is reviewing client charts to determine how well the staff perform when treating clients with community-acquired pneumonia. What outcome demonstrates that goals for this client type have been met? a. Antibiotics started before admission b. Blood cultures obtained within 20 minutes c. Chest x-ray obtained within 30 mins d. Pulse oximetry obtained on all clients

A. Antibiotics started before admission Goals for treatment of community-acquired pneumonia include initiating antibiotics prior to inpatient admission or within 6 hours of presentation to the ED. Timely collection of blood cultures, chest x-rays, and pulse ox are important as well but do not coincide with establish goals.

The charge nurse is making client assignments for the day shift. Which client is best to assign to an LPN/LVN? A. Client with polycystic kidney disease who is having a kidney ultrasound. B. Client with glomerulonephritis who is having a kidney biopsy. C. Client who is going for a cystoscopy and cystourethroscopy. D. Client who has just returned from having a kidney artery angioplasty.

A. Client with polycystic kidney disease who is having a kidney ultrasound.

Which laboratory test will the nurse assess as the best indicator of kidney function? A. Creatinine B. Blood urea nitrogen (BUN) C. Aspartate aminotransferase (AST) D. Alkaline phosphatase

A. Creatinine

What is the most common symptom that prompts clients to seek medical attention for problems with the kidneys or urinary tract? A. Pain in flank or abdomen, or pain when urinating B. Change in the frequency or amount of urination C. Exposure to one or more nephrotoxic substances D. Change in color, clarity, or odor of the urine

A. Pain in flank or abdomen, or pain when urinating

A client had a computed tomography (CT) scan with contrast dye 8 hours ago. Which nursing intervention is the priority for this client? A. Promoting fluid intake B. Medicating for pain C. Monitoring for hematuria D. Maintaining bedrest

A. Promoting fluid intake

The nurse is caring for client who has just returned from the operating room for cystoscopy performed under conscious sedation. Which assessment finding requires immediate nursing action? A. Temperature of 100.8° F (38.2° C) B. Lethargy C. Pink-tinged urine D. Urinary frequency

A. Temperature of 100.8° F (38.2° C)

A nurse cares for a client with right-sided HF. The client asks, "Why do I need to weigh myself every day?" How would the nurse respond? a. Weight is the best indication that you are gaining or losing fluid b. Daily weights will help us make sure that you're eating properly c. The hospital requires that all clients be weighed daily d. You need to lose weight to decrease the incidence of heart failure

A. Weight is the best indication that you are gaining or losing fluid Daily weights needed to document fluid retention or loss. 1 L of fluid = 2.2 lb (1 kg). Weight changes are the most reliable indicator of fluid loss or gain. The other responses do not address the importance of monitoring fluid retention/loss.

The clinic nurse teaches a patient with a 42 pack-year history of cigarette smoking about lung disease. Which information will be most important for the nurse to include? a. Options for smoking cessation b. Reasons for annual sputum cytology testing c. Erlotinib (Tarceva) therapy to prevent tumor risk d. Computed tomography (CT) screening for lung cancer

ANS: A Because smoking is the major cause of lung cancer, the most important role for the nurse is teaching patients about the benefits of and means of smoking cessation. CT scanning is currently being investigated as a screening test for high-risk patients. However, if there is a positive finding, the person already has lung cancer. Erlotinib may be used in patients who have lung cancer, but it is not used to reduce the risk of developing cancer

An older adult has had an instance of drug toxicity and asks why this happens, since the client has been on this medication for years at the same dose. What response by the nurse is best? a. "Changes in your liver cause drugs to be metabolized differently." b. "Perhaps you don't need as high a dose of the drug as before." c. "Stomach muscles atrophy with age and you digest more slowly." d. "Your body probably can't tolerate as much medication anymore."

ANS: A Decreased liver enzyme activity depresses drug metabolism, which leads to accumulation of drugs—possibly to toxic levels. The other options do not accurately explain this age-related change

14. A nurse teaches a young female client who is prescribed cephalexin for a urinary tract infection. Which statement would the nurse include in this client's teaching? a. "Use a second form of birth control while on this medication." b. "You will experience increased menstrual bleeding while on this drug." c. "You may experience an irregular heartbeat while on this drug." d. "Watch for blood in your urine while taking this medication."

ANS: A The client should use a second form of birth control because antibiotic therapy reduces the effectiveness of estrogen-containing contraceptives. She should not experience increased menstrual bleeding, an irregular heartbeat, or blood in her urine while taking the drug.

Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis? a. Weak, nonproductive cough effort b. Large amounts of greenish sputum c. Respiratory rate of 28 breaths/minute d. Resting pulse oximetry (SpO2) of 85%

ANS: A The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern

The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Document the amount of drainage every eight hours. b. Obtain samples of drainage for culture from the system. c. Assess patient pain level associated with the chest tube. d. Check the water-seal chamber for the correct fluid level.

ANS: A UAP education includes documentation of intake and output. The other actions are within the scope of practice and education of licensed nursing personnel

The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage slows significantly. What action by the nurse is most important? a. Increase the setting on the suction. b. Notify the provider immediately. c. Re-position the chest tube. d. Take the tubing apart to assess for clots.

ANS: B If the drainage in the chest tube decreases significantly and dramatically, the tube may be blocked by a clot. This could lead to cardiac tamponade. The nurse should notify the provider immediately. The nurse should not independently increase the suction, re-position the chest tube, or take the tubing apart. DIF: Applying/Application REF: 778

2. The nurse is caring for a client who has cirrhosis of the liver. What nursing action is appropriate to help control ascites? a. Monitor intake and output. b. Provide a low-sodium diet. c. Increase oral fluid intake. d. Weigh the patient daily

ANS: B A low-sodium diet is one means of controlling abdominal fluid collection. Monitoring intake and output does not control fluid accumulation, nor does weighing the client. These interventions merely assess or monitor the situation. Increasing fluid intake would not be helpful

A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first? a. Chest x-ray via stretcher b. Blood cultures from two sites c. Ciprofloxacin (Cipro) 400 mg IV d. Acetaminophen (Tylenol) rectal suppository

ANS: B Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest x-ray and acetaminophen administration can be done last

11. The nurse is caring for a client who is recovering from an open traditional Whipple surgical procedure. What action would the nurse take? a. Clamp the nasogastric tube. b. Place the patient in semi-Fowler position. c. Assess vital signs once every shift. d. Provide oral rehydration.

ANS: B Postoperative care for a patient recovering from an open Whipple procedure would include placing the client in a semi-Fowler position to reduce tension on the suture line and anastomosis sites and promote breathing, setting the nasogastric tube to low continuous suction to remove free air buildup and pressure, assessing vital signs frequently to assess fluid and electrolyte complications, and providing intravenous fluids

4. A client is admitted with acute pancreatitis. What priority problem would the nurse expect the client to report? a. Nausea and vomiting b. Severe boring abdominal pain c. Jaundice and itching d. Elevated temperature

ANS: B The client who has acute pancreatitis reports severe boring abdominal pain that is often rated by clients as a 10+ on a 0-10 pain scale. Nausea, vomiting, and fever may also occur, but that is not the client's priority for care.

A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority? a. Administer an aspirin. b. Call for an electrocardiogram (ECG). c. Maintain airway patency. d. Notify the provider.

ANS: C Airway always is the priority. The other actions are important in this situation as well, but the nurse should stay with the client and ensure the airway remains patent (especially if vomiting occurs) while another person calls the provider (or Rapid Response Team) and facilitates getting an ECG done. Aspirin will probably be administered, depending on the provider's prescription and the client's current medications. DIF: Applying/Application REF: 769

The provider requests the nurse start an infusion of an milrinone on a client. How does the nurse explain the action of these drugs to the client and spouse? a. "It constricts vessels, improving blood flow." b. "It dilates vessels, which lessens the work of the heart." c. "It increases the force of the heart's contractions." d. "It slows the heart rate down for better filling."

ANS:C Milrinone is an inotrope is a medication that increases the strength of the heart's contractions. The other options are not correct. DIF: Remembering/Knowledge REF: 772

The nurse is assessing a client for risk of developing metabolic syndrome. Which risk factor is associated with this health condition?

Abdominal obesity

A nurse is assessing a client who is recovering from a lung biopsy. Which assessment finding requires immediate action? a. Increased temperature b. Absent breath sounds c. Productive cough d. Incisional discomfort

Absent breath sounds. Absent breath sounds may indicate that the client has a pneumothorax, a serious complication after a needle biopsy or open lung biopsy. The other manifestations are not life threatening.

A nurse assesses a client who has diabetes mellitus and notes that the client is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup (120 mL) of orange juice, the client's signs and symptoms have not changed. What action would the nurse take next?

Administer another half-cup (120 mL) of orange juice.

A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. What action would the nurse take?

Administration of intravenous insulin

A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. Which action should the nurse take next? a. Call the physician and request a prescription for food and water. b. Provide the client with ice chips instead of a drink of water. c. Assess the clients gag reflex before giving any food or water. d. Let the client have a small sip to see whether he or she can swallow.

Assess the clients gag reflex before giving any food or water. The topical anesthetic used during the procedure will have affected the clients gag reflex. Before allowing the client anything to eat or drink, the nurse must check for the return of this reflex.

23. What complication does the nurse suspect when a client who had a gastrectomy develops tachycardia, syncope, and a desire to lie down 30 minutes after eating? A. Fluid overload B. Early dumping syndrome C. Late dumping syndrome D. Vitamin B12 deficiency

B

Which serum electrolyte value in a client with early-stage ascites from chronic liver disease who is taking spironolactone will the nurse report immediately to the primary health care provider? A. Sodium 133 mEq/L (mmol/L) B. Potassium 6.4 mEq/L (mmol/L) C. Chloride 101 mEq/L (mmol/L) D. Calcium 8.9 mg/dL (2.2 mmol/L)

B

Which patient does the charge nurse assign to an experienced LPN/LVN? A. A 28-year-old who requires teaching about how to catheterize a Kock ileostomy B. A 30-year-old who must receive neomycin sulfate (Mycifradin) before a colectomy C. A 34-year-old with ulcerative colitis (UC) who has a white blood cell count of 23,000/mm3 (23 × 109/L) D. A 38-year-old with gastroenteritis who is receiving IV fluids at 250 mL/hr

B. A 30-year-old who must receive neomycin sulfate (Mycifradin) before a colectomy The charge nurse assigns to an experienced LPN/LVN a 30-year-old who needs to receive neomycin sulfate before a colectomy. The LPN/LVN would be familiar with the purpose, adverse effects, and patient teaching required for neomycin.Teaching about how to catheterize a Kock ileostomy, assessing the patient with UC with a high white blood cell count, and monitoring the patient with gastroenteritis receiving IV fluids present complex problems that require assessment or intervention by an RN.

A nurse assesses a client who has a history of heart failure. Which question would the nurse ask to assess the extent of the client's heart failure? a. Do you have trouble breathing or chest pain? b. Are you still able to walk upstairs without fatigue? c. Do you awake with breathlessness during the night? d. Do you have new-onset heaviness in your legs?

B. Are you still able to walk upstairs without fatigue? Pts with hx of HF generally have negative findings, such as SOB and fatigue. Nurse needs to determine whether pt's activity is same or worse, or whether pt identifies a decrease in activity level. Trouble breathing, chest pain, breathlessness at night, and peripheral edema are symptoms of HF but don't provide data that can determine extent of HF.

Which client assessment data is essential for the nurse to report to the health care provider before a renal scan is performed? A. Pink-tinged urine B. Reports pregnancy C. Reports claustrophobia D. History of an aneurysm clip

B. Reports pregnancy

28. After esophagectomy for esophageal cancer, what is the nurse's priority for client care? A. Wound care B. Nutrition management C. Respiratory care D. Hydration status

C

5. Which diagnostic test does the nurse expect will be ordered for a client with suspected gastritis? A. Computed tomography (CT) scan B. Upper gastrointestinal (GI) series C. Esophagogastroduodenoscopy (EGD) D. Barium swallow

C

What would be the priority nursing action when a client experiences increasing pain, swelling, and tenseness after thrombectomy? A. Elevate the affected extremity and apply ice packs. B. Prepare to initiate systemic thrombolytic therapy. C. Report these symptoms to the health care provider immediately. D. Administer the prescribed pain medication as soon as possible.

C After thrombectomy, monitor for increasing pain, swelling, and tenseness. Report any of these symptoms to the health care provider immediately. These symptoms signal compartment syndrome which occurs when tissue pressure within a confined body space becomes elevated and restricts blood flow. The resulting ischemia can lead to tissue damage and eventually tissue death.

A nurse assesses an older adult client who has multiple chronic diseases. The clients heart rate is 48 beats/min. Which action should the nurse take first? a. Document the finding in the chart. b. Initiate external pacing. c. Assess the clients medications. d. Administer 1 mg of atropine.

C- Pacemaker cells in the conduction system decrease in number as a person ages, resulting in bradycardia. The nurse should check the medication reconciliation for medications that might cause such a drop in heart rate, then should inform the health care provider. Documentation is important, but it is not the priority action. The heart rate is not low enough for atropine or an external pacemaker to be needed.

A home health patient has had severe diarrhea for the past 24 hours. Which nursing action does the RN delegate to the home health aide (unlicensed assistive personnel [UAP]) who assists the patient with self-care? A. Instructing the patient about the use of electrolyte-containing oral rehydration products B. Administering loperamide (Imodium) 4 mg from the patient's medicine cabinet C. Checking and reporting the patient's heart rate and blood pressure in lying, sitting, and standing positions D. Teaching the patient how to clean the perineal area after each loose stool

C. Checking and reporting the patient's heart rate and blood pressure in lying, sitting, and standing positions The RN delegates to the UAP a home health patient with severe diarrhea who needs checking and reporting of the patient's heart rate and blood pressure in lying, sitting, and standing positions. Obtaining the patient's blood pressure and heart rate is included in the education of home health aides and other UAPs.Patient teaching and medication administration are complex skills that would be performed by licensed nurses who have the education and scope of practice needed to safely implement these actions.

A charge nurse is round on several older clients on ventilators in the Intensive Care Unit whom the nurse identifies as being at high risk for ventilator-associated pneumonia. To reduce this risk, what activity would the nurse delegate to assistive personnel? a. Encourage between-meal snacks b. Monitor temperature every 4 hours c. Provide oral care every 4 hours d. Report any new onset of cough

C. Provide oral care every 4 hours Oral colonization by gram-negative bacteria is a risk factor for healthcare associated pneumonia. Good, frequent oral care can help prevent this from developing and is a task that can be delegated to the AP. Encouraging good nutrition is important, but this will not prevent pneumonia. Monitoring temp and reporting new cough are important to detect the onset of possible pneumonia, but do not prevent it.

A nurse assesses a client after a lug biopsy. Which assessment finding is matched with the correct intervention? a. client states he is dizzy; nurse applies oxygen and pulse ox b. client HR 55 bpm; nurse withholds pain meds c. client has reduced breath sounds; nurse calls physician immediately d. client RR 18bpm; nurse decreases oxygen flow rate

Client has reduced breath sounds; nurse calls physician immediately. A potentially serious complication after biopsy is pneumothorax, which is indicated by decreased or absent breath sounds.

affects the arteries that provide blood, oxygen, and nutrients to the myocardium.

Coronary Artery Disease

10. From where does the nurse suspect a client with PUD is bleeding when massive coffee-ground emesis occurs? A. Colon B. Rectum C. Small intestine D. Upper GI system

D

The nurse is preparing to teach a client with chronic hepatitis B about lamivudine therapy. What health teaching would the nurse include? a. "Follow up on all appointments to monitor your lab values." b. "Do not take amiodorone at any time while on this drug." c. "Monitor for jaundice, rash, and itchy skin while on this drug." d. "Report any changes in urinary elimination while on this drug."

D

What are the priority nursing care concepts for clients with vascular problems? A. Perfusion and fluid balance B. Clotting and immunity C. Inflammation and perfusion D. Perfusion and clotting

D The priority care concepts for clients with vascular problems are perfusion and clotting. Inflammation is an interrelated concept for these clients.

What frequency of drug dosage therapy would the nurse advocate for an older client with hypertension who lives alone and is able to manage his or her self-care? A. Four times a day B. Three times a day C. Twice a day D. Once a day

D Research shows that clients, especially older adults, are more compliant with and able to manage self-care when drug dosages are prescribed once a day. The more frequently doses are scheduled, the more likely a client will be unable to follow the treatment regimen and miss doses of the prescribed drugs.

A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment should the nurse complete prior to this procedure? a. Clients level of anxiety b. Ability to turn self in bed c. Cardiac rhythm and heart rate d. Allergies to iodine-based agents

D- Before the procedure, the nurse should ascertain whether the client has an allergy to iodine-containing preparations, such as seafood or local anesthetics. The contrast medium used during the procedure is iodine based. This allergy can cause a life-threatening reaction, so it is a high priority. Second, it is important for the nurse to assess anxiety, mobility, and baseline cardiac status.

A nurse assesses a client after administering a prescribed beta blocker. Which assessment should the nurse expect to find? a. Blood pressure increased from 98/42 mm Hg to 132/60 mm Hg b. Respiratory rate decreased from 25 breaths/min to 14 breaths/min c. Oxygen saturation increased from 88% to 96% d. Pulse decreased from 100 beats/min to 80 beats/min

D- Beta blockers block the stimulation of beta1-adrenergic receptors. They block the sympathetic (fight-or-flight) response and decrease the heart rate (HR). The beta blocker will decrease HR and blood pressure, increasing ventricular filling time. It usually does not have effects on beta2-adrenergic receptor sites. Cardiac output will drop because of decreased HR.

A nurse cares for a client who has advanced cardiac disease and states, I am having trouble sleeping at night. How should the nurse respond? a. I will consult the provider to prescribe a sleep study to determine the problem. b. You become hypoxic while sleeping; oxygen therapy via nasal cannula will help. c. A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at night. d. Use pillows to elevate your head and chest while you are sleeping

D- The client is experiencing orthopnea (shortness of breath while lying flat). The nurse should teach the client to elevate the head and chest with pillows or sleep in a recliner. A sleep study is not necessary to diagnose this client. Oxygen and CPAP will not help a client with orthopnea.

A patient newly diagnosed with ulcerative colitis (UC) is started on sulfasalazine (Azulfidine). What does the nurse tell the patient about why this therapy has been prescribed? A. "It is to stop the diarrhea and bloody stools." B. "This will minimize your GI discomfort." C. "With this medication, your cramping will be relieved." D. "Your intestinal inflammation will be reduced."

D. "Your intestinal inflammation will be reduced." The nurse tells the newly diagnosed patient with UC who is started on sulfasalazine that, "Your intestinal inflammation will be reduced." Sulfasalazine (Azulfidine) is one of the primary treatments for UC. It is thought to inhibit prostaglandin synthesis and thereby reduce inflammation.Although it is hoped that reduction of inflammation will cause the diarrhea and bloody stools to stop, this is not the way that the drug works. Antidiarrheal drugs "stop" diarrhea. The drug's action as an anti-inflammatory will diminish the patient's pain as the inflammation subsides, but this is not the purpose of the drug. Sulfasalazine is an anti-inflammatory medication, not an analgesic.

What procedural instruction will the nurse provide for a client scheduled for an ultrasonography? A. Empty your bladder just before the test begins B. Stop taking your routine medications 24 hours before the test C. You must have nothing to eat or drink after midnight before the test D. Drink 500 ml to 1000 ml of water 2 to 3 hours before the test

D. Drink 500 ml to 1000 ml of water 2 to 3 hours before the test

Which symptom(s) in a client during the first 12 hours after a kidney biopsy indicates to the nurse a possible complication from the procedure? A. The client experiences nausea and vomiting after drinking juice. B. The biopsy site is tender to light palpation. C. The abdomen is distended, and the client reports abdominal discomfort. D. The heart rate is 118, blood pressure is 108/50, and peripheral pulses are thready.

D. The heart rate is 118, blood pressure is 108/50, and peripheral pulses are thready.

A patient has an anal fissure. Which intervention most effectively promotes perineal comfort for the patient? A. Administering a Fleet's enema when needed B. Applying heat to acute inflammation for pain relief C. Avoiding the use of bulk-forming agents D. Using hydrocortisone cream to relieve pain

D. Using hydrocortisone cream to relieve pain The intervention that most effectively promotes perineal comfort in a patient with anal fissure is using hydrocortisone skin cream to relieve perineal pain.Enemas would be avoided when an anal fissure is present. Cold packs would be applied to acute inflammation to diminish discomfort. Bulk-forming agents would be used to decrease pain associated with defecation.

what is the FIRST PRIORITY when a patient presents with chest pain?

EKG within 10 minutes

The nurse is caring for a newly admitted client who is diagnosed with hyperglycemic-hyperosmolar state (HHS). What is the nurse's priority action at this time?

Establish intravenous access to provide fluids.

A nurse assesses a client who has a 15-year history of diabetes and notes decreased tactile sensation in both feet. What action would the nurse take first?

Examine the client's feet for signs of injury.

A nurse reviews laboratory results for a client with diabetes mellitus who is prescribed an intensified insulin regimen: • Fasting blood glucose: 75 mg/dL (4.2 mmol/L) • Postprandial blood glucose: 200 mg/dL (11.1 mmol/L) • Hemoglobin A1C level: 5.5% How would the nurse interpret these laboratory findings?

Good control of blood glucose

The nurse is caring for a newly admitted older adult who has a blood glucose of 300 mg/dL (16.7 mmol/L), a urine output of 185 mL in the past 8 hours, and a blood urea nitrogen (BUN) of 44 mg/dL (15.7 mmol/L). What diabetic complication does the nurse suspect?

Hyperglycemic-hyperosmolar state (HHS)

The nurse assesses a client with diabetic ketoacidosis. Which assessment finding would the nurse correlate with this condition?

Increased rate and depth of respiration

A nurse assesses a client with diabetes mellitus who self-administers subcutaneous insulin. The nurse notes a spongy, swelling area at the site the client uses most frequently for insulin injection. What action would the nurse take?

Instruct the client to rotate sites for insulin injection.

A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies that the client has a 60 pack-year smoking history. Which action is most important for the nurse to take when interviewing this client? a. tell the client that he needs to quit smoking to stop further cancer development b. encourage the client to be completely honest about both tobacco and marijuana use c. maintain a nonjudgmental attitude to avoid causing the client to feel guilty d. avoid giving the client false hope regarding cancer treatment and prognosis.

Maintain a nonjudgmental attitude to avoid causing the client to feel guilty. Smoking history includes the use of cigarettes, cigars, pipe tobacco, marijuana, and other controlled substances. Because the client may have guilt or denial about this habit, assume a nonjudgmental attitude during the interview. This will encourage the client to be honest about the exposure. Pack-years= number of packs smoked daily x number of years the client has smoked. Quitting may not stop cancer development, don't give false hope.

A nurse assesses a clients respiratory status. Which information is of highest priority for the nurse to obtain? a. average daily checks b. neck circumference c. height and weight d. occupation and hobbies

Occupation and hobbies. Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in a clients occupation and hobbies. Although it will be important for the nurse to assess in the fluid intake, height and weight, these will not be as important as determining his occupation and hobbies. Determining the clients neck circumference will not be an important part of a respiratory assessment.

A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which would alert the nurse to intervene immediately?

Serum potassium level of 2.5 mEq/L (2.5 mmol/L)

A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement should the nurse include in this clients teaching? a. Make a list of reasons why smoking is a bad habit. b. Rise slowly when getting out of bed in the morning. c. Smoking while taking this medication will increase your risk of a stroke. d. Stopping this medication suddenly increases your risk for a heart attack.

Smoking while taking this medication will increase your risk of a stroke. Clients who smoke while using drugs for nicotine replacement therapy increase the risk of stroke and heart attack. Nurses should teach clients not to smoke while taking this drug. The other responses are inappropriate.

Melena

The laboratory report of a patient with acute gastritis states there are traces of blood in the stool. Which term would the nurse use to document this finding?

Gastric

The nurse is caring for a patient who has granular, dark vomitus that resembles coffee grounds. Which type of ulcer would the nurse suspect in this patient?

A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action? a. The client rates pain as a 5/10 at the site of the procedure. b. A small amount of drainage from the site is noted. c. Pulse oximetry is 93% on 2 liters of oxygen. d. The trachea is deviated toward the opposite side of the neck.

The trachea is deviated toward the opposite side of the neck. A deviated trachea is a manifestation of a tension pneumothorax, which is a medical emergency. The other findings are normal or near normal.

A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention should the nurse complete prior to the procedure? a. Measure oxygen saturation before and after a 12-minute walk. b. Verify that the client understands all possible complications. c. Explain the procedure in detail to the client and the family. d. Validate that informed consent has been given by the client.

Validate that informed consent has been given by the client. A thoracentesis is an invasive procedure with many potentially serious complications. Verifying that the client understands complications and explaining the procedure to be performed will be done by the physician or nurse practitioner, not the nurse. Measurement of oxygen saturation before and after a 12-minute walk is not a procedure unique to a thoracentesis.

A nurse is providing care after auscultating clients breath sounds. Which assessment finding is correctly matched to the nurses primary intervention? a. Hollow sounds are heard over the trachea. The nurse increases the oxygen flow rate. b. Crackles are heard in bases. The nurse encourages the client to cough forcefully. c. Wheezes are heard in central areas. The nurse administers an inhaled bronchodilator. d. Vesicular sounds are heard over the periphery. The nurse has the client breathe deeply.

Wheezes are heard in central areas. The nurse administers an inhaled bronchodilator. Wheezes are indicative of narrowed airways, and bronchodilators help to open the air passages. Hollow sounds are typically heard over the trachea, and no intervention is necessary. If crackles are heard, the client may need a diuretic. Crackles represent a deep interstitial process, and coughing forcefully will not help the client expectorate secretions. Vesicular sounds heard in the periphery are normal and require no intervention.

what percentage of occlusion does an artery need to reach for blood flow to be impaired to create myocardial ischemia when myocardial demand is increased

When an artery reaches 50% occlusion blood flow is impaired

Tarry or dark sticky stools, Decreased blood pressure, Dizziness or light-headedness, Bright red or coffee-ground-colored vomitus

Which clinical finding is associated with upper GI bleeding? Select all that apply. One, some, or all responses may be correct.

Hemorrhage

Which complication of peptic ulcer disease is more common in older adults?

Pernicious anemia

Which condition is a complication of chronic gastritis?

It strengthens the mucosal lining of the stomach

Which response would the nurse use when a patient with gastritis asks, "Why am I taking this drug called sucralfate?"

Avoid exposure to lead

Which self-management measure would the nurse teach the patient who has gastritis?

Which client with symptoms of chronic abdominal pain and frequent bowel movements will the nurse consider at highest risk for a diagnosis of ulcerative colitis? a. 26 yo woman of Jewish ancestry who has an identical twin sister with the disorder b. 40 yo black man who has just returned home from a business trip to SE Asia c. 50 yo Latino man with liver cirrhosis whose uncle died of colon cancer d. 65 yo obese asian woman who has chronic inflammatory cystitis

a. 26 yo woman of Jewish ancestry who has an identical twin sister with the disorder

6. A nurse cares for a client with an increased blood urea nitrogen (BUN)/creatinine ratio. Which action should the nurse take first? a. Assess the client's dietary habits. b. Inquire about the use of nonsteroidal anti-inflammatory drugs (NSAIDs). c. Hold the client's metformin (Glucophage). d. Contact the health care provider immediately.

a. Assess the client's dietary habits.

8. A nurse reviews laboratory results for a client who was admitted for a myocardial infarction and cardiogenic shock 2 days ago. Which laboratory test result should the nurse expect to find? a. Blood urea nitrogen (BUN) of 52 mg/dL b. Creatinine of 2.3 mg/dL c. BUN of 10 mg/dL d. BUN/creatinine ratio of 8:1

a. Blood urea nitrogen (BUN) of 52 mg/dL

To prevent harm after a surgical procedure for peritonitis, which action will the nurse teach a client to avoid? a. Taking additional acetaminophen to prevent liver toxicity b. Lifting for at least 6 months after an open surgical procedure c. Resuming normal activities for at least 3 to 4 days after the procedure d. Using stool softeners and laxatives to prevent diarrhea

a. Taking additional acetaminophen to prevent liver toxicity

A nurse participates in a community screening event for oral cancer. What client is the highest priority for referral to a primary health care provider? a. Client who has poor oral hygiene practices. b. Client who smokes and drinks daily. c. Client who tans for an upcoming vacation. d. Client who occasionally uses illicit drugs.

b Smoking and alcohol exposure create a high risk for this client. Poor oral hygiene is not related to the etiology of cancer but may cause a tumor to go unnoticed. Tanning is a risk factor, but short-term exposure does not have the same risk as daily exposure to tobacco and alcohol.

The nurse and health care provider are discussing a client who has pernicious anemia. The nurse anticipates that the client has which deficiency? a) Hydrochloric acid b) Intrinsic factor c) Glucagon d) Pepsinogen

b) Intrinsic factor

A client is being observed after a routine sigmoidoscopy with a tissue biopsy. Which assessment finding will the nurse report to the health care provider? a) Flatulence b) Rectal bleeding c) Mild abdominal pain d) Borborygmi

b) Rectal bleeding

The nurse is caring for a patient who has just undergone a cystoscopy. Which assessment finding necessitates an immediate intervention by the nurse? a. Back pain b. Bright red urine c. Urinary frequency d. Burning on urination

b. Bright red urine

10. A nurse cares for a client who has elevated levels of antidiuretic hormone (ADH). Which disorder should the nurse identify as a trigger for the release of this hormone? a. Pneumonia b. Dehydration c. Renal failure d. Edema

b. Dehydration

Which action will the nurse instruct a client with celiac disease to perform to reduce symptoms? a. Limiting caffeine b. Drinking more liquids c. Reading labels on prepared foods d. Avoiding raw fruits and vegetables

c. Reading labels on prepared foods

Which of these client assessment findings is typically associated with oral cancer? a. Dry sticky oral membranes b. Increased appetite c. Itchy rash in oral cavity d. Painless red or raised lesion

d A painless red or raised lesion often indicates a diagnosis of oral cancer. The client usually has a decreased appetite and thick secretions. Itchiness is not a common finding associated with oral cancer.

A client is admitted to the hospital with severe right upper quadrant (RUQ) abdominal pain. Which assessment technique does the nurse use for this client? a) Has the client lie in a supine position with legs straight and arms above the head. b) Assesses the following sequence: inspection, palpation, percussion, auscultation. c) Palpates any bulging mass very gently and documents findings. d) Examines the RUQ of the abdomen last following all other assessment techniques.

d) Examines the RUQ of the abdomen last following all other assessment techniques.

Which surgical client will the nurse recognize as having the highest risk for development of peritonitis? a. 35 yo having a laparoscopic appendectomy b. 45 yo having a vaginal hysterectomy c. 60 yo having a traditional cholecystectomy for cholelithiasis d. 72 yo having a bowel resection for colon cancer

d. 72 yo having a bowel resection for colon cancer

Which cardinal signs will the nurse expect to assess in a client diagnosed with peritonitis? a. Fever with headache and confusion b. Dizziness with nausea and vomiting c. Loss of appetite with nausea and weight loss d. Abdominal pain with distention and tenderness

d. Abdominal pain with distention and tenderness

3. A nurse reviews the urinalysis results of a client and notes a urine osmolality of 1200 mOsm/L. Which action should the nurse take? a. Contact the provider and recommend a low-sodium diet. b. Prepare to administer an intravenous diuretic. c. Obtain a suction device and implement seizure precautions. d. Encourage the client to drink more fluids.

d. Encourage the client to drink more fluids.

7. A nurse cares for a client with a urine specific gravity of 1.040. Which action should the nurse take? a. Obtain a urine culture and sensitivity. b. Place the client on restricted fluids. c. Assess the client's creatinine level. d. Increase the client's fluid intake.

d. Increase the client's fluid intake.

1. A nurse reviews the urinalysis of a client and notes the presence of glucose. Which action should the nurse take? a. Document findings and continue to monitor the client. b. Contact the provider and recommend a 24-hour urine test. c. Review the client's recent dietary selections. d. Perform a capillary artery glucose assessment.

d. Perform a capillary artery glucose assessment.

necrosis or cell death that occurs when severe ischemia is prolonged and decreased perfusion causes irreversible damage to tissue

infarctions

what happens when arteries are partially or completely blocked?

it causes ischemia or infarction

A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values would the nurse identify as potential ketoacidosis in this client?

pH 7.28, HCO3− 18 mEq/L (18 mmol/L), PCO2 28 mm Hg, PO2 98 mm Hg

Difference between stable and unstable angina?

stable - occurs with exertion and is relieved by rest or meds, predicable, occurring for more than 4 weeks. unstable - new angina or change in angina, occurs with or without exertion, unrelieved by rest or meds, occurring less than 4 weeks.

A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best? a. Assess the client's pupillary responses. b. Request a neurologic consultation. c. Stop the infusion and call the provider. d. Take and document a full set of vital signs.

ANS: C A change in neurologic status in a client receiving t-PA could indicate intracranial hemorrhage. The nurse should stop the infusion and notify the provider immediately. A full assessment, including pupillary responses and vital signs, occurs next. The nurse may or may not need to call a neurologist. DIF: Applying/Application REF: 768 KEY: Coronary artery disease| neurologic system| critical rescue| Rapid Response Team| thrombolytic agents MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

A nurse prepares a client for a colonoscopy scheduled for tomorrow. The client states, "My doctor told me that the fecal occult blood test was negative for colon cancer. I don't think I need the colonoscopy and would like to cancel it." How should the nurse respond? a. "Your doctor should not have given you that information prior to the colonoscopy." b. "The colonoscopy is required due to the high percentage of false negatives with the blood test." c. "A negative fecal occult blood test does not rule out the possibility of colon cancer." d. "I will contact your doctor so that you can discuss your concerns about the procedure

ANS: C A negative result from a fecal occult blood test does not completely rule out the possibility of colon cancer. To determine whether the client has colon cancer, a colonoscopy should be performed so the entire colon can be visualized and a tissue sample taken for biopsy. The client may want to speak with the provider, but the nurse should address the client's concerns prior to contacting the provider. DIF: Understanding/Comprehension REF: 1151 KEY: Colorectal cancer| assessment/diagnostic examination MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

A nurse cares for a client with diabetes mellitus who asks, "Why do I need to administer more than one injection of insulin each day?" How would the nurse respond?

"A single dose of insulin each day would not match your blood insulin levels and your food intake patterns."

Which assessment finding would require the nurse to take immediate action in a client who is 1 hour post kidney biopsy? Select all that apply. A. Pink-tinged urine B. Nausea and vomiting C. Increased bowel sounds D. Reports of flank pain E. The patient is ambulating to the bathroom

A. Pink-tinged urine

A home health care nurse is visiting an older client who lives alone after being discharged from the hospital after a coronary artery bypass graft. What finding in the home most causes the nurse to consider additional referrals? a. Dirty carpets in need of vacuuming b. Expired food in the refrigerator c. Old medications in the kitchen d. Several cats present in the home

ANS: B Expired food in the refrigerator demonstrates a safety concern for the client and a possible lack of money to buy food. The nurse can consider a referral to Meals on Wheels or another home-based food program. Dirty carpets may indicate the client has no household help and is waiting for clearance to vacuum. Old medications can be managed by the home health care nurse and the client working collaboratively. Having pets is not a cause for concern. DIF: Applying/Application REF: 781

A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first? a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg c. Client who is 1 day post percutaneous coronary intervention, going home this morning d. Client who is 2 days post coronary artery bypass graft, became dizzy this a.m. while walking

ANS: B Hypertension after coronary artery bypass graft surgery can be dangerous because it puts too much pressure on the suture lines and can cause bleeding. The charge nurse should see this client first. The client who became dizzy earlier should be seen next. The client on the nitroglycerin drip is stable. The client going home can wait until the other clients are cared for. DIF: Analyzing/Analysis REF: 777

An emergency room nurse assesses a client after a motor vehicle crash and notes ecchymotic areas across the client's lower abdomen. Which action should the nurse take first? a. Measure the client's abdominal girth. b. Assess for abdominal guarding or rigidity. c. Check the client's hemoglobin and hematocrit. d. Obtain the client's complete health history.

ANS: B On noticing the ecchymotic areas, the nurse should check to see if abdominal guarding or rigidity is present, because this could indicate major organ injury. The nurse should then notify the provider. Measuring abdominal girth or obtaining a complete health history is not appropriate at this time. Laboratory test results can be checked after assessment for abdominal guarding or rigidity. DIF: Applying/Application REF: 1162 KEY: Gastrointestinal trauma| hemorrhage MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A client has presented to the emergency department with an acute myocardial infarction (MI). What action by the nurse is best to meet The Joint Commission's Core Measures outcomes? a. Obtain an electrocardiogram (ECG) now and in the morning. b. Give the client an aspirin. c. Notify the Rapid Response Team. d. Prepare to administer thrombolytics.

ANS: B The Joint Commission's Core Measures set for acute MI require that aspirin is administered when a client with MI presents to the emergency department or when an MI occurs in the hospital. A rapid ECG is vital, but getting another one in the morning is not part of the Core Measures set. The Rapid Response Team is not needed if an emergency department provider is available. Thrombolytics may or may not be needed. DIF: Remembering/Knowledge REF: 766

A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the client's O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best? a. Administer oxygen at 2 L/min. b. Allow continued bathroom privileges. c. Obtain a bedside commode. d. Suggest the client use a bedpan.

ANS: B This client's physiologic parameters did not exceed normal during and after activity, so it is safe for the client to continue using the bathroom. There is no indication that the client needs oxygen, a commode, or a bedpan. DIF: Applying/Application REF: 769

A client has an intra-arterial blood pressure monitoring line. The nurse notes bright red blood on the client's sheets. What action should the nurse perform first? a. Assess the insertion site. b. Change the client's sheets. c. Put on a pair of gloves. d. Assess blood pressure.

ANS: C For the nurse's safety, he or she should put on a pair of gloves to prevent blood exposure. The other actions are appropriate as well, but first the nurse must don a pair of gloves. DIF: Applying/Application REF: 771

A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan? a. Purpose of antibiotic therapy b. Ways to limit oral fluid intake c. Appropriate use of cough suppressants d. Safety concerns with home oxygen therapy

ANS: C Cough suppressants are frequently prescribed for acute bronchitis. Because most acute bronchitis is viral in origin, antibiotics are not prescribed unless there are systemic symptoms. Fluid intake is encouraged. Home oxygen is not prescribed for acute bronchitis, although it may be used for chronic bronchitis

11. Which action is the priority for the nurse to take when caring for clients with oral cancers? A. Providing pain control B. Maintaining the airway C. Promoting tissue integrity D. Enhancing nutrition

B

The nurse is teaching a client who needs a clean-catch urine specimen. What teaching will the nurse include? A. "Save all urine for 24 hours." B. "Do not touch the inside of the container." C. "Use the sponges to cleanse the urethra, and then initiate voiding directly into the cup." D. "You will receive an isotope injection, then I will collect your urine."

B. "Do not touch the inside of the container."

A patient admitted with severe gastroenteritis has been started on an IV, but the patient continues having excessive diarrhea. Which medication does the nurse expect the primary health care provider to prescribe? A. Balsalazide (Colazal) B. Loperamide (Imodium) C. Mesalamine (Asacol) D. Milk of Magnesia (MOM)

B. Loperamide (Imodium) The nurse expects the primary health care provider to prescribe loperamide for a patient with severe gastroenteritis who still has excessive diarrhea. If the primary health care provider determines that antiperistaltic agents are necessary, an initial dose of loperamide (Imodium) 4 mg can be administered orally, followed by 2 mg after each loose stool, up to 16 mg daily.Balsalazide is not the best choice for control of diarrhea in this scenario. Mesalamine is used for patients with ulcerative colitis for long-term therapy. MOM is a laxative.

What would the nurse teach a client with peripheral arterial disease about positioning and position changes? A. Change positions slowly when getting out of bed. B. Sleep with legs elevated above the heart if legs are swollen. C. Avoid crossing legs at all times. D. Sit upright in a chair if legs are not swollen.

C Instruct all clients with the disease to avoid crossing their legs and avoid wearing restrictive clothing (e.g., garters to hold up nylon stockings commonly used by older women), which interfere with blood flow.

A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure? a. I have been drinking more water than usual b. I am awakened by the need to urinate at night c. I must stop halfway up the stairs to catch my breath d. I have experienced blurred vision on several occasions

C. I must stop halfway up the stairs to catch my breath Pts with left-sided HF report weakness/fatigue while performing ADLs, as well as difficulty breathing, or "catching their breath". This occurs as fluid moves into the alveoli. Nocturia is often seen with right-sided heart failure. Thirst and blurred vision are not related to HF.

25. What manifestation of esophageal cancer does the nurse recognize when a client describes experiencing a dull and steady substernal pain after drinking cold liquids? A. Angina B. Aspiration C. Dysphagia D. Odynophagia

D

The liquid form of this is preferable to chewable tablets.

Which information would the nurse provide the patient regarding aluminum hydroxide?

2. A client is admitted with a large oral tumor. What assessment by the nurse takes priority? a. Airway b. Breathing c. Circulation d. Nutrition

a Airway always takes priority. Airway must be assessed first and any problems managed if present.

The nurse is teaching an older adult client. Which gastrointestinal problem does the nurse discuss that takes place during the normal aging process? a) Increased peristalsis b) Decreased hydrochloric acid levels c) Increased liver size d) Excess lipase production

b) Decreased hydrochloric acid levels

What is the most important assessment for the nurse to perform before administering the first dose of sulfasalazine to a client diagnosed with ulcerative colitis? a. Obtaining an accurate weight b. Asking whether they have an allergy to sulfa drugs c. Measuring heart and respiratory rate and blood pressure d. Determining the number of times the client has had a stool today

b. Asking whether they have an allergy to sulfa drugs

For which client finding will the nurse withheld the scheduled monthly dose of a prescribed parenteral biologic for management of ulcerative colitis? a. 5lb weight gain b. Increased number of diarrhea stools per day c. Presence of occult blood in today's stool sample d. Cough and fever of 102 F

d. Cough and fever of 102 F

What are catecholamines?

dopamine, norepinephrine, epinephrine

The nurse is planning teaching for a client who is starting exenatide extended release (ER) for diabetes mellitus type 2. Which statement will the nurse include in the teaching?

"Give your drug injection the same day every week."

A nurse cares for a patient who is prescribed pioglitazone. After 6 months of therapy, the client reports that he has a new onset of ankle edema. What assessment question would the nurse take?

"Have you gained unexpected weight this week?"

A nurse teaches a client who is recovering from a colon resection. Which statement should the nurse include in this client's plan of care? a. "You may experience nausea and vomiting for the first few weeks." b. "Carbonated beverages can help decrease acid reflux from anastomosis sites." c. "Take a stool softener to promote softer stools for ease of defecation." d. "You may return to your normal workout schedule, including weight lifting."

ANS: C Clients recovering from a colon resection should take a stool softener as prescribed to keep stools a soft consistency for ease of passage. Nausea and vomiting are symptoms of intestinal obstruction and perforation and should be reported to the provider immediately. The client should be advised to avoid gas-producing foods and carbonated beverages, and avoid lifting heavy objects or straining on defecation. DIF: Applying/Application REF: 1155 KEY: Colorectal cancer| postoperative nursing| bowel care MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

The nurse is caring for a client who has diabetes mellitus. The nurse administers 6 units of regular insulin and 10 units of NPH insulin at 7:00 a.m. (0700). At which time would the nurse assess the client for potential hypoglycemia related to the NPH insulin?

4:00 p.m. (1600)

1. Which finding does the nurse understand is an early pathologic manifestation when a client is diagnosed with acute gastritis? A. Thickened, reddened mucous membrane with prominent rugae B. Patchy, diffuse inflammation C. H. pylori infection D. Thin, atrophied wall and lining of the stomach

A

13. What is the nurse's best first action when a client with a gastric ulcer is found lying in the knee-chest (fetal) position with a rigid, tender, and painful abdomen? A. Notify the primary health care provider. B. Administer opioid pain medication. C. Reposition the client supine. D. Measure the abdominal circumference.

A

15. Which drug does the nurse expect to administer to a client in order to decrease hydrochloric acid secretion in the stomach? A. Famotidine B. Gaviscon C. Mylanta D. Antibiotic

A

16. Which priority teaching will the nurse provide to an older client with GERD who is prescribed omeprazole for symptom relief? A. "Older adults taking this drug may be at increased risk for hip fracture because it interferes with calcium absorption." B. "Because of this drug's side effect of decreasing potassium, you may be prescribed a potassium supplement." C. "This drug causes sodium retention, so you may be prescribed a dietary sodium restriction." D. "A pacemaker may be necessary because this drug changes magnesium levels which can lead to life-threatening dysrhythmias."

A

24. What is the most common symptom the nurse expects clients with esophageal cancer to report? A. Difficulty with swallowing B. Shortness of breath C. Reflux especially at night D. Productive cough

A

31-3 Which waveform does the nurse recognize as atrial depolarization when a client is placed on a cardiac monitor? A. P wave B. PR segment C. QRS complex D. T wave

A

31-35 Which ECG strip pattern is evidence to the nurse that a client's temporary transveneous pacemaker has successfully depolarized the ventricles? A. A pacer spike followed by a QRS complex B. Two spikes followed by a QRS complex C. A pacer spike before and after the QRS complex D. No pacer spike but regular QRS complexes

A

31-41 What effect does the nurse expect a class IV drug to have on a client's cardiac conduction system? A. Slow the flow of calcium ions into the cell during depolarization to depress automaticity B. Stabilize membranes to depress automaticity C. Decrease HR and conduction velocity D. Lengthen the absolute refractory period and prolong repolarization

A

31-43 Which beta-blocker drug approved for treating dysrythmias is also a Class III anti dysrhythmic drug? A. Sotalol B. Esmolol C. Propranolol D. Acebutolol

A

31-5 To determine if a client has a pulse deficit, what procedure would the nurse follow? A. Assess the apical and radial pulses for a full minute and calculate the difference. B. Check the client's BP and substract the DBP from the SBP C. Take the clients pulse rate while supine and then in a standing position D. Assess the radial pulse for a minute, have the client rest, and then check the radial pulse again

A

6. Which priority teaching will the nurse provide to prevent harm when a client with an oral problem is prescribed viscous lidocaine? A. "Lidocaine causes an anesthetic effect so you may not feel burns from hot liquids." B. "You should avoid drinking either cool or cold liquids which can damage the tongue." C. "When you take viscous lidocaine, you should swish it around your mouth then spit it out." D. "Viscous lidocaine will decrease the pain in your mouth when you use it regularly."

A

8. Which question will the nurse be sure to ask a client suspected of having leukoplakia? A. "Do you smoke, dip, or chew tobacco products?" B. "How much alcohol do you drink each day?" C. "Do you consume many of fast food meals?" D. "How often do you have dental checkups?"

A

A client with diabetes has the following assessment changes after a percutaneous nephrolithotomy procedure. Which change requires immediate nursing intervention? A. Difficulty breathing and an oxygen saturation of 88% on 2 L of oxygen by nasal cannula B. A point-of-care blood glucose of 150 mg/dL and client report of thirst C. A decreased hematocrit by 1% (compared with preoperative values and hematuria) D. An oral temperature of 38° C (101° F) and cloudiness of urine draining from the nephrostomy tube after IV administration of a broad-spectrum antibiotic

A

For which client would the nurse expect to teach intermittent catheterization? A. 35-year-old woman who has multiple sclerosis and incontinence B. 48-year-old man who is admitted for pneumonia and is on complete bedrest C. 61-year-old woman who is admitted following a fall at home and has new-onset dysrhythmia D. 74-year-old man who has lung cancer with brain metastasis and has advanced dementia

A

The nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding would require immediate action by the nurse? a. Urine output via indwelling urinary catheter is 20 mL/hr b. Blood pressure increases from 110/58 to 120/62 mm Hg c. Respiratory rate decreases from 22 to 16 breaths/min d. A decrease in the client's weight by 3 lb (1.4 kg)

A

The nurse is caring for a client who is prescribed lactulose. The client states, "I do not want to take this medication because it causes diarrhea." How would the nurse respond? a. "Diarrhea is expected, that's how your body gets rid of ammonia." b. "You may take antidiarrheal medication to prevent loose stools." c. "Do not take any more of the medication until your stools firm up." d. "We will need to send a stool specimen to the laboratory as soon as possible."

A

The nurse is caring for a client with hepatitis C. The client's brother states, "I do not want to get this infection, so I'm not going into his hospital room." How would the nurse respond? a. "Hepatitis C is not spread through casual contact." b. "If you wear a gown and gloves, you will not get this virus." c. "This virus is only transmitted through a fecal specimen." d. "I can give you an update on your brother's status from here."

A

What will the nurse recognize as the cause of splenomegaly in a client who has cirrhosis? A. Increased pressure in the portal vein causing backflow of blood into the spleen B. The loss of cellular regulation in the liver spreading to the spleen and causing extensive scarring C. Chronic inflammation and infection increasing the spleen's maturation and release of white blood cells D. Direct destruction of spleen cells from alcohol or other toxins causing replacement with scar tissue formation

A

Which client will the nurse recognize as having the greatest risk for nonacoholic fatty liver disease (NAFLD)? A. 45-year-old Latino man who is 30 lb (13.9 kg) overweight and has type 2 diabetes B. 50-year-old white woman who drinks one glass of wine daily and has breast cancer C. 60-year-old black woman who is hypertensive and takes a diuretic daily D. 70-year-old Asian man who has gastroesophageal reflux disease (GERD)

A

Which neuromuscular assessment change indicates to the nurse that a client who has late-stage liver cirrhosis now has encephalopathy? A. Asterixis B. Positive Chvostek sign C. Increased deep tendon reflex responses D. Decreased deep tendon reflex responses

A

Which precaution is most important for the nurse to instruct a client with cirrhosis and his or her family about continuing care in the home? A. Avoid taking acetaminophen or drinking alcohol. B. Maintain one-floor living to prevent excessive fatigue. C. Use cool baths to reduce the sensation of itching. D. Report any change in cognition to the health care provider.

A

Which precaution is most important for the nurse to instruct clients with hepatitis C (HCV) who are receiving drug therapy with any second-generation protease inhibitor? A. Avoid crowds and people who are ill. B. Do not touch these drugs with your bare hands. C. Alternate periods of activity with periods of rest. D. Be sure to take vitamin K supplements with this drug.

A

A client is to receive a dopamine infusion. What does the nurse do to prepare for this infusion? A. gather central line supplies B. mark the client's pedal pulses C. monitor the clients vital signs D. ensure an accurate weight is charted

A dopamine should be infused through a central line to prevent extravasation and necrosis of tissue

Physiological Integrity 19. After being hit by a baseball, a patient arrives in the emergency department with a possible nasal fracture. Which finding by the nurse is most important to report to the health care provider? a. Clear nasal drainage b. Complaint of nasal pain c. Bilateral nose swelling and bruising d. Inability to breathe through the nose

A Clear nasal drainage may indicate a meningeal tear with leakage of cerebrospinal fluid. This would place the patient at risk for complications such as meningitis. The other findings are typical with a nasal fracture and do not indicate any complications. DIF: Cognitive Level: Apply (application) REF: 498 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC:

Physiological Integrity 6. The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse would best determine if the cuff has been properly inflated? a. Use a manometer to ensure cuff pressure is at an appropriate level. b. Check the amount of cuff pressure ordered by the health care provider. c. Suction the patient first with a fenestrated inner cannula to clear secretions. d. Insert the decannulation plug before the nonfenestrated inner cannula is removed.

A Measurement of cuff pressure using a manometer to ensure that cuff pressure is 20 mm Hg or lower will avoid compression of the tracheal wall and capillaries. Never insert the decannulation plug in a tracheostomy tube until the cuff is deflated and the nonfenestrated inner cannula is removed. Otherwise, the patient's airway is occluded. A health care provider's order is not required to determine safe cuff pressure. A nonfenestrated inner cannula must be used to suction a patient to prevent tracheal damage occurring from the suction catheter passing through the fenestrated openings. DIF: Cognitive Level: Apply (application) REF: 509 TOP: Nursing Process: Implementation MSC:

Safe and Effective Care Environment 18. The nurse is caring for a hospitalized older patient who has nasal packing in place to treat a nosebleed. Which assessment finding will require the most immediate action by the nurse? a. The oxygen saturation is 89%. b. The nose appears red and swollen. c. The patient's temperature is 100.1° F (37.8° C). d. The patient complains of level 8 (0 to 10 scale) pain.

A Older patients with nasal packing are at risk of aspiration or airway obstruction. An O2 saturation of 89% should alert the nurse to further assess for these complications. The other assessment data also indicate a need for nursing action but not as immediately as the low O2 saturation. DIF: Cognitive Level: Apply (application) REF: 499 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC:

Physiological Integrity 8. A nurse obtains a health history from a patient who has a 35 pack-year smoking history. The patient complains of hoarseness and tightness in the throat and difficulty swallowing. Which question is most important for the nurse to ask? a. "How much alcohol do you drink in an average week?" b. "Do you have a family history of head or neck cancer?" c. "Have you had frequent streptococcal throat infections?" d. "Do you use antihistamines for upper airway congestion?"

A Prolonged alcohol use and smoking are associated with the development of laryngeal cancer, which the patient's symptoms and history suggest. Family history is not a risk factor for head or neck cancer. Frequent antihistamine use would be asked about if the nurse suspected allergic rhinitis, but the patient's symptoms are not suggestive of this diagnosis. Streptococcal throat infections also may cause these clinical manifestations, but patients with this type of infection will also have pain and a fever. DIF: Cognitive Level: Apply (application) REF: 515 TOP: Nursing Process: Assessment MSC:

Physiological Integrity 12. Which action should the nurse take first when a patient develops a nosebleed? a. Pinch the lower portion of the nose for 10 minutes. b. Pack the affected nare tightly with an epistaxis balloon. c. Obtain silver nitrate that will be needed for cauterization. d. Apply ice compresses over the patient's nose and cheeks.

A The first nursing action for epistaxis is to apply direct pressure by pinching the nostrils. Application of cold packs may decrease blood flow to the area, but will not be sufficient to stop bleeding. Cauterization and nasal packing are medical interventions that may be needed if pressure to the nares does not stop the bleeding, but these are not the first actions to take for a nosebleed. DIF: Cognitive Level: Apply (application) REF: 499 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:

Physiological Integrity 15. Which patient in the ear, nose, and throat (ENT) clinic should the nurse assess first? a. A 23-year-old who is complaining of a sore throat and has a muffled voice b. A 34-year-old who has a "scratchy throat" and a positive rapid strep antigen test c. A 55-year-old who is receiving radiation for throat cancer and has severe fatigue d. A 72-year-old with a history of a total laryngectomy whose stoma is red and inflamed

A The patient's clinical manifestation of a muffled voice suggests a possible peritonsillar abscess that could lead to an airway obstruction requiring rapid assessment and potential treatment. The other patients do not have diagnoses or symptoms that indicate any life-threatening problems. DIF: Cognitive Level: Analyze (analysis) REF: 507 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Assessment MSC:

Psychosocial Integrity 11. The nurse completes discharge instructions for a patient with a total laryngectomy. Which statement by the patient indicates that additional instruction is needed? a. "I must keep the stoma covered with an occlusive dressing at all times." b. "I can participate in most of my prior fitness activities except swimming." c. "I should wear a Medic-Alert bracelet that identifies me as a neck breather." d. "I need to be sure that I have smoke and carbon monoxide detectors installed."

A The stoma may be covered with clothing or a loose dressing, but this is not essential. An occlusive dressing will completely block the patient's airway. The other patient comments are all accurate and indicate that the teaching has been effective. DIF: Cognitive Level: Apply (application) REF: 517 TOP: Nursing Process: Evaluation MSC:

Physiological Integrity 7. Which statement by the patient indicates that the teaching has been effective for a patient scheduled for radiation therapy of the larynx? a. "I will need to buy a water bottle to carry with me." b. "I should not use any lotions on my neck and throat." c. "Until the radiation is complete, I may have diarrhea." d. "Alcohol-based mouthwashes will help clean oral ulcers."

A Xerostomia can be partially alleviated by drinking fluids at frequent intervals. Radiation will damage tissues at the site being radiated but should not affect the abdominal organs, so loose stools are not a usual complication of head and neck radiation therapy. Frequent oral rinsing with non-alcohol-based rinses is recommended. Prescribed lotions and sunscreen may be used on radiated skin, although they should not be used just before the radiation therapy. DIF: Cognitive Level: Apply (application) REF: 515-516 TOP: Nursing Process: Evaluation MSC:

Which action increases the effectiveness of angiotensin II receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs) in controlling hypertension for African-American clients? A. The ARB or ACEI is given with a diuretic, beta blocker, or a calcium channel blocker. B. A much higher dose of ARB or ACEI is prescribed for an African-American client. C. The ARB or ACEI is combined with rigorous lifestyle modifications. D. Clients take the ARB or ACEI around the clock on an individualized schedule.

A ACEIs and ARBs are not as effective in African Americans unless they are taken with diuretics or another drug category such as a beta blocker or calcium channel blocker.

Which relatively new therapy would be tried for clients with familial hypercholesterolemia or for those who are unable to reduce LDLs with existing therapies? A. PCSK9 inhibitors B. Nicotinic acid C. Lovaza (omega-3 ethyl esters) D. Combination drugs (e.g., Caduet)

A The Food and Drug Administration (FDA) ap-proved the drug class, PCSK9 inhibitors, for use in clients with familial hypercholesterolemia or for those who are unable to reduce LDLs with existing therapies. Nicotinic acid (niacin) may lower LDL-C and very-low-density lipoprotein (VLDL) cholesterol levels and increase HDL-C levels but is poorly tolerated due to side effects. Lovaza (omega-3 ethyl esters) is approved by the FDA as an adjunct to diet to reduce TGs that are greater than 500 mg/dL. Caduet is used to decrease blood pressure while decreasing tri-glycerides (TGs), increasing HDL, and lowering LDL.

What drug would the nurse expect to be prescribed for a client with hypertension and for whom lifestyle modifications have failed to control blood pressure? A. Thiazide diuretic B. Calcium channel blocker C. Angiotensin-converting enzyme inhibitor D. Beta blocker

A Thiazide (low-ceiling) diuretics, such as hydro-chlorothiazide, inhibit sodium, chloride, and water reabsorption in the distal tubules while promoting potassium, bicarbonate, and magnesium excretion. Because of the low cost and high effectiveness of thiazide-type diuretics, they are usually the drugs of choice for clients with uncomplicated hypertension.

What is the priority action for the nurse when a client is to have unfractionated heparin (UFH) discontinued and to start receiving subcutaneous low-molecular-weight heparin (LMWH)? A. Discontinue the UFH at least 30 minutes before giving the first LMWH injection. B. Check the aPTT and INR laboratory results before giving the first LMWH injection. C. Assess the client's IV site and convert it to a saline lock before starting LMWH. D. Instruct the client about the need for frequent laboratory test to ensure the LMWH is working.

A When a client is prescribed a change from UFH to LMWH, the nurse's priority is to discontinue the UFH at least 30 minutes before the first LMWH injection. While the nurse should be familiar with the client's clotting study results, no laboratory values are necessary when the client is receiving LMWH.

Gastritis is the inflammation of the stomach mucosa.

A patient has been diagnosed with gastritis. Which information describes this condition?

Ability to swallow secretions

A patient has undergone an esophagogastroduodenoscopy (EGD) procedure. Which assessment would the nurse make the priority for this patient?

H. pylori infection is spread by the oral-to-oral or fecal-to-oral routes.

A patient is diagnosed with a duodenal ulcer caused by Helicobacter pylori infection. The patient asks the nurse how this infection was contracted. Which response would the nurse provide?

Starting a large-bore IV

A patient is experiencing bleeding related to peptic ulcer disease (PUD). Which action would the nurse take?

Do not take an antacid at the same time as sucralfate

A patient is prescribed sucralfate to treat symptoms of peptic ulcer disease. Which information would the nurse include when teaching the patient about this medication?

Helicobacter pylori

A patient presents to the clinic and is diagnosed with chronic gastritis. Which organism would the nurse suspect as the likely cause?

Calcium carbonate causes rebound acid secretion, which will make symptoms worse."

A patient tells the nurse that calcium carbonate has been effective in treating the discomfort associated with peptic ulcer disease. Which response would the nurse provide?

"Take the phenytoin 1 to 2 hours before or after the antacid."

A patient who currently takes phenytoin has been started on a multidrug regimen for treatment of peptic ulcer disease. Which information would the nurse provide about these medications?

Metabolic alkalosis

A patient who has peptic ulcer disease has developed pyloric obstruction. The nurse would monitor the patient's laboratory values closely to assess for which complication?

Contact the health care provider to discuss giving omeprazole or lansoprazole instead.

A patient with a duodenal ulcer receives a prescription for pantoprazole tablets. The patient has a small-bore nasogastric (NG) tube and is NPO. Which action would the nurse take?

Maintain NG suction.

A patient with a gastric ulcer has a nasogastric (NG) tube in place. The patient develops severe epigastric pain, and the nurse notes a rigid, board-like abdomen. After the nurse notifies the health care provider of this condition, which action would the nurse take?

It will prevent a type of anemia

A patient with chronic gastritis who is prescribed vitamin B12 asks the nurse why this vitamin is necessary. Which information would the nurse provide?

"Those herbs could be helpful. However, you should talk with your provider before adding them to your treatment regimen."

A patient with peptic ulcer disease (PUD) asks the nurse whether licorice and slippery elm might be useful in managing the disease. Which response would the nurse provide?

An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure? a. I get short of breath when I climb stairs. b. I see halos floating around my head. c. I have trouble remembering things. d. I have lost weight over the past month

A- Dyspnea on exertion is an early manifestation of heart failure and is associated with an activity such as stair climbing. The other findings are not specific to early occurrence of heart failure.

A nurse assesses a client who has aortic regurgitation. In which location in the illustration shown below should the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation? a. Location A b. Location B c. Location C d. Location D

A- The aortic valve is auscultated in the second intercostal space just to the right of the sternum.

A nurse assesses a client who had an MI and is hypotensive. Which additional assessment finding should the nurse expect? a. HR 120 beats/min b. Cool, clammy skin c. O2 sat 90% d. RR 8 breaths/min

A- When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node. This results in an increase in heart rate and respiratory rate. This tachycardia is an early response and is seen even when blood pressure is not critically low. An increased heart rate and respiratory rate will compensate for the low blood pressure and maintain oxygen saturations and perfusion. The client may not be able to compensate for long, and decreased oxygenation and cool, clammy skin will occur later

A male patient with a long history of ulcerative colitis experienced massive bleeding and had emergency surgery for creation of an ileostomy. He is very concerned that sexual intercourse with his wife will be impossible because of his new ileostomy pouch. How does the nurse respond? A. "A change in position may be what is needed for you to have intercourse with your wife." B. "Have you considered going to see a marriage counselor with your wife?" C. "What has your wife said about your pouch system?" D. "You must get clearance from your primary health care provider before you attempt to have intercourse."

A. "A change in position may be what is needed for you to have intercourse with your wife." The nurse tells the patient who had an emergency ileostomy that a simple change in positioning during intercourse may alleviate the patient's apprehension and facilitate sexual relations with his wife.Suggesting marriage counseling may address the patient's concerns, but it focuses on the wrong issue. The patient has not stated that he has relationship problems. Asking the patient what his wife has said about the pouch may address some of the patient's concerns, but it similarly focuses on the wrong issue. Telling the patient that he needs to get clearance from his primary health care provider is an evasive response that does not address the patient's primary concern.

A nurse is teaching a patient with Crohn's disease about managing the disease with the drug adalimumab (Humira). Which instruction does the nurse emphasize to the patient? A. "Avoid large crowds and anyone who is sick." B. "Do not take the medication if you are allergic to foods with fatty acids." C. "Expect difficulty with wound healing while you are taking this drug." D. "Monitor your blood pressure and report any significant decrease in it."

A. "Avoid large crowds and anyone who is sick." The nurse emphasizes that the patient taking adalimumab for Crohn's disease needs to avoid being around large crowds to prevent developing an infection. Adalimumab (Humira), a biologic response modifier (BRM), also known as a monoclonal antibody drug, has been approved for use in Crohn's disease when other drugs have been ineffective. BRMs are approved for refractory (not responsive to other therapies) cases. These drugs cause immunosuppression and should be used with caution. Patients must be taught to report any signs of a beginning infection, including a cold, and to also avoid others who are sick.The patient would not take the medication if he or she is allergic to certain proteins. Although immune suppression may occur to some degree, the patient would not experience difficulty with wound healing while taking adalimumab. Also, the patient would not experience a decrease in blood pressure from taking this drug.

A patient diagnosed with ulcerative colitis (UC) is to be discharged on loperamide (Imodium) for symptomatic management of diarrhea. What does the nurse include in the teaching about this medication? A. "Be aware of the signs/symptoms of toxic megacolon that we discussed." B. "If diarrhea increases, you must let your primary health care provider know." C. "You must avoid pregnancy." D. "You will need to decrease your dose of sulfasalazine (Azulfidine)."

A. "Be aware of the signs/symptoms of toxic megacolon that we discussed." In teaching a UC patient discharged on loperamide, the nurse tells the patient to be aware of signs/symptoms of toxic megacolon that were discussed. Antidiarrheal drugs may precipitate colonic dilation and toxic megacolon. Toxic megacolon is characterized by an enlarged colon with fever, leukocytosis, and tachycardia.Loperamide will decrease diarrhea rather than increase it. Constipation is sometimes a problem. No contraindication for pregnancy is noted. Sulfasalazine therapy typically continues on a long-term basis.

An older adult woman who reports a change in bladder function says, "I feel like a child who sometimes pees her pants." What is the best nursing response? A. "Have you tried using the toilet every couple of hours?" B. "How does that make you feel?" C. "We can fix that." D. "That happens when we get older."

A. "Have you tried using the toilet every couple of hours?"

A patient with an exacerbation of ulcerative colitis has been prescribed Vivonex PLUS. The patient asks the nurse how this is helpful for improving signs/symptoms. How does the nurse reply? A. "It is absorbed quickly and allows the affected part of the GI tract to rest and heal." B. "It provides key nutrients and extra calories to promote healing." C. "It is bland and reduces the secretion of gastric acids." D. "It does not contain caffeine or other GI tract stimulants."

A. "It is absorbed quickly and allows the affected part of the GI tract to rest and heal." Vivonex PLUS is an enteral elemental formula with components that are quickly absorbed in the small bowel that reduces bowel stimulation allowing the affected part of the GI tract to rest and heal. It helps to improve signs/symptoms of ulcerative colitis. For less severe exacerbations, a semielemental product of Vivonex PLUS may induce remission. These products are absorbed in the jejunum and therefore permit the distal small intestine and colon to rest.Nutritional supplements such as Ensure or Sustacal are added to provide nutrients and more calories. GI stimulants such as caffeinated beverages and alcohol need to be avoided, but this is not the reason for using Vivonex PLUS.

A patient with ulcerative colitis (UC) has stage 1 of a restorative proctocolectomy with ileo-anal anastomosis (RPC-IPAA) procedure performed. The patient asks the nurse, "How long do people with this procedure usually have a temporary ileostomy?" How does the nurse respond? A. "It is usually ready to be closed in about 1 to 2 months." B. "You need to talk to your primary health care provider about how long you will have this temporary ileostomy." C. "The period of time is indefinite—I am sorry that I cannot say." D. "You will probably have it for 6 months or longer, until things heal."

A. "It is usually ready to be closed in about 1 to 2 months." The nurse tells the patient with a temporary ileostomy that it is usually ready to be closed in about 1 to 2 months. The RPC-IPAA has become the most effective alternate method for ulcerative colitis (UC) patients who have surgery to remove diseased portions of intestines. Stage 1 creates a temporary ileostomy to be used while an internally created pouch is healing. Stage 2 closes the ileostomy, and the patient begins to use the pouch for storage of stool. The time between the surgeries is generally 1 to 2 months.Telling the patient that he or she will have to discuss it with the primary health care provider evades the question. The nurse can give generalities to the patient based on past practice and available data. The time that the patient has the ileostomy is not "indefinite." The intent of this procedure is to eliminate the need to have a permanent ileostomy. The pouch would heal in 1 to 2 months, not 6 months. This estimate is not based on the expected outcome.

A nurse assesses clients on a cardiac unit. Which client would the nurse identify as being at GREATEST risk for the development of left-sided heart failure? a. A 36 year old woman with aortic stenosis b. A 42 year old man with pulmonary hypertension c. A 59 year old woman who smokes cigarettes daily d. A 70 year old man who had a cerebral vascular accident

A. A 36 yer old woman with aortic stenosis Cause of LV failure include mitral or aortic valve disease, CAD, and HTN. Pulmonary HTN and chronic cig smoking are risk factors for RV failure. A CVA does not increase risk of HF.

The nurse is instructing a patient with recently diagnosed diverticular disease about diet. What food does the nurse suggest the patient include? A. A slice of 5-grain bread B. Chuck steak patty (6 ounces [170 grams]) C. Strawberries (1 cup [160 grams]) D. Tomato (1 medium)

A. A slice of 5-grain bread The nurse suggests to the patient with recently diagnosed diverticular disease to include a slice of 5-grain bread in the diet. Whole-grain breads are recommended to be included in the diet of patients with diverticular disease because cellulose and hemicellulose types of fiber are found in them. Dietary fat would be reduced in patients with diverticular disease.If the patient wants to eat beef, it must be of a leaner cut. Foods containing seeds, such as strawberries, must be avoided. Tomatoes would also be avoided unless the seeds are removed. The seeds may block diverticula in the patient and present problems leading to diverticulitis.

A patient is scheduled for discharge after surgery for inflammatory bowel disease. The patient's spouse will be assisting home health services with the patient's care. What is most important for the home health nurse to assess in the patient and the spouse with regard to the patient's home care? A. Ability of the patient and spouse to perform incision care and dressing changes B. Effective coping mechanisms for the patient and spouse after the surgical experience C. Knowledge about the patient's requested pain medications D. Understanding of the importance of keeping scheduled follow-up appointments

A. Ability of the patient and spouse to perform incision care and dressing changes It is most important for the home health nurse to assess the patient's and spouse's ability to carry out incision care and dressing changes. This assessment is essential to avoid further development of the infectious process, as well as infection of the surgical incision itself.Assessing coping mechanisms and knowledge of the patient's pain medication are important but are not the priority. Understanding the importance of scheduled follow-up appointments is important but is also not the priority.

A nurse admits a client from the emergency department. Client data are listed below: HISTORY: 70 years of age; History of diabetes; On insulin twice a day; Reports new onset dyspnea and productive cough PHYSICAL ASSESSMENT: crackles and rhonchi heard throughout the lungs; dullness to percussion LLL; afebrile; oriented to person only LABORATORY VALUES: WBC 5200/mm3; PaO2 on room air: 85 mmHg What action by the nurse is the priority? a. Administer oxygen at 4 L per nasal cannula b. Begin broad-spectrum antibiotics c. Collect a sputum sample for culture d. Start an IV of normal saline at 50 mL/hr

A. Administer oxygen at 4 L per nasal cannula All actions are appropriate for this client who has signs and symptoms of pneumonia. However, airway and breathing come first, so begin O2 administration and titrate it to maintain saturation greater than 95%. Start the IV and collect a sputum culture, and then begin antibiotics.

Which client being managed for dehydration does the nurse consider at greatest risk for possible reduced kidney function? A. An 80-year-old man who has benign prostatic hyperplasia B. A 62-year-old woman with a known allergy to contrast media C. A 48-year-old woman with established urinary incontinence D. A 45-year-old man receiving oral and intravenous fluid therapy

A. An 80-year-old man who has benign prostatic hyperplasia

A client has been hospitalized with tuberculosis. The client's spouse is fearful of entering the room where the client is in isolation and refuses to visit. What action by the nurse is BEST? a. Ask the spouse to explain the fear of visiting in further detail b. Inform the spouse that the precautions are meant to keep other clients safe c. Show the spouse how to follow the Isolation Precautions to avoid illness d. Tell the spouse that he or she has already been exposed, so it's safe to visit

A. Ask the spouse to explain the fear of visiting in greater detail. The nurse needs to obtain further info about the spouse's specific fears so they can be addressed. This will decrease stress and permit visitation, which will be beneficial for both client and spouse. Precautions for TB prevent transmission to all who come into contact with the client. Explaining Isolation Precautions and what do do when entering the room will be helpful, but this is too narrow in scope to be the best answer. Telling the spouse that it's safe to visit is demeaning of the spouse's feelings.

While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. What action would the nurse take next? a. Assess for symptoms of left-sided heart failure b. Document this as a normal finding c. Call the primary health care provider immediately d. Transfer the client to the intensive care unit

A. Assess for symptoms of left-sided heart failure The presences of an S3 gallop is an early diastolic filling sound indicative of increasing LV pressure and LV failure. The other actions are not warranted.

A nurse admits a client who is experiencing an exacerbation of heart failure. What action would the nurse take FIRST? a. Assess the client's respiratory status b. Draw blood to assess the client's serum electrolytes c. Administer intravenous furosemide d. Ask the client about current medications

A. Assess the client's respiratory status Assessment of respiratory and oxygenation status is the most important nursing intervention for the prevention of complications. Monitoring electrolytes, administering diuretics ad asking about current meds are important but not as important.

Which priority teaching will the nurse provide to prevent harm for a client after a renal biopsy? A. Avoid lifting heavy objects for 1 - 2 weeks after the procedure B. Do not go up or down stairs for 10 days C. Avoid light housework including cooking and washing dishes D. Stay out of the sun until after your follow-up appointment

A. Avoid lifting heavy objects for 1 - 2 weeks after the procedure

A nurse is teaching a client with heart failure who has been prescribed enalapril. Which statement would the nurse include in this client's teaching? a. Avoid using salt substitutes b. Take your medication with food c. Avoid using aspirin-containing products d. Check your pulse daily

A. Avoid using salt substitutes ACE inhibitors such as enalapril inhibit excretion of potassium. Hyperkalemia can be a life threatening side effect, and clients should be taught to limit potassium intake. Salt substitutes are composed of potassium chloride. ACE inhibitors do not need to be taken with food and have no impact on the pt's pulse rate. Aspirin is often prescribed with ACE inhibitors and is not contraindicated.

A client admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the client questions this action, saying "I have been drinking tons of water. How am I dehydrated?" What response by the nurse is BEST? a. Breathing so quickly can be dehydrating b. Everyone with pneumonia is dehydrated c. This is really just to administer your antibiotics d. Why do you think you are so dehydrated?

A. Breathing so quickly can be dehydrating Tachypnea and mouth breathing (from increased work of breathing), both seen in pneumonia, increase insensible water loss and can lead to a degree of dehydration. The other options do not give the client useful information that addresses this specific concern.

A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest PRIORITY? a. Educating the client on adherence to the treatment regimen b. Encouraging the client to eat a well-balanced diet c. Informing the client about follow-up sputum cultures d. Teaching the client ways to balance rest with activity

A. Educating the client on adherence to the treatment regimen The treatment regimen for TB often ranges from 26 weeks, but can be up to 2 years, making adherence problematic for many. The nurse would stress the absolute importance of following the tx plan for the entire duration of prescribed therapy. The other options are appropriate topics to educate this client but do not take priority.

A patient with a history of osteoarthritis has a 10-inch (25.5 cm) incision following a colon resection. The incision has become infected, and the wound requires extensive irrigation and packing. What aspect of the patient's care does the nurse make certain to discuss with the primary health care provider before the patient's discharge? A. Having a home health consultation for wound care B. Requesting an antianxiety medication C. Requesting pain medication for the patient's osteoarthritis D. Placing the patient in a skilled nursing facility for rehabilitation

A. Having a home health consultation for wound care The nurse makes sure to discuss an order for a home health consultation for wound care with the primary health care provider. Home health services are most appropriate for this patient because wound care will be extensive and the patient's mobility may be limited.No indication suggests that the patient is experiencing anxiety regarding postoperative care. Pain medication may be needed for the patient's osteoarthritis, but this is not the highest priority. A skilled nursing facility is not necessary if the patient can remain in his or her home with sufficient support services.

When performing bladder scanning to detect residual urine in a female client, the nurse must first assess which factor? A. History of hysterectomy B. Abdominal girth C. Hematuria D. Presence of urinary infection

A. History of hysterectomy

A nurse cares for an older adult client with heart failure. The client states, "I don't know what to do. I don't want to be a burden to my daughter, but I can't do it alone. Maybe I should die." What is the BEST response by the nurse? a. I can stay if you would like to talk more about this b. You are lucky to have such a devoted daughter c. It is normal to feel as though you are a burden d. Would you like to meet with the chaplain?

A. I can stay if you would to talk more about this Depression can occur in pts with HF, esp older adults. Having pt talk about feelings will help focus on actual problem. Open-ended statements allow pt to respond safely and honestly. Other options minimize pt concerns and do not allow nurse to obtain more information to provide pt centered care.

Which client assessment data indicates to the nurse that the client has a potential need for fluids? A. Increased blood urea nitrogen B. Increased creatinine C. Decreased sodium D. Pale-colored urine

A. Increased blood urea nitrogen

The nurse is caring for a client with uremia. What assessment data will the nurse anticipate? A. Nausea and vomiting B. Insomnia C. Cyanosis of the skin D. Tenderness at the costovertebral angle (CVA)

A. Nausea and vomiting

A client is scheduled for a cystoscopy later this morning. The consent form is not signed, and the client has not had any preoperative medication. The nurse notes that the health care provider (HCP) visited the client the day before. What action will the nurse take? A. Notifies the department and the HCP. B. Asks the client's spouse to sign the form. C. Cancels the procedure. D. Asks the client to sign the informed consent.

A. Notifies the department and the HCP.

A nurse cares for a client with infective endocarditis. Which infection control precautions would the nurse use? a. Standard Precautions b. Bleeding Precautions c. Reverse isolation d. Contact isolation

A. Standard Precautions Pt w/ infective endocarditis does not pose a threat of transmitting the causative organism. Standard Precautions would be used; others not necessary.

A nurse is caring for a client who is intubated and has an intra-aortic balloon pump. The client is restless and agitated. What action should the nurse perform first for comfort? a. Allow family members to remain at the bedside. b. Ask the family if the client would like a fan in the room. c. Keep the television tuned to the client's favorite channel. d. Speak loudly to the client in case of hearing problems

ANS: A Allowing the family to remain at the bedside can help calm the client with familiar voices (and faces if the client wakes up). A fan might be helpful but may also spread germs through air movement. The TV should not be kept on all the time to allow for rest. Speaking loudly may agitate the client more. DIF: Applying/Application REF: 780

A nursing student is caring for a client who had a myocardial infarction. The student is confused because the client states nothing is wrong and yet listens attentively while the student provides education on lifestyle changes and healthy menu choices. What response by the faculty member is best? a. "Continue to educate the client on possible healthy changes." b. "Emphasize complications that can occur with noncompliance." c. "Tell the client that denial is normal and will soon go away." d. "You need to make sure the client understands this illness."

ANS: A Clients are often in denial after a coronary event. The client who seems to be in denial but is compliant with treatment may be using a healthy form of coping that allows time to process the event and start to use problem-focused coping. The student should not discourage this type of denial and coping, but rather continue providing education in a positive manner. Emphasizing complications may make the client defensive and more anxious. Telling the client that denial is normal is placing too much attention on the process. Forcing the client to verbalize understanding of the illness is also potentially threatening to the client. DIF: Understanding/Comprehension REF: 769

A nurse assesses a client who is prescribed 5-fluorouracil (5-FU) chemotherapy intravenously for the treatment of colon cancer. Which assessment finding should alert the nurse to contact the health care provider? a. White blood cell (WBC) count of 1500/mm3 b. Fatigue c. Nausea and diarrhea d. Mucositis and oral ulcers

ANS: A Common side effects of 5-FU include fatigue, leukopenia, diarrhea, mucositis and mouth ulcers, and peripheral neuropathy. However, the client's WBC count is very low (normal range is 5000 to 10,000/mm3), so the provider should be notified. He or she may want to delay chemotherapy by a day or two. Certainly the client is at high risk for infection. The other assessment findings are consistent with common side effects of 5-FU that would not need to be reported immediately. DIF: Applying/Application REF: 1151 KEY: Colorectal cancer| medications| adverse effects MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

A client is in the clinic a month after having a myocardial infarction. The client reports sleeping well since moving into the guest bedroom. What response by the nurse is best? a. "Do you have any concerns about sexuality?" b. "I'm glad to hear you are sleeping well now." c. "Sleep near your spouse in case of emergency." d. "Why would you move into the guest room?"

ANS: A Concerns about resuming sexual activity are common after cardiac events. The nurse should gently inquire if this is the issue. While it is good that the client is sleeping well, the nurse should investigate the reason for the move. The other two responses are likely to cause the client to be defensive. DIF: Applying/Application REF: 781

A client is on a dopamine infusion via a peripheral line. What action by the nurse takes priority for safety? a. Assess the IV site hourly. b. Monitor the pedal pulses. c. Monitor the client's vital signs. d. Obtain consent for a central line.

ANS: A Dopamine should be infused through a central line to prevent extravasation and necrosis of tissue. If it needs to be run peripherally, the nurse assesses the site hourly for problems. When the client is getting the central line, ensuring informed consent is on the chart is a priority. But at this point, the client has only a peripheral line, so caution must be taken to preserve the integrity of the client's integumentary system. Monitoring pedal pulses and vital signs give indications as to how well the drug is working. DIF: Applying/Application REF: 773

A nurse assesses a client who is prescribed alosetron (Lotronex). Which assessment question should the nurse ask this client? a. "Have you been experiencing any constipation?" b. "Are you eating a diet high in fiber and fluids?" c. "Do you have a history of high blood pressure?" d. "What vitamins and supplements are you taking?"

ANS: A Ischemic colitis is a life-threatening complication of alosetron. The nurse should assess the client for constipation. The other questions do not identify complications related to alosetron. DIF: Applying/Application REF: 1146 KEY: Medications| adverse effects MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapi

An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate? a. Assess for any hemodynamic effects of the rhythm. b. Prepare to administer antidysrhythmic medication. c. Notify the provider or call the Rapid Response Team. d. Turn the alarms off on the cardiac monitor.

ANS: A Older clients may have dysrhythmias due to age-related changes in the cardiac conduction system. They may have no significant hemodynamic effects from these changes. The nurse should first assess for the effects of the dysrhythmia before proceeding further. The alarms on a cardiac monitor should never be shut off. The other two actions may or may not be needed. DIF: Applying/Application REF: 769

After teaching a client who has a femoral hernia, the nurse assesses the client's understanding. Which statement indicates the client needs additional teaching related to the proper use of a truss? a. "I will put on the truss before I go to bed each night." b. "I'll put some powder under the truss to avoid skin irritation." c. "The truss will help my hernia because I can't have surgery." d. "If I have abdominal pain, I'll let my health care provider know right away."

ANS: A The client should be instructed to apply the truss before arising, not before going to bed at night. The other statements show an accurate understanding of using a truss. DIF: Applying/Application REF: 1147 KEY: Herniation MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

A nurse cares for a client who states, "My husband is repulsed by my colostomy and refuses to be intimate with me." How should the nurse respond? a. "Let's talk to the ostomy nurse to help you and your husband work through this." b. "You could try to wear longer lingerie that will better hide the ostomy appliance." c. "You should empty the pouch first so it will be less noticeable for your husband." d. "If you are not careful, you can hurt the stoma if you engage in sexual activity."

ANS: A The nurse should collaborate with the ostomy nurse to help the client and her husband work through intimacy issues. The nurse should not minimize the client's concern about her husband with ways to hide the ostomy. The client will not hurt the stoma by engaging in sexual activity. DIF: Applying/Application REF: 1156 KEY: Ostomy care| support| coping MSC: Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity

A nurse cares for a client who has a new colostomy. Which action should the nurse take? a. Empty the pouch frequently to remove excess gas collection. b. Change the ostomy pouch and wafer every morning. c. Allow the pouch to completely fill with stool prior to emptying it. d. Use surgical tape to secure the pouch and prevent leakage.

ANS: A The nurse should empty the new ostomy pouch frequently because of excess gas collection, and empty the pouch when it is one-third to one-half full of stool. The ostomy pouch does not need to be changed every morning. Ostomy wafers with paste should be used to secure and seal the ostomy appliance; surgical tape should not be used. DIF: Applying/Application REF: 1154 KEY: Ostomy care MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

A nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago. The client states, "The stool in my pouch is still liquid." How should the nurse respond? a. "The stool will always be liquid with this type of colostomy." b. "Eating additional fiber will bulk up your stool and decrease diarrhea." c. "Your stool will become firmer over the next couple of weeks." d. "This is abnormal. I will contact your health care provider."

ANS: A The stool from an ascending colostomy can be expected to remain liquid because little large bowel is available to reabsorb the liquid from the stool. This finding is not abnormal. Liquid stool from an ascending colostomy will not become firmer with the addition of fiber to the client's diet or with the passage of time. DIF: Applying/Application REF: 1151 KEY: Ostomy care MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

To promote comfort and the passage of flatus after a colonoscopy, in what position does the nurse place the client? a. Left lateral b. Prone c. Right lateral d. Supine

ANS: A After colonoscopy, clients have less discomfort and quicker passage of flatus when placed in the left lateral position.

15. The nurse is caring for a client with hepatitis C. The client's brother states, "I do not want to get this infection, so I'm not going into his hospital room." How would the nurse respond? a. "Hepatitis C is not spread through casual contact." b. "If you wear a gown and gloves, you will not get this virus." c. "This virus is only transmitted through a fecal specimen." d. "I can give you an update on your brother's status from here."

ANS: A Although family members may be afraid that they will contract hepatitis C, the nurse would educate them about how the virus is spread. Hepatitis C is spread via blood-to-blood transmission and is associated with illicit IV drug needle sharing, blood and organ transplantation, accidental needlesticks, unsanitary tattoo equipment, and sharing of intranasal drug paraphernalia. Wearing a gown and gloves will not decrease the transmission of this virus. Hepatitis C is not spread through casual contact or a fecal specimen. The nurse would be violating privacy laws by sharing the client's status with the brother.

The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment would best evaluate the effectiveness of the therapies? a. Observe for distended neck veins. b. Auscultate for crackles in the lungs. c. Palpate for heaves or thrills over the heart. d. Review hemoglobin and hematocrit values.

ANS: A Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular venous distention, and right upper-quadrant abdominal tenderness would be expected. Crackles in the lungs are likely to be heard with left-sided heart failure. Findings in cor pulmonale include evidence of right ventricular hypertrophy on electrocardiogram ECG and an increase in intensity of the second heart sound. Heaves or thrills are not common with cor pulmonale. Chronic hypoxemia leads to polycythemia and increased total blood volume and viscosity of the blood. The hemoglobin and hematocrit values are more likely to be elevated with cor pulmonale than decreased

A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurse's most appropriate action to promote airway clearance? a. Assist the patient to splint the chest when coughing. b. Teach the patient about the need for fluid restrictions. c. Encourage the patient to wear the nasal oxygen cannula. d. Instruct the patient on the pursed lip breathing technique.

ANS: A Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal oxygen will improve gas exchange, but will not improve airway clearance. Pursed lip breathing is used to improve gas exchange in patients with COPD, but will not improve airway clearance

10. After teaching a client with a history of renal calculi, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? a. "I should drink at least 3 L of fluid every day." b. "I will eliminate all dairy or sources of calcium from my diet." c. "Aspirin and aspirin-containing products can lead to stones." d. "The doctor can give me antibiotics at the first sign of a stone."

ANS: A Dehydration contributes to the precipitation of minerals to form a stone. Although increased intake of calcium causes hypercalcemia and leads to excessive calcium filtered into the urine, if the client is well hydrated, the calcium will be excreted without issues. Dehydration increases the risk for supersaturation of calcium in the urine, which contributes to stone formation. The nurse would encourage the client to drink more fluids, not decrease calcium intake. Ingestion of aspirin or aspirin-containing products does not cause a stone. Antibiotics neither prevent nor treat a stone.

10. The nurse is teaching a client a client about taking elbasvir for hepatitis C. What information in the client's history would the nurse need prior to drug administration? a. History of hepatitis B b. History of kidney disease c. History of cardiac disease d. History of rectal bleeding

ANS: A Elbasvir can cause liver toxicity and therefore the nurse would assess for a history of or current hepatitis B

The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect? a. Increased tactile fremitus b. Dry, nonproductive cough c. Hyperresonance to percussion d. A grating sound on auscultation

ANS: A Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical. A grating sound is more representative of a pleural friction rub rather than pneumonia

5. After teaching a client who has stress incontinence, the nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? a. "I will limit my total intake of fluids." b. "I must avoid drinking alcoholic beverages." c. "I must avoid drinking caffeinated beverages." d. "I shall try to lose about 10% of my body weight."

ANS: A Limiting fluids concentrates urine and can irritate tissues, leading to increased incontinence or cystitis. Many people try to manage incontinence by limiting fluids. Alcoholic and caffeinated beverages are bladder stimulants. Obesity increases intra-abdominal pressure, causing incontinence.

An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding? a. Yellow-tinged skin b. Orange-colored sputum c. Thickening of the fingernails d. Difficulty hearing high-pitched voices

ANS: A Noninfectious hepatitis is a toxic effect of isoniazid (INH), rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial TB drug therapy. Presbycusis is an expected finding in the older adult patient. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider

The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider? a. Oxygen saturation is 88%. b. Blood pressure is 145/90 mm Hg. c. Respiratory rate is 22 breaths/minute when lying flat. d. Pain level is 5 (on 0 to 10 scale) with a deep breath.

ANS: A Oxygen saturation would be expected to improve after a thoracentesis. A saturation of 88% indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low oxygen saturation is the priority

A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment? a. Paradoxic chest movement b. Complaint of chest wall pain c. Heart rate of 110 beats/minute d. Large bruised area on the chest

ANS: A Paradoxic chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange

13. A nurse obtains the health history of a client with a suspected diagnosis of bladder cancer. Which question would the nurse ask when determining this client's risk factors? a. "Do you smoke cigarettes?" b. "Do you use any alcohol?" c. "Do you use recreational drugs?" d. "Do you take any prescription drugs?"

ANS: A Smoking is known to be a factor that greatly increases the risk of bladder cancer. Alcohol use, recreational drug use, and prescription drug use (except medications that contain phenacetin) are not known to markedly increase the risk of developing bladder cancer.

A client is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. What statement by the client indicates a need for further teaching? a. "It's a good thing I love orange and cherry gelatin." b. "My spouse will be here to drive me home." c. "I'll avoid ibuprofen for several days before the test." d. "I'll buy a case of clear Gatorade before the prep."

ANS: A The client would be advised to avoid beverages and gelatin that are red, orange, or purple in color as their residue can appear to be blood. The other statements show an understanding of the preparation for the procedure.

A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 (based on 0 to 10 scale) "whenever I take a deep breath." Which action will the nurse take next? a. Auscultate breath sounds. b. Administer the PRN morphine. c. Have the patient cough forcefully. d. Notify the patient's health care provider.

ANS: A The patient's statement indicates that pleurisy or a pleural effusion may have developed and the nurse will need to listen for a pleural friction rub and/or decreased breath sounds. Assessment should occur before administration of pain medications. The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider

6. The nurse is caring for a client who is prescribed lactulose. The client states, "I do not want to take this medication because it causes diarrhea." How would the nurse respond? a. "Diarrhea is expected; that's how your body gets rid of ammonia." b. "You may take antidiarrheal medication to prevent loose stools." c. "Do not take any more of the medication until your stools firm up." d. "We will need to send a stool specimen to the laboratory as soon as possible."

ANS: A The purpose of administering lactulose to this patient is to help ammonia leave the circulatory system through the colon. Lactulose draws water into the bowel with its high osmotic gradient, thereby producing a laxative effect and subsequently evacuating ammonia from the bowel. The patient must understand that this is an expected and therapeutic effect for him or her to remain compliant. The nurse would not suggest administering anything that would decrease the excretion of ammonia or holding the medication. There is no need to send a stool specimen to the laboratory because diarrhea is the therapeutic response to this medication.

18. A nurse assesses a client who presents with renal calculi. Which question would the nurse ask? a. "Do any of your family members have this problem?" b. "Do you drink any cranberry juice?" c. "Do you urinate after sexual intercourse?" d. "Do you experience burning with urination?"

ANS: A There is a strong association between family history and stone formation and recurrence. Nephrolithiasis is associated with many genetic variations; therefore, the nurse should ask whether other family members have also had renal stones. The other questions do not refer to renal calculi but instead are questions that should be asked of a patient with a urinary tract infection.

3. The nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding would require immediate action by the nurse? a. Urine output via indwelling urinary catheter is 20 mL/hr b. Blood pressure increases from 110/58 to 120/62 mm Hg c. Respiratory rate decreases from 22 to 16 breaths/min d. A decrease in the client's weight by 3 lb (1.4 kg

ANS: A decreased abdominal pressure, which can contribute to hypovolemia. This can be manifested by a decrease in urine output to below 30 mL/hr. A slight increase in systolic blood pressure is insignificant. A decrease in respiratory rate indicates that breathing has been made easier by the procedure. The nurse would expect the client's weight to drop as fluid is removed. To prevent hypovolemic shock, no more than 2000 mL are usually removed from the abdomen at one time. The patient's weight typically only decreases by less than 2 kg or 4.4 lb.

10. A nurse assesses a client who is recovering from a Whipple procedure. Which assessment finding alerts the nurse to immediately contact the primary health care provider? a. Drainage from a fistula b. Diminished bowel sounds c. Pain at the incision site d. Nasogastric (NG) tube drainage

ANS: A Complications of a Whipple procedure include secretions that drain from a fistula and peritonitis. Absent bowel sounds, pain at the incision site, and NG tube drainage are normal postoperative findings.

7. A nurse cares for a client with end-stage pancreatic cancer. The client asks, "Why is this happening to me?" How would the nurse respond? a. "I don't know. I wish I had an answer for you, but I don't." b. "It's important to keep a positive attitude for your family right now." c. "Scientists have not determined why cancer develops in certain people." d. "I think that this is a trial so you can become a better person because of it."

ANS: A The client is not asking the nurse to actually explain why the cancer has occurred. The client may be expressing his or her feelings of confusion, frustration, distress, and grief related to this diagnosis. Reminding the client to keep a positive attitude for his or her family does not address the client's emotions or current concerns. The nurse would validate that there is no easy or straightforward answer as to why the client has cancer. Telling a client that cancer is a trial is untrue and may negatively impact the client-nurse relationship.

20. A nurse assesses a client who has had two episodes of bacterial cystitis in the last 6 months. Which question(s) would the nurse ask? (Select all that apply.) a. "How much water do you drink every day?" b. "Do you take estrogen replacement therapy?" c. "Does anyone in your family have a history of cystitis?" d. "Are you on steroids or other immune-suppressing drugs?" e. "Do you drink grapefruit juice or orange juice daily?"

ANS: A, B, D Fluid intake, estrogen levels, and immune suppression all can increase the chance of recurrent cystitis. Family history is usually insignificant, and cranberry juice, not grapefruit or orange juice, has been found to increase the acidic pH and reduce the risk for bacterial cystitis.

A client has hemodynamic monitoring after a myocardial infarction. What safety precaution does the nurse implement for this client? a. Document pulmonary artery wedge pressure (PAWP) readings and assess their trends. b. Ensure the balloon does not remain wedged. c. Keep the client on strict NPO status. d. Maintain the client in a semi-Fowler's position.

ANS: B If the balloon remains inflated, it can cause pulmonary infarction or rupture. The nurse should ensure the balloon remains deflated between PAWP readings. Documenting PAWP readings and assessing trends is an important nursing action related to hemodynamic monitoring, but is not specifically related to safety. The client does not have to be NPO while undergoing hemodynamic monitoring. Positioning may or may not affect readings.

A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes the client's heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate? a. Allow the client to rest quietly. b. Assess the client for bleeding. c. Document the findings in the chart. d. Medicate the client for pain.

ANS: B A major complication related to intra-arterial blood pressure monitoring is hemorrhage from the insertion site. Since these vital signs are out of the normal range, are a change, and are consistent with blood loss, the nurse should assess the client for any bleeding associated with the arterial line. The nurse should document the findings after a full assessment. The client may or may not need pain medication and rest; the nurse first needs to rule out any emergent bleeding. DIF: Applying/Application REF: 771

A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an intravenous infusion of heparin. The client's spouse asks why the client needs this medication. What response by the nurse is best? a. "The t-PA didn't dissolve the entire coronary clot." b. "The heparin keeps that artery from getting blocked again." c. "Heparin keeps the blood as thin as possible for a longer time." d. "The heparin prevents a stroke from occurring as the t-PA wears off."

ANS: B After the original intracoronary clot has dissolved, large amounts of thrombin are released into the bloodstream, increasing the chance of the vessel reoccluding. The other statements are not accurate. Heparin is not a "blood thinner," although laypeople may refer to it as such. DIF: Understanding/Comprehension REF: 768

A nurse assesses a client who is recovering from a hemorrhoidectomy that was done the day before. The nurse notes that the client has lower abdominal distention accompanied by dullness to percussion over the distended area. Which action should the nurse take? a. Assess the client's heart rate and blood pressure. b. Determine when the client last voided. c. Ask if the client is experiencing flatus. d. Auscultate all quadrants of the client's abdomen.

ANS: B Assessment findings indicate that the client may have an over-full bladder. In the immediate postoperative period, the client may experience difficulty voiding due to urinary retention. The nurse should assess when the client last voided. The client's vital signs may be checked after the nurse determines the client's last void. Asking about flatus and auscultating bowel sounds are not related to a hemorrhoidectomy. DIF: Applying/Application REF: 1165 KEY: Postoperative nursing| urinary retention MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the client's understanding. Which menu selection indicates that the client correctly understands the dietary teaching? a. Ham sandwich on white bread, cup of applesauce, glass of diet cola b. Broiled chicken with brown rice, steamed broccoli, glass of apple juice c. Grilled cheese sandwich, small banana, cup of hot tea with lemon d. Baked tilapia, fresh green beans, cup of coffee with low-fat milk

ANS: B Clients with IBS are advised to eat a high-fiber diet (30 to 40 g/day), with 8 to 10 cups of liquid daily. Chicken with brown rice, broccoli, and apple juice has the highest fiber content. They should avoid alcohol, caffeine, and other gastric irritants. DIF: Applying/Application REF: 1145 KEY: Irritable bowel| nutritional requirements MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

A nurse cares for a middle-aged male client who has irritable bowel syndrome (IBS). The client states, "I have changed my diet and take bulk-forming laxatives, but my symptoms have not gotten better. I heard about a drug called Amitiza. Do you think it might help?" How should the nurse respond? a. "This drug is still in the research phase and is not available for public use yet." b. "Unfortunately, lubiprostone is approved only for use in women." c. "Lubiprostone works well. I will recommend this prescription to your provider." d. "This drug should not be used with bulk-forming laxatives."

ANS: B Lubiprostone (Amitiza) is a new drug for IBS with constipation that works by simulating receptors in the intestines to increase fluid and promote bowel transit time. Lubiprostone is currently approved only for use in women. Trials with increased numbers of male participants are needed prior to Food and Drug Administration approval for men. DIF: Applying/Application REF: 1146 KEY: Irritable bowel| medications MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

A client with coronary artery disease (CAD) asks the nurse about taking fish oil supplements. What response by the nurse is best? a. "Fish oil is contraindicated with most drugs for CAD." b. "The best source is fish, but pills have benefits too." c. "There is no evidence to support fish oil use with CAD." d. "You can reverse CAD totally with diet and supplements."

ANS: B Omega-3 fatty acids have shown benefit in reducing lipid levels, in reducing the incidence of sudden cardiac death, and for stabilizing atherosclerotic plaque. The best source is fish three times a week or some fish oil supplements. The other options are not accurate. DIF: Understanding/Comprehension REF: 761

A nurse cares for a client who is recovering from a hemorrhoidectomy. The client states, "I need to have a bowel movement." Which action should the nurse take? a. Obtain a bedside commode for the client to use. b. Stay with the client while providing privacy. c. Make sure the call light is in reach to signal completion. d. Gather supplies to collect a stool sample for the laboratory.

ANS: B The first bowel movement after hemorrhoidectomy can be painful enough to induce syncope. The nurse should stay with the client. The nurse should instruct clients who are discharged the same day to have someone nearby when they have their first postoperative bowel movement. Making sure the call light is within reach is an important nursing action too, but it does not take priority over client safety. Obtaining a bedside commode and taking a stool sample are not needed in this situation. DIF: Applying/Application REF: 1165 KEY: Postoperative care| syncope MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

A nurse cares for a client newly diagnosed with colon cancer who has become withdrawn from family members. Which action should the nurse take? a. Contact the provider and recommend a psychiatric consult for the client. b. Encourage the client to verbalize feelings about the diagnosis. c. Provide education about new treatment options with successful outcomes. d. Ask family and friends to visit the client and provide emotional support.

ANS: B The nurse recognizes that the client may be expressing feelings of grief. The nurse should encourage the client to verbalize feelings and identify fears to move the client through the phases of the grief process. A psychiatric consult is not appropriate for the client. The nurse should not brush aside the client's feelings with discussions related to cancer prognosis and treatment. The nurse should not assume that the client desires family or friends to visit or provide emotional support. DIF: Applying/Application REF: 1155 KEY: Colorectal cancer| coping MSC: Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity

A nurse is caring for four clients. Which client should the nurse assess first? a. Client with an acute myocardial infarction, pulse 102 beats/min b. Client who is 1 hour post angioplasty, has tongue swelling and anxiety c. Client who is post coronary artery bypass, chest tube drained 100 mL/hr d. Client who is post coronary artery bypass, potassium 4.2 mEq/L

ANS: B The post-angioplasty client with tongue swelling and anxiety is exhibiting manifestations of an allergic reaction that could progress to anaphylaxis. The nurse should assess this client first. The client with a heart rate of 102 beats/min may have increased oxygen demands but is just over the normal limit for heart rate. The two post coronary artery bypass clients are stable. 774

The primary health care provider documents that a client has a bruit over the abdominal aorta. What teaching will the nurse provide for assistive personnel (AP) based on this assessment finding? a. "Use warm compresses on the client's abdomen continuously." b. "Avoid washing the client's abdomen too aggressively." c. "Apply ice to the client's abdomen every 4 hours." d. "Massage the client's abdomen to help reduce pain."

ANS: B A bruit heard over the abdominal aorta possible indicates stenosis or an aneurysm which should not be palpated or percussed. Therefore, the AP should wash the client's abdomen very gently.

When caring for a patient who is hospitalized with active tuberculosis (TB), the nurse observes a student nurse who is assigned to take care of a patient. Which action, if performed by the student nurse, would require an intervention by the nurse? a. The patient is offered a tissue from the box at the bedside. b. A surgical face mask is applied before visiting the patient. c. A snack is brought to the patient from the unit refrigerator. d. Hand washing is performed before entering the patient's room.

ANS: B A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patient's room because the HEPA mask can filter out 100% of small airborne particles. Hand washing before entering the patient's room is appropriate. Because anorexia and weight loss are frequent problems in patients with TB, bringing food to the patient is appropriate. The student nurse should perform hand washing after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue

5. The nurse is caring for a client with hepatic portal-systemic encephalopathy (PSE). The client is thin and cachectic, and the family expresses distress that the patient is receiving little dietary protein. How would the nurse respond? a. "A low-protein diet will help the liver rest and will restore liver function." b. "Less protein in the diet will help prevent confusion associated with liver failure." c. "Increasing dietary protein will help the patient gain weight and muscle mass." d. "Low dietary protein is needed to prevent fluid from leaking into the abdomen."

ANS: B A low-protein diet is prescribed when serum ammonia levels increase and/or the client shows signs of PSE. A low-protein diet helps reduce excessive breakdown of protein into ammonia by intestinal bacteria. Encephalopathy is caused by excess ammonia. A low-protein diet has no impact on restoring liver function. Increasing the patient's dietary protein will cause complications of liver failure and would not be suggested. Increased intravascular protein will help prevent ascites, but clients with liver failure are not able to effectively synthesize dietary protein

2. A nurse reviews the laboratory findings of a client with a urinary tract infection (bacterial cystitis). The laboratory report notes a "shift to the left" in the client's white blood cell count. What action would the nurse take? a. Request that the laboratory perform a differential analysis on the white blood cells. b. Notify the primary health care provider and start an intravenous line for parenteral antibiotics. c. Ask assistive personnel (AP) to strain the client's urine for renal calculi. d. Assess the client for a potential allergic reaction and anaphylactic shock.

ANS: B An increase in band cells creates a "shift to the left." A left shift most commonly occurs with urosepsis and is seen rarely with uncomplicated urinary tract infections. The nurse will be administering antibiotics, most likely via IV, so he or she would notify the primary health care provider and prepare to give the antibiotics. The shift to the left is part of a differential white blood cell count. The nurse would not need to strain urine for stones. Allergic reactions are associated with elevated eosinophil cells, not band cells

A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving nifedipine (Procardia). Which assessment would best indicate to the nurse that the patient's condition is improving? a. Blood pressure (BP) is less than 140/90 mm Hg. b. Patient reports decreased exertional dyspnea. c. Heart rate is between 60 and 100 beats/minute. d. Patient's chest x-ray indicates clear lung fields.

ANS: B Because a major symptom of IPAH is exertional dyspnea, an improvement in this symptom would indicate that the medication was effective. Nifedipine will affect BP and heart rate, but these parameters would not be used to monitor the effectiveness of therapy for a patient with IPAH. The chest x-ray will show clear lung fields even if the therapy is not effective

11. A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago. The client states, "I'm having right belly pain and have a temperature of 101° F (38.3° C)." How would the nurse respond? a. "The anti-rejection drugs you are taking make you susceptible to infection." b. "You should go to the hospital immediately to get checked out." c. "You should take an additional dose of cyclosporine today." d. "Take acetaminophen every 4 hours until you feel better soon."

ANS: B Fever, right abdominal quadrant pain, and jaundice are signs of possible liver transplant rejection; the client would be admitted to the hospital as soon as possible for intervention. Antirejection drugs do make a client more susceptible to infection, but this client has signs of rejection, not infection. The nurse would not advise the client to take an additional dose of cyclosporine or acetaminophen as these medications will not treat the acute rejection.

An experienced nurse instructs a new nurse about how to care for a patient with dyspnea caused by a pulmonary fungal infection. Which action by the new nurse indicates a need for further teaching? a. Listening to the patient's lung sounds several times during the shift b. Placing the patient on droplet precautions and in a private hospital room c. Increasing the oxygen flow rate to keep the oxygen saturation above 90% d. Monitoring patient serology results to identify the specific infecting organism

ANS: B Fungal infections are not transmitted from person to person. Therefore no isolation procedures are necessary. The other actions by the new nurse are appropriate

7. After delegating care to assistive personnel (AP) for a client who is prescribed habit training to manage incontinence, a nurse evaluates the AP's understanding. Which action indicates that the AP needs additional teaching? a. Toileting the client after breakfast b. Changing the client's incontinence brief when wet c. Encouraging the client to drink fluids d. Recording the client's incontinence episodes

ANS: B Habit training is undermined by the use of absorbent incontinence briefs or pads. The nurse should reeducate the AP on the technique of habit training. The AP should continue to toilet the client after meals, encourage the client to drink fluids, and record incontinent episodes.

The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first? a. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled b. A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath c. A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes d. A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 100.2° F (37.8° C)

ANS: B Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism and requires immediate assessment and action such as oxygen administration. The other patients should also be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration

The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement, if made by the patient, indicates a good understanding of the instructions? a. "I will call the doctor if I still feel tired after a week." b. "I will continue to do the deep breathing and coughing exercises at home." c. "I will schedule two appointments for the pneumonia and influenza vaccines." d. "I'll cancel my chest x-ray appointment if I'm feeling better in a couple weeks."

ANS: B Patients should continue to cough and deep breathe after discharge. Fatigue is expected for several weeks. The Pneumovax and influenza vaccines can be given at the same time in different arms. Explain that a follow-up chest x-ray needs to be done in 6 to 8 weeks to evaluate resolution of pneumonia

The nurse knows that a client with prolonged prothrombin time (PT) values (not related to medication) probably has dysfunction in which organ? a. Kidneys b. Liver c. Spleen d. Stomach

ANS: B Severe acute or chronic liver damage leads to a prolonged PT secondary to impaired synthesis of clotting proteins. The other organs are not related to this issue.

16. The nurse assesses a client with a history of urinary incontinence who presents with extreme dry mouth, constipation, and an inability to void. Which question would the nurse ask first? a. "Are you drinking plenty of water?" b. "What medications are you taking?" c. "Have you tried laxatives or enemas?" d. "Has this type of thing ever happened before?"

ANS: B Some types of incontinence or other health problems are treated with anticholinergic medications. Anticholinergic side effects include dry mouth, constipation, and urinary retention. The nurse needs to assess the client's medication list to determine whether the he or she is taking an anticholinergic medication. The other questions are not as helpful to understanding the current situation.

The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective? a. "I will avoid being outdoors whenever possible." b. "My husband will be sleeping in the guest bedroom." c. "I will take the bus instead of driving to visit my friends." d. "I will keep the windows closed at home to contain the germs."

ANS: B Teach the patient how to minimize exposure to close contacts and household members. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. While still infectious, the patient should sleep alone, spend as much time as possible outdoors, and minimize time in congregate settings or on public transportation

A patient is admitted to the emergency department with an open stab wound to the left chest. What is the first action that the nurse should take? a. Position the patient so that the left chest is dependent. b. Tape a nonporous dressing on three sides over the chest wound. c. Cover the sucking chest wound firmly with an occlusive dressing. d. Keep the head of the patient's bed at no more than 30 degrees elevation.

ANS: B The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the left side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The head of the bed should be elevated to 30 to 45 degrees to facilitate breathing

After 2 months of tuberculosis (TB) treatment with isoniazid (INH), rifampin (Rifadin), pyrazinamide (PZA), and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next? a. Teach about treatment for drug-resistant TB treatment. b. Ask the patient whether medications have been taken as directed. c. Schedule the patient for directly observed therapy three times weekly. d. Discuss with the health care provider the need for the patient to use an injectable antibiotic.

ANS: B The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Assessment is the first step in the nursing process. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. The other options are interventions based on assumptions until an assessment has been completed

The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed? a. A large air leak in the water-seal chamber b. 400 mL of blood in the collection chamber c. Complaint of pain with each deep inspiration d. Subcutaneous emphysema at the insertion site

ANS: B The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. An air leak would be expected immediately after chest tube placement for a pneumothorax. Initially, brisk bubbling of air occurs in this chamber when a pneumothorax is evacuated. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax. A small amount of subcutaneous air is harmless and will be reabsorbed

A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink. What action by the nurse is appropriate? a. Allow the client cool liquids only. b. Assess the client's gag reflex. c. Remind the client to remain NPO. d. Tell the client to wait 4 hours.

ANS: B The local anesthetic used during this procedure depresses the client's gag reflex. After the procedure, the nurse would ensure that the gag reflex is intact before offering food or fluids. The client does not need to be restricted to cool beverages only and is not required to wait 4 hours before oral intake is allowed. Telling the client to remain NPO does not inform the client of when he or she can have fluids, nor does it reflect the client's readiness for them.

A patient with newly diagnosed lung cancer tells the nurse, "I don't think I'm going to live to see my next birthday." Which response by the nurse is best? a. "Would you like to talk to the hospital chaplain about your feelings?" b. "Can you tell me what it is that makes you think you will die so soon?" c. "Are you afraid that the treatment for your cancer will not be effective?" d. "Do you think that taking an antidepressant medication would be helpful?"

ANS: B The nurse's initial response should be to collect more assessment data about the patient's statement. The answer beginning "Can you tell me what it is" is the most open-ended question and will offer the best opportunity for obtaining more data. The answer beginning, "Are you afraid" implies that the patient thinks that the cancer will be immediately fatal, although the patient's statement may not be related to the cancer diagnosis. The remaining two answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate

The nurse develops a plan of care to prevent aspiration in a high-risk patient. Which nursing action will be most effective? a. Turn and reposition immobile patients at least every 2 hours. b. Place patients with altered consciousness in side-lying positions. c. Monitor for respiratory symptoms in patients who are immunosuppressed. d. Insert nasogastric tube for feedings for patients with swallowing problems.

ANS: B The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and oxygen saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Conditions that increase the risk of aspiration include decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and nasogastric intubation with or without tube feeding. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Other high-risk groups are those who are seriously ill, have poor dentition, or are receiving acid-reducing medications

7. After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the client's understanding. Which statement by the client indicates correct understanding of the teaching? a. "Some medications have been known to cause hepatitis A." b. "I may have been exposed when we ate shrimp last weekend." c. "I was infected with hepatitis A through a recent blood transfusion." d. "My infection with Epstein-Barr virus can co-infect me with hepatitis A."

ANS: B The route of transmission for hepatitis A infection is through close personal contact or ingestion of contaminated water or shellfish. Hepatitis A is not transmitted through medications, blood transfusions, or Epstein-Barr virus. Toxic and drug-induced hepatitis is caused from exposure to hepatotoxins, but this is not a form of hepatitis A. Hepatitis B can be spread through blood transfusions. Epstein-Barr virus causes a secondary infection that is not associated with hepatitis A.

12. A nurse assesses a client who is recovering from extracorporeal shock-wave lithotripsy for renal calculi. The nurse notes an ecchymotic area on the client's right lower back. What action would the nurse take? a. Administer fresh-frozen plasma. b. Apply an ice pack to the site. c. Place the client in the prone position. d. Obtain serum coagulation test results.

ANS: B The shock waves from lithotripsy can cause bleeding into the tissues through which the waves pass. Application of ice can reduce the extent and discomfort of the bruising. Although coagulation test results and fresh-frozen plasma are used to assess and treat bleeding disorders, ecchymosis after this procedure is not unusual and does not warrant a higher level of intervention. Changing the client's position will not decrease bleeding.

A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure? a. Start a peripheral IV line to administer the necessary sedative drugs. b. Position the patient sitting upright on the edge of the bed and leaning forward. c. Obtain a large collection device to hold 2 to 3 liters of pleural fluid at one time. d. Remove the water pitcher and remind the patient not to eat or drink anything for 6 hours.

ANS: B When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The patient does not usually require sedation for the procedure, and there are no restrictions on oral intake because the patient is not sedated or unconscious. Usually only 1000 to 1200 mL of pleural fluid is removed at one time. Rapid removal of a large volume can result in hypotension, hypoxemia, or pulmonary edema

2. A client has an external percutaneous transhepatic biliary catheter inserted for a biliary obstruction. What health teaching about catheter care would the nurse provide for the client? a. "Cap the catheter drain at night to prevent leakage and skin damage." b. "Position the drainage bag lower than the catheter insertion site." c. "Irrigate the catheter with an ounce of saline every night." d. "Pierce a hole in the top of the drainage bag to get rid of odors."

ANS: B An external temporary or permanent catheter drains bile by gravity into a bag that collects bile. Therefore, the drainage bag should be lower that the catheter insertion site. The catheter should not be capped or irrigated, and no holes should be made in the bag to prevent bile from having contact with the skin.

A nurse cares for a client with colon cancer who has a new colostomy. The client states, "I think it would be helpful to talk with someone who has had a similar experience." How should the nurse respond? a. "I have a good friend with a colostomy who would be willing to talk with you." b. "The enterostomal therapist will be able to answer all of your questions." c. "I will make a referral to the United Ostomy Associations of America." d. "You'll find that most people with colostomies don't want to talk about them."

ANS: C Nurses need to become familiar with community-based resources to better assist clients. The local chapter of the United Ostomy Associations of America has resources for clients and their families, including Ostomates (specially trained visitors who also have ostomies). The nurse should not suggest that the client speak with a personal contact of the nurse. Although the enterostomal therapist is an expert in ostomy care, talking with him or her is not the same as talking with someone who actually has had a colostomy. The nurse should not brush aside the client's request by saying that most people with colostomies do not want to talk about them. Many people are willing to share their ostomy experience in the hope of helping others. DIF: Applying/Application REF: 1157 KEY: Colorectal cancer| ostomy care| coping| support MSC: Integrated Process: Caring NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred? a. Blood pressure that is 20 mm Hg below baseline b. Oxygen saturation of 94% on room air c. Poor peripheral pulses and cool skin d. Urine output of 1.2 mL/kg/hr for 4 hours

ANS: C Poor peripheral pulses and cool skin may be signs of impending cardiogenic shock and should be reported immediately. A blood pressure drop of 20 mm Hg is not worrisome. An oxygen saturation of 94% is just slightly below normal. A urine output of 1.2 mL/kg/hr for 4 hours is normal. DIF: Remembering/Knowledge REF: 772

A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory abilities. To meet The Joint Commission's Core Measures set, by what time should the client have a percutaneous coronary intervention performed? a. 1530 (3:30 PM) b. 1600 (4:00 PM) c. 1630 (4:30 PM) d. 1700 (5:00 PM)

ANS: C The Joint Commission's Core Measures set for MI includes percutaneous coronary intervention within 90 minutes of diagnosis of myocardial infarction. Therefore, the client should have a percutaneous coronary intervention performed no later than 1630 (4:30 PM). DIF: Remembering/Knowledge REF: 774

A nurse teaches a client who is at risk for colon cancer. Which dietary recommendation should the nurse teach this client? a. "Eat low-fiber and low-residual foods." b. "White rice and bread are easier to digest." c. "Add vegetables such as broccoli and cauliflower to your new diet." d. "Foods high in animal fat help to protect the intestinal mucosa."

ANS: C The client should be taught to modify his or her diet to decrease animal fat and refined carbohydrates. The client should also increase high-fiber foods and Brassica vegetables, including broccoli and cauliflower, which help to protect the intestinal mucosa from colon cancer. DIF: Applying/Application REF: 1149 KEY: Colorectal cancer| nutritional requirements MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

A nurse assessing a client with colorectal cancer auscultates high-pitched bowel sounds and notes the presence of visible peristaltic waves. Which action should the nurse take? a. Ask if the client is experiencing pain in the right shoulder. b. Perform a rectal examination and assess for polyps. c. Contact the provider and recommend computed tomography. d. Administer a laxative to increase bowel movement activity.

ANS: C The presence of visible peristaltic waves, accompanied by high-pitched or tingling bowel sounds, is indicative of partial obstruction caused by the tumor. The nurse should contact the provider with these results and recommend a computed tomography scan for further diagnostic testing. This assessment finding is not associated with right shoulder pain; peritonitis and cholecystitis are associated with referred pain to the right shoulder. The registered nurse is not qualified to complete a rectal examination for polyps, and laxatives would not help this client. DIF: Applying/Application REF: 1151 KEY: Colorectal cancer| intestinal obstruction MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first? a. Assist the patient to sit upright in a chair. b. Splint the patient's chest during coughing. c. Medicate the patient with prescribed morphine. d. Observe the patient use the incentive spirometer.

ANS: C A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which increases with deep breathing and coughing). The first action by the nurse should be to medicate the patient to minimize incisional pain. The other actions are all appropriate ways to improve airway clearance but should be done after the morphine is given

A client had a colonoscopy and biopsy yesterday and calls the gastrointestinal clinic to report a spot of bright red blood on the toilet paper today. What response by the nurse is appropriate? a. Ask the client to call back if this happens again today. b. Instruct the client to go to the emergency department. c. Remind the client that a small amount of bleeding is possible. d. Tell the client to come to the clinic this afternoon.

ANS: C After a colonoscopy with biopsy, a small amount of bleeding is normal. The nurse would remind the client of this and instruct him or her to go to the emergency department for large amounts of bleeding, severe pain, or dizziness.

9. A client with pneumonia and dementia is admitted with an indwelling urinary catheter in place. During interprofessional rounds the following day, which question would the nurse ask the primary health care provider? a. "Do you want daily weights on this client?" b. "Will the client be able to return home?" c. "May we discontinue the indwelling catheter?" d. "Should we get another chest x-ray today?"

ANS: C An indwelling urinary catheter dramatically increases the risks of urinary tract infection and urosepsis. Nursing staff should ensure that catheters are left in place only as long as they are medically needed. The nurse would inquire about removing the catheter. All other questions might be appropriate, but because of client safety, this question takes priority.

12. After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? a. "I cannot drink any alcohol at all anymore." b. "I should not take over-the-counter medications." c. "I need to avoid protein in my diet." d. "I should eat small, frequent, balanced meals."

ANS: C Based on the degree of liver involvement and decreased function, protein intake may have to be decreased. However, some protein is necessary for the synthesis of albumin and normal healing. The other statements indicate accurate understanding of self-care measures for this client

14. The nurse is caring for a client who has cirrhosis from substance abuse. The client states, "All of my family hates me." How would the nurse respond? a. "You should make peace with your family." b. "This is not unusual. My family hates me too." c. "I will help you identify a support system." d. "You must attend Alcoholics Anonymous."

ANS: C Clients who have cirrhosis due to addiction may have alienated relatives over the years because of substance abuse. The nurse would assist the client to identify a friend, neighbor, clergy/spiritual leader, or group for support. The nurse would not minimize the patient's concerns. Attending AA may be appropriate, but this response doesn't address the client's concern. "Making peace" with the client's family may not be possible. This statement is not client-centered

A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is most appropriate? a. Document the presence of a large air leak. b. Notify the surgeon of a possible pneumothorax. c. Take no further action with the collection device. d. Adjust the dial on the wall regulator to decrease suction.

ANS: C Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. Increasing or decreasing the vacuum source will not adjust the suction pressure. The amount of suction applied is regulated by the amount of water in this chamber and not by the amount of suction applied to the system

The assistive personnel note that a client had a dark stool. What stool test would the nurse obtain for this client? a. Culture and sensitivity b. Parasites and ova c. Occult blood test d. Total fat content

ANS: C Dark stools are typical in clients who have lower GI bleeding. Therefore, an fecal occult blood test would be the most appropriate test as a follow-up.

A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the health care provider? a. The Mantoux test had an induration of 7 mm. b. The chest-x-ray showed infiltrates in the lower lobes. c. The patient is being treated with antiretrovirals for HIV infection. d. The patient has a cough that is productive of blood-tinged mucus.

ANS: C Drug interactions can occur between the antiretrovirals used to treat HIV infection and the medications used to treat TB. The other data are expected in a patient with HIV and TB.

A client is having an esophagogastroduodenoscopy (EGD) and has been given midazolam hydrochloride. The client's respiratory rate is 8 breaths/min. What action by the nurse is appropriate? a. Administer naloxone. b. Call the Rapid Response Team. c. Provide physical stimulation. d. Ventilate with a bag-valve-mask.

ANS: C For an EGD, clients are given mild sedation but would still be able to follow commands. For shallow or slow respirations after the sedation is given, the nurse's most appropriate action is to provide a physical stimulation such as a sternal rub and directions to breathe deeply. Naloxone is not the antidote for midazolam HCl. The Rapid Response Team is not needed at this point. The client does not need manual ventilation.

The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung. Which information should the nurse include about the patient's postoperative care? a. Positioning on the right side b. Bed rest for the first 24 hours c. Frequent use of an incentive spirometer d. Chest tube placement with continuous drainage

ANS: C Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis. To promote gas exchange, patients after pneumonectomy are positioned on the surgical side. Early mobilization decreases the risk for postoperative complications such as pneumonia and deep vein thrombosis. In a pneumonectomy, chest tubes may or may not be placed in the space from which the lung was removed. If a chest tube is used, it is clamped and only released by the surgeon to adjust the volume of serosanguineous fluid that will fill the space vacated by the lung. If the cavity overfills, it could compress the remaining lung and compromise the cardiovascular and pulmonary function. Daily chest x-rays can be used to assess the volume and space

A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which is the best response by the nurse? a. Ask if the patient is experiencing shortness of breath, hives, or itching. b. Ask the patient about any visual abnormalities such as red-green color discrimination. c. Explain that orange discolored urine and tears are normal while taking this medication. d. Advise the patient to stop the drug and report the symptoms to the health care provider.

ANS: C Orange-colored body secretions are a side effect of rifampin. The patient does not have to stop taking the medication. The findings are not indicative of an allergic reaction. Alterations in red-green color discrimination commonly occurs when taking ethambutol (Myambutol), which is a different TB medication

4. After teaching a client with bacterial cystitis who is prescribed phenazopyridine, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? a. "I will not take this drug with food or milk." b. "I will have my partners tested for STIs." c. "An orange color in my urine should not alarm me." d. "I will drink two glasses of cranberry juice daily."

ANS: C Phenazopyridine discolors urine, most commonly to a deep reddish orange. Many clients think that they have blood in their urine when they see this. In addition, the urine can permanently stain clothing. There are no dietary restrictions or needs while taking this medication.

An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action, if recommended by the nurse, will be most helpful in reducing the incidence of lung disease? a. Treat workers with pulmonary fibrosis. b. Teach about symptoms of lung disease. c. Require the use of protective equipment. d. Monitor workers for coughing and wheezing.

ANS: C Prevention of lung disease requires the use of appropriate protective equipment such as masks. The other actions will help in recognition or early treatment of lung disease but will not be effective in prevention of lung damage. Repeated exposure eventually results in diffuse pulmonary fibrosis. Fibrosis is the result of tissue repair after inflammation

The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take? a. Teach about the reason for the blood tests. b. Schedule an appointment for a chest x-ray. c. Teach about the need to get sputum specimens for 2 to 3 consecutive days. d. Instruct the patient to expectorate three specimens as soon as possible.

ANS: C Sputum specimens are obtained on 2 to 3 consecutive days for bacteriologic testing for M. tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not used for tuberculosis testing. A chest x-ray is not bacteriologic testing. Although the findings on chest x-ray examination are important, it is not possible to make a diagnosis of TB solely based on chest x-ray findings because other diseases can mimic the appearance of TB

4. The nurse is caring for a client who has a risk gene for developing cirrhosis. Which racial/ethnic group has this gene most often? a. Blacks b. Asian/Pacific Islanders c. Latinos d. French

ANS: C The Patatin-like phospholipase domain containing 3 gene (PNPLA3) has been identified as a risk gene for cirrhosis, which occurs most often in Latinos when compared to other populations

1. The nurse assesses a client who has possible bladder cancer. What common assessment finding associated with this type of cancer would the nurse expect? a. Urinary retention b. Urinary incontinence c. Painless hematuria d. Difficulty urinating

ANS: C The classic and most common finding in clients who have bladder cancer is painless and intermittent hematuria that can be with gross or microscopic. Dysuria, frequency, and urgency occur in clients who have bladder infection or obstruction.

17. A nurse teaches a client who is starting urinary bladder training. Which statement would the nurse include in this client's teaching? a. "Use the toilet when you first feel the urge, rather than at specific intervals." b. "Initially try to use the toilet at least every half hour for the first 24 hours." c. "Try to consciously hold your urine until the scheduled toileting time." d. "The toileting interval can be increased once you have been continent for a week."

ANS: C The client should try to hold urine consciously until the next scheduled toileting time. Toileting should occur at specific intervals during the training. The interval can be increased once the client becomes comfortable with the interval

The nurse is caring for a patient with idiopathic pulmonary arterial hypertension (IPAH) who is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action by the nurse? a. The oxygen saturation is 94%. b. The blood pressure is 98/56 mm Hg. c. The patient's central IV line is disconnected. d. The international normalized ratio (INR) is prolonged.

ANS: C The half-life of this drug is 6 minutes, so the nurse will need to restart the infusion as soon as possible to prevent rapid clinical deterioration. The other data also indicate a need for ongoing monitoring or intervention, but the priority action is to reconnect the infusion

Which action by the nurse will be most effective in decreasing the spread of pertussis in a community setting? a. Providing supportive care to patients diagnosed with pertussis b. Teaching family members about the need for careful hand washing c. Teaching patients about the need for adult pertussis immunizations d. Encouraging patients to complete the prescribed course of antibiotics

ANS: C The increased rate of pertussis in adults is thought to be due to decreasing immunity after childhood immunization. Immunization is the most effective method of protecting communities from infectious diseases. Hand washing should be taught, but pertussis is spread by droplets and contact with secretions. Supportive care does not shorten the course of the disease or the risk for transmission. Taking antibiotics as prescribed does assist with decreased transmission, but patients are likely to have already transmitted the disease by the time the diagnosis is made

A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment has been effective? a. Bronchial breath sounds are heard at the right base. b. The patient coughs up small amounts of green mucus. c. The patient's white blood cell (WBC) count is 9000/µL. d. Increased tactile fremitus is palpable over the right chest.

ANS: C The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed

Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB. Which information should the occupational health nurse plan to teach the staff nurse? a. Standard four-drug therapy for TB b. Need for annual repeat TB skin testing c. Use and side effects of isoniazid (INH) d. Bacille Calmette-Guérin (BCG) vaccine

ANS: C The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for individuals who have already had a positive skin test. BCG vaccine is not used in the United States for TB and would not be helpful for this individual, who already has a TB infection

19. The nurse is caring for a client with urinary incontinence. The client states, "I am so embarrassed. My bladder leaks like a young child's bladder." How would the nurse respond? a. "I understand how you feel. I would be mortified." b. "Incontinence pads will minimize leaks in public." c. "I can teach you strategies to help control your incontinence." d. "More people experience incontinence than you might think."

ANS: C The nurse would accept and acknowledge the client's concerns, and assist the client to learn techniques that will allow control of urinary incontinence. The nurse would not diminish the client's concerns with the use of pads or stating statistics about the occurrence of incontinence.

9. A nurse assesses a client who has cholecystitis. Which sign or symptom indicates that this condition is chronic rather than acute? a. Temperature of 100.1° F (37.8° C) b. Positive Murphy sign c. Clay-colored stools d. Upper abdominal pain after eating

ANS: C Jaundice, clay-colored stools, and dark urine are more commonly seen with chronic cholecystitis. The other symptoms are seen in clients with either chronic or acute cholecystitis.

6. The nurse documents the vital signs of a client diagnosed with acute pancreatitis: Apical pulse = 116 beats/min Respirations = 28 breaths/min Blood pressure = 92/50 What complication of acute pancreatitis would the nurse suspect that the client might have? a. Electrolyte imbalance b. Pleural effusion c. Internal bleeding d. Pancreatic pseudocyst

ANS: C The client is exhibiting signs of hypovolemia most likely due to internal bleeding or hemorrhage. Due to decreased blood volume, the blood pressure is low and the heart rate increases to compensate for hypovolemia to ensure organ perfusion. Respirations often increase to increase oxygen in the blood.

5. After teaching a client who is prescribed pancreatic enzyme replacement therapy, the nurse assesses the client's understanding. Which statement by the client indicates a need for further teaching? a. "The capsules can be opened and the powder sprinkled on applesauce if needed." b. "I will wipe my lips carefully after I drink the enzyme preparation." c. "The best time to take the enzymes is immediately after I have a meal or a snack." d. "I will not mix the enzyme powder with food or liquids that contain protein."

ANS: C The enzymes must be taken immediately before eating meals or snacks. If the client cannot swallow the capsules whole, they can be opened up and the powder sprinkled on applesauce, mashed fruit, or rice cereal. The client should wipe his or her lips carefully after drinking the enzyme preparation because the liquid could damage the skin. Protein items will be dissolved by the enzymes if they are mixed together.

A nurse assesses a client with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the client reports constant abdominal pain. Which action should the nurse take next? a. Administer intravenous opioid medications. b. Position the client with knees to chest. c. Insert a nasogastric tube for decompression. d. Assess the client's bowel sounds.

ANS: D A change in the nature and timing of abdominal pain in a client with a bowel obstruction can signal peritonitis or perforation. The nurse should immediately check for rebound tenderness and the absence of bowel sounds. The nurse should not medicate the client until the provider has been notified of the change in his or her condition. The nurse may help the client to the knee-chest position for comfort, but this is not the priority action. The nurse need not insert a nasogastric tube for decompression. DIF: Applying/Application REF: 1157 KEY: Intestinal obstruction| pain management MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

An emergency room nurse cares for a client who has been shot in the abdomen and is hemorrhaging heavily. Which action should the nurse take first? a. Send a blood sample for a type and crossmatch. b. Insert a large intravenous line for fluid resuscitation. c. Obtain the heart rate and blood pressure. d. Assess and maintain a patent airway.

ANS: D All of the options are important nursing actions in the care of a trauma client. However, airway always comes first. The client must have a patent airway, or other interventions will not be helpful. DIF: Applying/Application REF: 1162 KEY: GI trauma| emergency nursing MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A nurse assesses clients at a community health center. Which client is at highest risk for the development of colorectal cancer? a. A 37-year-old who drinks eight cups of coffee daily b. A 44-year-old with irritable bowel syndrome (IBS) c. A 60-year-old lawyer who works 65 hours per week d. A 72-year-old who eats fast food frequently

ANS: D Colon cancer is rare before the age of 40, but its incidence increases rapidly with advancing age. Fast food tends to be high in fat and low in fiber, increasing the risk for colon cancer. Coffee intake, IBS, and a heavy workload do not increase the risk for colon cancer. DIF: Applying/Application REF: 1149 KEY: Colorectal cancer| health screening MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5 mm Hg. What action by the nurse is most appropriate? a. Level the transducer at the phlebostatic axis. b. Lay the client in the supine position. c. Prepare to administer diuretics. d. Prepare to administer a fluid bolus.

ANS: D Normal right atrial pressures are from 1 to 8 mm Hg. Lower pressures usually indicate hypovolemia, so the nurse should prepare to administer a fluid bolus. The transducer should remain leveled at the phlebostatic axis. Positioning may or may not influence readings. Diuretics would be contraindicated. DIF: Applying/Application REF: 770

A client is in the preoperative holding area prior to an emergency coronary artery bypass graft (CABG). The client is yelling at family members and tells the doctor to "just get this over with" when asked to sign the consent form. What action by the nurse is best? a. Ask the family members to wait in the waiting area. b. Inform the client that this behavior is unacceptable. c. Stay out of the room to decrease the client's stress levels. d. Tell the client that anxiety is common and that you can help.

ANS: D Preoperative fear and anxiety are common prior to cardiac surgery, especially in emergent situations. The client is exhibiting anxiety, and the nurse should reassure the client that fear is common and offer to help. The other actions will not reduce the client's anxiety. DIF: Applying/Application REF: 776

A nurse cares for a client who has a family history of colon cancer. The client states, "My father and my brother had colon cancer. What is the chance that I will get cancer?" How should the nurse respond? a. "If you eat a low-fat and low-fiber diet, your chances decrease significantly." b. "You are safe. This is an autosomal dominant disorder that skips generations." c. "Preemptive surgery and chemotherapy will remove cancer cells and prevent cancer." d. "You should have a colonoscopy more frequently to identify abnormal polyps early."

ANS: D The nurse should encourage the client to have frequent colonoscopies to identify abnormal polyps and cancerous cells early. The abnormal gene associated with colon cancer is an autosomal dominant gene mutation that does not skip a generation and places the client at high risk for cancer. Changing the client's diet, preemptive chemotherapy, and removal of polyps will decrease the client's risk but will not prevent cancer. However, a client at risk for colon cancer should eat a low-fat and high-fiber diet. DIF: Applying/Application REF: 1155 KEY: Colorectal cancer| genetics MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

The nurse is preparing to change a client's sternal dressing. What action by the nurse is most important? a. Assess vital signs. b. Don a mask and gown. c. Gather needed supplies. d. Perform hand hygiene.

ANS: D To prevent a sternal wound infection, the nurse washes hands or performs hand hygiene as a priority. Vital signs do not necessarily need to be assessed beforehand. A mask and gown are not needed. The nurse should gather needed supplies, but this is not the priority. DIF: Applying/Application REF: 776

8. The nurse is caring for a client scheduled to have a transjugular intrahepatic portal-systemic shunt (TIPS) procedure. What client assessment would the nurse perform prior to this procedure? a. Musculoskeletal assessment b. Neurologic assessment c. Mental health assessment d. Cardiovascular assessment

ANS: D A postprocedure complication of a TIPS procedure is right-sided heart failure. Therefore, the nurse would perform a cardiovascular assessment before the procedure to determine if the client has signs and symptoms of heart failure.

A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough, and an oxygen saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the highest priority? a. Hyperthermia related to infectious illness b. Impaired transfer ability related to weakness c. Ineffective airway clearance related to thick secretions d. Impaired gas exchange related to respiratory congestion

ANS: D All these nursing diagnoses are appropriate for the patient, but the patient's oxygen saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved

An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen? a. Arrange for a friend to administer the medication on schedule. b. Give the patient written instructions about how to take the medications. c. Teach the patient about the high risk for infecting others unless treatment is followed. d. Arrange for a daily noon meal at a community center where the drug will be administered.

ANS: D Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients but are not likely to be as helpful for this patient

A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first? a. Codeine b. Guaifenesin (Robitussin) c. Acetaminophen (Tylenol) d. Piperacillin/tazobactam (Zosyn)

ANS: D Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The other medications are also appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy

13. The nurse is caring for a client who is scheduled for a paracentesis. Which action is appropriate for the nurse to take? a. Have the client sign the informed consent form. b. Get the patient into a chair before the procedure. c. Help the client lie flat in bed on the right side. d. Assist the client to void before the procedure.

ANS: D For safety, the patient would void just before a paracentesis to prevent bladder damage to the procedure. The primary health care provider would have the client sign the consent form. The proper position for a paracentesis is sitting upright in bed or, alternatively, sitting on the side of the bed and leaning over the bedside table.

15. A nurse teaches a client with functional urinary incontinence. Which statement would the nurse include in this client's teaching? a. "You must clean around your catheter daily with soap and water." b. "You will need to be on your drug therapy for life." c. "Operations to repair your bladder are available, and you can consider these." d. "You might want to get pants with elastic waistbands."

ANS: D Functional urinary incontinence occurs as the result of problems not related to the client's bladder, such as trouble ambulating or difficulty accessing the toilet. One desired outcome is that the client will be able to manage his or her clothing independently. Elastic waistband slacks that are easy to pull down and back up can help the client get on the toilet in time to void. The other instructions do not relate to functional urinary incontinence.

1. The nurse is caring for a client who has cirrhosis of the liver. Which risk factor is the leading cause of cirrhosis? a. Metabolic syndrome b. Liver cancer c. Nonalcoholic fatty liver disease d. Hepatitis C

ANS: D Hepatitis C is the leading cause of cirrhosis and an also cause liver cancer. Clients with nonalcoholic fatty liver disease often have metabolic syndrome and can also develop cirrhosis

A nurse is assessing a client reporting right upper quadrant (RUQ) abdominal pain. What technique would the nurse use to assess this client's abdomen? a. Auscultate after palpating. b. Avoid any type of palpation. c. Lightly palpate the RUQ first. d. Lightly palpate the RUQ last.

ANS: D If pain is present in a certain area of the abdomen, that area would be palpated last to keep the client from tensing which could possibly affect the rest of the examination. Auscultation of the abdomen occurs prior to palpation.

8. A nurse plans care for a client with overflow incontinence. Which intervention does the nurse include in this client's plan of care to assist with elimination? a. Stroke the medial aspect of the thigh. b. Use intermittent catheterization. c. Provide digital anal stimulation. d. Use the Valsalva maneuver.

ANS: D In patients with overflow incontinence, the voiding reflex arc is not intact. Mechanical pressure, such as that achieved through the Valsalva maneuver (holding the breath and bearing down as if to defecate), can initiate voiding. Stroking the medial aspect of the thigh or providing digital anal stimulation requires the reflex arc to be intact to initiate elimination. Due to the high risk for infection, intermittent catheterization should only be implemented when other interventions are not successful.

9. The nurse is preparing to teach a client with chronic hepatitis B about lamivudine therapy. What health teaching would the nurse include? a. "Follow up on all appointments to monitor your lab values." b. "Do not take amiodorone at any time while on this drug." c. "Monitor for jaundice, rash, and itchy skin while on this drug." d. "Report any changes in urinary elimination while on this drug."

ANS: D Lamivudine can cause renal impairment and the nurse would remind the client of changes that may indicate kidney damage.

Which intervention will the nurse include in the plan of care for a patient who is diagnosed with a lung abscess? a. Teach the patient to avoid the use of over-the-counter expectorants. b. Assist the patient with chest physiotherapy and postural drainage. c. Notify the health care provider immediately about any bloody or foul-smelling sputum. d. Teach about the need for prolonged antibiotic therapy after discharge from the hospital.

ANS: D Long-term antibiotic therapy is needed for effective eradication of the infecting organisms in lung abscess. Chest physiotherapy and postural drainage are not recommended for lung abscess because they may lead to spread of the infection. Foul smelling and bloody sputum are common clinical manifestations in lung abscess. Expectorants may be used because the patient is encouraged to cough

The nurse completes discharge teaching for a patient who has had a lung transplant. The nurse evaluates that the teaching has been effective if the patient makes which statement? a. "I will make an appointment to see the doctor every year." b. "I will stop taking the prednisone if I experience a dry cough." c. "I will not worry if I feel a little short of breath with exercise." d. "I will call the health care provider right away if I develop a fever."

ANS: D Low-grade fever may indicate infection or acute rejection so the patient should notify the health care provider immediately if the temperature is elevated. Patients require frequent follow-up visits with the transplant team. Annual health care provider visits would not be sufficient. Home oxygen use is not an expectation after lung transplant. Shortness of breath should be reported. Low-grade fever, fatigue, dyspnea, dry cough, and oxygen desaturation are signs of rejection. Immunosuppressive therapy, including prednisone, needs to be continued to prevent rejection

A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, "I would rather have chemotherapy than surgery." Which response by the nurse is most appropriate? a. "Are you afraid that the surgery will be very painful?" b. "Did you have bad experiences with previous surgeries?" c. "Surgery is the treatment of choice for stage I lung cancer." d. "Tell me what you know about the various treatments available."

ANS: D More assessment of the patient's concerns about surgery is indicated. An open-ended response will elicit the most information from the patient. The answer beginning, "Surgery is the treatment of choice" is accurate, but it discourages the patient from sharing concerns about surgery. The remaining two answers indicate that the nurse has jumped to conclusions about the patient's reasons for not wanting surgery. Chemotherapy is the primary treatment for small cell lung cancer. In non-small cell lung cancer, chemotherapy may be used in the treatment of nonresectable tumors or as adjuvant therapy to surgery

A patient is admitted with active tuberculosis (TB). The nurse should question a health care provider's order to discontinue airborne precautions unless which assessment finding is documented? a. Chest x-ray shows no upper lobe infiltrates. b. TB medications have been taken for 6 months. c. Mantoux testing shows an induration of 10 mm. d. Three sputum smears for acid-fast bacilli are negative.

ANS: D Negative sputum smears indicate that Mycobacterium tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether treatment has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be done because the result will not change even with effective treatment

The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test? a. "Is there any family history of TB?" b. "How long have you lived in the United States?" c. "Do you take any over-the-counter (OTC) medications?" d. "Have you received the bacille Calmette-Guérin (BCG) vaccine for TB?"

ANS: D Patients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (such as a chest x-ray) will need to be used in determining whether the patient has a TB infection. The other information also may be valuable but is not as pertinent to the decision about doing TB skin testing

The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed? a. UAP splint the patient's chest during coughing. b. UAP assist the patient to ambulate to the bathroom. c. UAP help the patient to a bedside chair for meals. d. UAP lower the head of the patient's bed to 15 degrees.

ANS: D Positioning the patient with the head of the bed lowered will decrease ventilation. The other actions are appropriate for a patient with pneumonia

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective? a. "I am going to buy a rib binder to wear during the day." b. "I can take shallow breaths to prevent my chest from hurting." c. "I should plan on taking the pain pills only at bedtime so I can sleep." d. "I will use the incentive spirometer every hour or two during the day."

ANS: D Prevention of the complications of atelectasis and pneumonia is a priority after rib fracture. This can be ensured by deep breathing and coughing. Use of a rib binder, shallow breathing, and taking pain medications only at night are likely to result in atelectasis

11. A nurse cares for a client who has kidney stones from gout ricemia. Which medication does the nurse anticipate administering? a. Phenazopyridine b. Doxycyline c. Tolterodine d. Allopurinol

ANS: D Stones caused by hyperuricmia caused by gout or other reason respond to allopurinol. Phenazopyridine is given to clients with urinary tract infections. Doxycycline is an antibiotic. Tolterodine is an anticholinergic with smooth muscle-relaxant properties.

The nurse is interviewing a client who reports having abdominal cramping, bloating, and diarrhea after drinking milk or ingesting other dairy products. What health problem does the client most likely have? a. Steatorrhea b. Ulcerative colitis c. Crohn disease d. Lactose intolerance

ANS: D The client is demonstrating signs and symptoms of lactose intolerance because they occur after the client eats or drinks dairy products which contain lactose

6. The nurse teaches a client who has stress incontinence methods to regain more urinary continence. Which health teaching is the most important for the nurse to include for this client? a. What type of incontinence pads to use? b. What types of liquids to drink and when? c. Need to perform intermittent catheterizations. d. How to do Kegel exercises to strengthen muscles?

ANS: D The client who has stress incontinence needs to strengthen the muscles of the pelvic floor using Kegel exercises. Catheterizations would not help with incontinence. Incontinence pads may need to be used by this client but that is not the most important thing to teach, and it does not help the client regain more control over his or her bladder.

A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/minute, blood pressure of 100/60 mmHg, and respirations of 42 breaths/minute. Which action should the nurse take first? a. Administer anticoagulant drug therapy. b. Notify the patient's health care provider. c. Prepare patient for a spiral computed tomography (CT). d. Elevate the head of the bed to a semi-Fowler's position.

ANS: D The patient has symptoms consistent with a pulmonary embolism (PE). Elevating the head of the bed will improve ventilation and gas exchange. The other actions can be accomplished after the head is elevated (and oxygen is started). A spiral CT may be ordered by the health care provider to identify PE. Anticoagulants may be ordered after confirmation of the diagnosis of PE

An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next? a. Milk the chest tube gently to remove any clots. b. Clamp the chest tube momentarily to check for the origin of the air leak. c. Assist the patient to deep breathe, cough, and use the incentive spirometer. d. Set up the patient controlled analgesia (PCA) and administer the loading dose of morphine.

ANS: D The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy and would not require milking of the chest tube. An air leak is expected in the initial postoperative period after thoracotomy

When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient? a. Emergency pericardiocentesis b. Stabilization of the chest wall with tape c. Administration of an inhaled bronchodilator d. Insertion of a chest tube with a chest drainage system

ANS: D The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient's clinical manifestations are not consistent with these problems

After change-of-shift report, which patient should the nurse assess first? a. 72-year-old with cor pulmonale who has 4+ bilateral edema in his legs and feet b. 28-year-old with a history of a lung transplant and a temperature of 101° F (38.3° C) c. 40-year-old with a pleural effusion who is complaining of severe stabbing chest pain d. 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion

ANS: D The patient's history and symptoms suggest possible tension pneumothorax, a medical emergency. The other patients also require assessment as soon as possible, but tension pneumothorax will require immediate treatment to avoid death from inadequate cardiac output or hypoxemia

1. A client is scheduled for a hepatobiliary iminodiacetic acid (HIDA) scan. What would the nurse include in client teaching about this diagnostic test? a. "You'll have to drink a contrast medium right before the test." b. "You'll need to do a bowel prep the nursing before the test." c. "You'll be able to drink liquids up until the test begins." d. "You'll have a large camera close to you during the test."

ANS: D Clients having a HIDA scan are NPO and receive an injectable nuclear medicine contrast. No bowel preparation is required. A large camera is close to the client for most of the test which can be a problem for clients who are claustrophobic.

8. A client had an open traditional Whipple procedure this morning. For what priority complication would the nurse assess? a. Urinary tract infection b. Chronic kidney disease c. Heart failure d. Fluid and electrolyte imbalances

ANS: D Due to the length and complexity of this type of surgery, the client is at risk for fluid and electrolyte imbalances. The nurse would assess for signs and symptoms of these imbalances so they can be managed early to prevent potentially life-threatening complications.

3. After teaching a client who has a history of cholelithiasis, the nurse assesses the client's understanding. Which menu selection indicates that the client understands the dietary teaching? a. Lasagna, tossed salad with Italian dressing, and low-fat milk b. Grilled cheese sandwich, tomato soup, and coffee with cream c. Cream of potato soup, Caesar salad with chicken, and a diet cola d. Roasted chicken breast, baked potato with chives, and orange juice

ANS: D Clients with cholelithiasis should avoid foods high in fat and cholesterol, such as whole milk, butter, and fried foods. Lasagna, low-fat milk, grilled cheese, cream, and cream of potato soup all have high levels of fat. The meal with the least amount of fat is the chicken breast dinner.

A nurse is caring for an older patient who has pulmonary infection. Which action should the nurse take first? a. encourage the client to increase fluid intake b. assess the clients level of consciousness c. raise the head of the bed to at least 45 degrees d. provide the client with humidified oxygen

Assess the client's LOC is the most important because it will show how the client is responding to the presence of infection. Although it will be important for the nurse to encourage the client to turn, cough and frequently breathe deeply; raise the head of the bed, increase oral fluid and humidify the oxygen administered, none of these actions will be as important as assessing the level of consciousness. A client with a pulmonary infection may not be able to cough productively if there is an area of abscess present

A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention should the nurse include in this clients plan of care? a. Assistance with activities of daily living b. Physical therapy activities every day c. Oxygen therapy at 2 liters per nasal cannula d. Complete bedrest with frequent repositioning

Assistance with activities of daily living. A client with dyspnea and difficulty completing activities such as climbing a flight of stairs has class III dyspnea. The nurse should provide assistance with activities of daily living. These clients should be encouraged to participate in activities as tolerated. They should not be on complete bedrest, may not be able to tolerate daily physical therapy, and only need oxygen if hypoxia is present.

12. Which complication does the nurse suspect when a client with PUD suddenly develops sharp epigastric pain that spreads over the entire abdomen? A. Gastric erosion B. Perforation C. Hemorrhage D. Gastric cancer

B

15. Which drugs will the nurse expect to administer to a client with PUD, caused by an H. pylori infection, who is prescribed PPI-triple therapy? A. A proton pump inhibitor, two antibiotics, and bismuth B. A proton pump inhibitor and two antibiotics C. An opioid drug, proton pump inhibitor, and an antibiotic D. An H2 histamine blocker, an antibiotic, and a proton pump inhibitor

B

20. Which food will the nurse recommend a client avoid when he or she reports fear of stomach cancer? A. Foods that cause reflux B. Pickled or processed foods C. Large, heavy meals D. Spicy foods that cause gas

B

21. How does the nurse expect a client's nasogastric (NG) tube drainage to appear immediately after Nissen fundoplication surgery? A. Bright red mixed with brown B. Dark brown C. Yellowish to green D. Green to clear

B

22. For which client with gastric cancer does the nurse expect that minimal invasive surgery (MIS) plus radiation therapy or chemotherapy may be curative? A. 45-year-old with advanced disease B. 50-year-old with early disease C. 60-year-old with liver metastases D. 65-year-old with invasion of the stomach muscle

B

27. Which nonsurgical treatment will the nurse expect the client with esophageal cancer to receive for immediate relief of dysphagia? A. Photodynamic therapy B. Esophageal dilation C. Radiation therapy D. Swallowing therapy

B

3. Which condition or symptom does the nurse associate with a client who has chronic gastritis? A. Hematemesis B. Pernicious anemia C. Dyspepsia D. Epigastric burning

B

31-11 Which serum electrolyte would the nurse check after noting tall and peaked T waves on a client's ECG? A. Sodium B. Potassium C. Magnesium D. Chloride

B

31-14 What is the first step when the nurse analyzes a client's ECG rhythm strip? A. Analyze the P waves B. Determine the HR C. Measure the QRS complex D. Assess for ST-segment elevation

B

31-17 What is the priority action for the nurse when the monitor technician states that a client's telemetry monitor shows a rhythm that appears as a wandering or fuzzy baseline? A. Check to see if the client has a do-not resuscitate order B. Assess the client to differentiate artifact from an actual lethal rhythm C. Immediately obtain a 12-lead ECG to assess the actual rhythm D. Ask the AP to take a set of VS on the client

B

31-31 Which procedure would the nurse provide teaching about to a client who has chronic atrial fibrillation and is at an increased risk for a stroke, but is not a candidate for anticoauglation? A. Radio frequency catheter ablation B. Left atrial appendage occlusion C. Biventricular pacing D. Surgical maze procedure

B

31-4 How would the nurse best interpret the ECG of a younger athletic client which shows sinus bradycardia with a rate of 64 bpm? A. Body's attempt to compensate for a decreased stroke volume by decreasing the HR B. Sinus bradycardia provides an adequate stroke volume that is associated with cardiac conditioning. C. Rapid filling rate that lengthens diastolic filling time and leads to decreased CO D. This is a common finding in healthy adults of all ages and would be considered a normal finding.

B

4. Which oral disorder does the nurse suspect when assessment findings reveal white plaquelike lesions that when wiped away show an underlying red and sore surface? A Leukoplakia B. Candidiasis C. Erythroplakia D. Kaposi's sarcoma

B

A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago. The client states, "I'm having right belly pain and have a temperature of 101° F (38.3° C)." How would the nurse respond? a. "The anti-rejection drugs you are taking make you susceptible to infection." b. "You should go to the hospital immediately to get checked out." c. "You should take an additional dose of cyclosporine today." d. "Take acetaminophen every 4 hours until you feel better soon."

B

After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the client's understanding. Which statement by the client indicates correct understanding of the teaching? a. "Some medications have been known to cause hepatitis A." b. "I may have been exposed when we ate shrimp last weekend." c. "I was infected with hepatitis A through a recent blood transfusion." d. "My infection with Epstein-Barr virus can co-infect me with hepatitis A."

B

How will the nurse interpret a client's laboratory finding of the presence of immunoglobulin G antibodies directed against hepatitis A (HAV)? A. Active, infectious HAV is present. B. Permanent immunity to HAV is present. C. This is the client's first infection to HAV. D. The risk for infection if exposed to HAV is high.

B

The nurse is caring for a client who has cirrhosis of the liver. What nursing action is appropriate to help control ascites? a. Monitor intake and output. b. Provide a low-sodium diet. c. Increase oral fluid intake. d. Weigh the patient daily.

B

The nurse is caring for a client with hepatic portal-systemic encephalopathy (PSE). The client is thin and cachectic, and the family expresses distress that the patient is receiving little dietary protein. How would the nurse respond? a. "A low-protein diet will help the liver rest and will restore liver function." b. "Less protein in the diet will help prevent confusion associated with liver failure." c. "Increasing dietary protein will help the patient gain weight and muscle mass." d. "Low dietary protein is needed to prevent fluid from leaking into the abdomen."

B

Which client's previous health history will the nurse most associate with a risk for developing postnecrotic cirrhosis of the liver? A. 28-year-old woman who had gallstones 1 year ago and has recently lost 20 lb (9 kg) on a low-calorie, low-fat diet B. 45-year-old man with hepatitis C infection and chronic use of acetaminophen C. 50-year-old man who has many years of excessive alcohol consumption D. 55-year-old woman who has chronic biliary obstruction

B

Physiological Integrity 17. Which nursing action could the registered nurse (RN) working in a skilled care hospital unit delegate to an experienced licensed practical/vocational nurse (LPN/LVN) caring for a patient with a permanent tracheostomy? a. Assess the patient's risk for aspiration. b. Suction the tracheostomy when needed. c. Teach the patient about self-care of the tracheostomy. d. Determine the need for replacement of the tracheostomy tube.

B Suctioning of a stable patient can be delegated to LPNs/LVNs. Patient assessment and patient teaching should be done by the RN. DIF: Cognitive Level: Apply (application) REF: 518 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC:

Physiological Integrity 16. The nurse obtains the following assessment data on an older patient who has influenza. Which information will be most important for the nurse to communicate to the health care provider? a. Fever of 100.4° F (38° C) b. Diffuse crackles in the lungs c. Sore throat and frequent cough d. Myalgia and persistent headache

B The crackles indicate that the patient may be developing pneumonia, a common complication of influenza, which would require aggressive treatment. Myalgia, headache, mild temperature elevation, and sore throat with cough are typical manifestations of influenza and are treated with supportive care measures such as over-the-counter (OTC) pain relievers and increased fluid intake. DIF: Cognitive Level: Apply (application) REF: 503 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC:

Physiological Integrity 14. Following a laryngectomy a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first? a. Cover stoma with sterile gauze and ventilate through stoma. b. Attempt to reinsert the tracheostomy tube with the obturator in place. c. Assess the patient's oxygen saturation and notify the health care provider. d. Ventilate the patient with a manual bag and face mask until the health care provider arrives.

B The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient's airway. Assessing the patient's oxygenation is an important action, but it is not the most appropriate first action in this situation. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube. Ventilating with a facemask is not appropriate for a patient with a total laryngectomy because there is a complete separation between the upper airway and the trachea. DIF: Cognitive Level: Apply (application) REF: 509 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:

Physiological Integrity 22. When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a temperature of 101.6° F (38.7° C), and yellow patches on the tonsils. Which action will the nurse anticipate taking? a. Teach the patient about the use of expectorants. b. Use a swab to obtain a sample for a rapid strep antigen test. c. Discuss the need to rinse the mouth out after using any inhalers. d. Teach the patient to avoid use of nonsteroidal antiinflammatory drugs (NSAIDs).

B The patient's clinical manifestations are consistent with streptococcal pharyngitis and the nurse will anticipate the need for a rapid strep antigen test and/or cultures. Because patients with streptococcal pharyngitis usually do not have a cough, use of expectorants will not be anticipated. Rinsing the mouth out after inhaler use may prevent fungal oral infections, but the patient's assessment data are not consistent with a fungal infection. NSAIDs are frequently prescribed for pain and fever relief with pharyngitis. DIF: Cognitive Level: Apply (application) REF: 506 TOP: Nursing Process: Planning MSC:

What is the nurse's best interpretation when reviewing a client's abdominal CT scan and noting that there is an outpouched segment coming off the abdominal aorta? A. Dissecting aneurysm B. Saccular aneurysm C. Fusiform aneurysm D. False aneurysm

B A saccular aneurysm is an outpouching affecting only a distinct portion of the artery. A fusiform aneurysm is a diffuse dilation affecting the entire circumference of the artery (often appears egg shaped on scans). A dissecting aneurysm is a false aneurysm which occurs when blood accumulates in the wall of an artery.

What would the nurse expect to find in the history of a client admitted with acute arterial occlusion? A. History of chronic venous stasis disease treated with debridement B. Acute myocardial infarction or atrial fibrillation within the previous weeks C. Episode of blunt trauma that occurred several months ago D. Family history of coronary artery disease

B Acute arterial occlusion is most often caused by an embolus (piece of a clot that travels and lodges in a new area). Emboli originating from the heart are the most common cause of acute arterial occlusions. Most clients with an embolic occlusion have had an acute myocardial infarction (MI) and/or atrial fibrillation within the previous weeks.

Which drug would the nurse expect the primary health care provider to prescribe for a client to decrease blood pressure, decrease triglycerides, increase high-density lipoprotein cholesterol (HDL-C), and lower low-density lipoprotein cholesterol (LDL-C)? A. Advicor B. Caduet C. Vytorin D. Ezetimibe

B Amlodipine and atorvastatin are combined as Caduet to decrease blood pressure while de-creasing triglycerides (TGs), increasing HDL-C, and lowering LDL-C. Vytorin (ezetimibe and simvastatin) is a combination of a selective inhibitor of intestinal cholesterol and statin used to treat elevated cholesterol. Ezetimibe is in a class of medications called cholesterol-lowering medications. It works by preventing the absorption of cholesterol in the intestine. Advicor is a combination of niacin XR and lovastatin used to lower cholesterol and triglyceride (fat) levels in the blood.

What is the nurse's best response when a client asks about the difference between arteriosclerosis and atherosclerosis? A. Arteriosclerosis is the sudden blockage of an artery while atherosclerosis is formation of plaque in arteries. B. Atherosclerosis is forming plaques in arteries but arteriosclerosis is thickening of arterial walls associated with aging. C. Arteriosclerosis is hardening of arterial walls while atherosclerosis involves permanent localized dilation of arteries D. Atherosclerosis is thickening of arterial walls but arteriosclerosis is clot formation usually in the deep veins.

B Arteriosclerosis is a thickening, or hardening, of the arterial wall which is often associated with aging. Atherosclerosis is a type of arteriosclerosis that involves the formation of plaque within the arterial wall and is the leading contributor to coronary artery and cerebrovascular disease. A sudden blockage is an acute arterial occlusion. Permanent dilation of arteries occurs with an aneurysm. Clot formation in the deep veins is a deep vein thrombosis (DVT).

During which timeframe is it most important for the nurse to monitor a client for graft occlusion after receiving revascularization with graft placement? A. First 2 hours B. First 24 hours C. Days 1 and 2 postoperative D. During the first week

B Graft occlusion (blockage) is a postoperative emergency that can occur within the first 24 hours after arterial revascularization. Monitor the client for and report severe, continuous, and aching pain, which may be the first indicator of postoperative graft occlusion and ischemia.

For which client would the nurse question the prescription of hydrochlorothiazide? A. Client with asthma B. Client with hypokalemia C. Client with hyperkalemia D. Client with chronic airway limitation

B Hydrochlorothiazide (HCTZ) is a thiazide di-uretic. The most frequent side effect associated with thiazide and loop diuretics is hypokalemia (low potassium level). Monitor serum potassium levels and assess for irregular pulse, dysrhythmias, and muscle weakness, which may indicate hypokalemia.

What is the recommended therapeutic range for the international normalized ratio (INR) for a client receiving warfarin sodium to prevent DVT and decrease the risk for stroke? A. 2.0-2.5 B. 1.5-2.0 C. 1.0-1.5 D. 0.5-1.0

B Most clients receiving warfarin should have an INR between 1.5 and 2.0 to prevent future DVT and to minimize the risk for stroke or hemorrhage.

Which drug would the nurse expect to administer to a client with Raynaud's or Buerger's disease? A. Captopril B. Nifedipine C. Warfarin D. Atorvastatin

B Nifedipine is a calcium channel blocker which acts as a vasodilator for both Raynaud's and Buerger's disease. It will help reverse the vasoconstriction that occurs with these conditions.

What is the best nonsurgical intervention for a client with a 3-cm abdominal aortic aneurysm to decrease the risk of rupture? A. Bedrest with bathroom privileges until the aneurysm shrinks B. Maintenance of normal blood pressure and avoidance of hypertension C. Heparin followed by warfarin therapy to prevent clotting D. Intraarterial thrombolytic therapy to dissolve any existing clots

B The desired outcome of nonsurgical management is to monitor the growth of the aneurysm and maintain the blood pressure at a normal level to decrease the risk for rupture. Clients with hypertension are treated with antihypertensive drugs to decrease the rate of enlargement and the risk for early rupture. Addition-ally, the client would receive frequent ultrasound or CT scans to monitor the growth of the aneurysm.

A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition should the nurse include in this clients teaching? a. The best way to lose weight is a high-protein, low-carbohydrate diet. b. You should balance weight loss with consuming necessary nutrients. c. A nutritionist will provide you with information about your new diet. d. If you exercise more frequently, you won't need to change your diet.

B- Clients at risk for cardiovascular diseases should follow the American Heart Association guidelines to combat obesity and improve cardiac health. The nurse should encourage the client to eat vegetables, fruits, unrefined whole-grain products, and fat-free dairy products while losing weight. High-protein food items are often high in fat and calories. Although the nutritionist can assist with client education, the nurse should include nutrition education and assist the client to make healthy decisions. Exercising and eating nutrient-rich foods are both important components in reducing cardiovascular risk.

A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention should the nurse be prepared to implement while this client waits for surgery? a. Administration of IV furosemide (Lasix) b. Initiation of an external pacemaker c. Assistance with endotracheal intubation d. Placement of central venous access

B- The RCA supplies the right atrium, the right ventricle, the inferior portion of the left ventricle, and the atrioventricular (AV) node. It also supplies the sinoatrial node in 50% of people. If the client totally occludes the RCA, the AV node would not function and the client would go into heart block, so emergency pacing should be available for the client. Furosemide, intubation, and central venous access will not address the primary complication of RCA occlusion, which is AV node malfunction.

A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The clients health history includes a previous myocardial infarction and pacemaker implantation. Which action should the nurse take? a. Schedule an electrocardiogram just before the MRI. b. Notify the health care provider before scheduling the MRI. c. Call the physician and request a laboratory draw for cardiac enzymes. d. Instruct the client to increase fluid intake the day before the MRI.

B- The magnetic fields of the MRI can deactivate the pacemaker. The nurse should call the health care provider and report that the client has a pacemaker so the provider can order other diagnostic tests. The client does not need an electrocardiogram, cardiac enzymes, or increased fluids.

A nurse auscultated heart tones on an older adult client. Which action should the nurse take based on heart tones heard? (Click the media button to hear the audio clip.) a. Administer a diuretic. b. Document the finding. c. Decrease the IV flow rate. d. Evaluate the clients medications.

B- The sound heard is an atrial gallop S4. An atrial gallop may be heard in older clients because of a stiffened ventricle. The nurse should document the finding, but no other intervention is needed at this time.

A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client should alert the nurse to the presence of edema? a. I wake up to go to the bathroom at night. b. My shoes fit tighter by the end of the day. c. I seem to be feeling more anxious lately. d. I drink at least eight glasses of water a day

B- Weight gain can result from fluid accumulation in the interstitial spaces. This is known as edema. The nurse should note whether the client feels that his or her shoes or rings are tight, and should observe, when present, an indentation around the leg where the socks end. The other answers do not describe edema.

A Certified Wound, Ostomy, and Continence Nurse (CWOCN) is teaching a patient about caring for a new ileostomy. What information is most important to include? A. "After surgery, output from your ileostomy may be a loose, dark-green liquid with some blood present." B. "Call your primary health care provider if your stoma has a bluish or pale look." C. "Notify the primary health care provider if output from your stoma has a sweetish odor." D. "Remember that you must wear a pouch system at all times."

B. "Call your primary health care provider if your stoma has a bluish or pale look." It is most important for the Certified Wound, Ostomy, and Continence nurse to tell the patient with a new ileostomy to call the primary health care provider if the stoma has a bluish or pale look. If the stoma has a bluish, pale, or dark look, its blood supply may be compromised and the primary health care provider must be notified immediately.It is true that output from the stoma after surgery may be a loose, greenish-colored liquid that may contain some blood, but this information is not the highest priority for instruction. It is normal for output from the stoma to have very little odor or a sweetish smell. Although it is true that the patient will be required to wear a pouch system at all times, this is not the highest priority for instruction.

A nurse is teaching a patient about dietary methods to help manage exacerbations (flare-ups) of diverticulitis. What does the nurse advice the patient? A. "Be sure to maintain an exclusively low-fiber diet to prevent pain on defecation." B. "Consume a low-fiber diet while your diverticulitis is active. When inflammation resolves, consume a high-fiber diet." C. "Maintain a high-fiber diet to prevent the development of hemorrhoids that frequently accompany this condition." D. "Make sure you consume a high-fiber diet while diverticulitis is active. When inflammation resolves, consume a low-fiber diet."

B. "Consume a low-fiber diet while your diverticulitis is active. When inflammation resolves, consume a high-fiber diet." The nurse teaches the patient that the most effective way to manage diverticulitis is to consume a low-fiber diet while inflammation is present, followed by a high-fiber diet once the inflammation has subsided.Neither an exclusively low-fiber diet nor an exclusively high-fiber diet will effectively manage diverticulitis. A high-fiber diet while diverticulitis is active will only worsen the disease and its symptoms.

A patient who developed viral gastroenteritis with vomiting and diarrhea is scheduled to be seen in the clinic the following day. What will the nurse teach the patient to do in the meantime? A. "Avoid all solid foods to allow complete bowel rest." B. "Consume extra fluids to replace fluid losses." C. "Take an over-the-counter antidiarrheal medication." D. "Contact your primary health care provider for an antibiotic medication."

B. "Consume extra fluids to replace fluid losses." The nurse tells the patient to drink extra fluids to replace fluid lost through vomiting and diarrhea.It is not necessary to stop all solid food intake. Antidiarrheal medications are used if diarrhea is severe. Antibiotics are used if the infection is bacterial.

The nurse is teaching a client how to provide a clean-catch urine specimen. Which client statement indicates that teaching was effective? A. "I will have to drink 2 L of fluid before providing the sample." B. "I'll start to urinate in the toilet, stop, and then urinate into the cup." C. "It is best to provide the sample while I am bathing." D. "I must clean with the wipes and then urinate directly into the cup."

B. "I'll start to urinate in the toilet, stop, and then urinate into the cup."

A patient is admitted with severe viral gastroenteritis caused by norovirus. The patient asks the nurse, "How did I get this disease?" Which answer by the nurse is correct? A. "You may have contracted it from an infected infant." B. "You may have consumed contaminated food or water." C. "You may have come into contact with an infected animal." D. "You may have had contact with the blood of an infected person."

B. "You may have consumed contaminated food or water." When a patient with severe viral gastroenteritis caused by norovirus asks, "How did I get this disease?", the nurse answers, "You may have consumed contaminated food or water." Norovirus is the leading foodborne disease that causes gastroenteritis. It is transmitted via the fecal-oral route from person to person and from contaminated food and water. Vomiting causes the virus to become airborne.Campylobacter, not novovirus, can be transmitted by contact with infected infants or animals. Escherichia coli, not novovirus, may be spread via animals and contaminated food, water, or fomites. HIV, not novovirus, may be spread via the blood. Campylobacter and E. coli both cause bacterial gastroenteritis, while norovirus causes viral gastroenteritis.

The RN receives a change-of-shift report about four patients. Which patient does the nurse assess first? A. A 20-year-old with ulcerative colitis (UC) who had six liquid stools during the previous shift B. A 25-year-old who has just been admitted with possible appendicitis and has a temperature of 102°F (37.9°C) C. A 56-year-old who had a colon resection earlier in the day and whose colostomy bag does not have any stool in it D. A 60-year-old admitted with acute gastroenteritis who is reporting severe cramping and nausea

B. A 25-year-old who has just been admitted with possible appendicitis and has a temperature of 102°F (37.9°C) After a change-of-shift report the RN first assess a 25-year-old who has just been admitted with possible appendicitis and has a temperature of 102°F (37.9°C). This patient with possible appendicitis may have developed a perforation and may be at risk for peritonitis. Rapid assessment and possible surgical intervention are needed.The patient with UC who had six liquid stools, the patient whose colostomy bag does not have any stool in it, and the patient who was admitted with acute gastroenteritis all need assessment and intervention by an RN, but they are not at immediate risk for life-threatening complications.

A client has been taking isoniazid for tuberculosis for 3 weeks. What laboratory results need to be reported to the primary health care provider immediately? a. Albumin: 5.1 g/dL b. Alanine aminotransferase (ALT): 180 U/L c. Red blood cell (RBC) count: 5.2 million/mcL d. White blood cell (WBC) count: 12,500/mm3

B. Alanine aminotransferase (ALT): 180 U/L INH can cause liver damage, especially if the client drinks alcohol. The ALT (one of the liver enzymes) is extremely high and needs to be reported immediately. The albumin and RBCs are normal. The WBCs are slightly high, but that would be expected with infection.

A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia would the nurse assess? a. Preventricular contractions b. Atrial fibrillation c. Symptomatic bradycardia d. Sinus tachycardia

B. Atrial fibrillation Afib is a clinical manifestation of mitral valve regurg/stenosis. PVCs and bradycardia are not associated with valvular problems but usually identified in pts with electrolyte imbalances, MI, and sinus node problems. Sinus tach is a manifestation of aortic regurg due to decrease in CO.

A nurse is providing discharge teaching to a client recovering from a heart transplant. Which statement would the nurse include? a. Use a soft-bristled toothbrush and avoid flossing b. Avoid large crowds and people who are sick c. Change positions slowly to avoid hypotension d. Check your heart rate before taking the medication

B. Avoid large crowds and people who are sick Heart transplant pts must take immunosuppressant therapy for rest of life. Nurse would teach pt to avoid crowds and sick ppl to reduce risk of becoming ill. Meds do not place pt at risk for bleeding, orthostatic hypotension, or changes in HR. Orthostatic hypotension from the denervated heart is generally only a problem in immediate postop period.

A nurse teaches a client with heart failure about energy conservation. Which statement would the nurse include in this client's teaching? a. Walk until you become short of breath, then walk back home b. Begin walking 200 feet a day three times a week c. Do not lift heavy weights for 6 months d. Eat plenty of protein to build your strength

B. Begin walking 200 feet a day three times a week A pt with HF would be taught to conserve energy and given an exercise plan. PT should begin walking 200-400 feet a day 3x a week. Pt should not walk until becoming SOB bc may not make it back home. Lifting restriction specific to pt after valve replacement. Protein helps build strength, not specific to HF.

A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, "Why will I need to take anticoagulants for the rest of my life?" What is the BEST response by the nurse? a. The prosthetic valve places you at greater risk for a heart attack b. Blood clots form more easily in artificial replacement valves c. The vein taken from your leg reduces circulation in the leg d. The surgery left a lot of small clots in your heart and lungs

B. Blood clots form more easily in artificial replacement valves Synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate easily and initiate the formation of clots. The other responses are inaccurate.

A patient has vague symptoms that indicate an acute inflammatory bowel disorder. Which signs/symptoms are most indicative of Crohn's disease (CD)? A. Abdominal pain relieved by bending the knees, constipation B. Chronic diarrhea, abdominal colicky pain, and fever C. Epigastric cramping & persistent rectal bleeding D. Hypotension with vomiting and headache

B. Chronic diarrhea, abdominal colicky pain, and fever Signs/symptoms that are most indicative of Crohn's disease (CD) are: chronic diarrhea, abdominal colicky pain, and fever. These signs/symptoms are more specific to CD than any of the other acute inflammatory bowel disorders.Abdominal pain that is relieved by bending the knees is indicative of peritonitis or pancreatitis. Epigastric cramping is a sign/symptom more indicative of appendicitis. Hypotension with vomiting is not characteristic of CD.

A nurse assesses a client with mitral valve stenosis. What clinical sign or symptom would alert the nurse to the possibility that the client's stenosis has progressed? a. Oxygen saturation of 92% b. Dyspnea on exertion c. Muted systolic murmur d. Upper extremity weakness

B. Dyspnea on exertion Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs increases. The other S&S do not relate.

Which action will the nurse include in postprocedural care for the client who has a renal scan? A. Administer captopril to increase renal blood flow B. Encourage oral fluids to assist with excretion of the isotope C. Insert a urinary catheter to measure urine output D. Administer prescribed laxatives to cleanse the bowel

B. Encourage oral fluids to assist with excretion of the isotope

A nurse assesses a client with pericarditis. Which assessment finding would the nurse expect to find? a. Heart rate that speeds up and slows down b. Friction rub at the left lower sternal border c. Presence of a regular gallop rhythm d. Coarse crackles in bilateral lung bases

B. Friction rub at the left lower sternal border PT with pericarditis may present with a pericardial friction rub at left lower sternal border. This sound is the result of friction from inflamed pericardial layers when they rub together. Other assessments not related.

A patient with a recent surgically created ileostomy refuses to look at the stoma and asks the nurse to perform all required stoma care. What does the nurse do next? A. Asks the patient whether family members could be trained in stoma care B. Has another patient with a stoma who performs self-care talk with the patient C. Requests that the primary health care provider request antidepressants and a psychiatric consult D. Suggests that the primary health care provider request a home health consultation so stoma care can be performed by a home health nurse

B. Has another patient with a stoma who performs self-care talk with the patient When a patient with a recently created ileostomy refuses to look at the stoma and wants the nurse to perform all required stoma care, the nurse has another patient with a stoma who performs self-care talk with the patient.If at all possible, the patient would perform stoma care so that he or she can be as independent as possible. Although the patient may need medication for depression, the priority is to encourage the patient to look at, touch, and begin caring for the stoma. A home health nurse can be a support but cannot provide all of the care that the patient will need.

After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the client's understanding. Which client statement indicates a need for ADDITIONAL teaching? a. I'll be able to carry heavy loads after 6 months of rest b. I will have my teeth cleaned by my dentist in 2 weeks c. I must avoid eating foods high in vitamin K, like spinach d. I must use an electric razor instead of a straight razor to shave

B. I will have my teeth cleaned by my dentist in 2 weeks Pts with defective or repaired valves at high risk for endocarditis. Pt with valve surgery should avoid dental procedures for 6 months bc of risk for endocarditis. When undergoing mitral valve replacement surgery, the pt needs to be on anticoagulant therapy to prevent vegetation forming on the new valve. Pts on anticoagulant therapy would be instructed on bleeding precautions including using an electric razor. If pt is prescribed warfarin, the pt should avoid foods high in vitamin K. Pt recovering from open-heart valve replacements should not carry anything heavy for 6 months while the chest incision and muscle heal.

A client seen in the emergency department reports fever, fatigue, and dry cough but no other upper respiratory symptoms. A chest x-ray reveals mediastinal widening. What action by the nurse is BEST? a. Collect a sputum sample for culture by deep suctioning b. Inform the client that oral antibiotics will be needed for 60 days c. Place the client on Airborne Precautions immediately d. Tell the client that directly observed therapy is needed

B. Inform the client that oral antibiotics will be needed for 60 days. The client has signs and symptoms of early inhalation anthrax. For tx, after IV antibiotics are finished, oral antibiotics are continued for at least 60 days. Sputum cultures are not needed. Anthrax is not transmissible from person to person, so Standard Precautions are adequate. Directly observed therapy is used for tuberculosis.

A patient has developed gastroenteritis while traveling outside the country. What is the likely cause of the patient's symptoms? A. Bacteria on the patient's hands B. Ingestion of parasites in the water C. Insufficient vaccinations D. Overcooked foods

B. Ingestion of parasites in the water The likely cause of gastroenteritis when a patient travels outside the country is ingestion of water that is infested with parasites.Bacteria on the patient's hands will not produce gastroenteritis unless food or water is contaminated with the bacteria. Insufficient vaccinations may cause other disease processes, but not gastroenteritis. Undercooked, not overcooked, food may produce gastroenteritis.

The charge nurse on a medical unit is preparing to admit several "clients" who have possible pandemic flu during a preparedness drill. What action by the nurse is BEST? a. Admit the "clients" on Contact Precautions b. Inquire as to recent travel outside the United States c. Do not allow pregnant caregivers to care for these "clients" d. Place the "clients" on enhanced Droplet Precautions

B. Inquire as to recent travel outside the US Preventing the spread of pandemic flu is equally important as caring for the clients who have it. Preventing the spread of disease is vital. The nurse would ask the "clients" about recent overseas travel to assess the risk of a pandemic flu. Clients with possible pandemic flu need to be in Contact and Airborne Precautions if the infectious organism is identified and routes of transmission known. There is no specific danger to pregnant caregivers. Droplet Precautions are not appropriate.

After administering the first dose of captopril to a client with heart failure, the nurse implements interventions to decrease complications. Which intervention is MOST important for the nurse to implement? a. Provide food to decrease nausea and aid in absorption b. Instruct the client to ask for assistance when rising from bed c. Collaborate with assistive personnel to bathe the client d. Monitor potassium levels and check for signs of hypokalemia

B. Instruct the client to ask for assistance when rising from bed Hypotension is a side effect of ACE inhibitors such as captopril. Pts with a fluid volume deficit should have their volume replaced or start at a lower dose of the drug to minimize this effect. The nurse would instruct the client to seek assistance before arising from bed to avoid injury from postural hypotension. ACE inhibitors do not need to be taken w/ food. Collab with AP to provide hygiene is not a priority. The pt would be encourage to complete ADLs as independently as possible. The nurse would monitor for hyperkalemia, not hypokalemia, especially if the pt has renal insufficiency secondary to HF.

A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right-sided heart failure? a. I sleep with four pillows at night b. My shoes fit really tight lately c. I wake up coughing every night d. I have trouble catching my breath

B. My shoes fit really tight lately Signs of systemic congestion occur with right-sided HF. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Left-sided HF symptoms include respiratory symptoms - orthopnea, coughing, and difficulty breathing all could be results.

An older adult is brought to the emergency department by a family member, who reports moderate change in mental status and mild cough. The client is afebrile. The primary health care provider orders a chest x-ray. The family member questions why this is needed since the symptoms seem so vague. What response by the nurse is BEST? a. Chest x-rays are always ordered when we suspect pneumonia b. Older people often have vague symptoms, so an x-ray is essential c. The x-ray can be done and read before laboratory work is reported d. We are testing for any possible source of infection in the client

B. Older people often have vague symptoms, so an x-ray is essential It is essential to obtain an early chest x-ray in older adults suspected of having pneumonia because symptoms are often vague. Waiting until definitive signs and symptoms are present to obtain the x-ray leads to a costly delay in treatment. Stating that chest x-rays are always ordered does not give the family definitive information. The x-ray can be done while lab values are still pending, but this also doesn't provide specific info about the important of a chest x-ray in this client. The client has symptoms of pneumonia, so the staff is not testing for any possible source of infection but rather is testing for a suspected disorder.

Which is a correct statement differentiating Crohn's disease (CD) from ulcerative colitis (UC)? A. Patients with CD experience about 20 loose, bloody stools daily. B. Patients with UC may experience hemorrhage. C. The peak incidence of UC is between 15 and 40 years of age. D. Very few complications are associated with CD.

B. Patients with UC may experience hemorrhage. A correct statement about differentiating Crohn's disease (CD) from ulcerative colitis (UC) is that patients with UC may experience hemorrhage. Patients with CD can have 5-6 soft, loose stools per day, but they are nonbloody.Five to six stools daily is common with CD, not 20 loose, bloody stools. The peak incidences of UC are between 30 and 40 years and again at 55 to 65 years of age, and not just 15 to 40 years of age. Fistulas commonly occur as a complication of CD.

Which teaching point is MOST important for the client with a peritonsillar abscess? a. Gargle with warm salt water b. Take all antibiotics as directed c. Let us know if you want liquid medications d. Wash hands frequently

B. Take all antibiotics as directed Any client on antibiotics must be instructed to complete the entire course. Not completing them can lead to complications or drug-resistant strains of bacteria. The other instructions are appropriate, just not the most important.

14. Which most accurate diagnostic test will the nurse expect to be ordered for a client to verify the diagnosis of GERD? A. Esophagogastroduodenoscopy (EGD) B. Esophageal manometry C. Ambulatory esophageal pH monitoring D. Motility testing

C

17. Which priority teaching will the nurse provide to a client who is prescribed bismuth for peptic ulcer disease (PUD)? A. "Take this drug with an aspirin." B. "You may experience dyspepsia between doses." C. "Bismuth may cause your tongue and stool to appear black." D. "Be sure to take this drug before each meal and snack."

C

23. Which client does the nurse assess as at highest risk for development of esophageal cancer? A. 45-year-old on a high-fiber diet B. 50-year-old with a sedentary lifestyle C. 55-year-old who smokes and is 25 lb overweight D. 60-year-old who is prescribed famotidine for reflux

C

3. For which reason will the nurse carefully examine the mouth of an older adult for candidiasis? A. Older clients are more likely to wear dentures which increases the risk for candidiasis. B. Older adults on fixed incomes consume fewer fresh vegetables and fruits. C. Older adults' immune systems decline with aging increasing their risk for candidiasis. D. Older clients are less likely to see a dentist and have healthy oral hygiene.

C

31-1 Which priority concept does the nurse focus on when a client is diagnosed with a dysrhythmia? A. Clotting B. Fluid & Electrolytes C. Perfusion D. Acid-base balance

C

31-10 Which condition is indicated when the nurse notes ST segment elevation or one to two small blocks on a client's ECG? A. Ventricular irritability B. Subarachnoid hemorrhage C. Myocardial injury or ischemia E. Malfunction of the SA node

C

31-13 Which would be the best method for the nurse to confirm a report from the monitor technician about a change in a monitored client's HR? A. Count QRS complexes in a 6-sec strip & multiply by 10 B. Analyze the ECG rhythm strip by using an ECG caliper C. Assess the client's HR directly by checking the apical pulse D. Request that the monitor tech run an ECG strip for a minute

C

31-20 What does the nurse determine is the client's HR when assessing a 6-sec telemetry ECG strip with 5 QRS complexes? A. 30 bpm, bradycardia B. 40 bpm, bradycardia C. 50 bpm, bradycardia D. 60 bpm, normal

C

31-30 How does the nurse interpret a client's telemetry ECG strip that shows 4 successive premature ventricular contractions (PVCs)? A. Monitor is showing 2 PVC couplets in a row B. This rhythm is ventricular systole as seen in a dying heart C. Client had an episode of nonsustained ventricular tachycardia (NSVT) D. Nurse must check the client for loose leads and artifact

C

31-33 Which drug does the nurse prepare to administer to a client diagnosed with the dysrhythmias torsades de pointes? A. Calcium chloride B. Epinephrine C. Magnesium sulfate D. Adenosine

C

31-39 Which safety precautions must be taken before defibrillating a client with ventricular fibrillation? A. Make sure that the defibrillator is set on the synchronous modee B. Be sure to hyperventilate the client before the defibrillation C. Command all health care team members to stand care of the client's bed D. Disconnect the monitor leads to prevent electrical shocks to the client

C

31-8 To perform a 12-lead ECG on a client, how does the nurse place the leads on the client? A. Four leads are placed on the limbs and four are placed on the chest B. The negative electrode is placed on the L arm and the positive electrode is placed on the R leg C. Four leads are placed on the limbs and six are placed on the chest D. The negative electrode is placed on the R arm and the positive electrode is placed on the L leg

C

7. What does the nurse suspect when assessing a client's mouth and finding an oral cavity tumor that appears as a red, velvety lesion on the tongue, palate, floor of the mouth, or mandibular mucosa? A. Kaposi's sarcoma B. Basal cell carcinoma C. Erythroplakia D. Leukoplakia

C

9. Which statement by a client indicates to the nurse that teaching about the action of sucralfate has been successful? A. "The main side effect of sucralfate is diarrhea." B. "I will take my sucralfate with each meal." C. "Sucralfate will work to heal my ulcer." D. "I will take my sucralfate with my antacid."

C

A 68-year-old male client is seeing the primary care provider for an annual examination. Which assessment finding alerts the nurse to an increased risk for bladder cancer? A. A 5 pack-year history of smoking 45 years ago B. Difficulty starting and stopping the urine stream C. A 30-year occupation as a long-distance truck driver D. A recent colon cancer diagnosis in his 72-year-old brother

C

After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? a. "I cannot drink any alcohol at all anymore." b. "I should not take over-the-counter medications." c. "I need to avoid protein in my diet." d. "I should eat small, frequent, balanced meals."

C

The nurse is caring for a client who has a risk gene for developing cirrhosis. Which racial/ethnic group has this gene most often? a. Blacks b. Asian/Pacific Islanders c. Latinos d. French

C

The nurse is caring for a client who has cirrhosis from substance abuse. The client states, "All of my family hates me." How would the nurse respond? a. "You should make peace with your family." b. "This is not unusual. My family hates me too." c. "I will help you identify a support system." d. "You must attend Alcoholics Anonymous."

C

What is the nurse's best first action when a client who just had a liver transplant develops oozing around two IV sites as well as has some new bruising? A. Applying pressure to the IV sites B. Checking the client's platelet levels C. Notifying the surgeon immediately D. Documenting the findings as the only action

C

What is the nurse's best response to a client who fears he may have been exposed to hepatitis A while attending a banquet last week after which three restaurant workers were diagnosed with hepatitis A? A. "Which types of food did you eat at the banquet?" B. "If you have no symptoms at this time, you are probably safe." C. "You can receive an immunoglobulin injection to prevent the infection." D. "Contact your primary health care provider about receiving the hepatitis A vaccine."

C

What is the nurse's priority action when a client with ascites reports increased abdominal pain and chills? A. Applying oxygen and making the client NPO B. Notifying the primary health care provider immediately C. Assessing for abdominal rigidity and taking the client's temperature D. Applying a heating blanket and raising the head of the bed to a 45-degree angle

C

What liver problem does the nurse suspect in a client whose liver is hard with a nodular texture and the hepatic enzymes remain normal? A. Prenecrotic inflammation B. Postnecrotic inflammation C. Compensated cirrhosis D. Decompensated cirrhosis

C

A nurse prepares a client for coronary artery bypass graft surgery. The client states, "I am afraid I might die." what is the nurse's best response? a. this is a routine surgery and the risk of death is very low b. would you like to speak with a chaplain prior to surgery C. tell me more about your concerns about the surgery D. what support systems do you have to assist you

C the nurse would discuss that client's feeling and concerns related to the surgery.

Safe and Effective Care Environment 5. A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action should the nurse include in the plan of care in collaboration with the speech therapist? a. Leave the tracheostomy inner cannula inserted at all times. b. Place the decannulation cap in the tube before cuff deflation. c. Assess the ability to swallow before using the fenestrated tube. d. Inflate the tracheostomy cuff during use of the fenestrated tube.

C Because the cuff is deflated when using a fenestrated tube, the patient's risk for aspiration should be assessed before changing to a fenestrated tracheostomy tube. The decannulation cap is never inserted before cuff deflation because to do so would obstruct the patient's airway. The cuff is deflated and the inner cannula removed to allow air to flow across the patient's vocal cords when using a fenestrated tube. DIF: Cognitive Level: Apply (application) REF: 511 TOP: Nursing Process: Planning MSC:

Physiological Integrity 10. A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal care. Which information obtained by the nurse is the best indicator that this identified problem is resolving? a. The patient lets the spouse provide tracheostomy care. b. The patient allows the nurse to suction the tracheostomy. c. The patient asks how to clean the tracheostomy stoma and tube. d. The patient uses a communication board to request "No Visitors."

C Independently caring for the laryngectomy tube indicates that the patient has regained control of personal care and hopelessness is at least partially resolved. Letting the nurse and spouse provide care and requesting no visitors may indicate that the patient is still experiencing hopelessness. DIF: Cognitive Level: Apply (application) REF: 518 TOP: Nursing Process: Evaluation MSC:

Physiological Integrity 3. The nurse discusses management of upper respiratory infections (URI) with a patient who has acute sinusitis. Which statement by the patient indicates that additional teaching is needed? a. "I can take acetaminophen (Tylenol) to treat my discomfort." b. "I will drink lots of juices and other fluids to stay well hydrated." c. "I can use my nasal decongestant spray until the congestion is all gone." d. "I will watch for changes in nasal secretions or the sputum that I cough up."

C The nurse should clarify that nasal decongestant sprays should be used for no more than 3 days to prevent rebound vasodilation and congestion. The other responses indicate that the teaching has been effective. DIF: Cognitive Level: Apply (application) REF: 502 TOP: Nursing Process: Evaluation MSC:

Physiological Integrity 4. A nurse who is caring for patient with a tracheostomy tube in place has just auscultated rhonchi bilaterally. If the patient is unsuccessful in coughing up secretions, what action should the nurse take? a. Encourage increased incentive spirometer use. b. Encourage the patient to increase oral fluid intake. c. Put on sterile gloves and use a sterile catheter to suction. d. Preoxygenate the patient for 3 minutes before suctioning.

C This patient needs suctioning now to secure a patent airway. Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. Preoxygenation for 3 minutes is not necessary. Incentive spirometer (IS) use opens alveoli and can induce coughing, which can mobilize secretions. However, the patient with a tracheostomy may not be able to use an incentive spirometer. Increasing oral fluid intake would not moisten and help mobilize secretions in a timely manner. DIF: Cognitive Level: Apply (application) REF: 510 TOP: Nursing Process: Implementation MSC:

What would be the nurse's best action when a client reports dizziness when changing position from sitting to standing and a sudden dry cough after starting a prescription of captopril? A. Instruct the client to change positions slowly and take an over-the-counter cough syrup. B. Tell the client to take the drug at bedtime and use over-the-counter throat lozenges. C. Notify the primary health care provider immediately about these side effects. D. Teach the client to increase fluid intake to at least 3 L/day.

C Captopril is an angiotensin-converting enzyme inhibitor (ACEI). Antihypertensive drugs all have the potential to cause hypotension. However, the most common side effect of this group of drugs is a nagging, dry cough. The nurse should immediately notify the primary health care provider of this finding. Clients must also be taught to report this problem as soon as possible. If a cough devel-ops, the drug is discontinued and the client is started on another drug therapy to control hypertension.

What is the nurse's best response when a client with peripheral arterial disease asks why he or she should exercise when walking causes pain? A. "This type of therapy is free and you can do it by yourself to improve the muscle tone in your legs." B. "The cramping will eventually stop if you continue the exercise routine. When you have too much pain, just rest a little while." C. "Exercise can improve blood flow to your legs because small blood vessels will compensate for the blood vessels that are blocked off." D. "Exercise is a nonsurgical, noninvasive technique used to increase arterial blood flow to your affected leg."

C Exercise may improve arterial blood flow to the affected leg through buildup of the collateral circulation. Collateral circulation provides blood to the affected area through smaller vessels that develop and compensate for the occluded vessels.

How does the nurse best interpret a client's low-density lipoprotein cholesterol (LDL-C) value which is greater than 190 mg/dL and does not respond to dietary intervention? A. The client should have total cholesterol and LDL-C testing repeated during the next routine examination. B. The client should be instructed to exercise 6 to 7 days per week to help bring the LDL-C level over time. C. The client should be evaluated for secondary causes of hyperlipidemia and treated with statin therapy because of the high LDL-C level. D. The client should be followed every 6 months routinely to check lipid profiles and detect trends in the values.

C Increased low-density lipoprotein cholesterol (LDL-C) ("bad" cholesterol) levels and low high-density lipoprotein cholesterol (HDL-C) ("good" cholesterol) indicate that a person is at an increased risk for atherosclerosis. For clients with elevated total cholesterol and LDL-C levels that do not respond adequately to dietary intervention, the primary health care provider prescribes a cholesterol-lowering agent, most likely a 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors or "statin" (e.g., lovastatin, simvastatin, atorvastatin), which would successfully reduce total cholesterol in most clients when used for an extended period.

What is the nurse's best explanation to a client for use of low-dose niacin to decrease LDL-C and very-low-density lipoprotein (VLDL) cholesterol levels? A. It will prevent muscle myopathies. B. It works well to prevent elevated blood pressure. C. It helps reduce side effects of flushing and feeling too warm. D. It will help prevent the undesirable side effect of hypokalemia.

C Low doses of niacin are recommended because many clients experience flushing and a very warm feeling all over with higher doses. Higher doses can also result in an elevation of hepatic enzymes. In statin-intolerant clients, niacin can be useful to help lower LDL cholesterol levels in combination with other drugs.

What is the most important teaching point for the nurse to emphasize with a client who has Buerger's disease? A. Decrease intake of fats and reduce cholesterol to reverse the disease process. B. Limit exposure to extreme warm temperatures because of vasodilation. C. Cease cigarette smoking and all exposure to tobacco to arrest the disease process. D. Perform exercises of fingers and toes at least twice a day to slow the disease process.

C The priority teaching would be to instruct the client about smoking cessation and avoidance of tobacco. Other teaching would include avoiding cold by wearing gloves and warm clothes, managing stress, avoiding caffeine; tell the client taking nifedipine to avoid grapefruit and grapefruit juice to prevent severe adverse effects, including possible death. These substances reduce the enzymes that metabolize nifedipine, allowing blood levels to increase to dangerous levels. Teach a client on vasodilators about side effects such as facial flushing, hypotension, headaches.

Which drug would the nurse prepare to administer when a client enters the emergency department with chest pain described as a "tearing" sensation, diaphoresis, blood pressure of 200/130 mm Hg, weak pulses, and a sense of apprehension? A. Oral beta blocker such as atenolol B. Calcium channel blocker such as amlodipine C. IV beta blocker such as esmolol D. Antianginal drug such as nitroglycerin

C This client's symptoms indicate that the client likely has an aortic dissection. The health care provider would prescribe IV morphine sulfate to relieve pain and an IV beta blocker, such as esmolol, to lower heart rate and blood pressure. If this regimen is not effective, nitroprusside or nicardipine hydrochloride may be used. For long-term medical treatment, the recommended target for blood pressure is less than 120/80 mm Hg. Beta blockers (e.g., propranolol) and calcium channel antagonists (e.g., amlodipine) are prescribed to assist with blood pressure maintenance once the client is stabilized.

A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention? a. Urinary output less than intake b. Bruising at the insertion site c. Slurred speech and confusion d. Discomfort in the left leg

C- A left-sided cardiac catheterization specifically increases the risk for a cerebral vascular accident. A change in neurologic status needs to be acted on immediately. Discomfort and bruising are expected at the site. If intake decreases, a client can become dehydrated because of dye excretion. The second intervention would be to increase the clients fluid status. Neurologic changes would take priority

A nurse cares for a client who is recovering from a myocardial infarction. The client states, I will need to stop eating so much chili to keep that indigestion pain from returning. How should the nurse respond? a. Chili is high in fat and calories; it would be a good idea to stop eating it. b. The provider has prescribed an antacid for you to take every morning. c. What do you understand about what happened to you? d. When did you start experiencing this indigestion?

C- Clients who experience myocardial infarction often respond with denial, which is a defense mechanism. The nurse should ask the client what he or she thinks happened, or what the illness means to him or her. The other responses do not address the clients misconception about recent pain and the cause of that pain.

A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect? a. Excruciating pain on inspiration b. Left lateral chest wall pain c. Disorientation and confusion d. Numbness and tingling of the arm

C- In older adults, disorientation or confusion may be the major manifestation of myocardial infarction caused by poor cardiac output. Pain manifestations and numbness and tingling of the arm could also be related to the myocardial infarction. However, the nurse should be more concerned about the new onset of disorientation or confusion caused by decreased perfusion.

A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action should the nurse take? a. Elevate the leg and apply a sandbag to the entrance site. b. Increase the flow rate of intravenous fluids. c. Assess the color and temperature of the left leg. d. Document the finding as left pedal pulse of +1/4.

C- Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial obstruction. The pulse may be faint because of edema. The left pulse should be compared with the right, and pulses should be compared with previous assessments, especially before the procedure. Assessing color (pale, cyanosis) and temperature (cool, cold) will identify a decrease in circulation. Once all peripheral and vascular assessment data are acquired, the primary health care provider should be notified. Simply documenting the findings is inappropriate. The leg should be positioned below the level of the heart or dangling to increase blood flow to the distal portion of the leg. Increasing intravenous fluids will not address the clients problem

A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for cardiovascular disease? a. An 86-year-old man with a history of asthma b. A 32-year-old Asian-American man with colorectal cancer c. A 45-year-old American Indian woman with diabetes mellitus d. A 53-year-old postmenopausal woman who is on hormone therapy

C- The incidence of coronary artery disease and hypertension is higher in American Indians than in whites or Asian Americans. Diabetes mellitus increases the risk for hypertension and coronary artery disease in people of any race or ethnicity. Asthma, colorectal cancer, and hormone therapy do not increase risk for cardiovascular disease.

A nurse prepares a client for coronary artery bypass graft surgery. The client states, I am afraid I might die. How should the nurse respond? a. This is a routine surgery and the risk of death is very low. b. Would you like to speak with a chaplain prior to surgery? c. Tell me more about your concerns about the surgery. d. What support systems do you have to assist you?

C- The nurse should discuss the clients feelings and concerns related to the surgery. The nurse should not provide false hope or push the clients concerns off on the chaplain. The nurse should address support systems after addressing the clients current issue.

A patient has been newly diagnosed with ulcerative colitis (UC). What does the nurse teach the patient about diet and lifestyle choices? A. "Drinking carbonated beverages will help with your abdominal distress." B. "It's OK to smoke cigarettes, but you should limit them to ½ pack per day." C. "Lactose-containing foods should be reduced or eliminated from your diet." D. "Raw vegetables and high-fiber foods may help to diminish your symptoms."

C. "Lactose-containing foods should be reduced or eliminated from your diet." The nurse teaches the newly diagnosed patient with ulcerative colitis that lactose-containing foods are often poorly tolerated and need to be reduced or eliminated from the diet.Carbonated beverages are GI stimulants that can cause discomfort and must be used rarely or completely eliminated from the diet. Cigarette smoking is a stimulant that can cause GI distress symptoms. Nurses would never advise patients that any amount of cigarette smoking is "OK." Raw vegetables and high-fiber foods can cause GI symptoms in patients with UC.

Which over the counter product will the nurse further explore with a client, for potential impact on kidney function? A. Mouthwash with alcohol B. Vitamin C C. Acetaminophen D. Fiber supplement

C. Acetaminophen

The nurse is preparing to obtain a sterile urine specimen from a client with a Foley catheter. What technique will the nurse use? A. Disconnect the Foley catheter from the drainage tube and collect urine directly from the Foley. B. Use a sterile syringe to withdraw urine from the urine collection bag. C. Clamp the tubing, attach a syringe to the specimen, and withdraw at least 5 mL of urine. D. Remove the existing catheter and obtain a sample during the process of inserting a new Foley.

C. Clamp the tubing, attach a syringe to the specimen, and withdraw at least 5 mL of urine.

A nurse working in a geriatric clinic sees clients with "cold" symptoms and rhinitis. The primary health care provider (PHCP) often leaves a prescription for diphenhydramine. What action by the nurse is BEST? a. Teach the client about possible drowsiness b. Instruct the client to drink plenty of water c. Consult with the PHCP about the medication d. Encourage the client to take the medication with food

C. Consult with the PHCP about the medication First-generation antihistamines are not appropriate for use in the older population. These drugs include chlorpheniramine, diphenhydramine, and hydroxyzine. The nurse would consult with the PHCP and request a different med. Diphenhydramine does cause drowsiness, but the nurse would request a different med. Drinking plenty of fluids is appropriate for the condition and is not related to the medication. Antihistamines can be taken without regard to food.

A patient with ulcerative colitis (UC) is prescribed sulfasalazine (Azulfidine) and corticosteroid therapy. As the disease improves, what change does the nurse expect in the patient's medication regimen? A. Corticosteroid therapy will be stopped. B. Sulfasalazine (Azulfidine) will be stopped. C. Corticosteroid therapy will be tapered. D. Sulfasalazine (Azulfidine) will be tapered.

C. Corticosteroid therapy will be tapered. The nurse expects that corticosteroid therapy will be tapered as the UC improves in the patient who was taking both sulfasalazine and corticosteroids. Once clinical improvement has been established, corticosteroids are tapered over a 2- to 3-month period.Stopping corticosteroid therapy abruptly is unsafe—steroids must be gradually decreased in patients. Usually the amount that they have been taking dictates how quickly or slowly they can be stopped. Sulfasalazine therapy will be taken on a long-term basis. It may be increased or decreased, depending on the patient's symptoms, but will likely never be stopped. These decisions are made over a long period of therapy.

A nurse has educated a client on isoniazid. What statement made by the client indicates that teaching has been effective? a. I need to take extra vitamin C when on isoniazid b. I should take this medicine with milk or juice c. I will take this medication on an empty stomach d. My contact lenses will be permanently stained

C. I will take this medication on an empty stomach Isoniazid needs to be taken on an empty stomach, either 1 hour before or 2 hours after meal. Extra vitamin B needs to be taken while on isoniazid. Staining of contact lenses commonly occurs while taking rifampin.

A patient returns to the unit after having an exploratory abdominal laparotomy. How does the nurse position this patient after the patient is situated in bed? A. High Fowler's B. Lateral Sims' (side-lying) C. Semi-Fowler's D. Supine

C. Semi-Fowler's The nurse places the postoperative abdominal laparotomy patient in the semi-Fowler's position in bed. The patient is maintained in this position to facilitate the drainage of peritoneal contents into the lower region of the abdominal cavity after an abdominal laparotomy. This position also helps increase lung expansion.High-Fowler's position would be too high for the patient postoperatively. It would place strain on the abdominal incision(s), and, if the patient was still drowsy from anesthesia, this position would not enhance the patient's ability to rest. Sims' position does not promote drainage to the lower abdomen. The supine position does not facilitate drainage to the abdomen or increased lung expansion. The patient would be more likely to develop complications (wound drainage stasis and atelectasis) in the supine position.

An obese patient is discharged 10 days after being hospitalized for peritonitis, which resulted in an exploratory laparotomy. Which assessment finding by the patient's home health nurse requires immediate action? A. Pain when coughing B. States, "I am too tired to walk very much" C. States, "I feel like the incision is splitting open" D. Temperature of 100.8°F (38.2°C).

C. States, "I feel like the incision is splitting open" The assessment finding of a patient who had an exploratory laparotomy that requires immediate action by the home health nurse is the patient stating, "I feel like the incision is splitting open." The patient feeling like the incision is splitting open is at risk for poor wound healing and possible wound dehiscence. The nurse must immediately assess the wound and notify the primary health care provider.Reports of pain when coughing, being too tired to ambulate, and a temperature of 100.8°F (38.2°C) all require further assessment or intervention but are not as great a concern as the possibility of wound dehiscence for this patient.

A nurse in a family practice clinic is preparing discharge instructions for a client reporting facial pain that is worse when bending over, tenderness across the cheeks, and postnasal discharge. What instruction will be most helpful? a. Ice packs may help with the facial pain b. Limit fluids to dry out your sinuses c. Try warm, moist heat packs on your face d. We will schedule a computed tomography scan this week

C. Try warm, moist heat packs on your face This client has rhinosinusitis. Comfort measures for this condition include humidification, hot packs, nasal saline irrigations, sleeping with the head elevated, increased fluids, and avoiding cigarette smoke. The client does not need a CT scan.

A patient admitted with severe diarrhea is experiencing skin breakdown from frequent stools. What is an important comfort measure for this patient? A. Applying hydrocortisone cream B. Cleaning the area with soap and hot water C. Using sitz baths three times daily D. Wearing absorbent cotton underwear

C. Using sitz baths three times daily An important comfort measure for a patient admitted with severe diarrhea experiencing skin breakdown is using sitz baths three times daily.Barrier creams, not hydrocortisone creams, may be used. The skin would be cleaned gently with soap and warm, not hot, water. Absorbent cotton underwear helps keep the skin dry but is not a comfort measure.

After teaching a client who is recovering from a heart transplant to change positions slowly, the client asks, "Why is this important?" How would the nurse respond? a. Rapid position changes can create shear and friction forces, which can tear out your internal vascular sutures b. Your new vascular connections are more sensitive to position changes, leading to increased intravascular pressure and dizziness c. Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes d. While your heart is recovering, blood flow is diverted away from the brain, increasing the risk of stroke when you stand up

C. Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes Bc new heart is denervated, the baroreceptor and other mechanisms that compensate for BP drops caused by position changes do not function. This allows orthostatic hypotension to persist in postop period. Other statements false.

10. What is the nurse's best response when a client asks which diagnostic test will determine if an oral tumor is cancerous? A. "MRI is the only test that you will need at this time." B. "No single test will make the diagnosis on its own." C. "Aqueous toluidine blue will be absorbed by malignancies." D. "Biopsy is the definitive method for diagnosing oral cancer."

D

19. Which diagnostic test will the nurse expect the client to undergo to best identify a hiatal hernia? A. Esophagogastroduodenoscopy (EGD) B. 24-hour ambulatory pH monitoring C. Esophageal manometry D. Barium swallow with fluoroscopy

D

25. What does the nurse suspect when assessment of a client after gastric resection reveals a tongue that is smooth, shiny, and appears "beefy"? A. Inadequate nutrition B. Hypovolemia C. Anemia D. Atrophic glossitis

D

29. Which cause does the nurse recognize as a potential intentional cause for a client's esophageal trauma? A. Nasogastric (NG) tube placement B. Esophageal ulcers C. Struck by a foreign object D. Chemical injury

D

3. A client is diagnosed with renal colic. What would the nurse do first? A. Prepare the client for lithotripsy. B. Encourage oral intake of fluids. C. Strain the urine and send for urinalysis. D. Administer opioids as prescribed.

D

31-22 What does the nurse suspect when assessing a client's telemetry ECG strip and noting a wide, distorted QRS complex of 0.14 seconds followed by a P wave? A. Delayed time of the impulse through the ventricles B. Problem with speed set on the ECG telemetry monitor C. Wide but normal complex with no cause for concern D. PVC followed by atrial contraction

D

31-24 Which dysrhythmias does the nurse consider life threatening because it causes the ventricles to quiver & results in the absence of cardiac output for a client? A. Asystole B. Ventricular tachycardia C. Atrial fibrillation D. Ventricular fibrillation

D

31-27 When a client has been in atrial fibrillation for 3 days and is scheduled for an elective cardioversion, what priority teaching does the nursing provide to the client? A. Consume potassium-rich food sources such as bananas B. Report muscle tremors or weakness to the HCP C. Get up slowly when getting out of bed or chair D. Watch for any signs of bleeding and report it to the HCP

D

31-29 Which client assessment takes priority when the nurse begins his or her shift? A. Client with chronic atrial fibrillation and ventricular rate of 72 bpm B. Client with sinus tachycardia & occasional PACs C. Client with paroxysmal supraventricular tachycardia that terminated D. Client with atrial fibrillation and sustained rapid ventricular response

D

31-7 Which definition best describes the electro physiologic property called automaticity of myocardial pacemaker cells A. Ability of atrial & ventricular muscle cells to shorten their fiber length causing sufficient pressure to push blood forward through the heart B. Ability to send an electrical stimulus from cell membrane to cell membrane C. Ability of non-pacemaker heart cells to respond to an electrical impulse that begins in pacemaker cells D. Ability of cardiac cells to generate an electrical impulse approximately and repetitively

D

4. For which hospitalized client does the nurse recommend the ongoing use of a urinary catheter? A. A 35-year-old woman who was admitted with a splenic laceration and femur fracture (closed repair completed) following a car crash B. A 48-year-old man who has established paraplegia and is admitted for pneumonia C. A 61-year-old woman who is admitted following a fall at home and has new-onset dysrhythmia D. A 74-year-old man who has lung cancer with brain metastasis and is being transitioned to hospice

D

7. What priority teaching will the nurse provide to prevent harm when a client with gastritis reports taking ibuprofen regularly for discomfort related to arthritis? A. "Do not take ibuprofen more than twice a day." B. "Ibuprofen can interfere with the action of the drugs you take for gastritis." C. "This drug is excellent for pain relief related to arthritis." D. "Avoid taking ibuprofen because it can cause gastritis."

D

The nurse is caring for a client scheduled to have a transjugular intrahepatic portal-systemic shunt (TIPS) procedure. What client assessment would the nurse perform prior to this procedure? a. Musculoskeletal assessment b. Neurologic assessment c. Mental health assessment d. Cardiovascular assessment

D

The nurse is caring for a client who has cirrhosis of the liver. Which risk factor is the leading cause of cirrhosis? a. Metabolic syndrome b. Liver cancer c. Nonalcoholic fatty liver disease d. Hepatitis C

D

The nurse is caring for a client who is scheduled for a paracentesis. Which action is appropriate for the nurse to take? a. Have the client sign the informed consent form. b. Get the patient into a chair before the procedure. c. Help the client lie flat in bed on the right side. d. Assist the client to void before the procedure.

D

Which assessment technique will the nurse use to most accurately determine increasing ascites in a client with advanced liver cirrhosis and portal hypertension? A. Interpreting the serum albumin value B. Measuring the client's abdominal girth C. Testing stool for the presence of occult blood D. Weighing the client daily at the same time of the day

D

Which essential nutrient will the nurse expect to be deficient in a client who has liver cirrhosis and ascites? A. Sodium B. Potassium C. Vitamin C D. Vitamin K

D

Physiological Integrity 20. A patient arrives in the ear, nose, and throat clinic complaining of a piece of tissue being "stuck up my nose" and with foul-smelling nasal drainage from the right nare. Which action should the nurse take first? a. Notify the clinic health care provider. b. Obtain aerobic culture specimens of the drainage. c. Ask the patient about how the cotton got into the nose. d. Have the patient occlude the left nare and blow the nose.

D Because the highest priority action is to remove the foreign object from the nare, the nurse's first action should be to assist the patient to remove the object. The other actions are also appropriate but should be done after attempting to clear the nose. DIF: Cognitive Level: Apply (application) REF: 506 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:

1. The nurse teaches a patient about discharge instructions after a rhinoplasty. Which statement, if made by the patient, indicates that the teaching was successful? a. "I can take 800 mg ibuprofen for pain control." b. "I will safely remove and reapply nasal packing daily." c. "My nose will look normal after 24 hours when the swelling goes away." d. "I will keep my head elevated for 48 hours to minimize swelling and pain."

D Maintaining the head in an elevated position will decrease the amount of nasal swelling. NSAIDs, such as ibuprofen, increase the risk for postoperative bleeding and should not be used postoperatively. The patient would not be taught to remove or reapply nasal packing, which is usually removed by the surgeon on the day after surgery. Although return to a preinjury appearance is the goal of the surgery, it is not always possible to achieve this result, especially in the first few weeks after surgery. DIF: Cognitive Level: Apply (application) REF: 498 TOP: Nursing Process: Implementation MSC:

Physiological Integrity 21. The nurse is caring for a patient who has acute pharyngitis caused by Candida albicans. Which action is appropriate for the nurse to include in the plan of care? a. Avoid giving patient warm liquids to drink. b. Assess patient for allergies to penicillin antibiotics. c. Teach the patient about the need to sleep in a warm, dry environment. d. Teach patient to "swish and swallow" prescribed oral nystatin (Mycostatin).

D Oral or pharyngeal fungal infections are treated with nystatin solution. The goal of the "swish and swallow" technique is to expose all of the oral mucosa to the antifungal agent. Warm liquids may be soothing to a sore throat. The patient should be taught to use a cool mist humidifier. There is no need to assess for penicillin/cephalosporin allergies because Candida albicans infection is treated with antifungals. DIF: Cognitive Level: Apply (application) REF: 506-507 TOP: Nursing Process: Planning MSC:

Physiological Integrity 13. A nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery what is the priority nursing action? a. Monitor for bleeding. b. Maintain adequate IV fluid intake. c. Suction tracheostomy every eight hours. d. Keep the patient in semi-Fowler's position.

D The most important goals after a laryngectomy and radical neck dissection are to maintain the airway and ensure adequate oxygenation. Keeping the patient in a semi-Fowler's position will decrease edema and limit tension on the suture lines to help ensure an open airway. Maintenance of IV fluids and monitoring for bleeding are important, but maintaining an open airway is the priority. Tracheostomy care and suctioning should be provided as needed. During the immediate postoperative period, the patient with a laryngectomy requires frequent suctioning of the tracheostomy tube. DIF: Cognitive Level: Apply (application) REF: 516 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:

Physiological Integrity 2. The nurse plans to teach a patient how to manage allergic rhinitis. Which information should the nurse include in the teaching plan? a. Hand washing is the primary way to prevent spreading the condition to others. b. Use of oral antihistamines for 2 weeks before the allergy season may prevent reactions. c. Corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use. d. Identification and avoidance of environmental triggers are the best way to avoid symptoms.

D The most important intervention is to assist the patient in identifying and avoiding potential allergens. Intranasal corticosteroids (not oral antihistamines) should be started several weeks before the allergy season. Corticosteroid nasal sprays have minimal systemic absorption. Acute viral rhinitis (the common cold) can be prevented by washing hands. DIF: Cognitive Level: Apply (application) REF: 500 TOP: Nursing Process: Planning MSC:

Health Promotion and Maintenance 9. A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, "Will I be able to talk normally after surgery?" What is the best response by the nurse? a. "You will breathe through a permanent opening in your neck, but you will not be able to communicate orally." b. "You won't be able to talk right after surgery, but you will be able to speak again after the tracheostomy tube is removed." c. "You won't be able to speak as you used to, but there are artificial voice devices that will give you the ability to speak normally." d. "You will have a permanent opening into your neck, and you will need to have rehabilitation for some type of voice restoration."

D Voice rehabilitation is planned after a total laryngectomy, and a variety of assistive devices are available to restore communication. Although the ability to communicate orally is changed, it would not be appropriate to tell a patient that this ability would be lost. Artificial voice devices do not permit normal-sounding speech. In a total laryngectomy, the vocal cords are removed, so normal speech is impossible. DIF: Cognitive Level: Apply (application) REF: 516 TOP: Nursing Process: Implementation MSC:

Which location would the nurse expect to be the most common for a client to form an aneurysm? A. Femoral artery B. Radial artery C. Thoracic aorta D. Abdominal aorta

D Aneurysms tend to occur at specific anatomic sites, most commonly in the abdominal aorta. They often occur at a point where the artery is not supported by skeletal muscles or on the lines of curves or flexion in the arterial tree. Abdominal aortic aneurysms (AAAs) account for most true aneurysms. They are commonly asymptomatic, and frequently rupture. Most of these are located between the renal arteries and the aortic bifurcation (dividing area).

What symptom would the nurse expect on assessment of a client with inflow peripheral arterial disease? A. Frequent episodes of rest pain B. Burning or cramping in the calves, ankles, feet, or toes after walking C. Waking often at night for pain relieved by hanging feet off the bed D. Discomfort in the lower back, buttocks, or thighs after walking

D Clients with inflow disease have discomfort in the lower back, buttocks, or thighs. Clients with mild inflow disease have discomfort after walking about two blocks. This discomfort is not severe but causes them to stop walking. The discomfort is relieved with rest.

Which condition would the nurse suspect when a client has these findings (BP 200/130 mm Hg; sudden headache, blurred vision, and dyspnea)? A. Sustained hypertension B. Primary hypertension C. Secondary hypertension D. Malignant hypertension

D Hypertensive crisis (or malignant hypertension) is a severe type of elevated BP that rapidly progresses and is considered a medical emergency. A person with this health problem usually has symptoms such as morning head-aches, blurred vision, and dyspnea and/or symptoms of uremia (accumulation in the blood of substances ordinarily eliminated in the urine). Clients are often in their 30s, 40s, or 50s with their systolic BP greater than 200 mm Hg.

What would the nurse suspect when assessing a client's lower extremities and finding decreased pedal pulses, skin that is cool to touch, loss of hair, and thickened toenails? A. Peripheral venous disease B. Raynaud's syndrome C. Deep vein thrombosis D. Peripheral arterial disease

D Specific findings for PAD depend on the severity of the disease. Assess for loss of hair on the lower calf, ankle, and foot; dry, scaly, dusky, pale, or mottled skin; and thickened toenails. With severe arterial disease, the extremity is cold and gray-blue (cyanotic) or darkened. Pallor may occur when the extremity is elevated.

What priority teaching would the nurse provide for a client who will be discharged with a prescription for atorvastatin? A. "Take over-the-counter ranitidine when you experience nausea or vomiting." B. "Go to the emergency department if you experience a nagging, nonproductive cough." C. "You can use acetaminophen if the drug causes mild to moderate headaches." D. "Immediately report any muscle cramping to your primary health care provider."

D Statins reduce cholesterol synthesis in the liver and increase clearance of LDL-C from the blood. Therefore, they are contraindicated in clients with active liver disease or during pregnancy because they can cause muscle myopathies and marked decreases in liver function. Statins also have the potential for interactions with other drugs, such as warfarin, cyclosporine, and selected antibiotics. They are discontinued if the client has muscle cramping or elevated liver enzyme levels.

For prevention of DVT, which drug would the nurse expect the health care provider to prescribe? A. Thrombolytic therapy B. IV unfractionated heparin C. Novel oral anticoagulants (NOACs) D. Subcutaneous low-molecular-weight heparin (LMWH)

D Subcutaneous low-molecular-weight heparins (LMWHs) such as enoxaparin or dalteparin have a consistent action and are preferred for prevention and treatment of DVT. Some clients taking LMWH may be safely managed at home with visits from a home care nurse. Candidates for home therapy must have stable DVT or PE, low risk for bleeding, adequate renal function, and normal vital signs. They must be willing to learn self-injection or have a family member, friend, or home care nurse administer the subcutaneous injections.

What does the nurse suspect when assessing a client on bedrest and finding that he or she has a left calf that is swollen, warm to touch, reddened, and moderately painful? A. Raynaud's syndrome B. Cellulitis C. Arterial occlusion D. Deep vein thrombosis

D The classic signs and symptoms of DVT are calf or groin tenderness and pain, and sudden onset of unilateral swelling of the leg. Examine the painful area, comparing the site with the other limb. Gently palpate the site, observing for induration (hardening) along the blood vessel and for warmth and edema. Redness may also be present.

Which activity would the nurse advise during the recovery period for a client returning home after AAA repair? A. Climbing a flight of stairs B. Driving a car C. Playing golf D. Gradually increased walking

D The client must follow instructions regarding activity level. Because stair climbing may be restricted initially, he or she may need a bed-side commode if the bathroom is inaccessible. Clients may not perform activities that involve lifting heavy objects (usually more than 15 to 20 lb [6.8 to 9.1 kg]) for 6 to 12 weeks after surgery. Advise them to use caution for activities that involve pulling, pushing, or straining. Most clients are restricted from driving a car for several weeks after discharge. Instruct clients to try to walk each day. They should gradually increase and walk a little more each day.

What is the nurse's best advice for a client, who is an avid golfer, but has been recently diagnosed with thoracic outlet syndrome? A. Check your blood pressure in both arms daily. B. Rest whenever shortness of breath occurs. C. Avoid walking for long distances. D. Don't elevate your arms above your head.

D Thoracic outlet syndrome is caused by compression of the subclavian artery by rib or muscle. It is more common in women and clients who have to keep arms moving or above their heads (e.g., golfers, swimmers). The best treatment is physical therapy for an exercise program, avoiding aggravating positions.

Which method would the postanesthesia care unit (PACU) nurse use to assess the patency of the graft after a client's arterial revascularization with graft placement? A. Gently palpate the site every 15 minutes for the first hour and assess for warmth, redness, and swelling. B. Ask the client if there is any pain or loss of sensation anywhere in the extremity. C. Check the dorsalis pedis and post tibial pulses for the first hour, then every 2 hours. D. Check the affected extremity, comparing it to the unaffected, for changes in color, temperature, and pulse intensity every 15 minutes for the first hour, then hourly.

D To assess graft patency after arterial revascularization, monitor the patency of the graft by checking the extremity every 15 minutes for the first hour and then hourly for changes in color, temperature, and pulse intensity. Compare the operative leg with the unaffected extremity. If the operative leg feels cold; becomes pale, ashen, or cyanotic; or has a decreased or absent pulse, contact the surgeon immediately!

Which symptom causes most clients to seek medical attention for peripheral arterial disease (PAD)? A. Pain at rest B. Rubor in the extremity C. Muscle atrophy D. Intermittent claudication

D Most clients initially seek medical attention for a classic leg pain known as intermittent claudication. Usually the client can walk only a certain distance before discomfort (e.g., cramping or burning muscular pain) forces them to stop. The pain goes away with rest. When clients resume walking, they walk the same distance and the pain returns. Because of this, the pain is considered reproducible. As the disease progresses, the client can walk only shorter and shorter distances before pain recurs. Ultimately, the pain may occur even while at rest.

An emergency department nurse triages clients who present with chest discomfort. Which client should the nurse plan to assess first? a. A 42-year-old female who describes her pain as a dull ache with numbness in her fingers b. A 49-year-old male who reports moderate pain that is worse on inspiration c. A 53-year-old female who reports substernal pain that radiates to her abdomen d. A 58-year-old male who describes his pain as intense stabbing that spreads across his chest

D- All clients who have chest pain should be assessed more thoroughly. To determine which client should be seen first, the nurse must understand common differences in pain descriptions. Intense stabbing, vise-like substernal pain that spreads through the clients chest, arms, jaw, back, or neck is indicative of a myocardial infarction. The nurse should plan to see this client first to prevent cardiac cell death. A dull ache with numbness in the fingers is consistent with anxiety. Pain that gets worse with inspiration is usually related to a pleuropulmonary problem. Pain that spreads to the abdomen is often associated with an esophageal-gastric problem, especially when this pain is experienced by a male client. Female clients may experience abdominal discomfort with a myocardial event. Although clients with anxiety, pleuropulmonary, and esophageal-gastric problems should be seen, they are not a higher priority than myocardial infarction.

Which blood pressure reading does the nurse expect will result in compromised kidney function for a client who sustained major injuries in an MVA? A. 160/80 mm Hg B. 140/100 mm Hg C. 80/60 mm Hg D. 68/40 mm Hg

D. 68/40 mm Hg

An intensive care unit (ICU) RN is "floated" to the medical-surgical unit. Which patient does the charge nurse assign to the float nurse? A. A 28-year-old with an exacerbation of Crohn's disease (CD) who has a draining enterocutaneous fistula B. A 32-year-old with ulcerative colitis (UC) who needs discharge teaching about the use of hydrocortisone enemas C. A 34-year-old who has questions about how to care for a newly created ileo-anal reservoir D. A 36-year-old with peritonitis who just returned from surgery with multiple drains in place

D. A 36-year-old with peritonitis who just returned from surgery with multiple drains in place The charge nurse assigns to the ICU nurse who was floated to the medical-surgical unit a 36-year-old patient with peritonitis who just returned from surgery with multiple drains in place. The ICU nurse is familiar with the care of a patient with peritonitis, including monitoring for complications such as sepsis and kidney failure.The patient with CD who has a draining enterocutaneous fistula, the patient with UC who needs discharge teaching, and the patient with questions about an ileo-anal reservoir are best assigned to a medical-surgical nurse who is more familiar with the care and teaching needed for patients with their respective disorders.

A nurse assesses a client after administering the first dose of a nitrate. The client reports a headache. What action would the nurse take? a. Initiate oxygen therapy b. Hold the next dose c. Instruct the client to drink water d. Administer PRN acetaminophen

D. Administer PRN acetaminophen The vasodilating fx of nitrates frequently cause pts to have headaches in the initial period of therapy. The nurse would inform the pt about this side effect and offer a mild analgesic, such as acetaminophen. The pt's headache is not related to hypoxia or dehydration so O2 or H2O would not help. The pt needs to take the med as prescribed to prevent angina; the med wouldn't be held.

Which client will the nurse encourage to consume 2 to 3 L of fluid each day? A. Client with heart failure B. Client with chronic kidney disease C. Client with complete bowel obstruction D. Client with hyperparathyroidism

D. Client with hyperparathyroidism

A nurse teaches a client who is prescribed digoxin therapy. Which statement would the nurse include in this client's teaching? a. Avoid taking aspirin or aspirin-containing products b. Increase your intake of foods that are high in potassium c. Hold this medication if your pulse rate is below 80 beats/min d. Do not take this medication within 1 hour of taking an antacid

D. Do not take this medication within 1 hour of taking an antacid GI absorption of digoxin is erratic. Many meds, especially antacids, interfere with its absorption. Pts are taught to hold their digoxin for bradycardia; a heart rate of 80 beats/min is too high for this cut off. Potassium and aspirin have no impact on digoxin absorption.

When a client with diabetes returns to the medical unit after a computed tomography (CT) scan with contrast dye, all of these interventions are prescribed. Which intervention will the nurse implement first? A. Administer captopril. B. Request a breakfast tray for the client. C. Administer lispro (Humalog) insulin, 10 units subcutaneously. D. Infuse 0.45% normal saline at 125 mL/hr.

D. Infuse 0.45% normal saline at 125 mL/hr.

The nurse assesses blood clots in a client's urinary catheter after a cystoscopy. What initial nursing intervention is appropriate? A. Administer heparin intravenously. B. Remove the urinary catheter. C. Irrigate the catheter with sterile saline. D. Notify the health care provider (HCP).

D. Notify the health care provider (HCP).

A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to the left side fo the neck. Which nonpharmacologic comfort measure would the nurse implement? a. Apply an ice pack to the client's chest b. Provide a neck rub, especially on the left side c. Allow the client to lie in bed with the lights down d. Sit the client up with a pillow to lean forward on

D. Sit the client up with a pillow to lean forward on Pain from acute pericarditis may worsen when pt lays supine. Nurse would position pt in a comfortable position, usually upright and leaning slight forward. An ice pack and neck rub will not relieve pain. Dimming lights will not help

An 80-year-old patient with a 2-day history of myalgia, nausea, vomiting, and diarrhea is admitted to the medical-surgical unit with a diagnosis of gastroenteritis. Which primary health care provider request does the nurse implement first? A. Administer acetaminophen (Tylenol) 650 mg rectally. B. Draw blood for a complete blood count and serum electrolytes. C. Obtain a stool specimen for culture and sensitivity. D. Start an IV solution of 5% dextrose in 0.45 normal saline at 125 mL/hr.

D. Start an IV solution of 5% dextrose in 0.45 normal saline at 125 mL/hr. The request the nurse implements first is to start an IV solution of 5% dextrose in 0.45 normal saline at 125 mL/hr. Although the dextrose 5% in 0.45% sodium chloride is hypertonic in the IV bag, once it is infused, the glucose is rapidly metabolized and the fluid is really hypotonic. Fluid therapy is the focus of treatment for patients with gastroenteritis. Older patients are at increased risk for the complications of dehydration such as hypovolemia and acute kidney failure.Acetaminophen 650 mg should be administered rectally soon, and blood draws and stool specimen collection would also be implemented soon, but prevention and treatment of dehydration are the priorities for this patient.

A client is in the family practice clinic reporting a sever "cold" that started 4 days ago. On examination, the nurse notes that the client also has a severe headache and muscle aches. What action by the nurse is BEST? a. Educate the client on oseltamivir b. Facilitate admission to the hospital c. Instruct the client to have a flu vaccine d. Teach the client to sneeze in the upper sleeve

D. Teach the client to sneeze in the upper sleeve Sneezing and coughing into one's sleeve helps prevent the spread of URIs. The client does have symptoms of the flu, but it is too late to start antivirals; to be effective, they must be started w/in 24-48 hours of symptom onset. The client does not need hospital admission. The client would be instructed to have a flu vaccination, but now that he or she has the flu, vaccination will have to wait until next year.

A client is being discharged on a long-term therapy for tuberculosis. What referral by the nurse is MOST appropriate? a. Community social worker for Meals on Wheels b. Occupational therapy for job retraining c. Physical therapy for homebound therapy services d. Visiting nurses for directly observed therapy

D. Visiting nurses for directly observed therapy. Directly observed therapy is often utilized for managing clients with TB in the community. The other options may or may not be appropriate.

A nurse teaches a client who has a history of heart failure. Which statement would the nurse include in this client's discharge teaching? a. Avoid drinking more than 3 quarts (3 L) of liquids each day b. Eat six small meals daily instead of three larger meals c. When you feel short of breath, take an additional diuretic d. Weigh yourself each day while wearing the same amount of clothing

D. Weigh yourself each day while wearing the same amount of clothing Pts with HF are instructed to weight themselves daily to detect worsening HF early and avoid complications. Other signs include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia. Fluid overload increases symptoms of HF. The pt would be taught to eat a heart healthy diet, balance intake and output to prevent dehydration and overload, and take meds as prescribed. The most important discharge teaching is daily weights as this provides the best data related to fluid retention.

A client has been admitted for suspected inhalation anthrax infection. What question by the nurse is MOST important? a. Are any family members also ill? b. Have you traveled recently? c. How long have you been ill? d. What is your occupation?

D. What is your occupation? Inhalation anthrax is rare and is an occupational hazard among people who work with animal wool, bone meal, hides, and skin, such as taxidermists and veterinarians. Inhalation anthrax seen in someone without an occupation risk is considered a bioterrorism event and must be reported to authorities immediately. The other questions are appropriate for anyone with an infection.

A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, "I know a transplant is my last chance, but I don't want to become a vegetable." How would the nurse respond? a. Would you like to speak with a priest or chaplain? b. I will arrange for a psychiatrist to speak with you c. Do you want to come off the transplant list? d. Would you like more information about advance directives?

D. Would you like more information about advance directives? Pt is verbalizing a real concern/fear about negative outcomes of surgery. This anxiety itself can have negative effects on the outcome because of SNS stimulation. The best action is to allow pt to verbalize concern and work toward positive outcome without making pt feel as though concerns are not valid. Pt needs to feel some control over future. Nurse personally provides care to address the pt's concerns instead of immediately calling for the chaplain or psychiatrist. Nurse would not jump to conclusions and suggest taking pt off transplant list, which is the best tx option.

A patient who had surgery for inflammatory bowel disease is being discharged. The case manager will arrange for home health care follow-up. The patient tells the nurse that family members will also be helping with care. What information is critically important for the nurse to provide to these collaborating members? A. A list of medical supply facilities where wound care supplies may be purchased B. Proper handwashing techniques to avoid cross-contamination of the patient's wound C. The amount of pain medication that the patient is allowed to take in each dose D. Written and oral instructions regarding signs/symptoms to report to the primary health care provider

D. Written and oral instructions regarding signs/symptoms to report to the primary health care provider It is critically important to provide the patient and case manager with both written and oral instructions on reportable signs/symptoms to avoid the development of complications.It will be the home health nurse's responsibility to bring supplies to the patient's home. Although instruction on proper handwashing and the patient's medication regimen are important, they are not the highest priority.

A nurse observes that a clients anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question should the nurse ask the client in response to this finding? a. Are you taking any medications or herbal supplements? b. Do you have any chronic breathing problems? c. How often do you perform aerobic exercise? d. What is your occupation and what are your hobbies?

Do you have any chronic breathing problems? The normal chest has a lateral diameter that is twice as large as the AP diameter. When the AP diameter approaches or exceeds the lateral diameter, the client is said to have a barrel chest. Most commonly, barrel chest occurs as a result of a long-term chronic airflow limitation problem, such as chronic obstructive pulmonary disease or severe chronic asthma. It can also be seen in people who have lived at a high altitude for many years. Therefore, an AP chest diameter that is the same as the lateral chest diameter should be rechecked but is not as indicative of underlying disease processes as an AP diameter that exceeds the lateral diameter. Medications, herbal supplements, and aerobic exercise are not associated with a barrel chest. Although occupation and hobbies may expose a client to irritants that can cause chronic lung disorders and barrel chest, asking about chronic breathing problems is more direct and should be asked first.

A nurse auscultates a harsh hollow sound over a clients trachea and larynx. Which action should the nurse take first? a. Document the findings. b. Administer oxygen therapy. c. Position the client in high-Fowlers position. d. Administer prescribed albuterol.

Document the findings. Bronchial breath sounds, including harsh, hollow, tubular, and blowing sounds, are a normal finding over the trachea and larynx. The nurse should document this finding. There is no need to implement oxygen therapy, administer albuterol, or change the clients position because the finding is normal.

3. A nurse cares for a postmenopausal client who has had two episodes of bacterial urethritis in the last 6 months. The client asks, "I never have urinary tract infections. Why is this happening now?" How would the nurse respond? a. "Your immune system becomes less effective as you age." b. "Low estrogen levels can make the tissue more susceptible to infection." c. "You should be more careful with your personal hygiene in this area." d. "It is likely that you have an untreated sexually transmitted disease."

G R A D E S L A B . C O M ANS: B Low estrogen levels decrease moisture and secretions in the perineal area and cause other tissue changes, predisposing it to the development of infection. Urethritis is most common in postmenopausal women for this reason. Although immune function does decrease with aging and sexually transmitted diseases are a known cause of urethritis, the most likely reason in this patient is low estrogen levels. Personal hygiene usually does not contribute to this disease process.

A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. Which action should the nurse take next? a. Administer an albuterol treatment. b. Notify the Rapid Response Team. c. Assess the clients peripheral pulses. d. Obtain blood and sputum cultures.

Notify the Rapid Response Team. Cyanosis unresponsive to oxygen therapy is a manifestation of methemoglobinemia, which is an adverse effect of benzocaine spray. Death can occur if the level of methemoglobin rises and cyanosis occurs. The nurse should notify the Rapid Response Team to provide advanced nursing care. An albuterol treatment would not address the clients oxygenation problem. Assessment of pulses and cultures will not provide data necessary to treat this client.

A nurse assesses a client with diabetes mellitus. Which assessment finding would alert the nurse to decreased kidney function in this client?

Presence of protein in the urine

A nurse develops a dietary plan for a client with diabetes mellitus and new-onset microalbuminuria. Which component of the client's diet would the nurse decrease?

Proteins

patients with unstable angina may present with what type of changes on a 12 lead EKG? but will not have changes in what lab?

ST changes; will not have troponin level changes. There is ischemia present but not enough to cause cell death

Infuse lactated Ringer's solution 500 mL

The admission assessment for a patient with acute gastric bleeding indicates a blood pressure of 82/40 mm Hg, pulse of 124/min beats/min, and respiratory rate of 26 breaths/min. Which admission prescription would the nurse implement first?

Administering IV fluids

The nurse finds a patient vomiting coffee ground-type emesis. The patient is acutely confused, has blood pressure of 100/74 mm Hg, and has a weak and thready pulse. Which intervention would the nurse expect to be prescribed?

"Water goes down the tube to clean out your stomach

The nurse has placed a nasogastric (NG) tube in a patient with upper GI bleeding to administer gastric lavage. The patient asks the nurse about the purpose of the NG tube for the procedure. Which response would the nurse provide?

Type O blood

The nurse is assessing a patient who reports episodes of abdominal pain. Which patient data suggest increased risk for duodenal ulcer?

Worsens with the ingestion of food

The nurse is assessing the nature of abdominal pain in a patient with a suspected gastric ulcer. Which feature of the patient's pain is consistent with a gastric ulcer?

Rapid urease testing

The nurse is assisting with an esophagogastroduodenoscopy (EGD) procedure on a patient who has symptoms of gastritis. Which diagnostic test will the health care provider request on the tissue samples to determine the presence of Helicobacter pylori infection?

Assess for a gag reflex.

The nurse is caring for a patient who has just returned from an endoscopic procedure. The patient's spouse verbalizes that the patient must be hungry. Which action would the nurse take?

The pain occurs 3 hours after meals and at night.

The nurse is caring for an older-adult man who reports stomach pain and heartburn. Which characteristic would lead the nurse to suspect the ulcer was duodenal rather than gastric in location?

Metronidazole

The nurse is reviewing the medications prescribed for a patient with peptic ulcer disease (PUD). Which drug treats Helicobacter pylori infection?

Use complementary and alternative therapies

The nurse is teaching a patient about self-management of gastritis. Which information would the nurse include?

"Take the famotidine at bedtime."

The nurse is teaching a patient about the use of famotidine and sucralfate to treat gastritis. Which information would the nurse include?

Nizatidine needs to be taken three times a day to be effective.

The nurse is teaching a patient with peptic ulcer disease about the prescribed drug regimen. Which statement made by the patient indicates a need for further teaching?

Atrophic gastritis

Which disorder in older adults has a direct association with mucosa-associated lymphoid tissue (MALT) lymphoma?

Pernicious anemia, Nausea and vomiting, Intolerance to fatty food

Which finding is a key feature of chronic gastritis? Select all that apply. One, some, or all responses may be correct.

Radiation therapy

Which information found in a patient's history frequently correlates with a diagnosis of chronic gastritis?

"It is important to eat a well-balanced diet.", Avoid alcoholic beverages in excessive amounts., Avoid excessive intake of coffee or decaffeinated coffee.", "Protect against exposure to toxic substances in the workplace."

Which information would the nurse include when teaching patients to prevent gastritis? Select all that apply. One, some, or all responses may be correct.

Antrum of the stomach

Which location is common for gastric ulcers?

Document instructions for a patient with chronic gastritis about how to use triple therapy

Which nursing action would the nurse delegate to an experienced licensed practical nurse/licensed vocation nurse (LPN/LVN)?

Reducing caffeine intake

Which nutritional recommendation would the nurse provide to the patient with peptic ulcer disease (PUD)?

The nurse notes that the primary health care provider documented the presence of mucosal erythroplasia in a client. What does the nurse understand that this most likely means for this client? a. Early sign of oral cancer b. Fungal mouth infection c. Inflammation of the gums d. Obvious oral tumor

a Mucosal erythroplasia is the earliest sign of oral cancer. It is not a fungal infection, inflammation of the gums, or an obvious tumor.

While working in the outpatient procedure unit, the RN is assigned to four clients. Which client will the nurse assess first? a) A 51 year old who just had an endoscopic retrograde cholangiopancreatography (ERCP). b) A 58 year old who has just arrived for a sigmoidoscopy. c) A 60 year old with questions about an endoscopic ultrasound examination. d) A 54 year old who is ready for discharge following a colonoscopy.

a) A 51 year old who just had an endoscopic retrograde cholangiopancreatography (ERCP).

The nurse is assessing an alert client who had abdominal surgery yesterday. Which assessment method will the nurse use to most accurately determine whether peristalsis has resumed? a) Ask if the client has passed flatus (gas) within the previous 12 to 24 hours. b) Perform auscultation with the diaphragm of the stethoscope. c) Listen for bowel sounds in all abdominal quadrants. d) Count the number of bowel sounds in each abdominal quadrant over 1 minute.

a) Ask if the client has passed flatus (gas) within the previous 12 to 24 hours.

Which lunch food selection made by a client with diverticulosis indicates to the nurse the correct understanding of the necessary dietary modifications for management of the problem? a. A turkey sandwich on whole weight bread, steamed carrots, and a raw apple b. Roasted chicken, potato salad, and a glass of milk c. Chicken salad sandwich on white bread, creamed soup, and hot tea d. Fried shrimp, lettuce and tomato salad, and a dinner roll

a. A turkey sandwich on whole weight bread, steamed carrots, and a raw apple

13. A nurse cares for a client with diabetes mellitus who is prescribed metformin (Glucophage) and is scheduled for an intravenous urography. Which action should the nurse take first? a. Contact the provider and recommend discontinuing the metformin. b. Keep the client NPO for at least 6 hours prior to the examination. c. Check the client's capillary artery blood glucose and administer prescribed insulin. d. Administer intravenous fluids to dilute and increase the excretion of dye.

a. Contact the provider and recommend discontinuing the metformin.

5. A nurse contacts the health care provider after reviewing a client's laboratory results and noting a blood urea nitrogen (BUN) of 35 mg/dL and a creatinine of 1.0 mg/dL. For which action should the nurse recommend a prescription? a. Intravenous fluids b. Hemodialysis c. Fluid restriction d. Urine culture and sensitivity

a. Intravenous fluids

What is the nurse's best first action when the stoma of a client who had a permanent ileostomy placed 2 days ago now has a dark bluish-purple appearance? a. Notifying the surgeon immediately b. Applying oxygen by nasal cannula c. Placing the client in a high-owlet position d. Documenting the findings as the only action

a. Notifying the surgeon immediately

12. A nurse reviews the allergy list of a client who is scheduled for an intravenous urography. Which client allergy should alert the nurse to urgently contact the health care provider? a. Seafood b. Penicillin c. Bee stings d. Red food dye

a. Seafood

18. After delegating to an unlicensed assistive personnel (UAP) the task of completing a bladder scan examination for a client, the nurse evaluates the UAP's performance. Which action by the UAP indicates the nurse must provide additional instructions when delegating this task? a. Selecting the female icon for all female clients and male icon for all male clients b. Telling the client, "This test measures the amount of urine in your bladder." c. Applying ultrasound gel to the scanning head and removing it when finished d. Taking at least two readings using the aiming icon to place the scanning head

a. Selecting the female icon for all female clients and male icon for all male clients

In which position will the nurse place a client with peritonitis to promote comfort and prevent harm from potential complications? a. Semi-Fowler b. Left side-lying with knees to chest c. Right side-lying with knees to chest d. Supine flat with hips and knees flexed

a. Semi-Fowler

Chest pain or discomfort

angina

The nurse is caring for a client diagnosed with oral cancer. What is the nurse's priority for client care? a. Encourage fluids to liquefy the client's secretions. b. Place the client on Aspiration Precautions. c. Remind the client to use an incentive spirometer. d. Manage the client's pain and inflammation.

b The client who has oral cancer often has difficulty swallowing and is at risk for aspiration and possibly aspiration pneumonia. Therefore, the most important nursing action is to place the client on precautions to prevent aspiration. The nurse would implement the other actions but they are not as vital to promote client safety.

A client is preparing to undergo a stool DNA (sDNA) test to screen for colon cancer. What preprocedure teaching does the nurse provide? a) "Do not eat or drink anything for 12 hours before the test." b) "No special preparation is needed prior to completing this test." c) "Give yourself tap water enemas until the fluid returns are clear." d) "Begin a clear liquid diet at least 24 hours before the test."

b) "No special preparation is needed prior to completing this test."

9. A nurse cares for a client with a urine specific gravity of 1.018. Which action should the nurse take? a. Evaluate the client's intake and output for the past 24 hours. b. Document the finding in the chart and continue to monitor. c. Obtain a specimen for a urine culture and sensitivity. d. Encourage the client to drink more fluids, especially water.

b. Document the finding in the chart and continue to monitor.

2. A nurse reviews the health history of a client with an oversecretion of renin. Which disorder should the nurse correlate with this assessment finding? a. Alzheimer's disease b. Hypertension c. Diabetes mellitus d. Viral hepatitis

b. Hypertension

Which statement by a client with gastroenteritis due to infection with the norovirus indicates that the nurse's teaching about this illness has been successful? a. I got this infection from being around my grandchildren when they had respiratory illnesses b. It is most likely that I got this infectious illness from either contaminated food or water c. I may have gotten sick when I was traveling last month to Florida d. It's really important that I don't go to restaurants for at least a month after I am well

b. It is most likely that I got this infectious illness from either contaminated food or water

11. A nurse reviews a female client's laboratory results. Which results from the client's urinalysis should the nurse recognize as abnormal? a. pH 5.6 b. Ketone bodies present c. Specific gravity of 1.020 d. Clear and yellow color

b. Ketone bodies present

Which new onset assessment finding in a client with Crohn disease indicates to the nurse the possibility of fistula development? a. Anorexia b. Pyuria with fever c. Smooth, beefy red tongue d. Decreased serum albumin

b. Pyuria with fever

Which action is appropriate for the nurse to take to prevent harm when caring for a client with ulcerative colitis who has undergone a total proctocolectomy with placement of a permanent ileostomy? a. Irrigating the ileostomy to maintain patency b. Using a skin barrier to prevent exorciation c. Monitoring the client for nausea due to decreased intestinal motility d. Giving small, frequent feedings to compensate for malnutrition from short-gut syndrome

b. Using a skin barrier to prevent exorciation

The nurse is teaching a client diagnosed with stomatitis about special mouth care. Which statement by the client indicates a need for further teaching? a. "I need to take out my dentures until my mouth heals." b. "I'll try to eat soft foods that aren't spicy and acidic." c. "I will use a more firm toothbrush to keep my mouth clean." d. "I'll be sure to rinse my mouth often with warm salt water."

c The client who has stomatitis has oral inflammation which causes discomfort. Therefore, all of these actions help to avoid irritation except for needing to use a soft toothbrush or gauze rather than a firm one.

A client has an open traditional hiatal hernia repair this morning. What is the nurse's priority for client care at this time? a. Managing surgical pain b. Ambulating the client early c. Preventing respiratory complications d. Managing the nasogastric tube

c The client who has traditional surgery (rather than minimally invasive surgery) is at risk for respiratory complications such as atelectasis and pneumonia because he or she has an incision that may prevent the client from taking deep breaths or using an incentive spirometer. Therefore, the nurse's priority is to prevent these potentially life-threatening respiratory problems.

The nurse is assessing a very thin client who has come to the emergency department with acute abdominal pain. Upon assessment, visible peristaltic movements are noted. What is the appropriate nursing action? a) Prepare to administer antibiotics as prescribed. b) Report finding to the health care provider. c) Monitor laboratory values for possible pancreatitis. d) Toilet quickly as diarrhea is imminent.

c) Monitor laboratory values for possible pancreatitis.

14. A nurse teaches a client who is recovering from a urography. Which instruction should the nurse include in this client's discharge teaching? a. "Avoid direct contact with your urine for 24 hours until the radioisotope clears." b. "You may have some dribbling of urine for several weeks after this procedure." c. "Be sure to drink at least 3 liters of fluids today to help eliminate the dye faster." d. "Your skin may become slightly yellow from the dye used in this procedure."

c. "Be sure to drink at least 3 liters of fluids today to help eliminate the dye faster."

4. A nurse assesses a client with renal insufficiency and a low red blood cell count. The client asks, "Is my anemia related to the renal insufficiency?" How should the nurse respond? a. "Red blood cells produce erythropoietin, which increases blood flow to the kidneys." b. "Your anemia and renal insufficiency are related to inadequate vitamin D and a loss of bone density." c. "Erythropoietin is usually released from the kidneys and stimulates red blood cell production in the bone marrow." d. "Kidney insufficiency inhibits active transportation of red blood cells throughout the blood."

c. "Erythropoietin is usually released from the kidneys and stimulates red blood cell production in the bone marrow."

What does the nurse suspect when a client comes to the ED with right lower cramping pain, nausea, vomiting, and guarding with rigidity of the abdomen? a. Gastroenteritis b. Ulcerative colitis c. Appendicitis d. Crohn disease

c. Appendicitis

15. A nurse cares for a client who is recovering from a closed percutaneous kidney biopsy. The client states, "My pain has suddenly increased from a 3 to a 10 on a scale of 0 to 10." Which action should the nurse take first? a. Reposition the client on the operative side. b. Administer the prescribed opioid analgesic. c. Assess the pulse rate and blood pressure. d. Examine the color of the client's urine.

c. Assess the pulse rate and blood pressure.

16. A nurse obtains a sterile urine specimen from a client's Foley catheter. After applying a clamp to the drainage tubing distal to the injection port, which action should the nurse take next? a. Clamp another section of the tube to create a fixed sample section for retrieval. b. Insert a syringe into the injection port and aspirate the quantity of urine required. c. Clean the injection port cap of the drainage tubing with povidone-iodine solution. d. Withdraw 10 mL of urine and discard it; then withdraw a fresh sample of urine.

c. Clean the injection port cap of the drainage tubing with povidone-iodine solution.

Which laboratory finding will the nurse expect to see in a client who is suspected of having an acute, uncomplicated appendicitis? a. Decreased serum potassium level b. Increased international normalized ratio c. Increased WBC count d. Decreased erythrocyte sedimentation rate

c. Increased WBC count

Which complication will the nurse suspect when a client with peritonitis reports increased pain in the upper left abdominal quadrant and in the left shoulder, especially during inhalation? a. Sepsis b. Pneumonia c. Localized abscess d. Bacterial hepatitis

c. Localized abscess

Which serum laboratory value is most important for the nurse to monitor when caring for an older client with gastroenteritis who has an irregular heart rate and reports "feeling weak"? a. Albumin b. Sodium c. Potassium d. Leukocyte count

c. Potassium

Catecholamine's are released in response to? What will this cause to happen to the hearts rate, contractility and afterload?

catecholamine's (epi and norepi) are released in response to hypoxia and pain. This may increase the heart's rate, contractility and afterload. If there is an increase in oxygen demand ventricular dysrhythmias occur

The nurse is teaching a client about the use of viscous lidocaine for oral pain. What health teaching would the nurse include? a. "Use the drug before every meal to prevent aspiration." b. "Increase your intake of citrus foods to help with healing." c. "Use the drug only at bedtime because you won't be eating." d. "Be sure to check food temperatures before eating."

d Viscous lidocaine has an anesthetic effect in the oral cavity. Therefore, to promote client safety, the nurse would want to teach the client to check food temperature before eating.

Which client does the charge nurse assign to an experienced LPN/LVN working on the adult medical unit? a) A 40 year old who needs administration of IV midazolam hydrochloride during an upper endoscopy. b) A 36 year old who needs teaching about an endoscopic retrograde cholangiopancreatography. c) A 46 year old who is admitted with abdominal cramping and diarrhea of unknown causes. d) A 32 year old with constipation who has received a laxative.

d) A 32 year old with constipation who has received a laxative.

Which client does the charge nurse on the adult medical unit assign to an RN who has floated from the outpatient gastrointestinal (GI) clinic? a) Client admitted with nausea, abdominal pain, and abdominal distention. b) Client who needs discharge teaching after an endoscopic retrograde cholangiopancreatography (ERCP). c) Client with epigastric pain who needs conscious sedation during endoscopy. d) Client who has had laxatives administered and needs monitoring before a colonoscopy.

d) Client who has had laxatives administered and needs monitoring before a colonoscopy.

17. A nurse cares for a client who is having trouble voiding. The client states, "I cannot urinate in public places." How should the nurse respond? a. "I will turn on the faucet in the bathroom to help stimulate your urination." b. "I can recommend a prescription for a diuretic to improve your urine output." c. "I'll move you to a room with a private bathroom to increase your comfort." d. "I will close the curtain to provide you with as much privacy as possible."

d. "I will close the curtain to provide you with as much privacy as possible."

Which drug will the nurse be sure to question to prevent harm when prescribed for an older adult with gastroenteritis? a. Azythromycin b. Protective skin barrier cream c. Ciprofloxacin d. Diphenoxylate hydrochloride with atropine sulfate

d. Diphenoxylate hydrochloride with atropine sulfate