Unit 3

Which data would indicate a potential complication associated with age-related changes in the musculoskeletal system? 1. Decrease in height 2. Overall sclerotic lesions 3. Diminished lean body mass 4. Changes in structural bone tissue

Changes in structural bone tissue

A client has just delivered an 8 lb 8 oz infant boy after a prolonged labor. The pediatrician prescribes ampicillin 50 mg to be given by the intramuscular route to the newborn every 8 hours. The nurse is initiating the first dose. Ampicillin is available in powder form for injection. The directions on the bottle indicate reconstitution with 0.9 mL of sterile diluent for a concentration of 125 mg/mL. How many milliliters (mL) should the nurse prepare to administer the first dose? Fill in the blank.

2.5 ml

A client originally was prescribed oral sertraline (Zoloft) 25 mg daily for depression. The dose has been gradually increased in an effort to control the symptoms. The current dose is 75 mg daily. The medication label reads 25 mg/tablet.To receive the correct dose, the nurse instructs the client to take how many tablets once daily? Fill in the blank.

3 Tablets

The nurse is reviewing the laboratory results from the lumbar puncture performed on a client with a diagnosis of meningitis. Which finding is indicative of a bacterial infection? Select all that apply. 1. Clear fluid sample 2. Increased glucose level 3. Protein level of 20 mg/dL 4. Increased white blood cells 5. A cerebrospinal fluid (CSF) pressure of 250 mm H2O

3. Protein level of 20 mg/dL 4. Increased white blood cells 5. A cerebrospinal fluid (CSF) pressure of 250 mm H2O

The nurse who is caring for a client with kidney failure notes that the client is dyspneic, and crackles are heard on auscultation of the lungs. Which additional signs/symptoms should the nurse expect to note in this client? 1. Rapid weight loss 2. Flat hand and neck veins 3. A weak and thready pulse 4. An increase in blood pressure

An increase in blood pressure. Rationale: Impaired cardiac or kidney function can result in fluid volume excess. Findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, an elevated blood pressure, a bounding pulse, an elevated central venous pressure, weight gain, edema, neck and hand vein distention, an altered level of consciousness, and a decreased hematocrit level.

The nurse should use which best method to open the victim's airway if the victim sustained a neck injury? 1. Head tilt-chin lift 2. Head tilt-jaw thrust 3. Jaw thrust maneuver 4. Neutral or sniffing position

Neutral or sniffing position

An antihypertensive medication has been prescribed for a client with hypertension. The client tells the nurse that she would like to take an herbal substance to help lower her blood pressure. Which statement by the nurse is the most important to provide to the client? 1. "Herbal substances are not safe and should never be used." 2. "I will teach you how to take your blood pressure so that it can be monitored closely." 3. "You will need to talk to your health care provider (HCP) before using an herbal substance." 4. "If you take an herbal substance, you will need to have your blood pressure checked frequently."

"You will need to talk to your health care provider (HCP) before using an herbal substance." Rationale: Although herbal substances may have some beneficial effects, not all herbs are safe to use. Clients who are being treated with conventional medication therapy should be advised to avoid herbal substances with similar pharmacological effects, because the combination may lead to an excessive reaction or unknown interaction effects. Therefore, the nurse would advise the client to discuss the use of the herbal substance with the HCP.

The nurse is assisting with collecting data from an African-American client admitted to the ambulatory care unit who is scheduled for a hernia repair. Which information about the client is of least priority during the data collection? 1. Respiratory 2. Psychosocial 3. Neurological 4. Cardiovascular

Psychosocial Rationale: The psychosocial data is the least priority during the initial admission data collection. In the African-American culture, it is considered intrusive to ask personal questions during the initial contact or meeting. Additionally, respiratory, neurological, and cardiovascular data include physiological assessments that would be the priority.

A client is diagnosed with cancer and is told that surgery followed by chemotherapy will be necessary. The client states to the nurse, "I have read a lot about complementary therapies. Do you think I should try any?" The nurse should respond by making which appropriate statement? 1. "I would try anything that I could if I had cancer." 2. "You need to ask your health care provider about it." 3. "No, because it will interact with the chemotherapy." 4. "Let's talk more about the different forms of complementary therapies."

"Let's talk more about the different forms of complementary therapies." Complementary (alternative) therapies include a wide variety of treatment modalities that are used in addition to conventional treatment to treat a disease or illness. These therapies complement conventional treatment, but they should be approved by the person's health care provider (HCP) to ensure that the treatment does not interact with prescribed therapy. Although the HCP should approve the use of a complementary therapy, it is important for the nurse to explore the complementary therapies first with the client, which would eliminate option 2. The statement in option 3 is inappropriate. Similarly, option 1 is an inappropriate response to the client. Option 4 addresses the client's question and encourages discussion.

The nurse is preparing to assist a client of Orthodox Jewish faith with eating lunch. A kosher meal is delivered to the client. Which nursing action is appropriate when assisting the client with the meal? 1. Unwrapping the eating utensils for the client 2. Replacing the plastic utensils with metal utensils 3. Carefully transferring the food from paper plates to glass plates 4. Allowing the client to unwrap the utensils and prepare his own meal for eating

Allowing the client to unwrap the utensils and prepare his own meal for eating. Rationale: Kosher meals arrive on paper plates and with plastic utensils sealed. Health care providers should not unwrap the utensils or transfer the food to another serving dish. Although the nurse may want to be helpful by assisting the client with the meal, the only appropriate option for this client is option 4.

The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse should tell the client that which food item is least likely to contain calcium? 1. Milk 2. Butter 3. Spinach 4. Collard greens

Butter Butter comes from milk fat and does not contain significant amounts of calcium. Milk, spinach, and collard greens are calcium-containing foods and should be avoided by the client on a calcium-restricted diet.

The nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which sign/symptom is an indication of this electrolyte imbalance? 1. Twitching 2. Positive Trousseau's sign 3. Hyperactive bowel sounds 4. Generalized muscle weakness

Generalized muscle weakness Generalized muscle weakness is seen in clients with hypercalcemia. Twitching, positive Trousseau's sign, and hyperactive bowel sounds are signs of hypocalcemia.

To assess for the presence of the posterior tibialis pulse, the nurse should palpate which areas? 1. In the groove just below the inguinal ligament 2. Behind the knee and lateral to the medial tendon 3. Lateral to and parallel with the extensor tendon of the big toe 4. In the groove behind the medial malleolus and the Achilles tendon

In the groove behind the medial malleolus and the Achilles tendon

The nurse is caring for a client who has been taking diuretics on a long-term basis. Which finding should the nurse expect to note as a result of this long-term use? 1. Gurgling respirations 2. Increased blood pressure 3. Decreased hematocrit level 4. Increased specific gravity of the urine

Increased specific gravity of the urine Clients taking diuretics on a long-term basis are at risk for fluid volume deficit. Findings of fluid volume deficit include increased respirations and heart rate, decreased central venous pressure, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, dark-colored and odorous urine, an increased hematocrit level, and an altered level of consciousness. Gurgling respirations, increased blood pressure, and decreased hematocrit as a result of hemodilution are seen in a client with fluid volume excess.

The nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. Which additional signs/symptoms should the nurse expect to note in this client if hyponatremia is present? 1. Intense thirst 2. Slow bounding pulse 3. Dry mucous membranes 4. Postural blood pressure changes

Postural blood pressure changes Postural blood pressure changes occur in the client with hyponatremia. Intense thirst and dry mucous membranes are seen in clients with hypernatremia. A slow, bounding pulse is not indicative of hyponatremia. In a client with hyponatremia, a rapid, thready pulse is noted.

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for a potassium deficit? 1. The client with Addison's disease 2. The client with metabolic acidosis 3. The client with intestinal obstruction 4. The client receiving nasogastric suction

The client receiving nasogastric suction Potassium-rich gastrointestinal (GI) fluids are lost through GI suction, which places the client at risk for hypokalemia. The client with intestinal obstruction, Addison's disease, and metabolic acidosis is at risk for hyperkalemia.

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for fluid volume deficit? 1. The client with cirrhosis 2. The client with a colostomy 3. The client with heart failure (HF) 4. The client with decreased kidney function

The client with a colostomy Rationale: Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, ileostomy, and colostomy. A client with cirrhosis, HF, or decreased kidney function is at risk for fluid volume excess.

The nurse reviews electrolyte values and notes a sodium level of 130 mEq/L. The nurse expects that this sodium level would be noted in a client with which condition? 1. The client with watery diarrhea 2. The client with diabetes insipidus (DI) 3. The client with an inadequate daily water intake 4. The client with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH)

The client with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH)Hyponatremia is a serum sodium level less than 135 mEq/L. Hyponatremia can occur secondary to SIADH. The client with an inadequate daily water intake, watery diarrhea, or diabetes insipidus is at risk for hypernatremia.

The nurse is caring for a group of clients who are taking herbal medications at home. Which client should be given instructions in regard to avoiding the use of herbal medications? 1. A 60-year-old male client with rhinitis 2. A 24-year-old male client with a lower back injury 3. The mother of a 10-year-old child with a urinary tract infection 4. A 45-year-old female client with a history of migraine headaches

The mother of a 10-year-old child with a urinary tract infection Rationale: Children should not be given herbal therapies, especially in the home and without professional supervision. There are no general contraindications for the clients described in options 1, 2, and 4.

The nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L. The nurse understands that a potassium value at this level should be noted with which condition? 1. Diarrhea 2. Traumatic burn 3. Cushing's syndrome 4. Overuse of laxatives

Traumatic burn A serum potassium level that exceeds 5.0 mEq/L is indicative of hyperkalemia. Clients who experience the cellular shifting of potassium, as in the early stages of massive cell destruction (i.e., with trauma, burns, sepsis, or metabolic or respiratory acidosis), are at risk for hyperkalemia. The client with Cushing's syndrome or diarrhea and the client who has been overusing laxatives are at risk for hypokalemia.