140 Unit 1, 140 Unit 2, 140 Unit 3

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 change in position may be what is needed for you to have intercourse with your wife." "Have you considered going to see a marriage counselor with your wife?" "What has your wife said about your pouch system?" "You must get clearance from your primary health care provider before you attempt to have intercourse."

"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 client diagnosed with rheumatoid arthritis (RA) is started on methotrexate (Rheumatrex). Which statement made by the client indicates to the nurse that further teaching is needed regarding drug therapy? "Drinking alcoholic beverages should be avoided." "The health care provider should be notified 3 months before a planned pregnancy." "Any side effects of this drug will be mild." "I will avoid any live vaccines."

"Any side effects of this drug will be mild." (Further teaching is needed if the client states that, "Any side effects of this drug will be mild." Methotrexate can have devastating side effects and toxic effects, and the client should be carefully monitored when taking this drug.)

Which information should the nurse include in discharge teaching for a client prescribed doxycycline (Vibramycin)? "Take the medication with milk to minimize gastrointestinal upset." "Apply sunscreen or wear protective clothing when outdoors." "Take the medication until you have no fever and feel better." "Keep the remainder of the medication in case of recurrence."

"Apply sunscreen or wear protective clothing when outdoors." (Photosensitivity is a common adverse effect of doxycycline, a tetracycline antibiotic. The client should avoid direct sun exposure and tanning bed use while taking this medication. Exposure to the sun can cause severe burns.)

Which instruction should be included in the discharge teaching for a patient with a transdermal nitroglycerin (Nitro-Dur) patch? "Make sure to rub a lotion or cream on the skin before putting on a new patch." "If you get chest pain, apply a second patch next to the first patch." "Apply the patch to a hairless, nonirritated area of the chest, upper arm, back or shoulder." "If you get a headache, remove the patch for 4 hours and then reapply."

"Apply the patch to a hairless, nonirritated area of the chest, upper arm, back or shoulder." (A nitroglycerin patch should be applied to a clean, residue-free, hairless, nonirritated area for the best and most consistent absorption rates. Sites should be rotated to prevent skin irritation, and if headache occurs, the patient should not change the patch removal schedule to avoid these headaches. Sublingual nitroglycerin should be used to treat chest pain.)

A client is admitted with dysentery caused by Clostridium difficile, or pseudomembranous colitis. To elicit the most helpful information about the cause of the dysentery, the nurse would ask the client "Are you taking any antibiotics?" "Do you ever go barefoot outside your home?" "Does anyone else in your family have bowel problems?" "Have you traveled in any foreign countries lately?"

"Are you taking any antibiotics?" (Infection with C. difficile is a bacterial dysentery often seen in clients who have been receiving large doses of antibiotics or who have taken antibiotics over a long period.)

Which statement indicates that the client needs additional discharge teaching after gastric bypass surgery? "I hope my type 2 diabetes is cured and I won't need insulin anymore." "As soon as I get home, I'm going to enjoy a nice bowl of fruit." "If I get nauseated, I know I'm eating too much at one time." "I will be sure to report any back, shoulder, or abdominal pain."

"As soon as I get home, I'm going to enjoy a nice bowl of fruit." (After gastric bypass surgery, clients are limited to fluids and pureed foods for about 6 weeks. Then the client can progress to a more normal diet. Eating fruit right after discharge would not be recommended. The other statements indicate good understanding.)

A patient has been diagnosed with mild gastroesophageal reflux disease (GERD) and asks the nurse about nonpharmacologic treatments to prevent symptoms. What does the nurse tell this patient? "Avoid caffeine-containing foods and beverages." "Eat three meals each day and avoid snacking between meals." "Peppermint lozenges help to reduce stomach upset." "Sleep on your left side with a pillow between your knees."

"Avoid caffeine-containing foods and beverages." (The nurse tells the patient to avoid caffeine-containing foods and beverages. The nurse also teaches the patient to limit or eliminate foods that decrease lower esophageal sphincter (LES) pressure and that irritate inflamed tissue, causing heartburn. These foods include peppermint, chocolate, alcohol, fatty foods (especially fried), caffeine, and carbonated beverages.The nurse also needs to remind the patient to eat four to six small meals each day rather than three large ones and avoid snacking between meals. Large meals increase the volume of and pressure in the stomach and delay gastric emptying. Peppermint decreases LES pressure and increases the risk of symptoms. Patients need to be taught to elevate the head by 6 to 12 inches (30 cm) for sleep to prevent nighttime reflux.)

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? "Avoid large crowds and anyone who is sick." "Do not take the medication if you are allergic to foods with fatty acids." "Expect difficulty with wound healing while you are taking this drug." "Monitor your blood pressure and report any significant decrease in it."

"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 client admitted for sleep apnea asks the nurse, "Why does it seem like I wake up every 5 minutes?" What is the nurse's best response? "Carbon dioxide builds up while you are not breathing which stimulates your body to wake up and breathe." "Because your body isn't getting enough oxygen you wake up and breathe." "Your tongue may be blocking your throat, and you wake up because you are choking." "You really aren't waking up that often. It just feels that way."

"Carbon dioxide builds up while you are not breathing which stimulates your body to wake up and breathe." (The nurse's best response is related to the buildup of carbon dioxide stimulating the body to wake up and breathe. During sleep, the muscles relax and the tongue and neck structures are displaced with the tongue falling back, causing an upper airway obstruction. This obstruction leads to apnea and increased levels of carbon dioxide. Respiratory acidosis stimulates neural centers in the brain, and the client awakens, takes a deep breath, and goes back to sleep. After the client returns to sleep, the cycle may be repeated as often as every 5 minutes as the airway is re-obstructed.Too much carbon dioxide, not a lack of oxygen, is the trigger that causes the client to awaken and breathe. Telling the client he is choking is not accurate. The loud snoring is caused by partial upper airway obstruction by the tongue. Also, telling the client he isn't really awakening that often minimizes the client's concern and is not correct. The client may be awakening every 5 minutes as the cycle repeats.)

A hematology unit is staffed by registered nurse's (RNs), licensed practical nurses (LPNs)/licensed vocational nurse (LVNs), and unlicensed assistive personnel (UAP). When the nurse manager is reviewing staff documentation, which entry indicates the need for staff education for his or her appropriate level of responsibility and client care? "Abdominal pain relieved by morphine 4 mg IV; client resting comfortably and denies problems. B.C., RN" "Ambulated in hallway for 40 feet (12 m) and denies shortness of breath at rest or with ambulation. T.Y., LPN" "Client reporting increased shortness of breath; oxygen increased to 4 L by nasal cannula. M.N., UAP" "Vital signs 98.6°F (37.0°C), heart rate 60, respiratory rate 20, blood pressure 110/68, and oximetry 98% on room air. L.D., UAP"

"Client reporting increased shortness of breath; oxygen increased to 4 L by nasal cannula. M.N., UAP" (The documentation entry that needs education is the one from the UAP that states that the "client reports increased shortness of breath and that oxygen was increased to 4 L by nasal cannula." Determination of the need for oxygen and administration of oxygen must be done by licensed nurses who have the education and scope of practice required to administer it.All other documentation entries reflect appropriate delegation and assignment of care.)

The nurse is instructing a group of overweight clients on the complications of obesity that develop when weight is not controlled through diet and exercise. Which lifestyle changes does the nurse emphasize? Select all that apply. "Begin a weight-training program for building muscle mass." "Consume a diet that is moderate in salt and sugar and low in fats and cholesterol." "Eat a variety of foods, especially grain products, vegetables, and fruits." "Engage in moderate physical activity for at least 30 minutes each day." "Foods eaten away from home tend to be higher in fat, cholesterol, and salt and lower in calcium than foods prepared at home." "Liquid dietary supplements can be substituted safely for solid food while attempting to lose weight."

"Consume a diet that is moderate in salt and sugar and low in fats and cholesterol." "Eat a variety of foods, especially grain products, vegetables, and fruits." "Engage in moderate physical activity for at least 30 minutes each day." "Foods eaten away from home tend to be higher in fat, cholesterol, and salt and lower in calcium than foods prepared at home." (Lifestyle changes the nurse emphasizes include consuming a diet that is moderate in salt and sugar and low in fats and cholesterol, and moderate physical activity for at least 30 minutes each day. These are smart strategies for a person who wants to lose weight. Eating a variety of foods, especially grain products, vegetables, and fruits, helps people achieve weight loss. These are foods that "burn" more calories as they are metabolized. Many foods eaten away from home tend to be higher in fat, cholesterol, and salt and lower in calcium than foods prepared at home. When dining out, people can make smart choices, but they have to be educated and careful.A weight-training program for building muscle mass does not need to be included in a weight loss program. Muscle weighs more and tends to increase weight in people who weight-train. Liquid dietary supplements cannot safely be substituted for solid food while attempting to lose weight.)

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? "Avoid all solid foods to allow complete bowel rest." "Consume extra fluids to replace fluid losses." "Take an over-the-counter antidiarrheal medication." "Contact your primary health care provider for an antibiotic medication."

"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.)

Which discharge instruction should the nurse include for a patient prescribed an antilipemic medication? "It is important to take a double dose to make up for a missed dose." "Stop taking the medication if it causes nausea and vomiting." "Continue your exercise program and maintain a low-fat diet." "Lifestyle changes are no longer necessary when taking this medication."

"Continue your exercise program and maintain a low-fat diet." (Antilipemic medications are in addition to, not a replacement of, therapeutic lifestyle changes used to decrease serum cholesterol. Maintain a low-fat, low-cholesterol diet is an integrated part of a change in lifestyle.)

A few months after bariatric surgery, a 56-year-old man tells the nurse, "My skin is hanging in folds. I think I need cosmetic surgery." Which response by the nurse is most appropriate? "The important thing is that you are improving your health." "The skinfolds will disappear once most of the weight is lost." "Cosmetic surgery is a possibility once your weight has stabilized." "Perhaps you would like to talk to a counselor about your body image."

"Cosmetic surgery is a possibility once your weight has stabilized." (Reconstructive surgery may be used to eliminate excess skinfolds after at least a year has passed since the surgery. Skinfolds may not disappear over time, especially in older patients. The response, "The important thing is that your weight loss is improving your health," ignores the patient's concerns about appearance and implies that the nurse knows what is important. Whereas it may be helpful for the patient to talk to a counselor, it is more likely to be helpful to know that cosmetic surgery is available.)

An insulin pump is instituted for a client with type 1 diabetes. The nurse plans discharge instructions. Which short-term goal is the priority for this client? "Adhere to the medical regimen." "Remain normoglycemic for 3 weeks." "Demonstrate correct use of the insulin pump." "List three self-care activities that help control the diabetes."

"Demonstrate correct use of the insulin pump." (Demonstrating correct use of the insulin pump is the short-term, client-oriented goal necessary for the client to manage the pump and avoid hypo- and hyperglycemia; this outcome can be measured by observing a return demonstration by the client. Adhering to the medical regimen is not a short-term goal. Remaining normoglycemic for 3 weeks is measurable but requires the client to manage the insulin pump. Although listing three self-care activities that help control the diabetes is a measurable short-term goal, it is not the priority when the client must master use of the insulin pump.)

The nurse is assessing the endurance level of a client in a long-term care facility. What question does the nurse ask to get this information? "How much exercise do you get?" "What is your endurance level?" "Are your feet or hands cold, even when you are in bed?" "Do you feel more tired after you get up and go to the bathroom?"

"Do you feel more tired after you get up and go to the bathroom?" (Asking about feeling tired after using the bathroom is the best question to ask to assess a client's endurance level. This question is pertinent to the client's activity and provides a comparison. The specific activity helps the client relate to the question and provides needed answers.The hospitalized client typically does not get much exercise. This would be a difficult assessment for a client in long-term care facility to make. Asking the client about his or her endurance level is too vague. The client may not know how to answer this question. Asking about cold feet or hands does not address the client's endurance.)

The nurse is completing an assessment on the client's sleep patterns. A specific question that the nurse should ask to determine the potential presence of sleep apnea is: "How easily do you fall asleep?" "Do you have vivid, lifelike dreams?" "Do you ever experience loss of muscle control or falling?" "Do you snore loudly or experience headaches?"

"Do you snore loudly or experience headaches?" (To assess for sleep apnea, the nurse may ask, "Do you snore loudly?" and, "Do you experience headaches after awakening?" A positive response may indicate that the client experiences sleep apnea. This question is directed at assessing the potential presence of insomnia. This question is directed at determining the potential presence of narcolepsy. This question is directed at determining the potential presence of narcolepsy.)

A 22-year-old man tells the nurse at the health clinic that he has recently had some problems with erectile dysfunction. Which question should the nurse ask first to assess for possible etiologic factors? "Do you experience an unusual amount of stress?" "Do you use any recreational drugs or drink alcohol?" "Do you have chronic cardiovascular or peripheral vascular disease?" "Do you have a history of an erection that lasted for 6 hours or more?"

"Do you use any recreational drugs or drink alcohol?" (A common etiologic factor for erectile dysfunction (ED) in younger men is use of recreational drugs or alcohol. Stress, priapism, and cardiovascular illness also contribute to ED, but they are not common etiologic factors in younger men.)

Which instructions given to a client with renal calculi would be most beneficial? Select all that apply. "Drink plenty of water." "Have spinach soup every day." "Substitute lemon juice for tea." "Include high amounts of protein in the diet." "Consume foods rich in omega-3-fatty acids."

"Drink plenty of water." "Substitute lemon juice for tea." (Renal calculi is the formation of kidney stones. Drinking plenty of water will keep the body hydrated and prevent further formation of stones. Tea contains caffeine, a diuretic, which causes dehydration. Therefore the client must be advised to replace tea with lemon juice. Spinach is rich in oxalates. Consuming spinach soup may aggravate the problem, due to the formation of oxalate crystals. Excessive consumption of proteins may precipitate uric acid stones. Therefore the use of proteins should not be encouraged. Foods rich in omega-3-fatty acids are beneficial in maintaining good health. However, the use of omega-3-fatty acids, specifically in the treatment, mitigation, or prevention of kidney stones, is not justified.)

The nurse is teaching a client the precautions to take while on warfarin (Coumadin) therapy. Which statement made by the client demonstrates that teaching has been effective? "I can use an electric razor or a regular razor." "Eating foods like green beans won't interfere with my Coumadin therapy." "If I notice I am bleeding a lot, I should stop taking Coumadin right away." "When taking Coumadin, I may notice some blood in my urine."

"Eating foods like green beans won't interfere with my Coumadin therapy." (Teaching about the precautions of warfarin has been effective when the client says "that eating foods like green beans won't interfere with my Coumadin therapy." Vitamin K is not found in foods such as green beans, so these foods will not interfere with the anticoagulant effects of Coumadin.Warfarin "thins" the blood, so the risk for cutting oneself and bleeding is very high with the use of a regular razor. The client needs to use an electric razor. Clients must apply pressure to bleeding wounds and must seek medical assistance immediately. They do not need to discontinue warfarin therapy. Blood in the urine of a client taking warfarin therapy is not a side effect. The client must notify the primary health care provider immediately if this occurs.)

A nurse is instructing her patient with ulcerative colitis regarding the need to avoid enteric coated medications. The nurse knows that the patient understands the reason for this teaching when he states which of the following? "The coating on these medications is irritating to my intestines." "I need a more immediate response from my medications than can be obtained from enteric coated medications." "Enteric coated medications are absorbed lower in the digestive tract and can be irritating to my intestines or inadequately absorbed by my inflamed tissue." "I don't need to use these medications because they cause diarrhea, and I have had enough trouble with diarrhea and rectal bleeding over the past weeks."

"Enteric coated medications are absorbed lower in the digestive tract and can be irritating to my intestines or inadequately absorbed by my inflamed tissue." (Enteric coatings on medications are designed to prevent breakdown and absorption of the medication until lower in the digestive tract, usually to prevent stomach irritation or to reach a certain point in the digestive tract for optimal absorption. For the patient with ulcerative colitis, the intestinal lining is inflamed or susceptible to inflammation and can have impaired absorption; therefore, enteric coated medications should be avoided. The coating is not irritating, but the medication can be. The response time of the medication is not a concern in this instance. Enteric coated medicines do not cause diarrhea simply because they are enteric coated.)

A client with diabetes asks how exercise will affect insulin and dietary needs. What information does the nurse share about insulin and exercise? "Exercise increases the need for carbohydrates and decreases the need for insulin." "Exercise increases the need for insulin and increases the need for carbohydrates." "Regular physical activity decreases the need for insulin and decreases the need for carbohydrates." "Intensive physical activity decreases the need for carbohydrates but does not affect the need for insulin."

"Exercise increases the need for carbohydrates and decreases the need for insulin." (Exercise increases the uptake of glucose by active muscle cells without the need for insulin; carbohydrates are needed to supply energy for the increased metabolic rate associated with exercise. The need for insulin is decreased.)

The nurse is educating a group of young women who have sickle cell disease (SCD). Which statement from a class member indicates further teaching is necessary? "The pneumonia vaccine is protection that I need." "Getting an annual 'flu shot' would be dangerous for me." "I must take my penicillin pills as prescribed, all the time." "Frequent handwashing is an important habit for me to develop."

"Getting an annual 'flu shot' would be dangerous for me." (Further teaching is needed when a young women with sickle cell disease says, "Getting an annual 'flu shot' would be dangerous for me." The client with SCD can receive annual influenza and pneumonia vaccinations. This helps prevent the development of these infections, which could cause a sickle cell crisis.The pneumonia vaccine is also appropriate for the client with sickle cell disease to receive. Prophylactic penicillin is given to clients with SCD orally twice a day to prevent the development of infection. Handwashing is a very important habit for the client with SCD to develop because it reduces the risk for infection.)

A client with typically well controlled diabetes has a glycosylated hemoglobin (HbA1C) level of 9.4%. Which response by the nurse is most appropriate? "Keep up the good work." "This is not good at all." "Have you been doing something differently? "You need an increase in your insulin dose."

"Have you been doing something differently? (The most appropriate response by the nurse is telling the client that the level is high and then assessing the client's regimen or changes he or she may have made. This is the best format to formulate interventions to gain control of blood glucose. HbA1C levels for diabetic clients need to be less than 7%. A value of 9.4% shows poor control over the past 3 months.Telling the client to "keep up the good work" is incorrect. A(HbA1C) level of 9.4% is too high. Scolding the client by saying "this is not good," although true, does not take into account problems the client may be having with the regimen or an undiagnosed illness. Although it may be true that the client needs more insulin, an assessment of the client's regimen is needed before decisions are made about medications.)

A 55-year-old male client is admitted to the emergency department with symptoms of a myocardial infarction. Which question by the nurse is the most appropriate before administering nitroglycerin? "On a scale from 0 to 10, what is the rating of your chest pain?" "Are you allergic to any food or medications?" "Have you taken any drugs like Viagra recently?" "Are you light-headed or dizzy right now?"

"Have you taken any drugs like Viagra recently?" (Phosphodiesterase-5 inhibitors such as sildenafil (Viagra) relax smooth muscles to increase blood flow to the penis for treatment of erectile dysfunction. In combination with nitroglycerin, there can be extreme hypotension with reduction of blood flow to vital organs. The other questions are appropriate but not the highest priority before administering nitroglycerin.)

A nurse is educating a preoperative client on how to cough effectively. What can the nurse tell the client to do to facilitate coughing? "Hold a pillow or folded bath blanket over the incision." "Get up and walk before you try to cough." "It would be best if you do not cough until you feel better." "When you cough, cover your nose and mouth with a tissue."

"Hold a pillow or folded bath blanket over the incision." (Because postoperative coughing is often painful, the client should be taught how to splint the incision by supporting it with a pillow or folded bath blanket.)

The nurse is providing discharge teaching to a client with type 2 diabetes and peripheral neuropathy. Which statement by the client indicates a need for further teaching about injury prevention? "I can break in my shoes by wearing them all day." "I need to monitor my feet daily for blisters or skin breaks." "I will never go barefoot." "I need to quit smoking."

"I can break in my shoes by wearing them all day." (Further teaching about injury prevention is needed when the client with diabetic peripheral neuropathy says that "I can break in my shoes by wearing them all day." Shoes need to be properly fitted and worn for a few hours a day to break them in, with frequent inspection for irritation or blistering.People with diabetes have decreased peripheral circulation, so even small injuries to the feet must be managed early. Going barefoot is contraindicated because if the client has diabetic neuropathy, stepping on something sharp or harmful would not be felt. Tobacco use further decreases peripheral circulation increasing the risk for vascular complications.)

The nurse is teaching a patient about dietary choices to prevent dumping syndrome after gastric bypass surgery. Which statement by the patient indicates a need for further teaching? "I will need to avoid sweetened fruit juice beverages." "I can eat ice cream in moderation." "I cannot drink alcohol at all." "It is okay to have a serving of sugar-free pudding."

"I can eat ice cream in moderation." (A need for further teaching about dietary changes related to dumping syndrome is indicated when the patient says that ice cream can be eaten in moderation. Milk products such as ice cream must be eliminated from the diet of a patient with dumping syndrome.The patient with dumping syndrome can no longer consume sweetened drinks. Alcohol must also be eliminated from the diet. The patient can eat sugar-free pudding, custard, and gelatin but with caution.)

Which of the following statements, if made by an adolescent preparing for abdominal surgery, would indicate to the nurse that the client requires additional instruction? "I can have a hamburger and French fries as soon as I wake up." "The better I eat before surgery, the more likely I will heal." "I might be sick to my stomach and throw up after surgery." "When I can eat again, the best meal would be steak and orange juice."

"I can have a hamburger and French fries as soon as I wake up." (Oral fluid and food may be withheld until intestinal motility resumes.)

Which statement by the patient demonstrates a need for further education regarding nitroglycerin (Nitrostat) sublingual tablets? "I should keep my nitroglycerin in a cool, dry place." "I should change positions slowly to avoid getting dizzy from the drug's effect on my blood pressure." "If I get a headache, I should keep taking my nitroglycerin and use Tylenol to relieve my headache." "I can take up to four tablets at 5-minute intervals for chest pain."

"I can take up to four tablets at 5-minute intervals for chest pain." (Patients are taught to take up to three sublingual tablets 5 minutes apart. According to current guidelines, if the chest pain or discomfort is not relieved in 5 minutes, after one dose, the patient (or family member) must call 911 immediately. The patient can take one more tablet while awaiting emergency care and a third tablet 5 minutes later, but no more than three tablets total. Patients should always sit or lie down before taking this medication.)

46-year-old female with gastroesophageal reflux disease (GERD) is experiencing increasing discomfort. Which patient statement indicates that additional teaching about GERD is needed? "I take antacids between meals and at bedtime each night." "I sleep with the head of the bed elevated on 4-inch blocks." "I eat small meals during the day and have a bedtime snack." "I quit smoking several years ago, but I still chew a lot of gum."

"I eat small meals during the day and have a bedtime snack." (GERD is exacerbated by eating late at night, and the nurse should plan to teach the patient to avoid eating at bedtime. The other patient actions are appropriate to control symptoms of GERD.)

During a preoperative assessment, which statement by a client requires further investigation by the nurse to assess surgical risks? "I am taking vitamins." "I drink a glass of wine a night." "I had a heart attack 4 months ago." "I quit smoking 10 years ago."

"I had a heart attack 4 months ago." (The statement by the client that he or she had a heart attack 4 months ago requires further investigation. Cardiac problems increase surgical risks, and the risk for a myocardial infarction during surgery is higher in clients who have heart problems.The type of vitamins the client takes should be assessed, but this is not the highest risk. Moderate alcohol consumption is not considered high-risk behavior. A past history of smoking should be noted, but current or more recent smoking is of greater concern.)

In evaluating a client for the presence of gallbladder disease, the nurse would recognize that the client's statement most suggestive of this problem is "I am having difficulty swallowing." "I get a sharp, stabbing pain every time I take a deep breath or cough." "I have a terrible pain in my stomach; it is so bad I can feel it in my shoulder." "I have a very strong craving for fatty foods like bacon and eggs fried in butter."

"I have a terrible pain in my stomach; it is so bad I can feel it in my shoulder." (The most specific and characteristic manifestation of gallstone disease is pain, or biliary colic, which is caused by spasm of the biliary ducts as they try to dislodge stones. This pain usually follows the temporary obstruction of the gallbladder outlet. Characteristically, the pain starts in the upper midline area, and it may radiate around to the back and right shoulder blade, although some clients report that it passes straight through to the back and substernal areas.)

A client has a history of renal calculi. Which statement by the client indicates a good understanding of preventive measures? "I know I should drink at least 3 to 4 liters of fluid every day." "I can't eat much dairy or other sources of calcium." "Aspirin and aspirin-containing products can lead to stones." "The doctor will give me antibiotics at the first sign of a stone."

"I know I should drink at least 3 to 4 liters of fluid every day." (Dehydration contributes to the precipitation of minerals to form a stone. Ingestion of calcium or aspirin does not cause a stone. Antibiotics neither prevent nor treat a stone.)

The nurse is caring for an obese client who will be taking orlistat (Xenical) to help her lose weight. Which statement indicates that the client understands teaching about orlistat? "This medication will help speed up my metabolism." "I may have loose stools after meals if I eat too much fat." "This medication will suppress my appetite so I won't be hungry." "This medication will make me feel full after I eat small amounts."

"I may have loose stools after meals if I eat too much fat." (Orlistat (Xenical) inhibits lipase, leading to partial hydrolysis of triglycerides. Fats are only partially digested and absorbed and are excreted in the feces. The client may experience nausea, cramps, and loose stools when fats are increased in the diet. Orlistat does not increase metabolism, suppress appetite, or make the client feel full after small meals.)

The nurse reviews a routine discharge teaching plan concerning postoperative care with a client. Which statement by the client indicates that teaching about wound care was effective? "I may need to restrict my activities for several months." "I should remove the dressing if the wound is draining." "Some bleeding from the incision is normal for several weeks." "The wound will completely heal in about 2 months."

"I may need to restrict my activities for several months." (To protect the integrity of the wound, activities may need to be restricted.The wound is usually open to air for healing, but draining wounds need to be covered. Bleeding and serosanguineous drainage is not normal after 5 days. The length of time it takes for a wound to heal varies, and can take up to 2 years to heal.)

The nurse is teaching a client with diabetes about proper foot care. Which statement by the client indicates that teaching was effective? "I will go barefoot in my house so that my feet are exposed to air." "I must inspect my shoes for foreign objects before putting them on." "I will soak my feet in warm water to soften calluses before trying to remove them." "I must wear canvas shoes as much as possible to decrease pressure on my feet."

"I must inspect my shoes for foreign objects before putting them on." (The statement by the diabetic client that indicates that teaching was effective is, "I must inspect my shoes for foreign objects before putting them on." To avoid injury or trauma to the feet, shoes need to be checked for foreign objects before the feet are inserted in them.Clients with diabetes would not go barefoot because foot injuries can occur in those clients who lack sensation. To avoid injury or trauma, a callus needs to be removed by a podiatrist, not by the client. To prevent injury, the client with diabetes must wear protective shoes for support and not canvas shoes.)

The nurse is teaching a client and family about home care after a stroke. Which statement made by the client's spouse indicates a need for further teaching? "I should spend all my time with my husband in case I'm needed." "My husband may get depressed." "My husband must take his medicine every day to prevent another stroke." "The physical therapist will show us how to use the equipment so my husband can climb the stairs and get into and out of bed."

"I should spend all my time with my husband in case I'm needed." (Further home care teaching is needed when the stroke client's wife says that "I need to spend all my time with my husband in case I'm needed." Although well intentioned, family members can start to feel socially isolated when caring for a loved one. The family may need to plan for regular respite care in a structured day-care respite program or through relief provided by a friend or neighbor.The life changes associated with stroke often cause a change in the client's self-esteem. The client who has had a stroke needs to maintain a regular medication regimen to help prevent another stroke. If it is determined necessary after a home assessment, the physical and occupational therapist will show the client and family how to use equipment so they are able to mobilize and function in the home setting.)

The nurse determines the patient has a good understanding of the discharge instructions regarding warfarin (Coumadin) with which patient statement? "I will double my dose if I forget to take it the day before." "I should keep taking ibuprofen for my arthritis." "I should use a soft toothbrush for dental hygiene." "I should decrease the dose if I start bruising easily."

"I should use a soft toothbrush for dental hygiene." (The patient should reduce the risk of bleeding, such as using a soft toothbrush. The other choices are inaccurate.)

A nurse educates an obese adolescent about healthy dietary habits and risks associated with obesity. Which statements by the adolescent indicate the need for further counseling? Select all that apply. "I should exercise regularly." "I should play more outdoor games." "I should watch more television to reduce the stress." "I should add lots of vegetables to my diet." "I should contact a surgeon about bariatric surgery."

"I should watch more television to reduce the stress." "I should contact a surgeon about bariatric surgery." (Stress is a major cause of obesity. Rather than watching television to reduce stress, physical activities such as playing outdoor games and regular exercise should be undertaken. Bariatric surgery is performed only when there is morbid obesity. Reducing the consumption of fat-rich foods and increasing the consumption of vegetables will help with weight reduction.)

A nurse is obtaining a health history from a client with the diagnosis of peptic ulcer disease. Which client statement provides evidence to support the identification of a possible contributory factor? "My blood type is A positive." "I smoke one pack of cigarettes a day." "I have been overweight most of my life." "My blood pressure has been high lately."

"I smoke one pack of cigarettes a day." (Smoking cigarettes increases the acidity of gastrointestinal secretions, which damages the mucosal lining. While blood type O is more frequently associated with duodenal ulcer, type A has no significance. Being overweight is unrelated to peptic ulcer disease. High blood pressure is not directly related to peptic ulcer disease.)

Which client statement indicates the need for further teaching about antiemetic medications? "I may take Tylenol to treat the headache caused by ondansetron (Zofran)." "I will not drive while I am taking these medications because they may cause drowsiness." "I should take my prescribed antiemetic before receiving my chemotherapy dose." "I will apply the scopolamine patch to my right or left arm and rotate sites of application."

"I will apply the scopolamine patch to my right or left arm and rotate sites of application." (Transdermal scopolamine patches should be applied to nonirritated areas behind the ear, not on the arms.)

The nurse is teaching a client with newly diagnosed type 2 diabetes about the importance of weight control. Which comment by the client indicates a need for further teaching? "I will begin exercising for at least an hour a day." "I will monitor my diet and avoid empty calories." "If I lose weight, I may not need to use the insulin anymore." "Weight loss can be a sign of diabetic ketoacidosis."

"I will begin exercising for at least an hour a day." (Further teaching is needed when the client says that "I will begin exercising for at least an hour a day." The goal of weight control for Type 2 diabetes is to change sedentary behavior to active behavior. This is begun by starting low-intensity activities in short sessions (less than 10 minutes). The client may increase sessions to moderate or vigorous aerobic physical activity to lose and or sustain weight loss.Monitoring the diet and avoiding empty calories is essential to managing type 2 diabetes. Weight loss can minimize the need for insulin and can also be a sign of diabetic ketoacidosis due to osmotic diuresis.)

The nurse is teaching a client about the manifestations and emergency management of hypoglycemia. Which response by the client indicates a correct understanding of what to do if the client feels hungry and shaky? "I will drink a glass of water." "I will eat three graham crackers." "I will give myself 1 mg of glucagon." "I will sit down and rest."

"I will eat three graham crackers." (Correct understanding of what the client needs to do if the client feels hungry and shaky is to eat three graham crackers. This is the correct management strategy for mild hypoglycemia.Drinking a glass of water or sitting down and resting does not remedy hypoglycemia. Glucagon is generally administered for episodes of severe not mild hypoglycemia.)

The nurse provides discharge instructions to a patient prescribed cholestyramine (Questran). Which statement by the patient indicates teaching was effective for this drug? "I will increase fiber in my diet and drink more fluids." "This drug can cause flushing, itching and gastrointestinal upset." "I will take Questran 1 hour before my other medications." "I will notify my health care provider if I have muscle pain."

"I will increase fiber in my diet and drink more fluids." (Cholestyramine can cause constipation; thus increasing dietary fiber and fluid intake is appropriate. All other drugs should be taken 1 hour before or 4 hours after cholestyramine to facilitate proper absorption.)

The nurse is giving discharge instructions to a patient prescribed warfarin (Coumadin) for atrial fibrillation. Which statement by the patient indicates a need for further instruction from the nurse? "I will take my medication in the early evening each day." "I will contact my health care provider if I develop excessive bruising." "I will increase the dark green leafy vegetables in my diet." "I will avoid activities that have a risk for injury such as contact sports."

"I will increase the dark green leafy vegetables in my diet." (Dark green leafy vegetables are rich in vitamin K, which would antagonize the effects of warfarin. Therefore, it is important to maintain a consistent daily intake of vitamin K and avoid eating large amounts of these foods.)

The nurse is providing discharge teaching for a patient with a new prescription for nitroglycerin (Nitrostat) sublingual tablets. Which statement by the patient indicates an understanding of the nurse's discharge instructions about this medication? "I will need to refill my prescription when I feel burning under my tongue." "I can take some aspirin if I get a headache related to nitroglycerin." "I will keep my nitroglycerin tablets in their original glass container." "My nitroglycerin tablets are not affected by cold or heat."

"I will keep my nitroglycerin tablets in their original glass container." (The sublingual dosage form of nitroglycerin needs to be kept in its original amber-colored glass container with metal lid to avoid loss of potency from exposure to heat, light, moisture, and cotton filler. It should be replaced every 3 to 6 months in order to maintain potency. Potency of the sublingual nitroglycerin is noted if there is burning or stinging when the medication is placed under the tongue; if the medication does not burn, then the drug has lost its potency, and a new prescription must be obtained. Headaches associated with nitrates last approximately 20 minutes (with sublingual forms) and may be managed with acetaminophen.)

Which statement by the patient indicates a need for further instruction about colestipol (Colestid) from the nurse? "I will mix and stir the powder thoroughly with at least 1 to 2 oz of fluid." "I should take this medication 1 hour after or 4 hours before my other medications." "The potential adverse effects of this drug are rash and itching." "I might need to take fat-soluble vitamins to supplement my diet."

"I will mix and stir the powder thoroughly with at least 1 to 2 oz of fluid." (Colestipol is available in powder form that must be mixed thoroughly with food or fluids (at least 4 to 6 oz of fluid) before administration to avoid esophageal irritation or obstruction and intestinal obstruction.)

A client who has undergone Nissen fundoplication for gastroesophageal reflux disease (GERD) is ready for discharge home. Which statement made by the client indicates understanding of the disease? "I will no longer need any medication for my GERD." "I will avoid spicy foods because they can irritate the suture line." "I should take anti-reflux medications when I eat a large meal." "I will need to continue to watch my diet and may still need medication."

"I will need to continue to watch my diet and may still need medication." (A high percentage of recurrence of reflux has been noted after this type of surgery, so clients are encouraged to continue anti-reflux regimens of medication and diet control. These include taking medications, eating small meals, and avoiding spicy or acidic foods.)

The nurse is caring for a client who is scheduled for a gastric bypass to treat morbid obesity. Which statement by the client indicates a good understanding of preventing dumping syndrome after meals? Select all that apply . "I will eat a bland diet." "I will not drink fluids when I eat meals." "I will avoid sweetened and spicy foods." "I will eat a low-protein, high-carbohydrate diet." "I will eat small, frequent meals instead of three large meals a day."

"I will not drink fluids when I eat meals." "I will avoid sweetened and spicy foods." "I will eat small, frequent meals instead of three large meals a day." (Total fluid intake does not have to be restricted; however, fluids should not be taken immediately before, during, or after a meal because they promote rapid stomach emptying. It is safe to take fluids before or after meals. Concentrated sweets pass rapidly out of the stomach and increase fluid shift; spicy foods may cause gastric irritation; both sweetened and spicy food should be avoided. Dumping syndrome after gastric surgery is managed by nutrition changes that include decreasing the amount of food taken at one time. Small feedings reduce the amount of bulk passing into the jejunum and therefore reduce the fluid that shifts into the jejunum. A bland diet is not necessary. The diet should be low to moderate in carbohydrates, high in protein, and high in fat to promote tissue repair and provide energy.)

A nurse is teaching a client about gastroesophageal reflux disease (GERD). Which statement made by the client indicates correct understanding of GERD management? "Three meals per day is the best regimen to avoid GERD symptoms." "I can reduce my GERD symptoms through a high-carbohydrate, low-fat diet." "A snack at bedtime will help reduce the acidity of my stomach during the night." "I will place a 6-inch (15 cm) block under the head of my bed to help with digestion."

"I will place a 6-inch (15 cm) block under the head of my bed to help with digestion." (Elevation of the head of the bed can enhance esophageal emptying and reduce symptoms of GERD. A low-fat, high-protein diet is recommended. Eating should be avoided three hours before bedtime to reduce acid production, and the client should be instructed to consume small, frequent meals throughout the day to avoid gastric distention.)

Which statement indicates that the client understands the management of his or her sliding hiatal hernia? "I will lie flat for 30 minutes after each meal." "I will remain upright for several hours after each meal." "I will have my blood count done in 2 weeks to check for anemia." "I will sleep at night while lying on my left side to prevent reflux."

"I will remain upright for several hours after each meal." (Clients with hiatal hernia experience gastroesophageal reflux disease (GERD). Positioning is an important intervention. The client should be taught to sleep with the head of the bed elevated, to remain upright after meals for 2 to 3 hours, and to avoid straining or restrictive clothing. The other actions are not consistent with managing a sliding hiatal hernia.)

In order to prevent the possibility of venous stasis, a nurse is teaching a surgical client how to perform leg exercises. Which of the client's following statements indicates a sound understanding of leg exercises? "I'll practice these now and try to start them as soon as I can after my surgery." "I'll try to do these lying on my stomach so that I can bend my knees more fully." "I'll make sure to do these, as long as my doctor doesn't tell me to stay on bed rest after my operation." "I'm pretty sure my stomach muscles are strong enough to lift both of my legs off the bed at the same time."

"I'll practice these now and try to start them as soon as I can after my surgery." (Leg exercises should be begun as soon as possible after surgery, unless contraindications exist. Bed rest does not preclude the performance of leg exercises and the legs should be lifted individually, not simultaneously. The client should perform leg exercises in a semi-Fowler's, not prone, position.)

The clinic nurse is providing teaching to a client with newly diagnosed diabetes. Which statement by the client indicates a correct understanding about the need to wear a MedicAlert bracelet? "If I become hyperglycemic, it is a medical emergency." "If I become hypoglycemic, I could become unconscious." "Medical personnel may need confirmation of my insurance." "I may need to be admitted to the hospital suddenly."

"If I become hypoglycemic, I could become unconscious." (The statement by the client that indicates a correct understanding about the need to wear a MedicAlert bracelet is, "If I become hypoglycemic, I could become unconscious." Hypoglycemia is the most common cause of medical emergency in clients with diabetes. A MedicAlert bracelet is helpful if the client becomes hypoglycemic and is unable to provide self-care.Hyperglycemia does not pose the same type of acute medical emergency as hypoglycemia unless it is severe and acidosis develops. Insurance information does not appear on a MedicAlert bracelet. Information on the MedicAlert bracelet may be helpful if a sudden hospitalization occurs when the client cannot communicate. However, it is standard procedure to assess blood glucose in that instance.)

The nurse is teaching a young female client how to prevent venous thromboembolism specific to her hospital stay after intensive orthopedic surgery. Which statement made by the client indicates the need for further teaching? "I must stop taking my birth control pills." "I should drink lots of water so I don't get dehydrated." "I should exercise my legs when I have been sitting or standing for a long time." "If I wear pantyhose, I won't have to wear the stockings the hospital gives me."

"If I wear pantyhose, I won't have to wear the stockings the hospital gives me." (Further teaching is needed about how to prevent venous thromboembolism when the client says that "If I wear pantyhose, I won't have to wear the stockings the hospital gives me." Wearing the graduated compression stockings is a type of prevention specific to the hospital setting. They are designed to prevent blood clots, unlike regular pantyhose.Discontinuation of birth control pills is a routine prevention for thromboembolism, but this prevention is not specific to the client's acute hospitalization. Drinking a lot of water, where the quantity is not specified, may not be indicated for this client. Exercise is a prevention that can be done outside the hospital.)

The healthcare provider prescribes isosorbide dinitrate 10 mg for a client with chronic angina pectoris. The client asks the nurse why the isosorbide dinitrate is prescribed. How will the nurse respond? "It prevents excessive blood clotting." "It suppresses irritability in the ventricles." "It improves oxygen supply to heart tissue." "The inotropic action increases the force of contraction of the heart."

"It improves oxygen supply to heart tissue." (Isosorbide dinitrate dilates the coronary vasculature, improving the supply of oxygen to the hypoxic myocardium. Preventing blood from clotting is the action of anticoagulants. Suppressing irritability in the ventricles is the action of antidysrhythmics. Increasing the force of contraction of the heart is the action of cardiac glycosides.)

An obese client is prescribed orlistat (Xenical). The client asks the nurse how the drug works. How does the nurse respond? "It decreases the amount of norepinephrine in your brain. This action will increase your feeling of being satisfied on less food." "It increases the amount of serotonin in your brain. This action will greatly increase your metabolic rate, and you will burn calories quicker." "It inhibits enzymes and changes the way your body digests fats. Because fats are only partially digested and absorbed, calorie intake is decreased." "It will alter the chemistry of your brain. Consequently, you will feel full before you overeat."

"It inhibits enzymes and changes the way your body digests fats. Because fats are only partially digested and absorbed, calorie intake is decreased." (The nurse explains to the client that Orlistat inhibits lipase and leads to partial hydrolysis of triglycerides. Because fats are only partially digested and absorbed, calorie intake is decreased.Orlistat does not decrease the amount of norepinephrine in the brain, increase the amount of serotonin in the brain, or alter the chemistry of the brain.)

The patient states to the nurse, "My friend said nitroglycerin relieves angina pain by reducing preload. What is preload?" Which statement by the nurse explains preload to this patient? "It is dilation of arteries and veins throughout the body." "It is the oxygen demand of the heart." "It is the pressure against which the heart must pump." "It is the blood return to the heart."

"It is the blood return to the heart." (Preload is determined by the amount of blood in the ventricle just before contraction.)

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? "It is usually ready to be closed in about 1 to 2 months." "You need to talk to your primary health care provider about how long you will have this temporary ileostomy." "The period of time is indefinite—I am sorry that I cannot say." "You will probably have it for 6 months or longer, until things heal."

"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 client has arrived in the same-day surgery suite. He states to the nurse, "I am so worried about being put to sleep and having the surgery." What would be the nurse's best response? "You don't have to worry. It will be fine." "Tell me what you are most worried about." "I will have the anesthesiologist talk to you." "Have you ever had surgery before?"

"Tell me what you are most worried about." (The nurse should first assess what the client is most worried about or fearful of and then provide emotional support.)

A patient is prescribed oral anticoagulant therapy while still receiving IV heparin infusion. The patient is concerned about risk for bleeding. What is the nurse's best response? "Bleeding is a common adverse effect of taking warfarin. If bleeding occurs, your health care provider will prescribe an injection of medication to stop the bleeding." "Because of your mechanical valve replacement, it is especially important for you to be fully anticoagulated, and the heparin and warfarin together are more effective than one alone." "Because you are now getting out of bed and walking around, you have a higher risk of blood clot formation and therefore need to be on both medications." "It usually takes 4 to 5 days to achieve a full therapeutic effect for warfarin, so the heparin infusion is continued to help prevent blood clots until the warfarin reaches its therapeutic effect."

"It usually takes 4 to 5 days to achieve a full therapeutic effect for warfarin, so the heparin infusion is continued to help prevent blood clots until the warfarin reaches its therapeutic effect." (Warfarin works by decreasing the production of clotting factors. However, it takes 4 to 5 days for the body to use up present clotting factors and thus achieve a full therapeutic anticoagulant effect. Because of this, heparin is continued until this is achieved.)

The patient asks the nurse, "How should sublingual nitroglycerin be stored when I travel?" What is the nurse's best response? "It's best to keep it in its original container away from heat and light." "You can put a few tablets in a resealable bag and carry it in your pocket." "You can protect it from heat by placing the bottle in an ice chest." "Keep it in the glove compartment of your car to prevent exposure to heat."

"It's best to keep it in its original container away from heat and light." (Although sublingual nitroglycerin needs to be kept in a cool, dry place, it should not be placed in an ice chest, where it could freeze. It should not be kept in the glove compartment of a car and needs to be kept away from heat, not in a clear plastic bag.)

The nurse is instructing a client about the use of antiembolism stockings. Which statement by the client indicates the need for further teaching? "I will take off my stockings one to three times a day for 30 minutes." "My stockings are too loose." "It's better if they are too tight rather than too loose." "These stockings help promote blood flow."

"It's better if they are too tight rather than too loose." (Antiembolism stockings should fit properly to achieve the desired result. Stockings that are too tight will impede blood flow.Frequent removal of the stockings is appropriate to allow for hygiene and a break from their wear. Stockings that are too loose are ineffective. Antiembolism stockings may be used during and after surgery to promote venous return.)

Which information will the nurse include for a patient with newly diagnosed gastroesophageal reflux disease (GERD)? "Peppermint tea may reduce your symptoms." "Keep the head of your bed elevated on blocks." "You should avoid eating between meals to reduce acid secretion." "Vigorous physical activities may increase the incidence of reflux."

"Keep the head of your bed elevated on blocks." (Elevating the head of the bed will reduce the incidence of reflux while the patient is sleeping. Peppermint will decrease lower esophageal sphincter (LES) pressure and increase the chance for reflux. Small, frequent meals are recommended to avoid abdominal distention. There is no need to make changes in physical activities because of GERD.)

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

"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.)

A client is eating a soft diet while recovering from a stroke. The client reports food accumulating in the cheek of the affected side. What is the nurse's best response? "Next time you eat, try lifting your chin when you swallow." "Let's advance your diet to solid food." "Let's see if the dietitian can help." "Let's see if the speech-language pathologist can help."

"Let's see if the speech-language pathologist can help." (The nurse's best response about food gathering in the cheek of a stroke client is to see what the speech pathologist says may help. The speech-language pathologist identifies strategies to prevent food from accumulating in the cheek of the affected side of a client recovering from a stroke. The speech pathologist will assist the client with tongue exercises that will help move the food bolus to the unaffected side.Lifting the chin is not an appropriate technique. A solid diet would not necessarily be the best choice. The dietitian will be consulted to evaluate the nutritional status of the client as well as make recommendations regarding the correct diet.)

A client expresses fear and anxiety over the life changes associated with diabetes, stating, "I am scared I can't do it all and I will get sick and be a burden on my family." What is the nurse's best response? "It is overwhelming, isn't it?" "Let's see how much you can learn today, so you are less nervous." "Let's tackle it piece by piece. What is most scary to you?" "Many people live with diabetes and do it just fine."

"Let's tackle it piece by piece. What is most scary to you?" (The nurse's best response is to suggest that the client tackle it piece by piece and ask what is most scary to him or her. This is the best client centered response, and acknowledges the client's concern, letting the client master survival skills first.Referring to the illness as overwhelming may reflect the client's feelings, but is a closed-ended question and does not encourage the client to express his feelings about the underlying fear. Trying to see how much the client can learn in one day may add to his anxiety by overwhelming him with information and the need to "do it all" in one day. Suggesting that other people handle the illness just fine criticizes the client and does not recognize his concerns.)

A client who is diagnosed with a duodenal ulcer asks, "Now that I have an ulcer, what comes next?" What is the nurse's best response? "Most peptic ulcers heal with medical treatment." "Clients with peptic ulcers have pain while eating." "Early surgery is advisable, especially after the first attack." "If ulcers are untreated, cancer of the stomach can develop."

"Most peptic ulcers heal with medical treatment." (Treatment with medications, rest, diet, and stress reduction relieves symptoms, heals the ulcer, and prevents complications and recurrence. Clients with duodenal ulcers have pain after eating and especially at night; gastric ulcers cause pain during or close to eating. Surgery may be done after multiple recurrences and for treating complications. Perforation, pyloric obstruction, and hemorrhage, not cancer, are major complications.)

Which statement by a client scheduled for a percutaneous transluminal coronary angioplasty (PTCA) indicates a need for further preoperative teaching? "I will be awake during this procedure." "I will have a balloon in my artery to widen it." "I must lie still after the procedure." "My angina will be gone for good."

"My angina will be gone for good." (In this situation, further teaching is needed when the client states that angina will be gone after the PTCA. The client's angina may not be eliminated. Reocclusion is possible after PTCA.The client is typically awake, but drowsy, during this procedure. PTCA uses a balloon to widen the artery, and the client will have to lie still after the procedure because of the large-bore venous access. Time is necessary to allow the hole to heal and prevent hemorrhage.)

The nurse is teaching a middle-aged adult client with a body mass index (BMI) of 27.5 and a height of 5'2" (157.5 cm) about what the BMI number means, and about malnutrition. Which client statement indicates a need for further instruction? "If I could get my BMI below 25, my risk for malnutrition would decrease." "I realize that this means that I have some increased health risks." "My goal should be to get my BMI below 18.5." "This means that I have an increased amount of total fat stored in my body."

"My goal should be to get my BMI below 18.5." (The client statement showing a need for further instruction is, "My goal should be to get my BMI below 18.5." The least risk for malnutrition is associated with scores between 18.5 and 25.Older adults need to have a BMI between 23 and 27. The client with a BMI greater than 24.9 does have increased health risks that a client with a lower number would not have. The client's BMI of 27.5 does mean that an increased amount of fat is stored in the body in relation to the client's height.)

Which statement by a nursing student indicates a need for further teaching about operating room (OR) surgical attire? "I must cover my facial hair." "I don't need a sterile gown to be in the OR." "If I go into the OR, I must wear a protective mask." "My scrubs will be sterile."

"My scrubs will be sterile." (Scrub attire is provided by the hospital and is clean, not sterile.All members of the surgical team must cover their hair, including any facial hair. Team members who are not scrubbed (e.g., anesthesia provider, student nurse) are not required to be sterile and may wear cover scrub jackets that are snapped or buttoned closed to prevent shedding of organisms from bare arms. Everyone who enters an OR in which a sterile field is present must wear a mask.)

When educating the client about immunosuppressant therapy, what information would the nurse include in the teaching? Select all that apply. "If you miss a dose of medication, take extra medicine to make up the missed dose." "Never stop taking these medications without being instructed by your health care provider." "Over-the-counter medications are alright to take as needed." "You must take all medications exactly as prescribed." "Medications must be taken at the correct time every time to avoid interactions."

"Never stop taking these medications without being instructed by your health care provider." "You must take all medications exactly as prescribed." "Medications must be taken at the correct time every time to avoid interactions." (Immunosuppressants must be taken exactly as directed and at the exact times and with the exact foods. Adherence to dosing schedules can be very difficult for clients because they are taking multiple medications that must be taken at different times throughout the day. Clients should never stop taking their immunosuppressants without being told to do so by their transplant health care provider. They should always talk to the transplant health care provider before taking any over-the-counter medications or if a scheduled dose is missed.)

The nurse is teaching a patient with peptic ulcer disease (PUD) about the prescribed drug regimen. Which statement made by the patient indicates a need for further teaching before discharge? "Nizatidine (Axid) needs to be taken three times a day to be effective." "Taking ranitidine (Zantac) at bedtime should decrease acid production at night." "Sucralfate (Carafate) should be taken 1 hour before and 2 hours after meals." "Omeprazole (Prilosec) should be swallowed whole and not crushed."

"Nizatidine (Axid) needs to be taken three times a day to be effective." (Further discharge teaching is needed when the patient says that Nizatidine works best when taken three times a day. Nizatidine is most effective if administered once daily.A dose of ranitidine at bedtime would decrease acid production throughout the night. Sucralfate is taken 1 hour before and 2 hours after meals. Because omeprazole is a delayed-release capsule, it needs to be swallowed whole and not crushed.)

A client with type 2 diabetes is taking one oral hypoglycemic tablet daily. The client asks whether an extra tablet should be taken before exercise. What is the best response by the nurse? "You will need to decrease your exercise." "An extra tablet will help your body use glucose correctly." "When taking medicine, your diet will not be affected by exercise." "No, but you should observe for signs of hypoglycemia while exercising."

"No, but you should observe for signs of hypoglycemia while exercising." (Exercise improves glucose metabolism; with exercise there is a risk of developing hypoglycemia, not hyperglycemia. Exercise should not be decreased because it improves glucose metabolism. An extra tablet probably will result in hypoglycemia because exercise alone improves glucose metabolism. Control of glucose metabolism is achieved through a balance of diet, exercise, and pharmacologic therapy.)

Which statement made by a client recently diagnosed with type 1 diabetes indicates that further education is necessary regarding the teaching plan? "I will need to have my eyes and vision examined once a year." "I will need to check my blood sugar at home to evaluate my response to my treatment plan." "I can improve metabolic and cardiac risk factors of this disease if I follow a low-calorie diet and lose weight." "Once I reach my target weight there is a good chance that I will be able to switch from insulin to an oral medication."

"Once I reach my target weight there is a good chance that I will be able to switch from insulin to an oral medication." (Type 1 diabetes mellitus (DM) is an autoimmune disorder in which beta cells are destroyed. No insulin or very little insulin is produced. Therefore a person with type 1 DM will need lifelong insulin injections to control blood sugar. Early detection of changes in the eye permits treatment plan adjustments that can slow or halt progression of retinopathy. Blood glucose monitoring should be done at home to evaluate the treatment plan. Disease risk factors can be improved with weight loss and a low-calorie diet.)

The nurse is educating a client who is about to undergo cardiac surgery with general anesthesia. Which statement by the client indicates the need for further instruction? "I will wake up with a tube in my throat." "I will have a bandage on my chest." "My family will not be able to see me right away." "Pain medication will take away my pain."

"Pain medication will take away my pain." (The client's statement that, "Pain medication will take away my pain," indicates the need for further instruction. Pain medication will reduce pain, but will not take it away completely.The client statement about waking up with a tube in the throat is accurate, because the client will be intubated. Following heart surgery, a dressing is placed on the chest. The client will not be able to see family immediately because he or she will go to recovery first.)

The nurse is teaching a client with newly diagnosed anemia about conserving energy. Which instructions would the nurse give to the client? Select all that apply. "Provide yourself with four to six small, easy-to-eat meals daily." "Perform your care activities in groups to conserve your energy." "Stop activity when shortness of breath or palpitations is present." "Allow others to perform your care during periods of extreme fatigue." "Drink small quantities of protein shakes and nutritional supplements daily." "Perform a complete bath daily to reduce your chance of getting an infection."

"Provide yourself with four to six small, easy-to-eat meals daily." "Stop activity when shortness of breath or palpitations is present." "Allow others to perform your care during periods of extreme fatigue." "Drink small quantities of protein shakes and nutritional supplements daily." (Having four to six small meals daily is preferred over three large meals. This practice conserves the body's expenditure of energy used in digestion and assimilation of nutrients. Stopping activities when strain on the cardiac or respiratory system is noted is critical. It is critical to have others help the anemic client who is extremely tired. Although it may be difficult for him or her to ask for help, this practice should be stressed to the client. Drinking small protein or nutritional supplements will help rebuild the client's nutritional status.A complete bath needs to be performed only every other day. On days in between, the client can be taught to take a "mini" sponge bath, which will conserve energy and still be safe in preventing the risks for infection. Care activities would be spaced every hour or so rather than in groups to conserve energy. Care activities need to be avoided just before and after meals.)

A patient with gastroesophageal reflux disease has undergone a laparoscopic Nissen fundoplication (LNF). What will the nurse include in postoperative home care instructions? "Consume carbonated beverages if you experience stomach upset." "Remain on a soft diet for about a week and avoid raw vegetables that are difficult to swallow." "You may resume running and weight lifting if you wish." "You may stop taking your antireflux medications after 1 week."

"Remain on a soft diet for about a week and avoid raw vegetables that are difficult to swallow." (After LNF, patients need to be taught to remain on a soft diet for 1 week and to avoid raw vegetables that are difficult to swallow.Carbonated beverages should be avoided. Patients may walk but need to avoid heavy lifting. Antireflux medications need to be taken for 1 month after the procedure.)

Which client statement demonstrates understanding of teaching by the nurse regarding the use of histamine₂-receptor antagonists? "Because I am taking this medication, it is OK for me to eat spicy foods." "Smoking decreases the effects of this medication, so I should look into cessation programs." "I should take this medication 1 hour after each meal to maximally decrease gastric acidity." "I should increase bulk and fluids in my diet to prevent constipation."

"Smoking decreases the effects of this medication, so I should look into cessation programs." (Clients taking histamine₂-receptor-blocking drugs should avoid spicy foods, extremes in temperatures, alcohol, and smoking. Diarrhea, not constipation, is a GI adverse effect. Whereas cimetidine should be taken with meals, famotidine can be taken without regard to meals.)

A client who has a gastric ulcer asks what to do if epigastric pain occurs. The nurse evaluates that teaching is effective when the client makes which statement? "Eliminating fluids with meals will prevent pain." "I will increase my food intake to avoid an empty stomach." "Taking an aspirin with milk will relieve my pain and coat my ulcer." "Taking an antacid preparation will decrease pain due to gastric acid."

"Taking an antacid preparation will decrease pain due to gastric acid." (Over-the-counter antacid preparations neutralize gastric acid and relieve pain. Although eating food initially prevents gastric acid from irritating the gastric walls, it can precipitate acid production. Aspirin is contraindicated because it irritates gastric mucosa and promotes bleeding by preventing platelet aggregation. Reduction of fluids with meals does not affect pain.)

A female client is concerned that her inability to conceive a child is connected to her morbid obesity. How does the nurse respond? "Do you feel that your obesity is keeping you from getting pregnant?" "Have you considered adoption as an option?" "Tell me about any changes in your menstrual cycle each month." "What has your health care provider told you about your problems in getting pregnant?"

"Tell me about any changes in your menstrual cycle each month." (The best response by the nurse is to ask the client who is concerned about her inability to conceive, is to ask her about changes in her menstrual cycle each month. Obesity has been known to produce changes in the menstrual cycle, thus causing difficulties in getting pregnant. Asking the client about her menstrual cycle directly addresses the client's concern and is designed to elicit helpful assessment information.Asking the client if she feels her obesity is keeping her from getting pregnant only asks the client to restate the obvious. It is also a closed question that requires only a "yes-or-no" response. Telling the client that adoption is an option is an intrusive response by the nurse and may alienate the client. It also does not address the client's concern about obesity. Asking what her health care provider told her is an evasive response from the nurse and does not address the client's concerns.)

After bariatric surgery, a patient who is being discharged tells the nurse, "I prefer to be independent. I am not interested in any support groups." Which response by the nurse is best? "I hope you change your mind so that I can suggest a group for you." "Tell me what types of resources you think you might use after this surgery." "Support groups have been found to lead to more successful weight loss after surgery." "Because there are many lifestyle changes after surgery, we recommend support groups."

"Tell me what types of resources you think you might use after this surgery." (This statement allows the nurse to assess the individual patient's potential needs and preferences. The other statements offer the patient more information about the benefits of support groups, but fail to acknowledge the patient's preferences.)

The nurse is performing a health assessment on an obese client who states, "I have tried many diets in an effort to lose weight, but have been unsuccessful." How does the nurse assess whether the client's response to stress is related to the client's obesity? "Do you have a history of mental problems, especially depression?" "Do you usually use alcohol or drugs when you feel stressed?" "Tell me what you do to relieve stress in your daily life." "What is it about your obesity that causes you to feel uncomfortable?"

"Tell me what you do to relieve stress in your daily life." (The best way to assess a client's response to obesity and stress is to say, "Tell me what you do to relieve stress in your daily life." This open-ended type of question is best because it cannot be answered with a "yes" or "no."Asking the client about mental health problems will cause the client to feel uncomfortable with the assessment; problems in handling stress do not mean mental health or depression problems. More effective methods can be used to determine the client's alcohol and drug habits. Having the client tell you what makes him or her uncomfortable about obesity will only cause the client to restate the obvious. It does not determine the effect that stress has on the client.)

The adult male patient with significant body hair is being prepared for abdominal surgery. The patient states his dad had the same surgery many years ago and was shaved prior to the procedure. The nurse would explain to the patient: "That practice is no longer standard as shaving may cause breaks in the skin." "We no longer shave skin before procedures but we will apply a lotion that will remove the hair." "Your abdomen will be shaved in the operating room." "You will be shaved as well."

"That practice is no longer standard as shaving may cause breaks in the skin." (A surgical "prep," or shaving of the hair in the affected area, was a common preoperative procedure a decade ago. Current research indicates that preoperative shaving increases the risk for surgical site infection by causing tiny breaks in skin integrity.)

The daughter of a client who has had a stroke asks the nurse for additional resources. What is the nurse's best response? "Call hospice." "Check the Internet." "The National Stroke Association has resources available." "The charge nurse at the desk has all of the information."

"The National Stroke Association has resources available." (The nurse's best response about additional resources for stroke is the National Stroke Association. The National Stroke Association is a specific and reliable resource that can be recommended. Additional resources are frequently provided as part of the discharge teaching the nurse will provide.Hospice care is appropriate for clients who are terminally ill, not a client who has had a stroke necessarily. Sources on the Internet may be very broad and unreliable or lack evidence to support their recommendations. The role of the client's nurse is to advocate for the client and not to refer all questions to the charge nurse.)

A primary healthcare provider prescribes a heart-healthy diet for a client with angina. The client's spouse says to the nurse, "I guess I'm going to have to cook two meals, one for my spouse and one for myself." Which is the most appropriate response by the nurse? "The diet prescribed for your spouse is a healthy diet. It contains guidelines that many of us should follow." "I wouldn't bother. For this diet all that you need to do is to reduce the amount of salt you use and fry foods in peanut oil." "You're right. Be careful to cook a small portion for each of you to eat to not waste food." "This is a difficult diet to follow. I recommend that you shop daily for food so there are no temptations in the kitchen."

"The diet prescribed for your spouse is a healthy diet. It contains guidelines that many of us should follow." (Heart-healthy diets are low in cholesterol, sodium, and fat, particularly saturated fats, and high in vegetables and fruits; this type of diet is advocated for all individuals. Fried foods are not advocated on a heart-healthy diet; peanut oil is a monounsaturated fatty acid, and these acids should not exceed 15% of the calories of the diet. The responses "You're right. Be careful to cook a small portion for each of you to eat to not waste food" and "This is a difficult diet to follow. I recommend that you shop daily for food so there are no temptations in the kitchen" can be discouraging and encourage noncompliance.)

A patient is taking omeprazole (Prilosec) for the treatment of gastroesophageal reflux disease (GERD). The nurse will include which statement in the teaching plan about this medication? "Take this medication once a day after breakfast." "You will be on this medication for only 2 weeks for treatment of the reflux disease." "The medication may be dissolved in a liquid for better absorption." "The entire capsule must be taken whole, not crushed, chewed, or opened."

"The entire capsule must be taken whole, not crushed, chewed, or opened." (Omeprazole needs to be taken before meals, and an entire capsule must be taken whole, not crushed, chewed, opened, or dissolved in liquid when treating GERD. This medication is used on a long-term basis to maintain healing.)

The nurse is teaching the spouse and client who has had a brain attack about rehabilitation. Which statement by the spouse demonstrates understanding of the nurse's instruction? "Frequent stimulation will help with the rehabilitation process." "My spouse will no longer need to take blood pressure medication." "Rehabilitation and physical therapy are the same thing." "The rehabilitation therapist will help identify changes needed at home."

"The rehabilitation therapist will help identify changes needed at home." (Understanding instructions about brain attack is demonstrated by the statement that the rehabilitation therapist will help identify any needed home changes. The rehabilitation therapist and home health professionals assist the client and family in adapting the home environment to the client's needs and assess the client's need for therapy.An appropriate amount of stimulation based on the client's needs will be determined by the therapist and incorporated into a comprehensive plan. Any medication regimen established for the client after the brain attack must be maintained. Rehabilitation is much more comprehensive than physical therapy.)

The nurse is reinforcing information about genetic counseling to a client with sickle cell disease who has a healthy spouse. What information would the nurse explain to the parents about the risk of a child having sickle cell disease? "Sickle cell disease will be inherited by your children." "The sickle cell trait will be inherited by your children." "Your children will have the disease, but your grandchildren will not." "Your children will not have the disease, but your grandchildren could."

"The sickle cell trait will be inherited by your children." (The statement that explains to parents about the risk of a child having sickle cell disease is that the children of the client with sickle cell disease will inherit the sickle cell trait but may not inherit the disease. If both parents have the sickle cell trait, their children could get the disease.The children of the client with sickle cell disease will inherit the sickle cell trait but may not inherit the disease. If both parents have the sickle cell trait, their children could get the disease.)

The nurse is caring for the postoperative patient in the PACU. The patient is concerned about the abdominal staples closing her wound for fear they will open and her "insides will fall out." Which of the following is the best response by the nurse? "Don't worry, the staples are properly placed and will not come out until they are removed by the physician." "If you are very careful and follow your postoperative instructions, there is no need to worry." "There are sutures in various levels below the staples that assist in keeping your wound intact." "Would you tell me why you are worried about that?" "That is possible, but we will keep a close eye on the staples."

"There are sutures in various levels below the staples that assist in keeping your wound intact." (A patient may have absorbable sutures closing the viscera and staples approximating the wound edges.)

A patient who is taking nitroglycerin (Nitrostat) sublingual tablets is complaining of flushing and headaches. What is the nurse's best response? "Put a cold wet washcloth or use an icepack on your forehead and lie down in a quiet place." "These are the most common adverse effects of nitroglycerin. They should subside with continued use of nitroglycerin." "Stop taking the nitroglycerin because you are experiencing an allergic reaction to the medication." "Immediately notify your health care provider because these symptoms are not related to the sublingual nitroglycerin."

"These are the most common adverse effects of nitroglycerin. They should subside with continued use of nitroglycerin." (Headache, flushing of the face, dizziness, and fainting are the most common adverse effects of nitroglycerin and the headache generally subsides after the start of therapy.)

A patient with peptic ulcer disease (PUD) asks the nurse whether licorice and slippery elm might be useful in managing the disease. What is the nurse's best response? "No, they probably won't be useful. You should use only prescription medications in your treatment plan." "These herbs could be helpful. However, you should talk with your primary health care provider before adding them to your treatment regimen." "Yes, these are known to be effective in managing this disease but make sure you research the herbs thoroughly before taking them." "No, herbs are not useful for managing this disease. You can use any type of over-the-counter drugs though. They have been shown to be safe."

"These herbs could be helpful. However, you should talk with your primary health care provider before adding them to your treatment regimen." (The nurse's best response is that although licorice and slippery elm may be helpful in managing PUD, the patient must consult his or her primary health care provider before making a change in the treatment regimen.Alternative therapies may or may not be helpful in managing PUD. The patient must not use over-the-counter medications without first discussing it with his or her primary health care provider.)

A client with unstable angina has received education about acute coronary syndrome. Which statement indicates that the client has understood the teaching? "This is a big warning; I must modify my lifestyle or I am at risk for having a heart attack." "Angina is just a temporary interruption of blood flow to my heart." "I need to tell my wife I've had a heart attack." "Because this was temporary, I will not need to take any medications for my heart."

"This is a big warning; I must modify my lifestyle or I am at risk for having a heart attack." (The statement by the client that unstable angina being a big warning and needing to alter his lifestyle shows that the client understands the teaching. Health promotion efforts are directed toward controlling or altering modifiable risk factors for CAD, which will then lower the risk of unstable angina and/or MI.Although anginal pain is temporary, it reflects underlying coronary artery disease (CAD), which requires attention, including lifestyle modifications. Unstable angina reflects tissue ischemia, but infarction represents tissue necrosis. Clients with underlying CAD may need medications such as aspirin, lipid-lowering agents, antianginals, or antihypertensives.)

A client diagnosed with acalculous cholecystitis asks the nurse how the gallbladder inflammation developed when there is no history of gallstones. What is the nurse's best response? "This may be an indication that you are developing sepsis." "The gallstones are present, but have become fibrotic and contracted." "This type of gallbladder inflammation is associated with hypovolemia." "This may be an indication of pancreatic disease."

"This type of gallbladder inflammation is associated with hypovolemia." (The nurse's best response about acalculous cholecystitis is that "This type of gallbladder inflammation is associated with hypovolemia."Although this type of gallbladder inflammation is associated with sepsis, it is not an indicator that sepsis is developing. Fibrotic and contracted gallstones are associated with chronic cholecystitis and this scenario states that there is no history of gallstones. The presence of acalculous cholecystitis is not an indicator that pancreatic disease has developed.)

The nurse is teaching a class of older adults in the community about engaging in "regular" exercise. What does the nurse advise them? "One to two hours of cardiovascular exercise every day is a good idea." "Joining a fitness program or gym will help greatly with your exercise." "Walking 30 to 40 minutes provides the same benefit as long periods of exercise." "You will benefit most if you get into a group that shares your exercise goals."

"Walking 30 to 40 minutes provides the same benefit as long periods of exercise." (The nurse advises the class of older adults to walk 30 to 40 minutes five days per week. Although some people think that regular exercise has to include joining a fitness program or exercising for long periods of time, simple forms of exercise like walking can provide the same type of benefit. Older adults can engage in this type of exercise which does not cost anything (unlike joining a program) and provides health benefits such as strengthening joints and improving cardiovascular health.One to two hours of cardiovascular exercise every day is not required to achieve benefits of exercise. Joining a gym is not necessary. In addition, many older adults have a fixed income and cannot afford memberships. A 30-minute walk can be accomplished with a group (such as "mall walking") or alone.)

A 40-year-old obese woman reports that she wants to lose weight. Which question should the nurse ask first? "What factors led to your obesity?" "Which types of food do you like best?" "How long have you been overweight?" "What kind of activities do you enjoy?"

"What factors led to your obesity?" (The nurse should obtain information about the patient's perceptions of the reasons for the obesity to develop a plan individualized to the patient. The other information also will be obtained from the patient, but the patient is more likely to make changes when the patient's beliefs are considered in planning.)

A client is having an arthroscopy of the left knee and has just been moved to the surgical holding area. Which statement by the nurse properly identifies the client while the nurse checks the identification label? "Are you Mr. Smith?" "Good morning, Mr. Smith." "What is your name, and when were you born?" "What surgery are you having today?"

"What is your name, and when were you born?" (The nurse must verify the client's identity with two types of identifiers, such as name and birthdate. This practice prevents errors by drowsy or confused clients.When asked to verify his or her name, or respond to a greeting, the client may respond inappropriately if he or she is anxious or sedated. Asking the client about his or her surgery does help with identification. However, it is really done to ascertain that the client's perception of the procedure, the operative permit, and the operative schedule are the same.)

Which statement by the nurse is most likely to help a morbidly obese 22-year-old man in losing weight on a 1000-calorie diet? "It will be necessary to change lifestyle habits permanently to maintain weight loss." "You will decrease your risk for future health problems such as diabetes by losing weight now." "You are likely to notice changes in how you feel with just a few weeks of diet and exercise." "Most of the weight that you lose during the first weeks of dieting is water weight rather than fat."

"You are likely to notice changes in how you feel with just a few weeks of diet and exercise." (Motivation is a key factor in successful weight loss and a short-term outcome provides a higher motivation. A 22-year-old patient is unlikely to be motivated by future health problems. Telling a patient that the initial weight loss is water will be discouraging, although this may be correct. Changing lifestyle habits is necessary, but this process occurs over time and discussing this is not likely to motivate the patient.)

The nurse is interviewing a client admitted for uncontrolled diabetes after binging on alcohol for the past 2 weeks. The client states, "I am worried about how I am going to pay my bills for my family while I am hospitalized." Which statement by the nurse would best elicit information from the client? "You are worried about paying your bills?" "Don't worry; your bills will get paid eventually." "When was the last time you were admitted for hyperglycemia?" "You really shouldn't be drinking alcohol because of your diagnosis of diabetes."

"You are worried about paying your bills?" (Reflection can help the client to elaborate. The statement "Don't worry; your bills will get paid eventually" offers false assurance; the statement "When was the last time you were admitted for hyperglycemia?" uses professional jargon; and the statement "You really shouldn't be drinking alcohol because of your diagnosis of diabetes" is offering advice, all of which can all restrict the client's response.)

A patient arrives at the urgent care center complaining of leg pain after a fall when rock climbing. The x-rays show no broken bones, but he has a large bruise on his thigh. The patient says he drives a truck and does not want to take anything strong because he needs to stay awake. Which statement by the nurse is most appropriate? "It would be best for you not to take anything if you are planning to drive your truck." "We will discuss with your doctor about taking an opioid because that would work best for your pain." "You can take acetaminophen, also known as Tylenol, for pain, but no more than 1000 mg per day." "You can take acetaminophen, also known as Tylenol, for pain, but no more than 3000 mg per day."

"You can take acetaminophen, also known as Tylenol, for pain, but no more than 3000 mg per day." (Acetaminophen is indicated for mild-to-moderate pain and does not cause drowsiness, as an opioid would. Currently, the maximum daily amount of acetaminophen is 3000 mg/day. The 1000-mg amount per day is too low. Telling the patient not to take any pain medications is incorrect.)

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? "You may have contracted it from an infected infant." "You may have consumed contaminated food or water." "You may have come into contact with an infected animal." "You may have had contact with the blood of an infected person."

"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.)

A nurse is educating a surgical client on postoperative p.r.n. pain control. Which of the following should be included? "We will bring you pain medications; you don't need to ask." "Even if you have pain, you may get addicted to the drugs." "You won't have much pain so just tough it out." "You need to ask for the medication before the pain becomes severe."

"You need to ask for the medication before the pain becomes severe." (If medication for pain is ordered p.r.n., there is a time restriction between doses. The client needs to ask for the medication and should do so before the pain becomes severe.)

A nurse is educating a client about regional anesthesia. Which of the following statements is accurate about this type of anesthesia? "You will be asleep and won't be aware of the procedure." "You will be asleep but may feel some pain during the procedure." "You will be awake but will not be aware of the procedure." "You will be awake and will not have sensation of the procedure."

"You will be awake and will not have sensation of the procedure." (Regional anesthesia occurs when an anesthetic agent is injected near a nerve or nerve pathway in or around the operative site, inhibiting the transmission of sensory stimuli to central nervous system receptors. The client remains awake but loses sensation in a specific area or region of the body.)

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? "It is to stop the diarrhea and bloody stools." "This will minimize your GI discomfort." "With this medication, your cramping will be relieved." "Your intestinal inflammation will be reduced."

"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.)

The nurse is caring for a male client who is 6 feet, 1 inch tall and weighs 215 pounds. The client asks the nurse if his weight is appropriate for his height. Which is the nurse's best response? "Your weight is just about right for someone your height." "Your weight is a few pounds under the ideal for your height." "Your weight is a few pounds over the ideal for your height." "Your weight is quite a few pounds over the ideal for your height."

"Your weight is a few pounds over the ideal for your height." (The client's BMI is 28.4, indicating that the client is overweight. However, he is not obese. The nurse should not state that the client's weight is just about right, a few pounds under, or quite a bit over the ideal weight for his height.)

The intensive care nurse is caring for a client admitted in a hyperglycemic-hyperosmolar state. Which of these prescriptions made by the primary health care provider will the nurse question? Add 20 mEq of KCl to each liter of IV fluid IV regular insulin at 2 units/hr IV normal saline at 100 mL/hr 1 ampule Sodium Bicarbonate IV now

1 ampule Sodium Bicarbonate IV now (Sodium Bicarbonate is given for the acid-base imbalance of diabetic ketoacidosis, not the hyperglycemic-hyperosmolar state that presents with hyperglycemia and absence of ketosis/acidosis.Insulin puts potassium into the cell. KCl 20 mEq for each liter of IV fluid will correct hypokalemia from osmotic diuresis and electrolyte shifts. IV regular insulin at 2 units/hr will help correct hyperglycemia. IV normal saline at 100 mL/hr will help correct dehydration.)

A client with type 1 diabetes receives regular insulin every morning at 8:00 AM. During what period of time does the nurse recognize the risk of hypoglycemia is greatest? 8:30 to 9:30 AM 8:00 PM to midnight 1:00 PM to 8:00 PM 10:00 AM to 1:00 PM

10:00 AM to 1:00 PM (Regular insulin peaks in 2 to 5 hours; therefore the greatest risk is between 10:00 AM and 1:00 PM. Although the onset of action occurs earlier, during the period from 8:30 to 9:30 AM, the level is not yet at its highest, so the risk of hypoglycemia is not at its greatest. NPH insulin's peak action is 4 to 12 hours; if hypoglycemia occurs, it will happen most likely between midnight and 8 PM.)

A client with type 1 diabetes mellitus received regular insulin at 7:00 a.m. The client will need to be monitored for hypoglycemia at which time? 7:30 a.m. 11:00 a.m. 2:00 p.m. 7:30 p.m.

11:00 a.m. (Regular insulin is a short-acting type of insulin. Onset of action to regular insulin is ½ to 1 hour. The peak effect time is when hypoglycemia may start to occur. Peak time for regular insulin is 2-4 hours. Therefore, 11:00 a.m. is the anticipated peak time for regular insulin received at 7:00 a.m.The other options for peak times for regular insulin are incorrect.)

The nurse is preparing to start an IV in the preoperative adult patient. The nurse would likely choose which gauge of IV catheter? 22 gauge 25 gauge 18 gauge 14 gauge

18 gauge (For any surgical patient, a large-gauge (e.g., 18-gauge) IV device should be used in case a blood transfusion is necessary during the surgical or postoperative period.)

The nurse is caring for a patient recently diagnosed with renal calculi. The nurse should instruct the patient to increase fluid intake to a level where the patient produces at least how much urine each day? 1,250 mL 2,000 mL 2,750 mL 3,500 mL

2,000 mL (Unless contraindicated by renal failure or hydronephrosis, patients with renal stones should drink at least eight 8-ounce glasses of water daily or have IV fluids prescribed to keep the urine dilute. A urine output exceeding 2 L a day is advisable.)

A nurse prepares to administer prescribed regular and NPH insulin. Place the nurse's actions in the correct order to administer these medications. 1. Inspect bottles for expiration dates. 2. Gently roll the bottle of NPH between the hands. 3. Wash your hands. 4. Inject air into the regular insulin. 5. Withdraw the NPH insulin. 6. Withdraw the regular insulin. 7. Inject air into the NPH bottle. 8. Clean rubber stoppers with an alcohol swab.

3. Wash your hands. 1. Inspect bottles for expiration dates. 2. Gently roll the bottle of NPH between the hands. 8. Clean rubber stoppers with an alcohol swab. 7. Inject air into the NPH bottle. 4. Inject air into the regular insulin. 6. Withdraw the regular insulin. 5. Withdraw the NPH insulin. (After washing hands, it is important to inspect the bottles and then to roll the NPH to mix the insulin. Rubber stoppers should be cleaned with alcohol after rolling the NPH and before sticking a needle into either bottle. It is important to inject air into the NPH bottle before placing the needle in a regular insulin bottle to avoid mixing of regular and NPH insulin. The shorter-acting insulin is always drawn up first.)

Which serum albumin level does the nurse expect to see in a healthy, ambulatory adult client? 2.3 g/dL (23 g/L) 3.7 g/dL (37 g/L) 5.1 g/dL (51 g/L) 5.8 g/dL (58 g/L)

3.7 g/dL (37 g/L) (The normal serum albumin level for men and women is 3.5 to 5.0 g/dL (35 to 50 g/L).The other options given are incorrect.)

When preparing to administer an intravenous (IV) infusion of metronidazole (Flagyl), the nurse will anticipate infusing the medication over how many minutes? 30 to 60 5 to 10 15 to 30 1 to 5

30 to 60 (Infuse IV doses of metronidazole as prescribed and generally are to infuse over 30 to 60 minutes and never as an IV bolus.)

Which information regarding a patient's sleep is most important for the nurse to communicate to the health care provider? 64-year-old nurse who works the night shift reports drinking hot chocolate before going to bed in the morning 21-year-old student who takes melatonin to assist in sleeping when traveling from the United States to Europe 41-year-old librarian who has a body mass index (BMI) of 42 kg/m² says that the spouse complains about snoring 32-year-old accountant who is experiencing a stressful week uses diphenhydramine (Benadryl) for several nights

41-year-old librarian who has a body mass index (BMI) of 42 kg/m² says that the spouse complains about snoring (The patient's BMI and snoring suggest possible sleep apnea, which can cause complications such as cardiac dysrhythmias, hypertension, and right-sided heart failure. Melatonin is safe to use as a therapy for jet lag. Short-term use of diphenhydramine in young adults is not a concern. Hot chocolate contains only 5 mg of caffeine and is unlikely to affect this patient's sleep quality.)

The RN receives a change-of-shift report about four patients. Which patient does the nurse assess first? A 20-year-old with ulcerative colitis (UC) who had six liquid stools during the previous shift A 25-year-old who has just been admitted with possible appendicitis and has a temperature of 102°F (37.9°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 A 60-year-old admitted with acute gastroenteritis who is reporting severe cramping and nausea

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.)

Which client does the nurse assign as a roommate for a client with aplastic anemia? A 34-year-old with idiopathic thrombocytopenia who is taking steroids A 23-year-old with sickle cell disease who has two draining leg ulcers A 30-year-old with leukemia who is receiving induction chemotherapy A 28-year-old with glucose-6-phosphate dehydrogenase (G6PD) deficiency anemia who is receiving mannitol (Osmitrol)

A 28-year-old with glucose-6-phosphate dehydrogenase (G6PD) deficiency anemia who is receiving mannitol (Osmitrol) (The nurse assigns as a roommate to the client with aplastic anemia a 28-year-old with glucose-6-pgisphate dehydrogenase (G6PD) deficiency anemia who is receiving mannitol. Because clients with aplastic anemia usually have low white blood cell counts that place them at high risk for infection, roommates such as the client with G6PD deficiency anemia would be free from infection or infection risk.The client with sickle cell disease has two draining leg ulcer infections that would threaten the diminished immune system of the client with aplastic anemia. The client with leukemia who is receiving induction chemotherapy and the client with idiopathic thrombocytopenia who is taking steroids are at risk for development of infection, which places the client with aplastic anemia at risk, too.)

Which morbidly obese client is the least likely candidate for bariatric surgery? A 34-year-old woman experiencing mental confusion A 44-year-old man with a history of hypertension A 50-year-old woman with a history of sleep apnea A 52-year-old man with a history of type 1 diabetes mellitus

A 34-year-old woman experiencing mental confusion (The least likely candidate is the client who is experiencing mental confusion. This client may have difficulty complying with the postoperative treatment regimen.The client with hypertension, the client with sleep apnea, and the client with diabetes are all candidates for bariatric surgery despite having these complications.)

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 28-year-old with an exacerbation of Crohn's disease (CD) who has a draining enterocutaneous fistula A 32-year-old with ulcerative colitis (UC) who needs discharge teaching about the use of hydrocortisone enemas A 34-year-old who has questions about how to care for a newly created ileo-anal reservoir A 36-year-old with peritonitis who just returned from surgery with multiple drains in place

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.)

The RN has just received reports about all of these clients on the inpatient surgical unit. Which client does the nurse care for first? A 43-year-old who had a bowel resection 7 days ago and has new serosanguineous drainage on the dressing A 46-year-old who had a thoracotomy 5 days ago and needs discharge teaching before going home A 48-year-old who had bladder surgery earlier in the day and is reporting pain when coughing A 49-year-old who underwent repair of a dislocated shoulder this morning and has a temperature of 100.4°F (38°C)

A 43-year-old who had a bowel resection 7 days ago and has new serosanguineous drainage on the dressing (The nurse would first care for the 7-day postoperative client who has new serosanguineous drainage. New drainage on the seventh postoperative day is unusual and suggests a complication that would require further assessment and possible immediate action.The client awaiting discharge teaching is not a priority. A temperature of 100.4°F (38°C) and pain upon coughing following bladder surgery are normal on the first postsurgical day.)

Which client is at greatest risk for slow wound healing? A 12-year-old healthy girl A 47-year-old obese man with diabetes A 48-year-old woman who smokes A 98-year-old healthy man

A 47-year-old obese man with diabetes (Obesity and diabetes would significantly put a client at greatest risk for slow wound healing.The healthy 12-year-old would likely heal quickly. The 48-year-old smoker will experience delayed wound healing, but is not as high a risk as an obese client who is diabetic. The healthy 98-year-old is not at risk for delayed wound healing.)

Which of the following clients experiencing disrupted sleep patterns is most at risk for obstructive sleep apnea (OSA)? A 15-year-old boy with type 1 diabetes A 22-year-old diagnosed with Crohn's disease A 49-year-old man who is an avid cross-county runner A 58-year-old woman diagnosed with chronic depression

A 58-year-old woman diagnosed with chronic depression (Many think OSA affects middle-age men more frequently, particularly when they are obese. However, obstructive sleep apnea is also common in postmenopausal women, younger women, and children. Although the clients in all of the options may experience OSA, the postmenopausal woman has the greatest risk.)

Which of these clients with diabetes will the endocrine unit charge nurse assign to an RN who has floated from the labor/delivery unit? A client with sensory neuropathy who needs teaching about foot care A client with diabetic ketoacidosis who has an IV running at 250 mL/hr A client who needs blood glucose monitoring and insulin before each meal A client who was admitted with fatigue and shortness of breath

A client who needs blood glucose monitoring and insulin before each meal (A nurse from the labor/delivery unit would be familiar with blood glucose monitoring and insulin administration because clients with type 1 and gestational diabetes are frequently cared for in the labor/delivery unit.The clients with sensory neuropathy, diabetic ketoacidosis, and the client with fatigue and shortness of breath all have specific teaching or assessment needs that are better handled by nurses more familiar with caring for adults with diabetes-related complications.)

A patient has chronic confusion secondary to dementia. As a result, he is unable to sign an informed consent for surgery. In this situation: An informed consent is not needed. Two nurses may sign the informed consent for the patient. The surgeon must sign the informed consent. A family member will be asked to sign the informed consent.

A family member will be asked to sign the informed consent. (In most states, a family member, conservator, or legal guardian may give consent for a procedure if a patient is not capable of giving an informed consent or if the patient is a minor.)

A client has a suspected peptic ulcer in the duodenum. What should the nurse expect the client to report when describing the pain associated with this disease? An ache radiating to the left side An intermittent colicky flank pain A gnawing sensation relieved by food A generalized abdominal pain intensified by moving

A gnawing sensation relieved by food (The act of eating allows the hydrochloric acid in the stomach to work on and be neutralized by food rather than irritate the intestinal mucosa. An ache radiating to the left side is not specific to duodenal ulcers. An intermittent colicky flank pain may indicate renal colic. A generalized abdominal pain intensified by moving is not specific to duodenal ulcers.)

The nurse is assessing a patient for contraindications to drug therapy with acetaminophen (Tylenol). Which patient should not receive acetaminophen? A patient with a fever of 101° F (38.3° C) A patient who is complaining of a mild headache A patient with a history of liver disease A patient with a history of peptic ulcer disease

A patient with a history of liver disease (Liver disease is a contraindication to the use of acetaminophen. Fever and mild headache are both possible indications for the medication. Having a history of peptic ulcer disease is not a contraindication.)

Which patient has the highest risk for development of a blood clot? A woman who smokes and is taking estrogen-containing birth control pills A distance runner A man with a history of asthma A woman who is taking aspirin for menstrual cramps

A woman who smokes and is taking estrogen-containing birth control pills (The combination of hormones and smoking may cause a hypercoagulability state. Distance running does not increase the risk of forming a blood clot. A patient with asthma does not predispose the formation of a blood clot. A patient taking aspirin will have a decreased risk of development of a blood clot due to the antiplatelet action of aspirin.)

At what point would the patient sign the consent form for a surgical procedure? A. After the surgeon explains the procedure B. During the preoperative consultation at the surgeon's office C. After receiving preoperative medication D. At the completion of the physical examination

A. After the surgeon explains the procedure (Rationale: The consent form for a surgical procedure is signed after the surgeon explains the procedure. The patient does not always have a preoperative consultation at the surgeon's office. Even when such a consultation occurs, it is too early for the patient to be asked to sign a surgical consent form. The consent form for a surgical procedure could be considered invalid if the patient signs it after receiving preoperative medication. The consent form for a surgical procedure is signed after the surgeon explains the procedure. This occurs before a physical examination is completed.)

What will the nurse do when discontinuing PCA? A. Ensure that the main intravenous line is intact. B. Pull the intravenous access device from the patient. C. Tell the patient that pain medication has been discontinued. D. Change the PCA pump infusion rate to keep vein-open status.

A. Ensure that the main intravenous line is intact. (Rationale: The main intravenous infusion should remain intact when discontinuing PCA. Pain medication has not been discontinued. The PCA delivery approach has been discontinued. Changing the PCA pump infusion rate to keep the vein open is not discontinuing the medication.)

Which action will help support the postsurgical patient's respiratory status? A. Extending the patient's head when not contraindicated B. Maintaining the patient in a supine position C. Frequently calling the patient by name in a moderate tone D. Reporting to the health care provider a systolic drop of 10 points or more from the baseline blood pressure

A. Extending the patient's head when not contraindicated (Rationale: Extending the neck helps to ensure a patent airway. The supine position does not support the patient's respiratory status or best facilitate oxygenation. Calling the patient's name may help to rouse him or her from anesthesia during the immediate postoperative period, but doing so would not help support the patient's respiratory status. Reporting a significant drop in the patient's systolic blood pressure is appropriate, but doing so would not help support the patient's respiratory status.)

To decrease the skin flushing adverse effect reaction of niacin (nicotinic acid), which action should the nurse take? Administer niacin with a liquid antacid. Administer aspirin 30 minutes before each dose. Give niacin with all other morning medications. Apply cold compresses to the head and neck.

Administer aspirin 30 minutes before each dose. (To help minimize the adverse effect flushing of the skin, the patient should take a small dose of aspirin or nonsteroidal antiinflammatory drugs 30 minutes before taking niacin, but only as prescribed or recommended by the health care provider.)

Which nursing action is of highest priority for a 68-year-old patient with renal calculi who is being admitted to the hospital with gross hematuria and severe colicky left flank pain? Administer prescribed analgesics. Monitor temperature every 4 hours. Encourage increased oral fluid intake. Give antiemetics as needed for nausea.

Administer prescribed analgesics. (Although all of the nursing actions may be used for patients with renal lithiasis, the patient's presentation indicates that management of pain is the highest priority action. If the patient has urinary obstruction, increasing oral fluids may increase the symptoms. There is no evidence of infection or nausea.)

Which condition is not an anticipated adverse effect of azathioprine (Imuran)? Alopecia Thrombocytopenia Leukopenia Hepatotoxicity

Alopecia (Common adverse effects of azathioprine include leukopenia, thrombocytopenia, and hepatotoxicity. Alopecia (hair loss) is not an expected adverse effect.)

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? Ability of the patient and spouse to perform incision care and dressing changes Effective coping mechanisms for the patient and spouse after the surgical experience Knowledge about the patient's requested pain medications Understanding of the importance of keeping scheduled follow-up appointments

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 diabetic client is undergoing surgery to amputate a gangrenous foot. This procedure would be considered which of the following categories of surgery based on purpose? Diagnostic Ablative Palliative Reconstructive

Ablative (Ablative surgery is performed to remove a diseased body part. Diagnostic surgery is performed to make or confirm a diagnosis. Palliative surgery involves relieving or reducing intensity of an illness. Reconstructive surgery restores function to traumatized or malfunctioning tissue.)

While admitting a patient for treatment of an acetaminophen (Tylenol) overdose, the nurse prepares to administer which medication to prevent toxicity? Methylprednisolone (Solu-Medrol) Acetylcysteine (Mucomyst) Naloxone (Narcan) Phytonadione (vitamin K)

Acetylcysteine (Mucomyst) (Acetylcysteine is the antidote for acetaminophen overdose. It must be administered as a loading dose followed by subsequent doses every 4 hours for 17 additional doses and started as soon as possible after the acetaminophen ingestion (ideally within 12 hours).)

PPIs have the ability to almost totally inhibit gastric acid secretion. Because of this possibility, the use of the medication can lead to what condition? Gastric ulcer formation Gastroesophageal reflux disease (GERD) Achlorhydria Diverticulosis

Achlorhydria (Because PPIs stop the final step of acid secretion, they can block up to 90% of acid secretion, leading to achlorhydria (without acid).)

The nurse would assess which laboratory value to determine the effectiveness of intravenous heparin (Hemochron)? Complete blood count Activated partial thromboplastin time (aPTT) Blood urea nitrogen Prothrombin time (PT)

Activated partial thromboplastin time (aPTT) (Heparin dosing is based on aPTT results. The PT is reflective of warfarin's anticoagulant effect.)

Surgeries are commonly classified by which of the following? Choose all that apply. Acuity Level of urgency Length of surgery Organ involved

Acuity Level of urgency (Surgeries can be classified by body systems, purpose, level of urgency, and degree of seriousness. The length of surgery and organ involved are not used for classifying surgeries.)

A client with abdominal incisions experiences excruciating pain when he tries to cough. What should the nurse do to reduce the client's discomfort when coughing? Administer prescribed pain medication just before coughing. Ask the client to drink plenty of water before coughing. Ask the client to lie in a lateral position when coughing. Administer prescribed pain medication 30 minutes before deliberately attempting to cough.

Administer prescribed pain medication 30 minutes before deliberately attempting to cough. (Coughing is painful for clients with abdominal or chest incisions. Administering pain medication approximately 30 minutes before coughing, or splinting the incision when coughing, can reduce discomfort. Making the client lie in a lateral position or asking the client to drink plenty of water is not helpful because it will make breathing and coughing even more difficult for the client.)

A 57-year-old woman being treated for end-stage breast cancer has been using a transdermal opioid analgesic as part of the management of pain. Lately, she has been experiencing breakthrough pain. The nurse expects this type of pain to be managed by which of these interventions? Administering NSAIDs Administering an immediate-release opioid Changing the opioid route to the rectal route Making no changes to the current therapy

Administering an immediate-release opioid (If a patient is taking long-acting opioid analgesics, breakthrough pain must be treated with an immediate-release dosage form that is given between scheduled doses of the long-acting opioid. The other options are not appropriate actions.)

The nurse is preparing an intraoperative care plan for a client. Which intervention should be excluded from the care plan? Ensuring the client's skin integrity Reviewing the preoperative instructions Administering general anesthetic to the client Placing the client in the correct position on the operating table

Administering general anesthetic to the client (Only anesthesiologists who are specially trained can administer anesthesia. Therefore, the nurse should exclude this intervention from the nursing care plan. In the operating room, the nurse should ensure the client's skin integrity to prevent complications such as pressure sores. The nurse should review the preoperative care plan to establish or amend the plan if changes are required. The nurse should place the client in the correct position to prevent the client from injury during the operation.)

A 78-year-old patient is in the recovery room after having a lengthy surgery on his hip. As he is gradually awakening, he requests pain medication. Within 10 minutes after receiving a dose of morphine sulfate, he is very lethargic and his respirations are shallow, with a rate of 7 per minute. The nurse prepares for which priority action at this time? Assessment of the patient's pain level Immediate intubation and artificial ventilation Administration of naloxone (Narcan) Close observation of signs of opioid tolerance

Administration of naloxone (Narcan) (Naloxone, an opioid-reversal agent, is used to reverse the effects of acute opioid overdose and is the drug of choice for reversal of opioid-induced respiratory depression. This situation is describing an opioid overdose, not opioid tolerance. Intubation and artificial ventilation are not appropriate because the patient is still breathing at 7 breaths/min. It would be inappropriate to assess the patient's level of pain.)

The RN working in the hospital emergency department is assigned to care for these four clients. Which client does the nurse attend to first? Adolescent with an erection for "10 or 11 hours" who is reporting severe pain Young adult with a swollen, painful scrotum who has a recent history of mumps infection Middle-aged adult discharged 2 days ago after a transurethral resection of the prostate who has increased hematuria Older adult with a history of benign prostatic hyperplasia and palpable bladder distention

Adolescent with an erection for "10 or 11 hours" who is reporting severe pain (The nurse first attends to the client who has had an erection for "10 or 11 hours." This client has symptoms of priapism which is considered a urologic emergency because the circulation to the penis may be compromised. With an erect penis, the client may also be unable to void.The client with a swollen, painful scrotum, the client with hematuria, and the client with a history of benign prostatic hyperplasia do not require the nurse's immediate attention.)

The nurse is teaching a group of adults in the community about the 2015-2020 Dietary Guidelines for Americans. What does the nurse emphasize as a dietary strategy suggested in these guidelines? Half of each meal should consist of dairy, fruits, and proteins. Adults should focus on variety and nutrient density and not calories. Older adults should consider lacto-ovarian diets for improved health. Adults should include a multivitamin with iron and vitamin B12 in their diet.

Adults should focus on variety and nutrient density and not calories. (The nurse emphasizes the need to focus on "shifts" to include a variety of nutrient-dense foods rather than less nutritious foods. The focus involves the client making active choices. This strategy is included in the 2015-2020 Dietary Guidelines for Americans. Examples of other guidelines are listed in Table 60-1.The most recent guidelines in 2015-2020 do not recommend that half of the diet include proteins and dairy. Using the My Plate recommendations, half of the diet should be fruits and vegetables. Lacto-ovarian diets are not emphasized. A multivitamin with iron and B12 is not recommended if the diet is adequate.)

Which of the following nursing interventions occurs in the postoperative phase of the surgical experience? Airway/oxygen therapy/pulse oximetry Teaching deep breathing exercises Reviewing the meaning of p.r.n. orders for pain medications Putting in IV lines and administering fluids

Airway/oxygen therapy/pulse oximetry (Airway/oxygen therapy/pulse oximetry occur in the postanesthesia unit in the postoperative phase. Teaching deep-breathing exercises and reviewing the meaning of p.r.n. orders for medications occur in the preoperative phase. Putting in IV lines and administering fluids occurs in the intraoperative phase.)

The nurse is caring for a patient admitted for an outpatient surgical procedure. Which of the following will the nurse include in the care? Select all that apply. Begin discharge teaching as soon as the procedure is completed. Allow family members to be present during discharge teaching. Begin discharge teaching in the preoperative period. Investigate the patient's home care and discharge transportation following the procedure. Discuss discharge transportation during the preoperative period.

Allow family members to be present during discharge teaching. Begin discharge teaching in the preoperative period. Discuss discharge transportation (Patient teaching begins during the preoperative period and continues throughout all perioperative phases of care. In the preoperative phase, assess the patient's and family's readiness to learn and their knowledge base so that teaching can be individualized. If the patient will be discharged on the day of surgery, be sure to identify someone who can take the patient home and assist during the postoperative recovery period.)

The removal of a toddler's clothing and application of monitoring equipment after anesthesia is administered will Minimize blood loss Ensure temperature control Provide baseline vital signs Allow sufficient relaxation

Allow sufficient relaxation (Relaxation can be enhanced by removing the child's clothing, applying the grounding pad, and applying monitoring devices after the child is anesthetized.)

Which is the best referral that the community health nurse can suggest to a client who has been newly diagnosed with diabetes? American Diabetes Association (ADA) Centers for Disease Control and Prevention Primary health care provider office Pharmaceutical representative

American Diabetes Association (ADA) (The American Diabetes Association is the best agency to refer the diabetic client to. The ADA provides national and regional support and resources to clients with diabetes and their families.The Centers for Disease Control and Prevention does not specifically focus on diabetes. The client's primary health care provider's office is limited in the resources available to the client with diabetes. A pharmaceutical representative is not an appropriate resource for diabetes information and support.)

After an acute episode of gastrointestinal (GI) bleeding, a client is diagnosed with a gastric ulcer. The client receives a prescription for ranitidine 150 mg twice a day. What concern prompts the nurse to contact the health care provider about the prescription? Ranitidine can increase bleeding risk. An administration route is not specified. Ranitidine is contraindicated for gastric ulcers. The recommended dose is higher than prescribed.

An administration route is not specified. (It is necessary to clarify the route of administration because ranitidine can be given by mouth, intravenously, or intramuscularly; the health care provider's prescription is incomplete. Ranitidine usually is given with meals. Ranitidine is used to decrease gastric acid and is helpful for clients with a peptic ulcer. 150 mg twice a day is the usual dose of ranitidine when given twice a day.)

Surgery can lead to hypothermia. Of the following clients, who is at greatest risk for hypothermia? A woman delivering by C-section An adolescent for arthroscopic surgery A young adult with a fractured leg An elderly man with a fractured hip

An elderly man with a fractured hip (The risk of hypothermia increases in the very young and the very old.)

Identify the desired effects of general anesthesia. Choose all that apply. Reduction of risk Analgesia Amnesia Muscle relaxation

Analgesia Amnesia Muscle relaxation (General anesthesia is used to control pain (analgesia), relax muscles, and promote amnesia. Anesthesia is not used for the purpose of obtaining a reduction in risk potential; however, surgical risk is influenced by the type of anesthesia used.)

The nurse is teaching a patient who recently began taking sulfasalazine (Azulfidine) about the drug. What side effects does the nurse tell the patient to report to the primary health care provider? Select all that apply. Anorexia Depression Drowsiness Frequent urination Headache Vomiting

Anorexia Headache Vomiting (Anorexia, headache, and nausea/vomiting are side effects of sulfasalazine that must be reported to the primary health care provider.Depression, drowsiness, and urinary problems are not side effects of sulfasalazine.)

A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the unlicensed assistive personnel (UAP) for deep-vein thrombosis (DVT) prevention? Select all that apply. Apply compression stockings Assist with ambulation Encourage coughing and deep breathing Offer fluids frequently Teach leg exercises

Apply compression stockings Assist with ambulation Offer fluids frequently (The UAP can apply compression stockings, assist with ambulation, and offer fluids frequently to help prevent DVT. The UAP can also encourage the patient to do pulmonary exercises, but these don't decrease the risk of DVT. Teaching is a nursing function.)

A client diagnosed with gastroesophageal reflux disease (GERD) is being treated with antacid therapy. When teaching the client about the therapy, what does the nurse reinforce? Antacids should be taken 1 hour before meals. These should be scheduled at 4-hour intervals. Antacid tablets are just as fast and effective as the liquid form. Antacids commonly interfere with the absorption of other drugs.

Antacids commonly interfere with the absorption of other drugs. (Antacids interfere with absorption of drugs such as anticholinergics, barbiturates, tetracycline, and digoxin. Liquid antacids are faster acting and more effective than antacid tablets. Antacids should be taken 1 or 2 hours after meals and at bedtime. Antacid tablets may be taken more frequently than every 4 hours.)

The proliferation of Clostridium difficile causes Antibiotic-associated diarrhea Escherichia coli diarrhea Urinary Clostridium infection Anal yeast infection

Antibiotic-associated diarrhea (Normal intestinal flora inhibit the growth of Clostridium difficile. When broad-spectrum antibiotics, especially third-generation cephalosporins, are administered, normal flora is altered and C. difficile can proliferate and release toxins that cause antibiotic-associated diarrhea.)

Which statement about why multidrug-resistant organisms and other infections are increasing in incidence is correct? Antibiotics have been given to clients for conditions that do not require antibiotics. Microorganisms are more susceptible to antibiotics today than when they were given years ago. Additional precautions are taken, along with Standard Precautions, to prevent infection. Most antibiotics are effective for infection.

Antibiotics have been given to clients for conditions that do not require antibiotics. (Antibiotics have often been prescribed for conditions that do not require them, or have been given at higher doses or for longer periods of time than needed. As a result, a number of microorganisms have become resistant to certain antibiotics.Microorganisms are more resistant to certain antibiotics. Strictly adhered-to Standard Precautions are adequate to prevent infection. Most antibiotics are not effective for every infection.)

A postoperative home care client has developed thrombophlebitis in her right leg. What category of medications will probably be prescribed for this cardiovascular complication? Anticoagulants Antibiotics Antihistamines Antigens

Anticoagulants (Thrombophlebitis is an inflammation of a vein associated with thrombus formation. Thrombophlebitis from venous stasis is most commonly seen in the legs of postoperative clients. Nursing interventions include administering ordered medications, most often anticoagulants.)

Antidopaminergic drugs are useful to treat not only nausea and vomiting but also which other conditions? Select all that apply. Anxiety Bone marrow suppression Seizures Intractable hiccups Schizophrenia

Anxiety Intractable hiccups Schizophrenia (Antidopaminergic drugs are used to treat psychotic disorders (mania, schizophrenia, anxiety), intractable hiccups, nausea, and vomiting.)

A nurse is providing ongoing postoperative care to a client who has had knee surgery. The nurse assesses the dressing and finds it saturated with blood. The client is restless and has a rapid pulse. What should the nurse do next? Document the data and apply a new dressing. Apply a pressure dressing and report findings. Reassure the family that this is a common problem. Make assessments every 15 minutes for four hours.

Apply a pressure dressing and report findings. (Hemorrhage is an excessive internal or external loss of blood. Common indications of hemorrhage include a rapid, thready pulse. If bleeding occurs, the nurse should apply a pressure dressing to the site, report findings to the physician, and be prepared to return the client to the operating room if bleeding cannot be stopped or is massive.)

A patient is to have a sequential compression device (SCD) applied on the postoperative unit. The patient is wearing knee-high elastic (antiembolism) stockings. When applying the SCD, what should the nurse do? Remove the antiembolism stockings and not replace them. Replace the knee-high stockings with thigh-high stockings. Notify the surgeon that the patient is wearing antiembolism stockings. Apply the SCD over the knee-high antiembolism stockings.

Apply the SCD over the knee-high antiembolism stockings. (If elastic stockings have been ordered with the sequential compression device, leave them in place; if the patient is not yet wearing them, obtain them and put them on the patient. Knee-high stockings do not need to be replaced with thigh-high stockings. Some research has shown knee-high stockings to be equally effective. There is no need to notify the surgeon, as patients commonly return from surgery wearing antiembolism stockings, as prescribed.)

To prevent the development of tolerance to nitroglycerin (Nitro-Bid) transdermal patch, the nurse instructs the patient to perform which action? Use the nitroglycerin patch for acute episodes of angina only. Apply the nitroglycerin patch in the morning and remove it at night for 8 hours. Switch to sublingual nitroglycerin when the systolic blood pressure is greater than 140 mm Hg. Apply a new nitroglycerin patch every other day.

Apply the nitroglycerin patch in the morning and remove it at night for 8 hours. (To avoid development of tolerance to transdermal nitroglycerin patches, maintain an 8-hour nitrate-free period each day. A common regimen with transdermal patches is to remove them at night for 8 hours and apply a new patch in the morning.)

When applying nitroglycerin (Nitro-Bid) ointment, the nurse should perform which action? Massage and then gently rub the ointment into the skin. Apply a thick layer of ointment on the nitroglycerin paper. Use the fingers to spread the ointment evenly over a 3-inch area. Apply the ointment to a nonhairy part of the upper torso.

Apply the ointment to a nonhairy part of the upper torso. (Use the proper dosing paper supplied by the drug company to apply a thin layer of ointment on clean, dry, hairless skin of the upper arms or body. Avoid areas below the knees and elbows. Wear gloves to avoid contact with the skin and subsequent absorption. Do not rub the ointment into the skin; cover the area with an occlusive dressing if not provided (e.g., plastic wrap).)

To evaluate an obese patient for adverse effects of lorcaserin (Belviq), which action will the nurse take? Take the apical pulse rate. Check sclera for jaundice. Ask about bowel movements. Assess for agitation or restlessness.

Ask about bowel movements. (Constipation is a common side effect of lorcaserin. The other assessments would be appropriate for other weight-loss medications.)

A preoperative client wears a hearing aid and is extremely hard of hearing without it. What does the nurse do to help reduce this client's anxiety? Actively listen to this client's concerns. Allow the client to wear the hearing aid to surgery. Ask if the client may wear the hearing aid until anesthesia is given. Explain that it is hospital policy to remove a hearing aid before surgery.

Ask if the client may wear the hearing aid until anesthesia is given. (The nurse needs to ask if the client can wear the hearing aid to the operating room (OR). In some facilities, clients may wear eyeglasses and hearing aids until after anesthesia induction.Listening isn't always enough; more intervention is needed. Sending the client to the OR with the hearing aid without checking first is inappropriate. The OR staff may have a different policy, considering that the hearing aid may get lost. Telling the client that a policy precludes the client's needs is not therapeutic.)

A client with type 2 diabetes who is taking metformin (Glucophage) is seen in the diabetic clinic. The fasting blood glucose is 108 mg/dL (6.0 mmol/L), and the glycosylated hemoglobin (HbA1C) is 8.2%. Which action will the nurse take next? Instruct the client to continue with the current diet and metformin use. Discuss the need to check blood glucose several times every day. Talk about the possibility of adding rapid-acting insulin to the regimen. Ask the client about current dietary intake and medication use.

Ask the client about current dietary intake and medication use. (The nurse's next action would be to assess the client's adherence to the currently prescribed diet and medications. The nurse would also check for any stressors or undocumented illnesses. Glycosylated hemoglobin (HbA1C) levels >8% indicate poor diabetes control and need for adherence to regimen or changes in therapy.Instructing the client to continue with current diet and metformin use is inappropriate without further assessment. Checking blood glucose more frequently and/or using rapid-acting insulin may be appropriate, but this will depend on the assessment data. The HbA1C indicates that the client's average glucose level is higher than the target range, but discussing the need to check blood glucose several times every day assumes that the client is not compliant with the therapy and glucose monitoring. The nurse would not assume that adding insulin, which must be prescribed by the primary health care provider, is the answer without assessing the underlying reason for the treatment failure.)

A nurse is assisting a postoperative client with deep-breathing exercises. Which of the following is an accurate step for this procedure? Place the client in prone position, with the neck and shoulders supported. Ask the client to place the hands over the stomach, so he or she can feel the chest rise as the lungs expand. Ask the client to exhale rapidly and completely, and inhale through the nose rapidly and completely. Ask the client to hold his or her breath for three to five seconds and mentally count "one, one thousand, two, one thousand" and so forth.

Ask the client to hold his or her breath for three to five seconds and mentally count "one, one thousand, two, one thousand" and so forth. (The nurse should place the client in semi-Fowler's position, with the neck and shoulders supported, and ask the client to place the hands over the rib cage, so he or she can feel the chest rise as the lungs expand. Then, ask the patient to exhale gently and completely, inhale through the nose gently and completely, hold his or her breath for three to five seconds, and mentally count "one, one thousand, two, one thousand" etc., then exhale as completely as possible through the mouth with lips pursed (as if whistling).)

A client is admitted voluntarily to a psychiatric unit. Later, the client develops severe pain in the right lower quadrant and is diagnosed as having acute appendicitis. How should the nurse prepare the client for the appendectomy? Have two nurses witness the client signing the operative consent form. Ensure that the primary healthcare provider and the psychiatrist sign for the surgery because it is an emergency procedure. Ask the client to sign the operative consent form after the client has been informed of the procedure and required care. Inform the client's next of kin that it will be necessary for one of them to sign the consent form because the client is on a psychiatric unit.

Ask the client to sign the operative consent form after the client has been informed of the procedure and required care. (Because the client is not certified as incompetent, the right of informed consent is retained. The client can sign the consent, but the client's signature requires only one witness. Because there is no evidence of incompetence, the client should sign the consent.)

A client with sleep apnea who has a new order for continuous positive airway pressure (CPAP) with a facemask returns to the outpatient clinic after 2 weeks with a report of ongoing daytime sleepiness. Which action should the nurse take first? Ask the client whether the mask fits tightly over the mouth and nose. Discuss the use of autotitrating positive airway pressure (APAP). Plan to teach the client about treatment with modafinil (Provigil). Suggest that a nasal mask be used instead of a full facemask.

Ask the client whether the mask fits tightly over the mouth and nose. (Assessment is the first step of the nursing process. The nurse should assess whether the mask fits tightly over the mouth and nose and if the client has been consistently using CPAP at night, as initial adjustments to this therapy may be needed.With APAP, the pressures are adjusted continuously depending on the client's needs; this may be more comfortable for the client. Modafinil treats narcolepsy or daytime sleepiness; it does not correct the cause of sleep apnea, but may be used to help some of the side effects of obstructive sleep apnea. A nasal mask may be an option for the client if the facemask used with CPAP is uncomfortable.)

A 58-year-old man with erectile dysfunction (ED) tells the nurse he is interested in using sildenafil (Viagra). Which action should the nurse take first? Assure the patient that ED is common with aging. Ask the patient about any prescription drugs he is taking. Tell the patient that Viagra does not always work for ED. Discuss the common adverse effects of erectogenic drugs.

Ask the patient about any prescription drugs he is taking. (Because some medications can cause ED and patients using nitrates should not take sildenafil, the nurse should first assess for prescription drug use. The nurse may want to teach the patient about realistic expectations and adverse effects of sildenafil therapy, but this should not be the first action. Although ED does increase with aging, it may be secondary to medication use or cardiovascular disease.)

A patient in the outpatient clinic tells the nurse about experiencing heartburn and nighttime coughing episodes. Which action does the nurse take first? Teach the patient about antacid effects and side effects. Ask the patient about oral intake, current medications and description of episodes. Suggest that the patient sleep with the head elevated 6 inches (15 cm). Tell the patient to avoid drinking alcohol late in the evening.

Ask the patient about oral intake, current medications and description of episodes. (The nurse's first action would be further assessment of the patient's risk factors for gastroesophageal reflux disease (GERD). Before suggesting interventions or beginning patient teaching, the nurse must elicit more information about the patient's symptoms.The nurse needs additional data before telling the patient about antacid effects, sleeping with the head elevated, or not drinking alcohol late in the evening.)

Which nursing action is appropriate when coaching obese adults enrolled in a behavior modification program? Having the adults write down the caloric intake of each meal Asking the adults about situations that tend to increase appetite Suggesting that the adults plan rewards, such as sugarless candy, for achieving their goals Encouraging the adults to eat small amounts frequently rather than having scheduled meals

Asking the adults about situations that tend to increase appetite (Behavior modification programs focus on how and when the person eats and de-emphasize aspects such as calorie counting. Nonfood rewards are recommended for achievement of weight-loss goals. Patients are often taught to restrict eating to designated meals when using behavior modification.)

As the unit nurse is about to give a preoperative medication to a client going into surgery, it is discovered that the surgical consent form is not signed. What does the nurse do after verifying the procedure with the client? Calls the surgeon Calls the anesthesiologist Gives the medication as ordered Asks the client to sign the consent form

Asks the client to sign the consent form (The unit nurse will ask the client to sign the consent form, after which the medication can be administered.Calling the surgeon or the anesthesiologist is not necessary. It is illegal for the client to sign the permit after being sedated.)

Which of the following interventions are recommended guidelines for meeting client postoperative elimination needs? Assess abdominal distention, especially if bowel sounds are audible or are low pitched. Assess for the return of peristalsis by auscultating bowel sounds every four hours when the client is awake. Encourage food and fluid intake when ordered, especially dairy products and low-fiber foods. Assess for bladder distention by Palpating below the symphysis pubis if the client has not voided within eight hours after surgery.

Assess for the return of peristalsis by auscultating bowel sounds every four hours when the client is awake. (Assess for the return of peristalsis by auscultating bowel sounds every four hours when the client is awake. Assess abdominal distention, especially if bowel sounds are inaudible or are high pitched. Encourage food and fluid intake when ordered, especially fruit juices and high-fiber foods. Assess for bladder distention by palpating above the symphysis pubis if the client has not voided within eight hours after surgery.)

The nurse is caring for a client following a laparoscopic cholecystectomy. Which nursing action is priority? Monitor the abdominal dressing for bleeding Instruct on using patient-controlled analgesia Teach about six-week activity restriction Assess puncture sites for bleeding

Assess puncture sites for bleeding (The one to four puncture sites used to perform the surgery laparoscopically should be monitored for any possible bleeding. There will not be an abdominal dressing unless a traditional cholecystectomy is performed. Patient-controlled analgesia is not necessary as there is no abdominal incision. Activity restriction is about one week with a laparoscopic cholecystectomy.)

The postanesthesia care nurse is caring for a client who had gastric banding surgery and was extubated an hour ago. The client's blood gases are as follows: pH, 7.22; HCO₃⁻ 21 mEq/L; PCO₂, 65 mm Hg; and PO₂, 58 mm Hg. Which is the priority action by the nurse? Assess the client's airway. Increase the client's oxygen flow rate. Check the client's oxygen saturation level. Document findings in the client's chart.

Assess the client's airway. (Obese clients are at higher risk for hypoventilation. The arterial blood gas values indicate acute respiratory acidosis with hypoxia. The client needs oxygen. However, if the airway is not patent, increasing the oxygen flow rate will be of minimal benefit. The first action is to ensure a patent airway and then apply oxygen, notify the physician, and document events. The client may need to be re-intubated and mechanically ventilated. Checking the client's oxygen saturation level will provide no additional information about the client's oxygenation status.)

A client returning to the floor after orthopedic surgery is complaining of nausea. The nurse is aware that an appropriate intervention is to do which of the following? Avoid strong smelling foods. Provide clear liquids with a straw. Avoid oral hygiene until the nausea subsides. Hold all medications.

Avoid strong smelling foods. (Nursing care for a client with nausea includes avoiding strong smelling foods, providing oral hygiene, administering prescribed medications (especially medications ordered for nausea and vomiting), and avoiding use of a straw.)

A client hospitalized for hypertension presses the call light and reports "feeling funny." When the nurse gets to the room, the client is slurring words and has right-sided weakness. What does the nurse do first? Assesses airway, breathing, and circulation Calls the provider Performs a neurologic check Assists the client to a sitting position

Assesses airway, breathing, and circulation (When a client reports "feeling funny" and then starts slurring words and has right-sided weakness, the nurse must first assess for airway, breathing, and circulation. The priority is assessment of the "ABCs"—airway, breathing, and circulation.Calling the Rapid Response Team, not the provider, after assessing ABCs would be appropriate. The first 10 minutes after onset of symptoms is crucial. A neurologic check will be performed rapidly but is not the top priority. The client would be placed in bed, easily accessible for healthcare providers to assess and begin treatment. This does not need to be a seated position.)

What is the priority nursing intervention for a client with stroke who is transitioned from ED to other settings? Monitoring vital signs Reassuring the client and family Assessing the level of consciousness Monitoring specific patient manifestations of stroke

Assessing the level of consciousness (Assessing the level of consciousness is the priority nursing action in the client with stroke and who is transitioned from ED to other settings. Monitoring the vital signs, reassuring the client and family, and monitoring specific patient manifestations of stroke are ongoing nursing interventions.)

When caring for patients with sleep disorders, which activity can the nurse appropriately delegate to unlicensed assistive personnel (UAP)? Interview a new patient about risk factors for obstructive sleep disorders. Discuss the benefits of oral appliances in decreasing obstructive sleep apnea. Help a patient choose an appropriate continuous positive airway pressure (CPAP) mask. Assist a patient to place the CPAP device correctly over the nose and mouth at bedtime.

Assist a patient to place the CPAP device correctly over the nose and mouth at bedtime. (Because CPAP mask placement is consistently done in the same way, this is appropriate to delegate to UAP. The other actions require critical thinking and nursing judgment, and should be done by the RN.)

The nurse is planning care for an immobilized client who has suffered a stroke. The client has right-sided hemiparesis. Which activity takes priority for this client? Assess the client lung sounds every 8 hours. Assist the client in performing range-of-motion (ROM) exercises every 1 to 2 hours. Allow the client to sit upright in the chair for as long as tolerated. Have the nursing assistant turn and reposition the client every 2 to 3 hours.

Assist the client in performing range-of-motion (ROM) exercises every 1 to 2 hours. (ROM exercises should be performed often to prevent muscle atrophy and contractures. Assessing the client's lung sounds every 8 hours is the minimum the nurse should assess lung sounds, and it is important, but it is not a priority in planning care for immobilization. The client should not be allowed to dangle in a chair for prolonged periods of time because of skin breakdown and venous return. The nursing assistant should be instructed to turn the client at least every 2 hours.)

Which nursing action will the home health nurse delegate to a home health aide who is making daily visits to a client with newly diagnosed type 2 diabetes? Assist the client's spouse in choosing appropriate dietary items. Evaluate the client's use of a home blood glucose monitor. Inspect the extremities for evidence of poor circulation. Assist the client with washing the feet and applying moisturizing lotion.

Assist the client with washing the feet and applying moisturizing lotion. (The nursing action that the home health nurse can delegate to a home health aide who is making daily visits to a newly diagnosed type 2 diabetic client is assisting with personal hygiene. This action is included in the role of home health aides.Assisting with appropriate dietary selections, evaluating the effectiveness of teaching, and performing assessments are complex actions that would be performed by licensed nurses.)

A patient had a colon resection for removal of a cancerous tumor. Postoperatively, on the surgical floor which of the following activities would the nurse perform for the purpose of decreasing the risk of postoperative complications? Choose all that apply. Assist the patient to turn, breathe deeply, and cough every 2 hours. Teach the patient about the type of tumor removed. Assess the drainage from the surgical site. Monitor vital signs on a regular basis.

Assist the patient to turn, breathe deeply, and cough every 2 hours. Assess the drainage from the surgical site. Monitor vital signs on a regular basis. (The nurse assists the patient to turn, breathe deeply, and cough every 2 hours in order to decrease the risk of postoperative atelectasis or pneumonia. The nurse assesses the wound drainage to monitor for signs of bleeding, infection, or wound complications. Vital signs are monitored to detect the potential for infection or hemorrhage, not to prevent them. The nurse may teach the patient about cancerous tumors; however, this intervention will not decrease the risk of postoperative complications.)

A 61-year-old man is being admitted for bariatric surgery. Which nursing action can the nurse delegate to unlicensed assistive personnel (UAP)? Demonstrate use of the incentive spirometer. Plan methods for bathing and turning the patient. Assist with IV insertion by holding adipose tissue out of the way. Develop strategies to provide privacy and decrease embarrassment.

Assist with IV insertion by holding adipose tissue out of the way. (UAP can assist with IV placement by assisting with patient positioning or holding skinfolds aside. Planning for care and patient teaching require registered nurse (RN)-level education and scope of practice.)

A client has a large renal calculus. Which assessment finding may indicate the development of a complication? Blood pressure of 178/94 mmHg Urine output of 5600 mL/24 hr Client reports of pain on urination Asymmetric, tender flank area

Asymmetric, tender flank area (Hydronephrosis, indicated by an asymmetric flank with tenderness, is commonly caused by obstruction such as a renal calculus. As the kidney continues to make urine, the volume of urine backs up into the kidney, increasing pressure, and the kidney is enlarged as a result. An asymmetric tender flank would be one manifestation of this condition. Polyuria, dysuria, and hypertension are not complications associated with renal calculi.)

A nurse is providing discharge instructions for a client with a diagnosis of gastroesophageal reflux disease (GERD). What should the nurse advise the client to do to limit symptoms of GERD? Select all that apply. Avoid heavy lifting. Lie down after eating. Avoid drinking alcohol. Eat small, frequent meals. Increase fluid intake with meals. Wear an abdominal binder or girdle.

Avoid heavy lifting. Avoid drinking alcohol. Eat small, frequent meals. (Heavy lifting increases intraabdominal pressure, allowing gastric contents to move up through the lower esophageal sphincter (regurgitation), causing heartburn (pyrosis). Alcohol, in addition to peppermints, caffeine, and chocolate, decreases lower esophageal sphincter (LES) pressure, which permits gastric contents to move from the stomach into the esophagus. Eating small, frequent meals limits the amount of food in the stomach, which limits gastroesophageal reflux. Lying down after eating promotes reflux and should be avoided. Increasing fluids with meals increases gastric volume, causing distention and reflux. Constrictive garments, such as belts, binders, and girdles, increase intraabdominal pressure and may lead to reflux.)

The nurse prepares a teaching session regarding lifestyle changes needed to decrease the discomfort associated with a patient's gastroesophageal reflux disease (GERD). Which change does the nurse recommend to this patient? Eat only two or three meals daily. Sleep flat in a left side-lying position. Drink tea instead of coffee. Avoid working while bent over the computer.

Avoid working while bent over the computer. (The patient should avoid working while bent over because this position presses on the diaphragm, causing discomfort.The patient with GERD needs to eat four to six meals a day. The head of the patient's bed would be elevated approximately 6 inches (15 cm). Both tea and coffee need to be eliminated from this patient's diet because of the caffeine content.)

What instruction might the nurse give to nursing assistive personnel (NAP) regarding postoperative exercises? A. "Find out if the patient has any language barriers." B. "Let me know when the patient actually begins exercising." C. "Please review a copy of the preoperative literature with the patient." D. "Assess the method of learning the patient would prefer."

B. "Let me know when the patient actually begins exercising." (Rationale: NAP may let the nurse know if the patient is exercising. No aspect of patient assessment may be delegated to NAP. Patient education may not be delegated to NAP. Because assessment of learning preferences is part of patient education, NAP may not carry out this responsibility.)

When a patient returns to the unit from the PACU, how would the nurse assess possible urinary retention? A. Straight-catheterize the patient. B. Complete a bladder scan. C. Encourage the patient to void. D. Check the chart for lab values specific to urinary function.

B. Complete a bladder scan. (Rationale: Performing a bladder scan identifies how much fluid is present in the bladder, accurately identifying the retention. Before straight catheterization could be considered, a bladder scan would need to be completed to see how much retention is present. It is correct to encourage the patient to void, but doing so will not assess if urinary retention is occurring. Although it is good to monitor kidney function after surgery, such lab values will not specifically show urinary retention.)

Before teaching a patient postsurgical exercises, the nurse premedicates the patient for pain. What benefit does this have specific to the patient's learning? A. Reduced pain B. Improved focus C. Decreased relaxation D. Decreased irritability

B. Improved focus (Rationale: When pain is controlled, the patient is better able to concentrate. Although reduced pain is a desired outcome, this answer fails to address a specific effect on patient learning. To decrease relaxation would mean that the patient would be less relaxed and, with pain relief, the patient would be more relaxed. This option is also unrelated to a patient's learning. Although reduced pain may make the patient less irritable, this outcome is not directly related to learning.)

Which patient outcome best reflects adequate management for pain originally rated as 8 out of 10 on a pain scale? A. The patient is observed quietly watching television. B. The patient rates current pain as 4 out of 10. C. The patient tells NAP that he is "not hurting as much." D. The patient is observed sleeping, with a respiratory rate of 20 breaths/min.

B. The patient rates current pain as 4 out of 10. (Rationale: This self-rated improvement is the best sign that pain management is adequate. The patient quietly watching TV is not the most definitive indicator of good pain management. The patient may be using distraction as a way to manage pain. The patient telling the NAP that he is "not hurting as much" is too ambiguous to indicate good pain management. Sleep is not always an indication that a patient is pain free.)

Why might a nurse teach a patient scheduled for surgery how to do postoperative exercises? A. To maximize a sense of well-being B. To minimize postoperative complications C. To identify cultural factors that reflect the patient's perception of pain D. To evaluate the patient's ability to participate in postoperative activities

B. To minimize postoperative complications (Rationale: Teaching postoperative exercises can minimize the patient's risk for injury. Promoting a sense of well-being is not why patients are taught postoperative exercises, although doing so may have that effect. Cultural factors are unrelated to postoperative exercise teaching. There is no link between teaching postoperative exercises and evaluating the patient's ability to participate in postoperative activities.)

Why does the nurse place a patient on bed rest after administering preoperative medication? A. To ensure that the surgical site is not injured B. To protect the patient from injury C. To maintain a calm environment D. To maintain the intravenous infusion

B. To protect the patient from injury (Rationale: A patient is placed on bed rest after receiving preoperative medication to ensure that he or she is not injured in a fall. Bed rest is not specifically required to prevent injury to the surgical site. A patient is not placed on bed rest after receiving preoperative medication in order to maintain a calm environment, although doing so might have that effect. Bed rest is not required in order to maintain an intravenous infusion.)

Which instruction might a nurse give a patient in order to protect a surgical incision when turning in bed? A. Hold your breath when turning. B. Use a pillow to splint the incision. C. Take pain medication 30 minutes before turning. D. Keep both legs straight when turning.

B. Use a pillow to splint the incision. (Rationale: Using a pillow to splint the incision will protect the incision when turning in bed. Holding one's breath when turning in bed is not appropriate technique and will not protect the incision. Taking pain medication before turning in bed will not protect the incision. Keeping both legs straight when turning in bed is not appropriate technique and will not protect the incision.)

When caring for a patient with angina pectoris, the nurse would question a prescription for a noncardioselective beta blocker in a patient with which preexisting condition? Atrial fibrillation Bronchial asthma Myocardial infarction Hypertension

Bronchial asthma (Noncardioselective beta blockers should be used with caution in patients with bronchial asthma, because any level of blockade of beta2-receptors can promote bronchoconstriction.)

During a diabetes mellitus campaign, the community nurse is assessing different clients. Which client should be treated first? A: A1C% 5.6, fasting BG 110, post-prandial BG 150 B: A1C% 6.8, fasting BG 130, post-prandial BG 200 C: A1C% 6.0, fasting BG 120, post-prandial BG 130 D: A1C% 6.1, fasting BG 100, post-prandial BG 140

B: A1C% 6.8, fasting BG 130, post-prandial BG 200 (The client with an A1 C % level of less than 7%, fasting plasma glucose > 126 mg/dL, and 2-hour plasma glucose > 200 mg/dL indicates diabetes mellitus. Client B has increased values for A1 C %, fasting plasma glucose, and 2-hour plasma glucose. Therefore client B should be treated first. Clients A, C, and D have normal values for diabetes mellitus and, therefore, can be treated after client B.)

How does the nurse accurately calculate a client's body mass index? (weight/height) BMI = kg/meters² BMI = lb/inches² BMI = kg/meters BMI = lb/meters

BMI = kg/meters² (The correct formula to accurately calculate a client's body mass index (BMI) is: BMI = weight (kg)/height (in meters)².)

A nurse teaches a client with calcium-based renal calculi about foods that can be eaten on a low-calcium diet. The nurse concludes that the teaching is effective when the client selects which food items from the menu? Select all that apply. Baked chicken Chocolate pudding Salmon loaf with cheese sauce Roast beef with mashed potato Vanilla ice cream with chocolate syrup

Baked chicken Roast beef with mashed potato (Baked chicken is relatively low in calcium. Roast beef and mashed potato have moderate amounts of calcium. Pudding is made with milk and is high in calcium. Cheese is high in calcium. Ice cream is made with milk and is high in calcium.)

The nurse is providing education to a client regarding pain control after surgery. What time does the nurse inform the client is the best time to request pain medication? Before the pain becomes severe When the client experiences a pain rating of "10" on a 1-to-10 pain scale When there is no pain, but it is time for the medication to be administered After the pain becomes severe and relaxation techniques have failed

Before the pain becomes severe (If a pain medication is ordered p.r.n., the client should be instructed to ask for the medication before the pain becomes severe.)

The nurse knows the term perioperative phase refers to care given to the client Before, during, and after the operative phase From the start of surgery until its conclusion Immediately before an operative procedure Immediately after the operative phase

Before, during, and after the operative phase (Perioperative nursing includes three distinct phases: preoperative, intraoperative, and postoperative.)

Which statement by the nurse explains to the patient the action of cholestyramine (Questran) to decrease blood lipid levels? Inhibits lipolysis in adipose tissue and decreases the hepatic synthesis of triglycerides in the liver. Stimulates the biliary system to increase excretion of dietary cholesterol. Binds to bile in the intestinal tract, forming an insoluble complex that is excreted in the feces. Inhibits absorption of dietary cholesterol in the small and large intestine.

Binds to bile in the intestinal tract, forming an insoluble complex that is excreted in the feces. (Cholestyramine is an anion exchange resin that binds to bile acids in the small intestine to form an insoluble complex that is excreted in the feces. The liver must then use cholesterol to synthesize more bile.)

The nurse will assess a patient receiving gemfibrozil (Lopid) and warfarin (Coumadin) for the increased risk of which adverse effect? Bleeding Clotting Vitamin K toxicity Deep vein thrombosis

Bleeding (Gemfibrozil can bind with vitamin K in the intestinal tract, reducing vitamin K absorption. Because vitamin K is the antidote for warfarin, a lack of vitamin K increases the anticoagulant effect of warfarin and thus the risk of bleeding.)

A client is admitted with renal calculi. Which clinical manifestations does a nurse expect the client to report? Select all that apply. Blood in the urine Irritability and twitching Dry, itchy skin and pyuria Frequency and urgency of urination Pain radiating from the kidney to a shoulder

Blood in the urine Frequency and urgency of urination (Hematuria is a common clinical manifestation of renal calculi. Frequency and a sense of urgency may occur because of irritation caused by the calculi; the most common expectation is sharp, severe pain. Irritability may occur because of discomfort; twitching does not occur. Pyuria may occur when infection is present; skin problems do not occur. Pain radiates from the flank to the groin area.)

A nurse is caring for a client who has a 20-year history of type 2 diabetes. The nurse should assess for what physiologic changes associated with a long history of diabetes? Blurry, spotty, or hazy vision Arthritic changes in the hands Hyperactive knee and ankle jerk reflexes Dependent pallor of the feet and lower legs

Blurry, spotty, or hazy vision (Blurry, spotty, or hazy vision; floaters or cobwebs in the visual field; and cataracts or complete blindness can occur as a result of diabetes. Diabetic retinopathy is characterized by abnormal growth of new blood vessels in the retina (neovascularization). More than 60% of clients with type 2 diabetes have some degree of retinopathy after 20 years. Arthritic changes of the hands are not a usual complication associated with diabetes mellitus. Clients who are diabetic have peripheral neuropathy, which is characterized by hypoactive, not hyperactive, reflexes. Peripheral vascular disease is indicated by dependent rubor with pallor on elevation, not dependent pallor.)

The nurse is assessing a client with hemorrhagic stroke due to a motor bike accident. Which condition of the client requires immediate attention? Glasgow Coma score of 10 Body temperature of 81.2°F Oxygen saturation of 90 percent Presence of carotid pulse with blood pressure of 80 mm Hg

Body temperature of 81.2°F (Severe hypothermia such as body temperature of 81.2° F must be immediately corrected by infusing warm fluids and blood. This helps to prevent hypothermia-related complications. A Glasgow Coma score of 10 needs medium priority since it does indicate immediate danger to the client. Oxygen saturation of 90 percent indicates a manageable status. Presence of carotid pulse with blood pressure of 80 mm Hg is acceptable.)

The nurse would question a prescription for colesevelam (Welchol) in a patient with which condition? Hepatic disease Bowel obstruction Renal disease Glaucoma

Bowel obstruction (Colesevelam (Welchol) is contraindicated in patients with a history of bowel obstruction.)

In conducting a postoperative assessment of a client, what is important for the nurse to examine first? Breathing pattern Level of consciousness Oxygen saturation Surgical site

Breathing pattern (Respiratory assessment is the first and most important.Assessing level of consciousness, oxygen saturation, and the surgical site are important, but not the priority.)

How does sucralfate (Carafate) achieve a therapeutic effect? By inhibiting the production of gastric acid secretion By enhancing gastric absorption By forming a protective barrier over the gastric mucosa By neutralizing gastric acid

By forming a protective barrier over the gastric mucosa (Sucralfate has a local effect only on the gastric mucosa. It forms a protective barrier that can be thought of as a liquid bandage in the stomach. This liquid bandage adheres to the gastric lining, protecting against adverse effects related to gastric acid. It also stimulates healing of any ulcerated areas of the gastric mucosa.)

What instruction might the nurse give to nursing assistive personnel (NAP) caring for a postsurgical patient? A. "Assess his urine output, and compare it to intake." B. "Please reassure the family, and explain to them what is going on." C. "Let me know when the patient's family arrives on the floor." D. "Please teach him about the incentive spirometer while I speak with the physician."

C. "Let me know when the patient's family arrives on the floor." (Rationale: The task of notifying the nurse of the family's arrival may be delegated to NAP. The skill of assessment may not be delegated to NAP. Education of a postsurgical patient may not be delegated to NAP. Education may not be delegated to NAP for even a short period of time.)

When a patient is using PCA, which statement is appropriate for the nurse to make to nursing assistive personnel (NAP)? A. "Let me know if the patient has any problems using the PCA pump." B. "Let me know when the patient's vital signs indicate that he has pain." C. "Tell me if the patient is in too much pain to assist with his bath." D. "The patient is confused and will need your help operating the PCA pump."

C. "Tell me if the patient is in too much pain to assist with his bath." (Rationale: NAP may assist with the bath and should report to the nurse if the patient is in too much pain to help. The responsibility of assessing if the patient has problems using the PCA pump or assessing the patient's vital signs to indicate pain may not be delegated to NAP. Neither NAP nor anyone other than the patient may routinely assume responsibility for a PCA pump.)

What is one step the nurse would take if a patient receiving patient-controlled analgesia (PCA) were difficult to arouse? A. Assess the infusion tubing to make sure it has not become occluded. B. Check the infusion site for infiltration and any symptoms of infection. C. Assess respiration, and then notify the health care provider immediately. D. Check the infusion of maintenance fluid to make sure the correct rate is running.

C. Assess respiration, and then notify the health care provider immediately. (Rationale: If a patient on PCA were difficult to arouse, a possible sign of life-threatening respiratory depression, the nurse would assess respiration (if none, would need to call code) and then notify the health care provider immediately and be prepared to administer an antidote, such as an opioid-reversing agent. The nurse would take other measures as well, such as monitoring the patient's vital signs and administering oxygen if indicated. Assessing the infusion tubing would not help if a patient on PCA were difficult to arouse. Checking the infusion site for infiltration or infection would not help if a patient on PCA were difficult to arouse. Checking the infusion of maintenance fluid would not help if a patient on PCA were difficult to arouse.)

The nurse is concerned that a patient will not be able to turn independently in bed after having surgery. What must the nurse do to help this patient? A. Reinstruct the patient in proper turning techniques. B. Document that the patient refuses to turn independently. C. Communicate that the staff must turn the patient after surgery. D. Restrict turning unless absolutely necessary.

C. Communicate that the staff must turn the patient after surgery. (Rationale: The nurse must let the staff know to turn the patient after surgery. Reinstructing the patient will not improve the patient's ability to turn in bed. Documenting that the patient refuses to turn independently is not accurate. The patient is unable, but not necessarily unwilling, to turn without assistance. Restricting the patient from turning can lead to preventable postoperative complications. This should not be done.)

What is the primary way in which the nurse can lower a patient's risk for postsurgical complications? A. Adequately prepare the patient for discharge from the agency. B. Provide continuity of nursing care throughout the patient's stay at the agency. C. Identify deviations from normal that may interfere with the recovery process. D. Evaluate the patient's emotional reaction to the surgical process.

C. Identify deviations from normal that may interfere with the recovery process. (Rationale: Deviations from normal, such as vital signs that fall outside the expected range, may affect the success of the patient's recovery. Adequate preparation for discharge is appropriate, but it is not the primary way in which the nurse can lower a patient's postsurgical risk. Continuity of care is appropriate, but it is not the primary way in which the nurse can lower a patient's postsurgical risk. Evaluating the patient's emotional reaction to the surgical process does not minimize the patient's postsurgical risk.)

A patient scheduled for same-day surgery tells the nurse that he had a "few sips" of coffee while driving to the hospital. What would the nurse do first with this information? A. Document that the patient had coffee B. Notify the operating room C. Notify the surgeon D. Inform the recovery room nurse

C. Notify the surgeon (Rationale: The nurse would first notify the surgeon that the patient has not complied with NPO instructions. The procedure may need to be rescheduled. Although documentation is important, it would not be the first requirement in this situation. Notifying the operating room that the patient has not complied with NPO instructions may or may not be necessary. The patient has not had surgery yet; therefore the recovery room nurse does not need this information.)

What is the nurse's primary goal for appropriate, effective pain management when considering the patient's risk for injury? A. To minimize the potential for analgesic-induced dependency B. To evaluate the effect of pain on the patient's ability to provide self-care C. To maximize pain relief while maintaining the patient's ability to function D. To identify the patient's need for both physical and emotional pain relief

C. To maximize pain relief while maintaining the patient's ability to function (Rationale: Maintaining patient function is the nurse's primary goal because it directly affects the patient's risk for injury. Minimizing the potential for analgesic-induced dependency will not reduce the patient's risk for injury. Evaluating the effect of pain on the patient's ability to provide self-care will not reduce the patient's risk for injury. Identifying the patient's need for both physical and emotional pain relief will not reduce the patient's risk for injury.)

Which patient choice for a snack 2 hours before bedtime indicates that the nurse's teaching about gastroesophageal reflux disease (GERD) has been effective? Chocolate pudding Glass of low-fat milk Cherry gelatin with fruit Peanut butter and jelly sandwich

Cherry gelatin with fruit (Gelatin and fruit are low fat and will not decrease lower esophageal sphincter (LES) pressure. Foods such as chocolate are avoided because they lower LES pressure. Milk products increase gastric acid secretion. High-fat foods such as peanut butter decrease both gastric emptying and LES pressure.)

The telemetry unit nurse is reviewing laboratory results for a client who is scheduled for an operative procedure later in the day. The nurse notes on the laboratory report that the client has a serum potassium level of 6.5 mEq/L, indicative of hyperkalemia. The nurse informs the physician of this laboratory result because the nurse recognizes hyperkalemia increases the client's operative risk for which of the following? Cardiac problems Infection Bleeding and anemia Fluid imbalances

Cardiac problems (Hyperkalemia or hypokalemia increases the client's risk for cardiac problems. A decrease in the hematocrit and hemoglobin level may indicate the presence of anemia or bleeding. An elevated white blood cell count occurs in the presence of infection. Abnormal urine constituents may indicate infection or fluid imbalances.)

A client newly diagnosed with diabetes is not ready to learn diabetes control during the hospital stay. Which information is the priority for the nurse to teach the client and the client's family? Select all that apply. Pathophysiology of diabetes Causes and treatment of hypoglycemia Dietary control of blood glucose Insulin administration Physical activity and exercise

Causes and treatment of hypoglycemia Insulin administration (The priority information the nurse needs to teach the client and family about diabetes are the causes and treatment of hypoglycemia and proper insulin administration. This information is essential for the client's survival and must be understood by both the client and family to ensure client safety.The pathophysiology of diabetes and hyperglycemia is a topic for secondary teaching and is not a survival need or the priority during hospitalization. Dietary control and exercise regimen are important, but are not the priority during the acute care stay.)

The nurse is reviewing the medication history for a patient diagnosed with gastroesophageal reflux disease (GERD) who has been prescribed esomeprazole (Nexium) once daily. The patient reports that this proton pump inhibitor medication doesn't completely control the symptoms. The nurse contacts the primary health care provider to discuss which intervention? Adding a second proton pump inhibitor medication Increasing the dose of esomeprazole Changing to a twice-daily dosing regimen Switching to omeprazole (Prilosec)

Changing to a twice-daily dosing regimen (The nurse contacts the primary health care provider about changing the Proton pump inhibitor to twice daily. These medications are usually effective when given once daily but can be given twice daily if symptoms are not well controlled.Adding a second medication, increasing the dose, or switching to another proton pump inhibitor is not recommended.)

Before administration of an immunosuppressant drug, the nurse should perform which actions? Select all that apply. Check liver enzyme tests. Measure abdominal girth. Assess blood pressure and heart rate. Check blood urea nitrogen and creatinine levels. Assess level of consciousness.

Check liver enzyme tests. Assess blood pressure and heart rate. Check blood urea nitrogen and creatinine levels. Assess level of consciousness. (Serious adverse effects to immunosuppressant drugs include neurotoxicity, nephrotoxicity, hepatotoxicity, and hypertension.)

A client with type 1 diabetes arrives in the emergency department breathing deeply and stating, "I can't catch my breath." The client's vital signs are: T 98.4°F (36.9°C), P 112 beats/min, R 38 breaths/min, BP 91/54 mm Hg, and O2 saturation 99% on room air. Which action will the nurse take first? Check the blood glucose. Administer oxygen. Offer reassurance. Attach a cardiac monitor.

Check the blood glucose. (The nurse would first obtain the client's glucose level. Breathing deeply and stating, "I can't catch my breath" is indicative of Kussmaul respirations which is a sign of diabetic ketoacidosis.Based on the oxygen saturation, oxygen administration is not indicated. The nurse provides support, but it is early in the course of assessment and intervention to offer reassurance without more information. Cardiac monitoring may be implemented, but the first action would be to obtain the glucose level.)

For a patient receiving IV nitroglycerin (Tridil), what are the priority nursing interventions? (Select all that apply.) Check the heart rate. Monitor blood pressure. Measure intake and output. Assess for worsening chest pain. Auscultate lung sounds.

Check the heart rate. Monitor blood pressure. Assess for worsening chest pain. (IV nitroglycerin can cause sudden and severe hypotension, worsening of chest pain, and significant changes in heart rate (less than 60 beats/min or greater than 100 beats/min).)

Which assessment action will help the nurse determine if an obese patient has metabolic syndrome? Take the patient's apical pulse. Check the patient's blood pressure. Ask the patient about dietary intake. Dipstick the patient's urine for protein.

Check the patient's blood pressure. (Elevated blood pressure is one of the characteristics of metabolic syndrome. The other information also may be obtained by the nurse, but it will not assist with the diagnosis of metabolic syndrome.)

The nurse and the dietitian are planning sample diet menus for a patient who is experiencing dumping syndrome. Which sample meal is best for this patient? Chicken salad on whole wheat bread Liver and onions Chicken and rice Cobb salad with buttermilk ranch dressing

Chicken and rice (Chicken and rice is the best sample meal for this patient. It is the only selection suitable for the patient who is experiencing dumping syndrome because it contains high protein without the addition of milk or wheat products.The patient with dumping syndrome would not be allowed to have mayonnaise, onions, or buttermilk ranch dressing. Buttermilk dressing is made from milk products. The patient can have whole wheat bread only in very limited amounts.)

The nurse is caring for a postoperative patient with a history of obstructive sleep apnea. The nurse monitors for which of the following? Choking and noisy, irregular respirations Shallow respirations Moaning and reports of pain Disorientation

Choking and noisy, irregular respirations (One of the greatest concerns after general anesthesia is airway obstruction. Choking and noisy, irregular respirations are classic signs and symptoms of airway obstruction. A number of factors contribute to obstruction, including a history of obstructive sleep apnea; weak pharyngeal/laryngeal muscle tone from anesthetics; secretions in the pharynx, bronchial tree, or trachea; and laryngeal or subglottic edema. In the postanesthetic patient, the tongue is a major cause of airway obstruction. Shallow respirations are indicative of respiratory depression. Moaning and reports of pain are common in all surgical patients and are an expected event. Disorientation is common when first awakening from anesthesia but can be a sign of hypoxia.)

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

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.)

Which staff member will be best for the nurse manager to assign to update standard nursing care plans and policies for care of the client in the operating room (OR)? Surgical technologist with 10 years of experience in the OR at this hospital Certified registered nurse first assistant (CRNFA) who has worked for 5 years in the ORs of multiple hospitals Holding room RN who has worked in the hospital holding room for longer than 15 years Circulating RN who has been employed in the hospital OR for 7 years

Circulating RN who has been employed in the hospital OR for 7 years (The circulating RN is the best staff member for the nurse manager to assign. This nurse has the experience and background to write OR policy, has been employed in the hospital for 7 years, and is aware of hospital policy and procedures.A surgical technologist does not have the background to write policy for nurses. A CRNFA has worked in multiple hospitals but does not have a work history with this specific hospital to be aware of the unit policy. A holding room or preoperative or postoperative care nurse would not be the choice to write OR policy.)

During surgery, who is most responsible for monitoring for possible breaks in sterile technique? Circulating nurse Holding nurse Anesthesiologist Surgeon

Circulating nurse (All operating room team members are responsible, but the circulating nurse moves around the room and can see more of what is happening.The holding nurse is not in the operating room. The anesthesiologist is focused on providing sedation to the client. The surgeon is concentrating on the surgery and usually cannot monitor all staff.)

Who is the most likely person to administer blood products in an operating suite? Circulating nurse Holding area nurse Scrub nurse Specialty nurse

Circulating nurse (The circulating nurse is the most likely person to administer blood products to a client in the operating suite. Circulating nurses or "circulators" are registered nurses who coordinate, oversee, and are involved in the client's nursing care in the operating room.Holding area nurses manage the client's care before surgery; blood would not yet be needed at this point. Scrub nurses set up the sterile field, drape the client, and hand sterile supplies, sterile equipment, and instruments to the surgeon and the assistant. Specialty nurses may be in charge of a particular type of surgical specialty. They are responsible for nursing care specific to clients who need that type of surgery, such as assessing, maintaining, and recommending equipment, instruments, and supplies.)

A physician has ordered a nurse to administer conscious sedation to a client. Which of the following is possible after administering conscious sedation to a client? Client can respond verbally despite physical immobility. Client can tolerate long therapeutic surgical procedures. Client is relaxed, emotionally comfortable, and conscious. Client's consciousness level can be monitored by equipment.

Client is relaxed, emotionally comfortable, and conscious. (Conscious sedation refers to a state in which the client is sedated in a state of relaxation and emotional comfort, but is not unconscious. The client is free of pain, fear, and anxiety and can tolerate unpleasant diagnostic and short therapeutic surgical procedures, such as an endoscopy or bone marrow aspiration. The client can respond verbally and physically. However, no equipment can replace a nurse's careful observations for monitoring clients.)

While caring for a client who has received recombinant tissue plasminogen activator (t-PA) for a large deep vein thrombus, the nurse becomes most concerned when the client develops which condition? Small amount of blood at the IV insertion site Heavy menstrual bleeding +1 pitting edema of the affected extremity Client stating that the year is 1967

Client stating that the year is 1967 (The nurse becomes most concerned after a client receives t-PA for a large vein thrombus when the client states that the year is 1967. The most serious complication from thrombolytic therapy is intracerebral bleeding, manifested by changes in the level of consciousness. Thrombolytics such as t-PA dissolve clots. Even without this medication, a small amount of blood at the insertion site is not abnormal. Anticoagulants and thrombolytics may cause heavier-than-usual menstrual bleeding. Swelling is expected in the extremity with deep vein thrombosis.)

The nurse has just taken change-of-shift report on a group of clients on the medical-surgical unit. Which client does the nurse assess first? Client taking repaglinide (Prandin) who has nausea and back pain Client taking glyburide (Diabeta) who is dizzy and sweaty Client taking metformin (Glucophage) who has abdominal cramps Client taking pioglitazone (Actos) who has bilateral ankle swelling

Client taking glyburide (Diabeta) who is dizzy and sweaty (The nurse needs to first assess the client taking glyburide (Diabeta) who is dizzy and sweaty and has symptoms consistent with hypoglycemia. Because hypoglycemia is the most serious adverse effect of antidiabetic medications, this client must be assessed as soon as possible.Nausea is a documented side effect of repaglinide. Checking the client's back pain requires assessment, which can be performed after the nurse assesses the client displaying signs and symptoms of hypoglycemia. Metformin may cause abdominal cramping and diarrhea, but the client taking it does not require immediate assessment. Ankle swelling is an expected side effect of pioglitazone.)

The nurse working on a medical surgical endocrine unit has just received change-of-shift report. Which client will the nurse see first? Client with type 1 diabetes whose insulin pump is beeping "occlusion" Newly diagnosed client with type 1 diabetes who is reporting thirst Client with type 2 diabetes who has a blood glucose of 150 mg/dL (8.3 mmol/L) Client with type 2 diabetes with a blood pressure of 150/90 mm Hg

Client with type 1 diabetes whose insulin pump is beeping "occlusion" (The client the nurse sees first is the client with type 1 diabetes whose insulin pump is beeping "occlusion." Because glucose levels will increase quickly in clients whose continuous insulin pumps malfunction, the nurse must assess this client and the insulin pump first to avoid hyperglycemia or diabetic ketoacidosis.Thirst is an expected symptom of hyperglycemia and, although important, is not a priority. The nurse could delegate fingerstick blood glucose to unlicensed assistive personnel while assessing the client whose insulin pump is beeping. Although a blood glucose reading of 150 mg/dL (8.3 mmol/L) is mildly elevated, this does not require immediate action. Mild hypertension does not require immediate action. The nurse can later assess if this is within the client's usual range or represents a change before taking action.)

Which medication is an antiplatelet drug? Clopidogrel (Plavix) Alteplase (Activase) Enoxaparin (Lovenox) Heparin (Hemochron)

Clopidogrel (Plavix) (Clopidogrel (Plavix) is an antiplatelet drug. Enoxaparin and heparin are anticoagulants. Alteplase is a thrombolytic drug.)

A nurse is assessing a client with Crohn disease who is to have an upper gastrointestinal series. Which condition necessitates the cancellation of the upper gastrointestinal series? Hemorrhoids Hyperkalemia Inflamed colon Colon perforation

Colon perforation (When a client has a perforated viscera, barium can leak out of the intestinal tract and cause inflammation or an abscess. Although hemorrhoids may be irritating, they do not contraindicate barium studies. Serum potassium is unaffected; barium is insoluble and will not affect blood content. Barium studies are not contraindicated when the bowel is inflamed. An upper gastrointestinal series is useful in diagnosing ulcerative colitis and Crohn disease.)

A nurse is caring for a client who is scheduled to undergo a breast biopsy. Which of the following major tasks does the nurse perform immediately during the pre-operative period? Obtain a signature on the consent form. Review the surgical checklist. Conduct a nursing assessment. Reduce the dosage of toxic drugs.

Conduct a nursing assessment. (During the immediate pre-operative period, the nurse conducts a nursing assessment. Nurses obtain the signature of the client, nearest blood relative, or someone with durable power of attorney before the administration of any pre-operative sedatives. They also administer medications as ordered by the physician regardless of their toxicity. They assist the client with psychosocial preparation and complete the surgical checklist, which is reviewed by the operating room personnel.)

The nurse is providing teaching to a client who recently has been diagnosed with type 1 diabetes. The nurse reinforces the importance of monitoring for ketoacidosis. What are the signs and symptoms of ketoacidosis? Select all that apply. Confusion Hyperactivity Excessive thirst Fruity-scented breath Decreased urinary output

Confusion Excessive thirst Fruity-scented breath (Diabetic ketoacidosis signs and symptoms often develop quickly, sometimes within 24 hours. Diabetic ketoacidosis is a serious complication of diabetes that occurs when the body produces high levels of ketones (blood acids). Diabetic ketoacidosis develops when the body is unable to produce enough insulin. Without enough insulin, the body begins to break down fat as an alternative fuel. This process produces a buildup of ketones (toxic acids) in the bloodstream, eventually leading to diabetic ketoacidosis if untreated. Signs and symptoms include excessive thirst, frequent urination, nausea and vomiting, abdominal pain, weakness or fatigue, shortness of breath, fruity-scented breath, and confusion. Frequent urination, not decreased urination, is a symptom. Weakness or fatigue, not hyperactivity, is a symptom.)

The nurse will monitor a client taking an aluminum-containing antacid, such as aluminum hydroxide (Amphojel), for which adverse effect? Constipation Gastrointestinal (GI) upset Fluid retention Diarrhea

Constipation (Aluminum- and calcium-containing antacids cause constipation, magnesium-containing antacids cause diarrhea, and sodium-containing antacids cause sodium and fluid retention.)

The nurse knows iron supplementation has which common adverse effect? Flatus Heartburn Constipation Fatigue

Constipation (Constipation and change in the color of stool to darker or green are the most common complaints with iron supplementation and are expected adverse effects.)

When assessing a patient for adverse effects related to morphine sulfate (MS Contin), which clinical findings is the nurse MOST likely to find? (Select all that apply.) Weight gain Excessive bruising Constipation Inability to void Diarrhea

Constipation Inability to void (Morphine sulfate causes a decrease in GI motility (delayed gastric emptying and slowed peristalsis). This leads to constipation, not diarrhea. Morphine can also cause urinary retention (inability to void).)

Vicodin (acetaminophen/hydrocodone) is prescribed for a patient who has had surgery. The nurse informs the patient that which common adverse effects can occur with this medication? (Select all that apply.) Diarrhea Constipation Lightheadedness Nervousness Urinary retention Itching

Constipation Lightheadedness Urinary retention Itching (Constipation (not diarrhea), lightheadedness (not nervousness), urinary retention, and itching are some of the common adverse effects that the patient may experience while taking Vicodin.)

A nurse is teaching a group of clients with peripheral vascular disease about a smoking cessation program. Which physiologic effect of nicotine should the nurse explain to the group? Constriction of the superficial vessels dilates the deep vessels. Constriction of the peripheral vessels increases the force of flow. Dilation of the superficial vessels causes constriction of collateral circulation. Dilation of the peripheral vessels causes reflex constriction of visceral vessels.

Constriction of the peripheral vessels increases the force of flow. (Constriction of the peripheral blood vessels and the resulting increase in blood pressure impairs circulation and limits the amount of oxygen being delivered to body cells, particularly in the extremities. Nicotine constricts all peripheral vessels, not just superficial ones. Its primary action is vasoconstriction; it will not dilate deep vessels. Nicotine constricts rather than dilates peripheral vessels.)

A nursing home patient has been diagnosed with Clostridium difficile. What type of precautions should the nurse implement to prevent the spread of this infectious disease to other residents? Contact Droplet Airborne Positive pressure isolation

Contact (Contact precautions are used for organisms that are spread by skin-to-skin contact, such as antibiotic-resistant organisms or Clostridium difficile. Droplet precautions are used for organisms that can be transmitted by close, face-to-face contact, such as influenza or meningococcal meningitis. Airborne precautions are required for patients with presumed or proven pulmonary TB or chickenpox. Positive pressure isolation is unnecessary and ineffective.)

As the nurse obtains informed consent, the client asks, "Now what exactly are they going to do to me?" What is the nurse's response? Contact the anesthesiologist. Contact the surgeon. Explain the procedure. Have the client sign the form.

Contact the surgeon. (The nurse will contact the surgeon to convey the client's question. The nurse is not responsible for explaining or providing detailed information about the surgical procedure. Rather, the nurse's role is to clarify facts that have been presented by the health care provider and dispel myths that the client or family may have heard about the surgical experience.The anesthesiologist is responsible for the anesthesia, not the surgical details. Although the nurse is only witnessing the signature, it is the nurse's role to ensure that the facts are clarified before the consent form is signed.)

The nurse provides discharge teaching to a client with a history of angina. The nurse instructs the client to call for emergency services immediately if the client's pain exhibits which characteristic? Causes mild perspiration Occurs after moderate exercise Continues after rest and nitroglycerin Precipitates discomfort in the arms and jaw

Continues after rest and nitroglycerin (When neither rest nor nitroglycerin relieves the pain, the client may be experiencing an acute myocardial infarction. Angina may cause mild diaphoresis; acute myocardial infarction causes profuse diaphoresis, which should be reported. Chest pain after exercise is expected; activity increases cardiac output, which can cause angina. Anginal pain can, and often does, radiate.)

A client has Barrett's esophagus. Which client assessment by the nurse requires consultation with the health care provider? Sleeping with the head of the bed elevated Coughing when eating or drinking Wanting to eat several small meals during the day Chewing antacid tablets frequently during the day

Coughing when eating or drinking (In Barrett's esophagus (a complication of gastroesophageal reflux disease [GERD]), fibrosis and scarring that accompany the healing process can cause esophageal stricture, leading to difficulty in swallowing. This can be manifested by coughing when the client eats or drinks and requires consultation with the health care team. The other assessments are typical of clients trying to control their GERD.)

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? Corticosteroid therapy will be stopped. Sulfasalazine (Azulfidine) will be stopped. Corticosteroid therapy will be tapered. Sulfasalazine (Azulfidine) will be tapered.

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 patient with a diagnosis of pneumonia asks the nurse, "Why am I receiving codeine when I have no pain?" The nurse's response is based on knowledge that codeine also has what effect? Bronchodilation Increases sputum production Expectorant Cough suppressant

Cough suppressant (Codeine provides both analgesic and antitussive (cough suppressant) therapeutic effects.)

A client with a history of recurrent cholecystitis is scheduled for an abdominal cholecystectomy. What should the nurse specifically emphasize when planning preoperative teaching for this client? Possible complications Food and fluid restrictions Coughing and deep breathing Isometric exercises of the extremities

Coughing and deep breathing (The operative site's proximity to the diaphragm results in the client taking shallow respirations to limit pain; failure to expand the lungs can cause hypostatic pneumonia. The healthcare provider explores possible complications when providing information for an informed consent. The nurse should not emphasize possible complications because it may increase the client's anxiety. Preoperative teaching should focus on the interventions that prevent complications. Food and fluid restrictions should be included in preoperative teaching; however, this is not the priority. Isometric exercises of the extremities are unnecessary; the client will be allowed out of bed within several hours after surgery.)

Which action does the nurse implement for a client with wound evisceration? Apply direct pressure to the wound. Cover the wound with a sterile, warm, moist dressing. Irrigate the wound with warm, sterile saline. Replace tissue protruding into the opening.

Cover the wound with a sterile, warm, moist dressing. (Covering the wound with a sterile, warm, moist dressing protects the organs until the surgeon can repair the wound. Evisceration occurs when a wound opens up and body organs are exposed.Applying direct pressure to a wound traumatizes the organs. Irrigating the wound is not necessary. Replacing protruding tissue could induce infection.)

A client recovering from a stroke reports double vision that is preventing the client from effectively completing activities of daily living. How does the nurse help the client compensate? Approaches the client on the affected side Covers the affected eye Encourages turning the head from side to side Places objects in the client's field of vision

Covers the affected eye (The nurse helps the stroke client compensate with double vision by covering the affected eye. Covering the client's affected eye with a patch prevents diplopia.The client who is recovering from a stroke would always be approached on the unaffected side. The nurse may encourage side-to-side head turning for clients with hemianopsia (blindness in half of the visual field). Objects would be placed in the field of vision for the client with a decreased visual field.)

Which electrolyte laboratory result does the nurse report immediately to the anesthesiologist? Creatinine, 1.9 mg/dL (168 mcmol/L) Fasting glucose, 80 mg/dL (4.4 mmol/L) Potassium, 3.9 mEq/L (3.9 mmol/L) Sodium, 140 mEq/L (140 mmol/L)

Creatinine, 1.9 mg/dL (168 mcmol/L) (The nurse will immediately report a creatinine of 1.9 mg/dL (168 mcmol/L) to the anesthesiologist. A creatinine of 1.9 mg/dL (168 mcmol/L) is outside the normal range and may indicate renal problems.A fasting glucose of 80 mg/dL (4.4 mmol/L), a potassium level of 3.9 mEq/L (3.9 mmol/L), and sodium level of 140 mEq/L (140 mmol/L) are normal laboratory values.)

In an effort to prevent superinfections of the GI tract such as Clostridium difficile, the nurse will instruct clients to eat which foods? Cultured dairy products such as yogurt Low-fat meats such as chicken and pork Multigrain wheat bread Raw fruits and vegetables

Cultured dairy products such as yogurt (The natural flora in the GI tract may be killed off by antibiotics, leaving other bacteria such as C. difficile to overgrow. This process may be prevented through consumption of probiotics (e.g., yogurt, buttermilk, kefir).)

When reviewing ordered pain medicine for a postoperative patient whose pain is not currently controlled, which nursing action has priority? A. Asking the family member if the patient seems in pain B. Reviewing the surgeon's preoperative pain medication order C. Examining the patient's medical record for analgesics used with previous surgeries D. Asking the postanesthesia care unit (PACU) nurse when the patient last received pain medication

D. Asking the postanesthesia care unit (PACU) nurse when the patient last received pain medication (Rationale: Asking the PACU nurse when the patient received his last dose of analgesic is the priority action because it establishes when the patient can safely be given more pain medication. The nurse would ask the patient for pain level. The nurse would not need to review the surgeon's preoperative pain medication order before administering the pain medication; looking at the postoperative order would be appropriate. The priority is on the current situation and orders.)

After the nurse provides a patient with preoperative medication, the patient needs to void. What would the nurse do? A. Walk the patient to the bathroom. B. Insert an indwelling urinary catheter. C. Insert an intermittent urinary catheter. D. Provide the patient with a bedpan.

D. Provide the patient with a bedpan. (Rationale: A bedpan both allows the patient to remain in bed and provides the patient with a way to void after receiving preoperative medication. After receiving preoperative medication, the patient must remain in bed. Although the patient must remain in bed, he or she does not need an indwelling urinary catheter. The patient does not need to have an intermittent urinary catheter to void, even though he or she must remain in bed after receiving preoperative medication.)

What might the nurse do to accommodate a patient's request to wear a wedding ring during surgery? A. Explain that the ring may be lost during surgery B. Suggest that the ring be placed in the top drawer of the bedside stand C. Recommend that family take the ring home D. Tape the ring to the patient's finger

D. Tape the ring to the patient's finger (Rationale: Taping the ring securely to the patient's finger keeps it from coming off during surgery and complies with the patient's wishes. The patient does not want to take the ring off, so explaining that the ring could be lost during surgery fails to address the patient's request. Valuables left in the room can be stolen. In addition, suggesting that the ring be placed in the top drawer of the bedside stand fails to address the patient's request. While recommending that the family take the ring home is often a good solution for valuables, this suggestion fails to address the patient's request.)

A client states to the nurse, "I must take my iron supplement with a meal to avoid stomach upset." To increase uptake of oral iron, which food group should the nurse instruct the client to avoid? Proteins Dairy Vegetables Fruits

Dairy (Many individuals find that they need to take oral iron products with meals or food because of the commonly encountered adverse effect of gastrointestinal upset even though altered absorption occurs. If antacids or milk products are used, schedule them at least 1 to 2 hours before or after the oral dosage of iron or avoid taking with dairy products.)

The nurse is teaching a client with vitamin B12 deficiency anemia about dietary intake. Which type of food does the nurse encourage the client to eat? Grains Dairy products Leafy vegetables Starchy vegetables

Dairy products (The nurse encourages the client to eat dairy products such as milk, cheese, and eggs. These foods will provide the vitamin B12 that the client needs.Grains, leafy vegetables, and starchy vegetables are not a source of vitamin B12.)

A client is diagnosed with a peptic ulcer. When teaching about peptic ulcers, the nurse instructs the client to report what kind of stools? Frothy Ribbon shaped Pale or clay colored Dark brown or black

Dark brown or black (Dark brown or black stools (melena) indicate gastrointestinal bleeding and need to be reported. Frothy stools are indicative of inadequate fat absorption and are associated with sprue. Ribbon-shaped stools indicate a bowel mass or obstruction. Clay-colored stools usually are related to problems that cause a decrease in bile.)

For which clinical indicators should the nurse monitor when caring for a client with cholelithiasis and obstructive jaundice? Select all that apply. Dark urine Yellow skin Pain on urination Clay-colored stool Coffee-ground vomitus

Dark urine Yellow skin Clay-colored stool (When bile levels in the bloodstream are high, as in obstructive jaundice, there is bile in the urine, causing it to have a dark color. Jaundice (bile pigments causing yellow skin, sclera, and mucous membranes) results from failure of bile to enter the intestines, with subsequent backup into the biliary system and diffusion into the blood; the bilirubin is carried to all body regions. The stools are clay-colored, not brown, because the bile pigments are not present in the gastrointestinal (GI) tract as a result of the obstruction of the common bile duct. Pain is experienced in the right upper quadrant, not on urination, because of spasm of the gallbladder, whether or not there is biliary obstruction. Coffee-ground vomitus indicates gastric bleeding; it is not a unique sign of cholelithiasis with obstructive jaundice.)

A patient receiving IV nitroglycerin at 20 mcg/min complains of dizziness. Nursing assessment reveals a blood pressure of 85/40 mm Hg, heart rate of 110 beats/min, and respiratory rate of 16 breaths/min. What is the nurse's best action? Recheck the patient's vital signs in 1 hour. Assess the patient's lung sounds. Increase the IV nitroglycerin by 10 mcg/min. Decrease the IV nitroglycerin by 10 mcg/min.

Decrease the IV nitroglycerin by 10 mcg/min. (Nitroglycerin, as a vasodilator, causes a decrease in blood pressure. Because it is short-acting, decreasing the infusion rate will allow the blood pressure to rise. The patient should be monitored every 10 minutes while changing the rate of the IV nitroglycerin infusion.)

The nurse is performing an admission assessment on a 52-year-old client admitted with type 2 diabetes. -------------------------------- • Lungs clear • Glucose 179 mg/dL (9.9 mmol/L) • Regular insulin 8 units if blood glucose 250 to 275 mg/dL (13.9 to 15.3 mmol/L) • Right great toe mottled and cold to touch • Hemoglobin A1c 6.9% • Regular insulin 10 units if glucose 275 to 300 mg/dL (15.3 to 16.7 mmol/L) • Client states wears eyeglasses to read -------------------------------- After completing the above assessment, which complication of diabetes does the nurse report to the primary health care provider? Poor glucose control Visual changes Respiratory distress Decreased peripheral perfusion

Decreased peripheral perfusion (A cold, mottled right great toe may indicate arterial occlusion secondary to arterial occlusive disease or embolization. This must be reported to the primary health care provider to avoid potential gangrene and amputation.Although one glucose reading is elevated, the hemoglobin A1c indicates successful glucose control over the past 3 months. After the age of 40, reading glasses may be needed due to difficulty in accommodating to close objects. Lungs are clear and no evidence of distress is noted.)

In developing a plan of care for a client receiving an antihistamine antiemetic drug, which nursing diagnosis would be the highest priority? Deficient fluid volume related to nausea and vomiting Impaired physical mobility related to adverse effects of drugs Deficient knowledge regarding medication administration Risk for injury related to adverse effects of medication

Deficient fluid volume related to nausea and vomiting (Although all of the options are appropriate nursing diagnoses, fluid volume deficit is the highest priority because it has the highest associated mortality rate. Although a fall or injury could also prove fatal, this diagnosis is a risk; actual nursing diagnoses have priority over potential diagnoses.)

While caring for an obese client who underwent a cholecystectomy, the nurse notices a separation in the surgical incision. Which complication does the nurse identify? Adhesions Dehiscence Evisceration Contractions

Dehiscence (Dehiscence is the separation and disruption of previously joined wound edges; this condition typically occurs in obese clients. Adhesions are bands of scar tissue that form between or around organs. Evisceration occurs when wound edges separate to the extent that intestines protrude through the wound. Contractions are a normal part of healing, but excessive contractions result in deformity.)

The nurse is caring for a patient who had abdominal surgery 3 days ago and will be discharged home later today. The nurse will know that teaching is effective if the patient does which of the following? Choose all that apply. Describes clinical findings associated with infection Performs the dressing change as prescribed Demonstrates freedom from surgical incision pain Completes the regimen of prescribed antibiotics

Describes clinical findings associated with infection Performs the dressing change as prescribed Completes the regimen of prescribed antibiotics (The nurse would know that patient teaching was effective if the patient verbalizes signs and symptoms of infection, can perform the ordered dressing change, and completes the regimen of ordered antibiotics. Nurses cannot teach a patient to be free of pain. Pain is subjective. The nurse can teach the patient strategies to assist with pain, but they may not remove the pain completely.)

A 23-year-old woman is brought to the ED complaining of stomach cramps, nausea, vomiting, and diarrhea. The care team suspects food poisoning. What is the key to treatment in food poisoning? Administering IV antibiotics Assessing immunization status Determining the source and type of food poisoning Determining if anyone else in the family is ill

Determining the source and type of food poisoning (Determining the source and type of food poisoning is essential to treatment, and is more important than determining other sick family members. Antibiotics are not normally indicated and immunizations are not relevant to diagnosis or treatment of food poisoning.)

An RN and an LPN/LVN are working together in caring for a client who needs all of these interventions after orthopedic surgery. Which action(s) would be best for the RN to accomplish? Reinforce the need to cough and deep-breathe every 2 to 4 hours. Develop the discharge teaching plan in conjunction with the client. Administer narcotic pain medications before assisting the client with ambulation. Listen for bowel sounds and monitor the abdomen for distention and pain.

Develop the discharge teaching plan in conjunction with the client. (The best and most appropriate action for the nurse to take is to develop the discharge teaching plan with the client. Education and preparation for discharge are within the scope of practice of the RN, but not within that of the LPN/LVN.Reinforcing the need to cough and deep-breathe and monitoring the client are within the scope of the LPN/LVN nurse. LPN/LVNs can also administer pain medications.)

A client is admitted to the hospital with the diagnosis of a right-sided brain attack (stroke). The client is right-handed. Which task will be most difficult for this client? Eating meals Writing letters Combing the hair Dressing every morning

Dressing every morning (If the client is right-handed, there will be difficulty with dressing because it requires the use of two hands, and some clothing requires movement of both sides of the body when dressing. A right-handed client is able to continue to use the right hand for eating meals, writing letters, and combing the hair because it is the left side that is affected by a lesion on the right side of the brain.)

The nurse completes the preoperative checklist on a client scheduled for general surgery. Which factor contributes the greatest risk for the planned procedure? Age 59 years General anesthesia complications experienced by the client's brother Diet-controlled diabetes mellitus Ten pounds (4.5 kg) over the client's ideal body weight

Diet-controlled diabetes mellitus (The client's greatest risk factor is diabetes mellitus. Diabetes contributes an increased risk for surgery or postsurgical complications.Older adults are at greater risk for surgical procedures, but this client is not classified as an older adult. Family medical history and problems with anesthetics may indicate possible reactions to anesthesia, but this is not the best answer. Obesity increases the risk for poor wound healing, but being 10 pounds (4.5 kg) overweight does not categorize this client as obese.)

When planning administration of antiemetic medications to a client, the nurse is aware that combination therapy is preferred because of which drug effect? It is easier to achieve the desired level of sedation. There are faster drug absorption and distribution. Different vomiting pathways are blocked. The risk of constipation is decreased.

Different vomiting pathways are blocked. (Combining antiemetic drugs from various categories allows the blocking of the vomiting center and chemoreceptor trigger zone (CTZ) through different pathways, thus enhancing the antiemetic effect.)

A client has undergone an 8-hour surgical procedure under general anesthesia. In assessing the client for complications related to positioning, the nurse is most concerned with which finding? Decreased sensation in the lower extremities Diminished peripheral pulses in the lower extremities Pale, cool extremities Reddened areas over bony prominences

Diminished peripheral pulses in the lower extremities (The nurse is most concerned with diminished peripheral pulses in the lower extremities. This could indicate diminished blood flow.Decreased sensation; pale, cool extremities; and reddened areas over bony prominences can be normal occurrences in clients who have undergone a long surgical procedure.)

A client, scheduled for open-heart surgery, tells the nurse he does not want to be "saved" if he dies during surgery. What should the nurse do next? Discuss with and document the wishes of the client and family Administer the ordered oral and intravenous preoperative medications Notify the physician after completion of the surgical procedure Verbally report the client's wishes to the operating room supervisor

Discuss with and document the wishes of the client and family (Advance directives allow the client to specify instructions for health care treatment if unable to communicate these wishes during or after surgery. It is important for the nurse to discuss and document exact do not resuscitate (DNR) wishes of the client and family before surgery.)

Which factor indicates to the nurse the only similarity between discoid lupus erythematosus (DLE) and systemic lupus erythematosus (SLE)? Feeling tired and having a temperature that runs about 100° F (37.8° C) during the day Disfiguring and embarrassing rash Peripheral neuropathies and cranial nerve palsies High risk for renal inflammation

Disfiguring and embarrassing rash (Skin lesions associated with disfiguring and embarrassing rash are common to SLE and DLE.)

A patient is to receive acetylcysteine (Mucomyst) as part of the treatment for an acetaminophen (Tylenol) overdose. Which action by the nurse is appropriate when giving this medication? Giving the medication undiluted for full effect Avoiding the use of a straw when giving this medication Disguising the flavor with soda or flavored water Preparing to give this medication via a nebulizer

Disguising the flavor with soda or flavored water (Acetylcysteine has the flavor of rotten eggs and so is better tolerated if it is diluted and disguised by mixing with a drink such as cola or flavored water to help increase its palatability. The use of a straw helps to minimize contact with the mucous membranes of the mouth and is recommended. The nebulizer form of this medication is used for certain types of pneumonia, not for acetaminophen overdose.)

The nurse is educating a client on dietary sources of folic acid. The nurse should teach the client that which food source has the highest amount of folic acid? Apples Steak Dried beans Swiss cheese

Dried beans (Dried beans, green vegetables, and oranges are some of the common folate-containing foods.)

The nurse is preparing a care plan for a patient recently diagnosed with obstructive sleep apnea. The patient complains of daytime sleepiness, fatigue and excessive snoring that "wakes me up". What nursing diagnosis would be appropriate for this patient? Disturbed Sleep Pattern as evidenced by complaints of daytime sleepiness Disturbed Sleep Pattern related to obstructive sleep apnea as evidenced by excessive snoring Disturbed Sleep Pattern related to periods of apnea as evidenced by excessive snoring Disturbed Sleep Pattern related to obstructive sleep apnea

Disturbed Sleep Pattern related to periods of apnea as evidenced by excessive snoring (Disturbed Sleep Pattern related to periods of apnea as evidenced by excessive snoring is the correct nursing diagnosis. The medical diagnosis of obstructive sleep apnea should not be used in the nursing diagnosis.)

A healthcare provider prescribes dietary and medication therapy for a client with the diagnosis of gastroesophageal reflux disease (GERD). What is most appropriate for the nurse to teach the client about meal management? Snack daily in the evenings Divide food into four to six meals a day Eat the last of three daily meals by 8:00 PM Suck a peppermint candy after each meal

Divide food into four to six meals a day (The volume of food in the stomach should be kept small to limit pressure on the lower esophageal sphincter. Snacking in the evening can cause reflux. The last meal should be eaten at least three hours before bedtime; individual bedtimes vary. Peppermint promotes reflux because it relaxes the lower esophageal sphincter, allowing food to be regurgitated into the esophagus.)

A client had a gastric bypass procedure to treat morbid obesity. After surgery the client reports weakness, sweating, palpitations, and dizziness after eating. What should the nurse encourage the client to do? Reduce the intake of protein-rich foods Drink 8 ounces (240 mL) of water with meals Divide the daily caloric intake into six smaller meals Remain in an upright position for one hour after eating

Divide the daily caloric intake into six smaller meals (The client's clinical manifestations are related to the dumping syndrome from the gastric bypass procedure. Smaller meals along with other interventions will help minimize this response. After gastric bypass, a bolus of hypertonic fluid enters the intestines before carbohydrates and electrolytes are diluted. Extracellular fluid is drawn into the bowel lumen; this causes a decrease in plasma volume, distention of the bowel lumen, and rapid intestinal transit. Protein intake should be increased, not decreased, to meet energy needs and promote healing. Fluids should be avoided at mealtimes because they increase the volume in the stomach and decrease the transit time of gastric contents moving from the stomach to the intestine, which contributes to dumping syndrome. An upright position decreases the transit time of gastric contents moving from the stomach to the intestines via gravity, which contributes to the dumping syndrome; clients may lie flat after eating for a short time.)

The nurse understands that a patient receiving nitroglycerin should be monitored for which common adverse effects associated with this medication? (Select all that apply.) Dizziness Blurred vision Hypotension Flushing Headache

Dizziness Hypotension Flushing Headache (The common adverse effects of nitroglycerin include flushing of the face, dizziness, fainting, headache, and hypotension.)

When a client is receiving an IV infusion of metronidazole (Flagyl), what adverse effect would the nurse immediately report to the health care provider? Elevated blood pressure Dark colored urine Diminished breath sounds Dizziness or confusion

Dizziness or confusion (During use of this drug, metronidazole administered intravenously, report to the health care provider any changes in neurologic status (e.g., dizziness, confusion).)

The nurse is teaching a group of teens about prevention of heart disease. Which point is most important for the nurse to emphasize? Reduce abdominal fat Avoid stress Do not smoke or chew tobacco Avoid alcoholic beverages

Do not smoke or chew tobacco (The most important point for the nurse to emphasize when teaching a group of teens about heart disease prevention is not to smoke or chew tobacco. Tobacco exposure, including secondhand smoke, reduces coronary blood flow, causing vasoconstriction, endothelial dysfunction, and thickening of the vessel walls. Smoking also increases carbon monoxide and decreases oxygen. Because it is highly addicting, beginning smoking in the teen years may lead to decades of exposure.Teens are not likely to experience metabolic syndrome from obesity but are very likely to use tobacco. Avoiding stress is a less modifiable risk factor, which is less likely to cause heart disease in teens. The risk of smoking outweighs the risk of alcohol use.)

The nurse is teaching a group of teens about prevention of heart disease. Which point is most important for the nurse to emphasize? Reduce abdominal fat. Avoid stress. Do not smoke or chew tobacco. Avoid alcoholic beverages.

Do not smoke or chew tobacco. (The most important point for the nurse to emphasize when teaching a group of teens about heart disease prevention is not to smoke or chew tobacco. Tobacco exposure, including secondhand smoke, reduces coronary blood flow, causing vasoconstriction, endothelial dysfunction, and thickening of the vessel walls. Smoking also increases carbon monoxide and decreases oxygen. Because it is highly addicting, beginning smoking in the teen years may lead to decades of exposure.Teens are not likely to experience metabolic syndrome from obesity but are very likely to use tobacco. Avoiding stress is a less modifiable risk factor, which is less likely to cause heart disease in teens. The risk of smoking outweighs the risk of alcohol use.)

A nurse is reviewing results of preoperative screening tests and notes the client's potassium level is dangerously low. What should the nurse do next? Nothing; potassium levels have no influence on surgical outcome. Include the information in the postoperative end of shift report. Document the data and notify the physician who will do the surgery. Ask the client and family members why the potassium is low.

Document the data and notify the physician who will do the surgery. (Either high or low levels of potassium put the surgical client at increased risk for cardiac problems during and after surgery. The nurse's role includes recording the data in the client's record and reporting abnormal findings.)

A diabetic client who is scheduled for vascular surgery is admitted on the day of surgery with several orders. Which order does the nurse accomplish first? Use electric clippers to cut hair at the surgical site. Start an infusion of lactated Ringer's solution at 75 mL/hr. Administer one-half of the client's usual lispro insulin dose. Draw blood for glucose, electrolyte, and complete blood count values.

Draw blood for glucose, electrolyte, and complete blood count values. (The blood sample needs to be drawn and sent to the laboratory first to confirm that results are within normal limits. If blood work is abnormal, the surgery may be rescheduled.Removal of hair can be accomplished in the operating room directly before the start of surgery. The IV infusion can be accomplished after the laboratory orders have been completed. The nurse should check blood glucose with the laboratory orders before administration of lispro.)

The nurse will be teaching self-management to patients after gastric bypass surgery. Which information will the nurse plan to include? Drink fluids between meals but not with meals. Choose high-fat foods for at least 30% of intake. Developing flabby skin can be prevented by exercise. Choose foods high in fiber to promote bowel function.

Drink fluids between meals but not with meals. (Intake of fluids with meals tends to cause dumping syndrome and diarrhea. Food choices should be low in fat and fiber. Exercise does not prevent the development of flabby skin.)

The nurse is assessing a patient with gastroesophageal reflux disease (GERD). Which findings does the nurse expect to observe? Select all that apply. Blood-tinged sputum Dyspepsia Excessive salivation Flatulence Regurgitation

Dyspepsia Excessive salivation Flatulence Regurgitation (When assessing a patient for GERD, the nurse expects to find dyspepsia (heartburn), excessive salivation, flatulence which is common after eating, and regurgitation (backward flow of food and fluid into the throat).Blood-tinged sputum is not a symptom of GERD.)

A patient admitted to the ED with severe diarrhea and vomiting is subsequently diagnosed with food poisoning. The nurse caring for this patient assesses for signs and symptoms of fluid and electrolyte imbalances. For what signs and symptoms would this nurse assess? Select all that apply. Dysrhythmias Hypothermia Hypotension Hyperglycemia Delirium

Dysrhythmias Hypotension Delirium (The patient is assessed for signs and symptoms of fluid and electrolyte imbalances, including lethargy, rapid pulse rate, fever, oliguria, anuria, hypotension, and delirium. Hyperglycemia and hypothermia are not typically associated with fluid and electrolyte imbalances.)

The nurse in the endocrine clinic is providing education for a client who has just been diagnosed with diabetes. Which factor is most important for the nurse to assess before providing instruction to the client about the disease and its management? Current lifestyle Educational and literacy level Sexual orientation Current energy level

Educational and literacy level (The most important factor for the nurse to determine before providing instruction to the newly diagnosed client with diabetes is the client's educational level and literacy level. A large amount of information must be synthesized. Written instructions are typically given. The client's ability to learn and read is essential to provide the client with instructions and information about diabetes.Although lifestyle would be taken into account, it is not the priority. Sexual orientation will have no bearing on the ability of the client to provide self-care. Although energy level will influence the ability to exercise, it is not essential.)

A female client is scheduled for liposuction surgery to reduce her weight. Based on urgency, how is this surgery classified? Urgent Elective Emergency Emergent

Elective (A liposuction procedure is classified as elective surgery, in which the procedure is preplanned and based on the client's choice. Other classifications are urgent (surgery is necessary for the client's health but not an emergency) and emergency (the surgery must be done immediately to preserve life, body part, or body function).)

A client presents with gastric pain, vomiting, dehydration, weakness, lethargy, and shallow respirations. Laboratory results indicate metabolic alkalosis. The diagnosis of gastric ulcer has been made. What is the primary nursing concern? Chronic pain Risk for injury Electrolyte imbalance Inadequate gas exchange

Electrolyte imbalance (The stomach produces about 3 L of secretions per day. Fluid lost through vomiting can produce inadequate fluid volume and electrolyte imbalance, which can lead to dysrhythmias and death. Although pain is associated with gastric ulcers and requires intervention, it is not life threatening as is an electrolyte imbalance. Although the risk for injury is a concern, it is not the priority. Although respirations may be shallow when the client is experiencing pain, this is not the priority.)

A client with the diagnosis of ulcerative colitis has surgery for the creation of an ileostomy. Postoperatively, for which potential life-threatening complication should the nurse assess the client? Wound infection Ischemia of the stoma Electrolyte imbalances Excoriation of skin around the stoma

Electrolyte imbalances (An ileostomy directs liquid feces out of the body, bypassing the large intestine, where fluid and electrolytes normally are reabsorbed. The continuous excretion of liquid feces may deplete the body of fluid and electrolytes, resulting in a life-threatening fluid deficit and electrolyte imbalance. Although a wound infection is always a possibility after surgery, it is unlikely and not life threatening. Although the stoma should be assessed to ensure that it is not dark, but pink and moist, which indicates adequate circulation, this complication is unlikely and not life threatening. Although impaired skin integrity can occur when liquid feces remain on the skin surrounding the stoma, this should not occur if an appliance to collect the discharge is used correctly. Also, impaired skin integrity is not a life-threatening complication.)

Which of the following interventions is of major importance during preoperative education? Performing skills necessary for gastrointestinal preparation Encouraging the client to identify and verbalize fears Discussing the site and extent of the surgical incision Telling the client not to worry or be afraid of surgery

Encouraging the client to identify and verbalize fears (A surgical procedure causes anxiety and fear. The nurse should encourage the client to identify and verbalize fears; often simply talking about fears helps to diminish their magnitude.)

A client with gastroesophageal reflux disease reports having difficulty sleeping at night. What should the nurse instruct the client to do? Drink a glass of milk before retiring. Elevate the head of the bed on blocks. Eliminate carbohydrates from the diet. Take antacids, such as sodium bicarbonate.

Elevate the head of the bed on blocks. (Elevating the head of the bed on blocks raises the upper torso and minimizes reflux of gastric contents. Increasing the content of the stomach before lying down will aggravate the symptoms associated with gastroesophageal reflux. Eliminating carbohydrates from the diet will have no effect on the reflux of gastric contents. The effect of antacids is not long-lasting enough to promote a full night's sleep; sodium bicarbonate is not recommended as an antacid.)

A patient had a hip replacement 3 days ago. The patient states that the right leg is swollen below the knee and is warm to the touch. The patient has the diagnosis of deep vein thrombosis. Which intervention is appropriate for the patient? Massage the extremity to decrease pain. Place the leg in a dependent position. Apply ice bags to the lower leg. Elevate the right lower leg when the patient is in the sitting position.

Elevate the right lower leg when the patient is in the sitting position. (A patient with a deep venous thrombosis elevates the extremity when sitting or lying to enhance venous return to the heart. Massaging the extremity may dislodge a thrombus. If the leg is in the dependent position, blood return from the venous system will not be enhanced. Applying ice bags to the extremity may cause tissue injury.)

The nurse is caring for a 54-year-old female patient on the first postoperative day after a Roux-en-Y gastric bypass procedure. Which assessment finding should be reported immediately to the surgeon? Bilateral crackles audible at both lung bases Redness, irritation, and skin breakdown in skinfolds Emesis of bile-colored fluid past the nasogastric (NG) tube Use of patient-controlled analgesia (PCA) several times an hour for pain

Emesis of bile-colored fluid past the nasogastric (NG) tube (Vomiting with an NG tube in place indicates that the NG tube needs to be repositioned by the surgeon to avoid putting stress on the gastric sutures. The nurse should implement actions to decrease skin irritation and have the patient cough and deep breathe, but these do not indicate a need for rapid notification of the surgeon. Frequent PCA use after bariatric surgery is expected.)

The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan? Maintain the patient on bed rest. Auscultate lung sounds every 4 hours. Monitor for Trousseau's and Chvostek's signs. Encourage fluid intake up to 4000 mL every day.

Encourage fluid intake up to 4000 mL every day. (To decrease the risk for renal calculi, the patient should have a fluid intake of 3000 to 4000 mL daily. Ambulation helps decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia. Trousseau's and Chvostek's signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent assessment of lung sounds, although these would be assessed every shift.)

A client with gastroesophageal reflux disease (GERD) should make diet and lifestyle changes. Which instructions should the nurse include in the client's discharge teaching? Select all that apply. Encourage to quit smoking Elevate the foot of the bed Avoid caffeine-containing products Eat three large, evenly spaced meals daily Avoid lying down for 2 to 3 hours after eating

Encourage to quit smoking Avoid caffeine-containing products Avoid lying down for 2 to 3 hours after eating (Smoking cessation should be encouraged. Caffeine should be avoided because it decreases esophageal sphincter pressure, which permits reflux. Advise the client not to lie down for 2 to 3 hours after eating. Coffee and tea contain caffeine, which decreases esophageal sphincter pressure and should be avoided; milk does not have to be eliminated from the diet unless the client has lactose intolerance. The head, not the foot, of the bed should be elevated to prevent nighttime reflux; at night infrequent swallowing and the recumbent position impair esophageal clearance. Three large meals increase the volume pressure in the stomach, which delays gastric emptying; four to six smaller meals are preferred.)

The nurse is caring for a client who is postoperative day 2 from an open cholecystectomy and notes the presence of bibasilar crackles. The nurse suspects atelectasis. Which nursing actions will be appropriate for this client? Select all that apply . Encourage turning, coughing, and deep breathing exercises Perform frequent breath sounds assessment Decrease by mouth fluid intake Offer a high-potassium diet Obtain a chest x-ray

Encourage turning, coughing, and deep breathing exercises Perform frequent breath sounds assessment (This client likely has postoperative atelectasis and requires frequent breath sounds assessment because of the presence of adventitious breath sounds. Also, the client should turn, cough, and deep breathe to prevent further atelectasis and pneumonia. The client may be encouraged to increase intake to facilitate thinning of any secretions that may be present. High-potassium diet will have no effect on the resolution of atelectasis. Obtaining a chest x-ray is not a nursing action and requires a healthcare provider prescription; the nurse can review or request an x-ray.)

A nurse is caring for a client who had an open abdominal cholecystectomy because of biliary colic. Which nursing action is most important during the postoperative period? Maintaining T-tube drainage Ensuring a pain-free experience Encouraging coughing and deep breathing Providing a heating pad for shoulder pain for 15 minutes hourly

Encouraging coughing and deep breathing (Because of the high abdominal surgical incision, clients often avoid deep breathing and coughing and therefore need support and encouragement to accomplish these actions. Although maintaining T-tube drainage is important, encouraging coughing and deep breathing supports effective gas exchange, which is essential to prevent serious respiratory complications. Ensuring a pain-free experience may not be possible; some discomfort is expected. The nursing goal is to keep the client's pain at least at a tolerable level. Providing a heating pad for shoulder pain for 15 minutes hourly is employed for the shoulder pain caused by retained carbon dioxide after a laparoscopic cholecystectomy, not for an abdominal cholecystectomy.)

The focus of nursing care in the intraoperative phase is to: Prepare the patient for surgery. Maintain the sterile field. Ensure patient safety during the surgery. Obtain a signed informed consent.

Ensure patient safety during the surgery. (The intraoperative phase begins when the patient enters the operating suite and ends when the patient is admitted to the postanesthesia care unit. The nursing focus is to ensure patient safety during the surgical procedure by functioning as an advocate when clients cannot advocate for themselves and by monitoring the client and surgical environment throughout the procedure. Although the sterile field must be maintained in this phase, the focus of care is broader than the maintenance of sterility. Obtaining informed consent and preparing the patient for surgery are activities associated with the preoperative phase.)

A client who is preparing to undergo a vaginal hysterectomy is concerned about being exposed. How does the nurse ensure that this client's privacy will be maintained? Remind the client that she will be asleep. Ensure that drapes will minimize perianal exposure. Explain postoperative expectations. Restrict the number of technicians in the procedure.

Ensure that drapes will minimize perianal exposure. (Using drapes is the best action to take to ensure the client's privacy.Telling the client that she will be asleep or explaining the procedure will not alleviate the client's anxiety. The number of people involved in the procedure is not something the nurse can necessarily control.)

An unidentified client from the emergency department requires immediate surgery, but he is not conscious and no one is with him. What must the nurse, who is verifying the informed consent, do? Ensure written consultation of two noninvolved physicians. Read the surgeon's consult to determine whether the client's condition is life-threatening. Sign the operative permit. Withhold surgery until the next of kin is notified.

Ensure written consultation of two noninvolved physicians. (In a life-threatening situation in which every effort has been made to contact the person with medical power of attorney, consent is desired but not essential. In place of written or oral consent, written consultation by at least two physicians who are not associated with the case may be requested by the health care provider.It is not within the nurse's role to make a judgment about the client's life-threatening status based on the surgeon's consult. Signing documents on the client's behalf is not legal. Withholding surgery is not in this client's best interests.)

It is MOST important for the nurse to instruct a patient prescribed nitroglycerin to avoid which substance? Potassium-sparing diuretics Grapefruit juice Erectile dysfunction drugs Antacids

Erectile dysfunction drugs (Concurrent administration of nitrate drugs and erectile dysfunction drugs such as sildenafil citrate (Viagra), tadalafil (Cialis), and vardenafil (Levitra) can cause an additive hypotensive effect.)

The formation of erythrocytes and maturation of the red blood cell (RBC) is driven by what hormone? Progesterone Testosterone Erythropoietin Free thyroxin

Erythropoietin (Erythropoiesis is the process of erythrocyte formation and this involves the maturation of a nucleated RBC precursor into a hemoglobin-filled, nucleus-free erythrocyte. This process is driven by the hormone erythropoietin, which is produced by the kidneys. Erythropoietin is also produced commercially and is used to treat anemia in certain specific circumstances.)

Hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (statins) are generally administered at which time of day? Evening 12:00 noon Afternoon Morning

Evening (The liver produces the majority of cholesterol during the night. Thus, statin drugs, which decrease the cholesterol synthesis, are generally administered in the evening or bedtime so that the peak drug levels coincide with cholesterol production.)

The nurse teaches a patient prescribed the fentanyl (Duragesic) transdermal delivery system to change the patch at what interval? When pain recurs Every 72 hours Once a week Every 24 hours

Every 72 hours (The fentanyl transdermal delivery system is designed to slowly release analgesic over a 72-hour time frame.)

Which of the following information provided by the client's bed partner is most associated with sleep apnea? Restlessness Talking during sleep Somnambulism Excessive snoring

Excessive snoring (Partners of clients with sleep apnea often complain that the client's snoring disturbs their sleep. Restlessness is not most associated with sleep apnea. Sleeptalking is associated with sleep-wake transition disorders, not sleep apnea. Somnambulism is associated with parasomnias (specifically arousal disorders and sleep-wake transition disorders).)

A client who had surgery for a ruptured appendix develops peritonitis. Which clinical findings related to peritonitis should the nurse expect the client to exhibit? Select all that apply. Fever Hyperactivity Extreme hunger Urinary retention Abdominal muscle rigidity

Fever Abdominal muscle rigidity (A moderate fever is associated with inflammation of the peritoneal membrane. Muscular rigidity over the affected area is a classic sign of peritonitis. Malaise, rather than hyperactivity, is often associated with peritonitis. Nausea, not hunger, is a common occurrence with peritonitis. Urinary retention may occur following surgery as a complication of anesthesia, not peritonitis.)

The preoperative patient has called the nurse about his upcoming surgical procedure, which will be six weeks from now. He is concerned about receiving blood after surgery for fear of acquiring a bloodborne disease. Which of the following might the nurse do? Instruct the patient to notify the physician. Remind the patient that blood is tested prior to administration, making it safe and free of disease. Ask the patient if he has ever had any blood products. Explain to the patient the use of autologous blood donation. Instruct patient to refuse transfusion.

Explain to the patient the use of autologous blood donation. (Because of the fears of hepatitis B and human immunodeficiency virus infection associated with blood transfusion, donation of autologous blood (one's own blood) for surgery is becoming a common practice. If the patient wishes, provide the necessary information about blood donation if the patient is seen a number of weeks before surgery.)

A slightly overweight client is to be discharged from the hospital after a cholecystectomy. What is most important for the nurse to include in teaching the client about nutrition? Listing low-protein foods that may be included in the diet Explaining that fatty foods may not be tolerated for several weeks Teaching the importance of a low-calorie diet to promote weight reduction Encouraging the intake of high vitamin C, vitamin A, and zinc foods at each meal

Explaining that fatty foods may not be tolerated for several weeks (Bile, which aids in fat digestion, is not as concentrated as before surgery. Once the body adapts to the absence of the gallbladder, the client should be able to tolerate a regular diet that contains fat. Initially the client should avoid fatty foods unless otherwise indicated. A low-protein diet is not necessary. Although teaching the client about a low-calorie diet to promote weight reduction is important, it is not as important as temporary avoidance of fatty foods with the gradual resumption of a regular diet. While vitamin C, vitamin A, and zinc are important, they are not the priority.)

A client is being discharged home after treatment for a brain attack. What is the mnemonic that the nurse can teach the family and client to help recognize and act on another stroke? A-V-P-U F-A-S-T K-I-N-D O-P-Q-R-S-T

F-A-S-T (The mnemonic F-A-S-T is utilized to teach the client, family, and community how to recognize and respond to a stroke. The purpose is to observe the Face, Arms, Speech, and then Time of onset and knowing it's Time to call 9-1-1.A-V-P-U is the mnemonic for level of awareness (alert, verbal, painful, and unresponsive). K-I-N-D is a mnemonic for treatment of hyperkalemia (kayexalate, insulin, NaHCO3, diuretics). O-P-Q-R-S-T is a mnemonic for assessing pain (onset, provokes, quality, radiates, severity, time).)

After thrombolytic therapy, the nurse working in the cardiac catheterization laboratory would be alarmed to notice which sign? A 1-inch (2.5 cm) backup of blood in the IV tubing Facial drooping Partial thromboplastin time (PTT) 68 seconds Report of chest pressure during dye injection

Facial drooping (During and after thrombolytic administration, facial drooping may indicate intracranial bleeding, including changes in neurologic status.A 1-inch (2.5 cm) backup of blood in the IV tubing may be related to IV positioning. If heparin is used, PTT reflects a therapeutic value which is 1½ to 2½ times the control. Reports of chest pressure during dye injection or stent deployment are considered an expected result of the procedure.)

While counseling the parents of an adolescent with anemia related to an inadequate diet, a nurse explains that several different nutrients, including protein, iron, and vitamin B 12, are involved. What other nutrient should the nurse include in the teaching? Calcium Thiamine Folic acid Riboflavin

Folic acid (Folic acid acts as a necessary coenzyme in the formation of heme, the iron-containing protein in hemoglobin. Calcium is not involved in the production of red blood cells. Thiamine is a coenzyme in carbohydrate metabolism. Riboflavin is a control agent for energy production and tissue formation.)

A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions? Postural drainage Cupping the chest Nasotracheal suctioning Frequent changes of position

Frequent changes of position (Frequent changes of position minimize pooling of respiratory secretions and maximize chest expansion, which aids in the removal of secretions; this helps maintain the airway and is an independent nursing function. Postural drainage and cupping the chest are part of pulmonary therapy that requires a healthcare provider's prescription. Nasotracheal suctioning will remove secretions once they accumulate in the upper airway, but will not prevent their accumulation.)

A client experiences occasional right upper quadrant pain attributed to cholecystitis. The nurse is providing discharge instructions, including a list of foods that cause dyspepsia. Which foods should be on the list the nurse provided the client? Nuts and popcorn Meatloaf and baked potato Chocolate and boiled shrimp Fried chicken and buttered corn

Fried chicken and buttered corn (Cholecystitis is often accompanied by intolerance to fatty foods, including fried foods and butter. Nuts and popcorn have a high fiber content but have less fat than fried foods; nuts and popcorn cause flatulence and pain for clients with lower intestinal problems, such as diverticulosis. Meatloaf and baked potato contain less fat than do fried foods or butter. Neither chocolate nor boiled seafood contains as much fat as fried chicken or butter.)

The nurse recognizes that the patient understands the teaching about warfarin (Coumadin) when the patient verbalizes an increased risk of bleeding with concurrent use of which herbal product? (Select all that apply.) Garlic St. John's wort Glucosamine Dong quai Ginkgo

Garlic St. John's wort Dong quai Ginkgo (Garlic, ginkgo, dong quai, and St. John's wort alter blood coagulation and may increase the risk of bleeding when given concurrently with oral anticoagulants. Glucosamine does not affect coagulation.)

A client is evaluated at a clinic, and the healthcare provider suspects that the client has anemia and a peptic ulcer. To determine if the client has a peptic ulcer, the nurse expects that what diagnostic test will be performed? Barium enema Gastric biopsy Gastric culture Stool examination

Gastric culture (A gastric culture enables the healthcare provider to identify the presence of Helicobacter pylori. Two thirds of individuals with gastric or duodenal ulcers are infected with this organism. A barium enema outlines structural changes in the lower gastrointestinal tract; it will not outline the stomach or duodenum. A gastric biopsy is done to identify the presence of malignant cells. A stool examination may identify melena or parasites, but it is not definitive for peptic ulcers.)

A patient with elevated triglyceride levels unresponsive to HMG-CoA reductase inhibitors will most likely be prescribed which drug? Colestipol (Colestid) Gemfibrozil (Lopid) Simvastatin (Zocor) Cholestyramine (Questran)

Gemfibrozil (Lopid) (Gemfibrozil, a fibric acid derivative, promotes catabolism of triglyceride-rich lipoproteins.)

The patient tells the nurse, "I'm so nervous. I want to be knocked out for the surgery so that I don't know what is going on." When the nurse communicates with the surgeon and anesthetist, she tells them that the patient desires which type of anesthesia? Conscious sedation General anesthesia Local anesthesia Regional anesthesia

General anesthesia (General anesthesia produces rapid unconsciousness and loss of sensation. During conscious sedation, the client feels sleepy but is easily aroused by touch or speech. Regional anesthesia interrupts nerve impulses to and from the affected area, but the patient remains alert. Local anesthesia produces loss of pain sensation at the desired site and is typically used for minor procedures. The client remains alert during local anesthesia.)

A nurse is eliciting a health history from a client with ulcerative colitis. Which factor does the nurse consider to be most likely associated with the client's colitis? Food allergy Infectious agent Dietary components Genetic predisposition

Genetic predisposition (Studies indicate that inflammatory bowel diseases, which include ulcerative colitis and Crohn disease, are familial, which suggests that they are hereditary. Although food allergy and infectious agent may be causative factors, they are not the most common factors. No specific dietary component has been identified.)

According to the Center for Disease Control (CDC) guidelines, which personal protective equipment will the nurse put on when assessing a patient who is on contact precautions for diarrhea caused by Clostridium difficile? (select all that apply)? Mask Gown Gloves Shoe covers Eye protection

Gown Gloves (Because the nurse will have substantial contact with the patient and bedding when doing an assessment, gloves and gowns are needed. Eye protection and masks are needed for patients in contact precautions only when spraying or splashing is anticipated. Shoe covers are not recommended in the CDC guidelines.)

A client has been taking aspirin since his heart attack in 1997. The client is at risk for Infection Thrombophlebitis Hemorrhage Blood clots

Hemorrhage (Current medication use, especially use of medications that can affect coagulation status (warfarin, nonsteroidal anti-inflammatory drugs, aspirin) is important and should be reported to the surgeon.)

At 8:00 a.m., the registered nurse is admitting a client scheduled for sinus surgery to the outpatient surgery department. Which information given by the client is of most immediate concern to the nurse? An allergy to iodine and shellfish Being nauseated after a previous surgery Having a small glass of juice at 7:00 a.m. Expressing anxiety about the surgery

Having a small glass of juice at 7:00 a.m. (Clients need to be NPO for a sufficient length of time before surgery to prevent aspiration of fluid into the lungs. Intake of food or fluids may delay the start time of the surgery, so the nurse must notify the surgeon and anesthesiologist for possible rescheduling.The nurse would confirm that all allergies are charted, and that the client has the correct allergy band identification. Many clients experience nausea after surgery; the nurse would document this in the client's information as well. The nurse would talk with the client and explore the anxiety; this is a normal feeling before surgery.)

A client with a history of coronary artery disease is admitted with pneumonia. The healthcare provider prescribes atenolol. What should the nurse monitor to determine the therapeutic effect of atenolol? Heart rate Respirations Temperature Pulse oximetry

Heart rate (Atenolol, a beta-blocker, slows the rate of sinoatrial (SA) node discharge and AV node conduction, thus decreasing the heart rate; it prevents angina by decreasing the cardiac workload and myocardial oxygen consumption. Atenolol may promote bronchospasm and wheezing; however, the question specified therapeutic effects, not adverse effects. Atenolol is not an antipyretic. Atenolol does not directly affect gas exchange in the lungs.)

A client is admitted to the hospital with a diagnosis of peptic ulcer. Which most common complication should the nurse assess for in this client? Perforation Hemorrhage Pyloric obstruction Esophageal varices

Hemorrhage (Hemorrhage because of erosion of blood vessel walls is the most common complication of peptic ulcer disease. The complication of gastric perforation usually occurs after, and is not as common as, hemorrhage. Pyloric obstruction is not a common complication of peptic ulcer disease. Esophageal varices occur with portal hypertension, not peptic ulcer disease.)

The nurse would question a prescription for simvastatin (Zocor) in a patient with which condition? Hepatic disease Diabetes Leukemia Heart failure

Hepatic disease (Simvastatin (Zocor) can cause an increase in liver enzymes and thus should not be used in patients with preexisting liver disease.)

A 38-year-old man has come into the urgent care center with severe hip pain after falling from a ladder at work. He says he has taken several pain pills over the past few hours but cannot remember how many he has taken. He hands the nurse an empty bottle of acetaminophen (Tylenol). The nurse is aware that the most serious toxic effect of acute acetaminophen overdose is which condition? Tachycardia Central nervous system depression Hepatic necrosis Nephropathy

Hepatic necrosis (Hepatic necrosis is the most serious acute toxic effect of an acute overdose of acetaminophen. The other options are incorrect.)

While instructing a community group regarding risk factors for coronary artery disease, the nurse provides a list of risk factors that cannot be modified. What should be included on the list? Heredity Hypertension Cigarette smoking Diabetes mellitus

Heredity (Heredity refers to genetic makeup and cannot be changed. Cigarette smoking is a lifestyle habit that involves behavior modification. Hypertension and diabetes mellitus are risk factors of coronary artery disease that can be controlled with diet, medication, and exercise.)

Which are risk factors for stroke? Select all that apply. High blood pressure Previous stroke or transient ischemic attack (TIA) Smoking Use of oral contraceptives Female gender

High blood pressure Previous stroke or transient ischemic attack (TIA) Smoking Use of oral contraceptives (Common modifiable risk factors for developing a stroke include smoking and the use of oral contraceptives. Other risk factors include high blood pressure and history of a previous TIA.Gender is not a known risk factor for stroke; however, the female client is at risk for delayed recognition of early stroke symptoms.)

A patient is recovering from abdominal surgery, which he had this morning. He is groggy but complaining of severe pain around his incision. What is the most important assessment data to consider before the nurse administers a dose of morphine sulfate to the patient? His pulse rate His respiratory rate The appearance of the incision The date of his last bowel movement

His respiratory rate (One of the most serious adverse effects of opioids is respiratory depression. The nurse must assess the patient's respiratory rate before administering an opioid. The other options are incorrect.)

A nurse reviews the history of a client who is hospitalized with a diagnosis of urinary calculi and identifies that which factor may have contributed to the development of the calculi? Increased fluid intake Urine specific gravity of 1.017 Jogging 3 miles (4.8 km) a day History of hyperparathyroidism

History of hyperparathyroidism (Hyperparathyroidism results in high serum calcium levels; as the blood is filtered through the nephron, precipitates of calcium may form calculi. Increased fluid intake will discourage stone formation by preventing stagnation of urine. A urine specific gravity of 1.017 is within the expected range of 1.010 to 1.030 and will not increase the risk of developing urinary calculi. A jogging schedule of 3 miles (4.8 km) daily reduces the risk of developing urinary calculi; activity improves glomerular filtration and inhibits calcium from leaving the bone.)

A surgical client has signed do-not-resuscitate (DNR) orders before going to the operating room (OR). A complication requiring resuscitation occurs during surgery. What is the nurse's proper action? Call the legal department. Call the client's primary health care provider. Honor the DNR order. Resuscitate per OR procedure.

Honor the DNR order. (According to the Association of Perioperative Registered Nurses, suspending a DNR order during surgery violates a client's right to self-determination.Calling the legal department or the client's health care provider is not an appropriate response. Resuscitating this client after a DNR has been signed is inappropriate.)

A patient will be discharged with a 1-week supply of an opioid analgesic for pain management after abdominal surgery. The nurse will include which information in the teaching plan? How to prevent dehydration due to diarrhea The importance of taking the drug only when the pain becomes severe How to prevent constipation The importance of taking the drug on an empty stomach

How to prevent constipation (Gastrointestinal (GI) adverse effects, such as nausea, vomiting, and constipation, are the most common adverse effects associated with opioid analgesics. Physical dependence usually occurs in patients undergoing long-term treatment. Diarrhea is not an effect of opioid analgesics. Taking the dose with food may help minimize GI upset.)

A 32-year-oldclient is recovering from a sickle cell crisis. The client's discomfort is controlled with pain medications and discharge planning has been initiated. What medication will the nurse anticipate to be prescribed before discharge? Heparin (Heparin) Warfarin (Coumadin) Hydroxyurea (Droxia) Tissue plasminogen activator (t-PA)

Hydroxyurea (Droxia) (The nurse anticipates Hydroxyurea to be prescribed for pain for a sickle cell disease client who is being discharge. Hydroxyurea (Droxia) has been used successfully to reduce sickling of cells and pain episodes associated with sickle cell disease (SCD).Clients with SCD are not prescribed anticoagulants such as heparin or warfarin (Coumadin). t-PA is used as a "clot buster" in clients who have had ischemic strokes.)

Although the most common effect of obstructive sleep apnea is a disrupted sleep pattern, the condition can cause a serious decline in arterial oxygen levels that may result in: (Select all that apply.) Hypertension Angina attacks Alzheimer's disease Cardiac dysrhythmias Cerebral vascular accidents Type 2 diabetes

Hypertension Angina attacks Cardiac dysrhythmias Cerebral vascular accidents (Obstructive apnea causes a serious decline in arterial oxygen saturation level. Clients are at risk for cardiac dysrhythmias, right-sided heart failure, pulmonary hypertension, angina attacks, stroke, and hypertension. The other options are not directly related to a diminished supply of arterial oxygen.)

Being overweight or obese increases the risk for many diseases and health conditions, including which of the following? (Select all that apply.) Hypertension Coronary heart disease Sleep apnea Respiratory problems Hypotension

Hypertension Coronary heart disease Sleep apnea Respiratory problems (Being overweight or obese increases the risk for many diseases and health conditions, including hypertension, dyslipidemia, type 2 diabetes, coronary heart disease, stroke, sleep apnea, and respiratory problems. These conditions increase risks for postoperative complications. Hypotension is not a complication of obesity.)

A client is being considered for bariatric surgery. Which client health problem does the nurse identify as consistent with morbid obesity? Dumping syndrome Compartment syndrome Hypoventilation syndrome Inappropriate antidiuretic hormone syndrome (ADH)

Hypoventilation syndrome (Ventilation insufficiency occurs in response to inadequate chest wall expansion caused by weight of adipose tissue on the rib cage and the body's need for oxygen to all body cells. Diarrhea, distention, and abdominal cramps often occur in the postoperative period after gastric bypass in response to the hyperosmolar shift of fluid from the intravascular compartment into the intestine in response to rapid emptying of hyperosmolar food without usual dilution in the stomach; this fluid shift initiates the systemic response of weakness, tachycardia, and diaphoresis. Compartment syndrome generally is a complication of trauma; increased pressure within the limited anatomic space (e.g., muscle compartment) contributes to decreased microcirculation, which causes nerve and muscle anoxia and necrosis of tissue. Inappropriate antidiuretic hormone syndrome is excessive secretion of ADH, a hypo-osmolar state with a dilutional hyponatremia; the most common cause is oat cell carcinoma of the lung, in addition to other malignant tumors that produce ADH.)

Which statement accurately represents a recommended guideline when providing postoperative care for the following clients? Force fluids for an adult client who has a urine output of less that 30 mL per hour. If client is febrile within 12 hours of surgery, notify the physician immediately. If the dressing was clean but now has a large amount of fresh blood, remove the dressing and reapply it. If vital signs are progressively increasing or decreasing from baseline, notify the physician of possible internal bleeding.

If vital signs are progressively increasing or decreasing from baseline, notify the physician of possible internal bleeding. (A continued decrease in blood pressure or an increase in heart rate could indicate internal bleeding, and the physician should be notified. If an adult client has a urine output of less than 30 mL per hour, the physician should be notified, unless this is expected. If the client is febrile within 12 hours of surgery, the nurse should assist the client with coughing and deep-breathing exercises. When large amounts of fresh blood are present, the dressing should be reinforced with more bandages and the physician notified.)

Which of the following clients will see the greatest permanent changes in lifestyle following surgery? Right total knee replacement Left mastectomy Ileostomy Appendectomy

Ileostomy (Permanent changes in the client's activity level may occur as a result of surgery. The client with an ileostomy will encounter the greatest changes in lifestyle.)

The nurse anesthetist notices that a surgical client has an unexpected rise in the end-tidal carbon dioxide level, with a decrease in oxygen saturation and sinus tachycardia. What is the nurse anesthetist's initial action? Administer cardiopulmonary resuscitation. Continue as normal. Immediately stop all inhalation anesthetic agents and succinylcholine. Inform the surgeon.

Immediately stop all inhalation anesthetic agents and succinylcholine. (The nurse anesthetist's initial action is to stop all inhalation anesthetic agents and succinylcholine. This client is exhibiting early symptoms of malignant hyperthermia (MH). The most sensitive indication of MH is an unexpected rise in the end-tidal carbon dioxide level, along with a decrease in oxygen saturation. Another early indication is sinus tachycardia. Survival depends on early diagnosis and the actions of the entire surgical team. Time is crucial when MH is diagnosed, and MH requires immediate intervention.This client does not require resuscitation. Continuing as normal is inappropriate. Informing the surgeon is not the priority.)

A male patient with diabetes who is taking medication for erectile dysfunction is experiencing pain and discomfort related to the side effect of priapism. The nurse knows that this patient is at greatest risk for Sexual dysfunction related to low self-esteem. Impaired circulation due to medication. Anxiety related to erectile dysfunction. Ineffective coping related to chronic illness.

Impaired circulation due to medication. (The most immediate concern for a patient with priapism, a condition caused by lack of circulation to the penis, is that this can cause further health complications. Anxiety, sexual dysfunction, and ineffective coping are all also valid nursing diagnoses but are not a priority for this patient. The diagnosis that causes the most harm to the patient should be addressed first.)

In developing a plan of care for a patient receiving morphine sulfate (MS Contin), which nursing diagnosis has the highest priority? Constipation related to decreased GI motility Acute pain related to metastatic tumor cancer Impaired gas exchange related to respiratory depression Risk for injury related to CNS adverse effects

Impaired gas exchange related to respiratory depression (Using Maslow's hierarchy of needs and the ABCs of prioritization, impaired gas exchange is a priority over pain, constipation, and a risk for injury. If a patient cannot oxygenate sufficiently, all of the other problems will not matter because the patient will not live to worry about them.)

A client has been admitted with a diagnosis of stroke (brain attack). The nurse suspects that the client has had a right hemisphere stroke because the client exhibits which symptoms? Aphasia and cautiousness Impulsiveness and smiling Inability to discriminate words Quick to anger and frustration

Impulsiveness and smiling (Impulsiveness and smiling are symptoms indicative of a right hemisphere stroke. Aphasia, cautiousness, the inability to discriminate words, quick to anger, and frustration are symptoms indicative of a left hemisphere stroke.)

nurse knows that specific areas in the ureters have a propensity for obstruction. Prompt management of renal calculi is most important when the stone is located where? In the ureteropelvic junction In the ureteral segment near the sacroiliac junction In the ureterovesical junction In the urethra

In the ureteropelvic junction (The three narrowed areas of each ureter are the ureteropelvic junction, the ureteral segment near the sacroiliac junction, and the ureterovescial junction. These three areas of the ureters have a propensity for obstruction by renal calculi or stricture. Obstruction of the ureteropelvic junction is most serious because of its close proximity to the kidney and the risk of associated kidney dysfunction. The urethra is not part of the ureter.)

The nurse teaching a health awareness class identifies which situation as being the highest risk factor for the development of a deep vein thrombosis (DVT)? Pregnancy Inactivity Aerobic exercise Tight clothing

Inactivity (A DVT, or thrombus, may form as a result of venous stasis. It may lodge in a vein and can cause venous occlusion. Inactivity is a major cause of venous stasis leading to DVT. Pregnancy and tight clothing are also risk factors for DVT secondary to inactivity. Aerobic exercise is not a risk factor for DVT.)

A client with diabetes who is receiving long-term corticosteroid therapy is admitted to the hospital with leg ulcers. What increased risk does the nurse consider when assessing this client? Weight loss Hypoglycemia Decreased blood pressure Inadequate wound healing

Inadequate wound healing (Because the antiinflammatory response is depressed as a result of increased cortisol levels, the wounds of clients receiving long-term corticosteroid therapy tend to heal slowly. A common finding associated with long-term corticosteroid use is weight gain, caused not only by fluid retention but also by alterations in fat, carbohydrate, and protein metabolism. Persistent hyperglycemia (steroid diabetes) occurs because of altered glucose metabolism. Hypertension, not hypotension, occurs as a result of sodium and fluid retention.)

A 2-year-old child is scheduled for a tonsillectomy. When determining the plan of care, the nurse should: Include the parents or caregivers in the plan of care. Explain to the child that she will have a sore throat after surgery. Tell the child that she can have her favorite foods for the first 24 hours after surgery. Prepare the child for discharge from the hospital as soon as she is alert.

Include the parents or caregivers in the plan of care. (It is developmentally normal for toddlers to experience anxiety with separation from parents or caregivers. Be sure to include these people in the plan of care. Developmentally, a 2-year-old lives in the "here and now" and wouldn't grasp an intangible concept, such as pain in the future. The toddler would take liquids and soft foods within the first 24 hours when her throat is sore during swallowing. She should not eat foods that are rough and crunchy because they may scratch her throat and cause bleeding. After a tonsillectomy, the child will need to be monitored for bleeding and stable vital signs; therefore, she will not be discharged as soon as she is alert.)

A patient is prescribed an opioid analgesic for chronic pain. Which information should the nurse discuss with the patient to minimize the GI adverse effects? Avoid eating foods high in lactobacilli. Increase fluid intake and fiber in the diet. Take diphenoxylate-atropine (Lomotil) with each dose. Take the medication on an empty stomach.

Increase fluid intake and fiber in the diet. (Opioid analgesics decrease GI intestinal motility (peristalsis), leading to constipation. Increasing fluid and fiber in the diet or use of stool softener or mild laxative can prevent constipation.)

After a prostatectomy, a client's plan of care will include the prevention of postoperative deep vein thrombosis. Which nursing goal will best achieve prevention? Increase coagulability of the blood. Increase velocity of the venous return. Increase effectiveness of internal respiration. Increase oxygen-carrying capacity of the blood.

Increase velocity of the venous return. (Because venous stasis is the major predisposing factor of pulmonary emboli, venous flow velocity should be increased through activity. Increasing the coagulability of the blood can lead to the development of deep vein thrombosis. Effectiveness of internal respiration and oxygen-carrying capacity of the blood will not affect the prevention of deep vein thrombosis.)

A patient who is immobile complains of severe pain in the right flank. The physician diagnoses the patient with renal calculi. This condition often results from Increased serum calcium Decreased serum calcium Increased serum phosphorous Decreased serum phosphorous

Increased serum calcium (Urinary stasis and an increased serum calcium level promote the formation of renal calculi.)

Which diagnostic results lead the nurse to suspect that a client may have gallbladder disease? Increased white blood cell (WBC) count, visualization of calcified gallstones, edema of the gallbladder wall Decreased WBC count, visualization of calcified gallstones, increased alkaline phosphatase Increased WBC count, visualization of noncalcified gallstones, edema of the gallbladder wall Decreased WBC count, visualization of noncalcified gallstones, increased alkaline phosphatase

Increased white blood cell (WBC) count, visualization of calcified gallstones, edema of the gallbladder wall (An increased WBC count, calcified gallstones visualized on the abdominal X-ray, and edema of the gallbladder wall are the best diagnostic results to indicate gallbladder disease. Acute cholecystitis is seen as edema of the gallbladder wall and pericholecystic fluid. Ultrasonography of the right upper quadrant is the best diagnostic test for cholecystitis.An increased WBC count, not decreased, is evidence of inflammation. Only calcified gallstones, not noncalcified gallstones, will be visualized on abdominal X-ray. Alkaline phosphatase will be elevated if liver function is abnormal; this is not common in gallbladder disease.)

Which characteristics place women at high risk for myocardial infarction (MI)? Select all that apply. Premenopausal Increasing age Family history Abdominal obesity Breast cancer

Increasing age Family history Abdominal obesity (Increasing age is a risk factor, especially after 70 years. Family history is a significant risk factor in both men and women. Also, a large waist size and/or abdominal obesity are risk factors for both metabolic syndrome and MI.Premenopausal women are not at higher risk for MI, and breast cancer is not a risk factor for MI.)

The nurse is teaching a health promotion class about weight loss and asks students to list health risks that can occur as a result of obesity. Which student responses indicate that additional teaching is required? (Select all that apply.) Sleep apnea Infertility Rheumatoid arthritis Cervical cancer Cholecystitis Hypothyroidism

Infertility Rheumatoid arthritis Cervical cancer Hypothyroidism (Sleep apnea and cholecystitis are potential health risks that can occur as a result of obesity. The other conditions are not caused by obesity.)

The preoperative nurse is preparing a patient for surgery. Identify the interventions the nurse will perform. Choose all that apply. Inform the family to wait in the surgical waiting room. Prepare the surgical suite for the operation. Remove the patient's dentures and contact lenses. Assist the patient to complete a living will.

Inform the family to wait in the surgical waiting room. Remove the patient's dentures and contact lenses. (Before being transported to the operating suite, the patient must remove all artificial body parts, such as dentures, artificial limbs, or contact lenses. Wigs, eyeglasses, makeup, and jewelry must also be removed. The nurse will also inform the patient's relatives where they may wait during the surgery. The surgical suite will be prepared by the surgical team. It is not necessary to have a living will prior to surgery. However, the nurse will ask the patient if there is one when obtaining the nursing history.)

A patient who is prescribed an anticoagulant requests an aspirin (acetylsalicylic acid) for headache relief. What is the nurse's best action? Administer 650 mg of acetylsalicylic acid and reassess pain in 30 minutes. Inform the patient of potential drug interactions with anticoagulants. Explain that a common initial adverse effect is a headache for this drug. Explain that acetylsalicylic acid is contraindicated and administer ibuprofen.

Inform the patient of potential drug interactions with anticoagulants. (Patients taking an anticoagulant should not use medications that would further increase the risk of bleeding.)

The nurse is preparing to send a client to the operating room for an exploratory laparoscopy. The nurse recognizes that there is no informed consent for the procedure on the client's chart. The nurse informs the physician who is performing the procedure. The physician asks the nurse to obtain the informed consent signature from the client. What is the nurse's best action to the physician's request? Inform the physician that it is his or her responsibility to obtain the signature. Obtain the signature and ask another nurse to cosign the signature. Inform the physician that the nurse manager will need to obtain the signature. Call the house officer to obtain the signature.

Inform the physician that it is his or her responsibility to obtain the signature. (The responsibility for securing informed consent from the client lies with the person who will perform the procedure. The nurse's best action is to inform the physician that it is his or her responsibility to obtain the signature.)

Ranitidine has been prescribed to help treat a client's gastric ulcer. The nurse expects this drug to act specifically by which mechanism? Lowering the gastric pH Promoting the release of gastrin Regenerating the gastric mucosa Inhibiting the histamine at H₂ receptors

Inhibiting the histamine at H₂ receptors (Ranitidine inhibits histamine at H₂ receptor sites in parietal cells, which limits gastric secretion. Lowering the gastric pH is not the direct action of this drug. Promoting the release of gastrin is undesirable; gastric hormones increase gastric acid secretion. Ranitidine does not regenerate the gastric mucosa; the drug prevents its erosion by gastric secretions.)

A patient is admitted from a local skilled nursing facility to the outpatient surgery center for surgical débridement of a stage IV sacral pressure ulcer. The perioperative nurse discovers that the patient does not have a signed consent form for the surgery on the chart or in the surgery center. The patient says that she has not talked to the surgeon and that she has many questions regarding her surgery. When informed of this, the surgeon tells the nurse to have the patient sign the informed consent form, and he will review it prior to the surgery. What should the nurse do? Follow the surgeon's orders, and ask the patient to sign the surgical consent form. Inform the surgeon that she will have the patient sign after he discusses the surgery with the patient. Ensure that the signed surgical consent is witnessed by two nurses, because the surgeon is not available. Cancel the surgery and transfer the patient back to the long-term care facility.

Inform the surgeon that she will have the patient sign after he discusses the surgery with the patient. (Informed surgical consent requires that the surgeon present information about the surgery to the patient, that the patient understands the information and agrees to the surgery, and that the patient has not been coerced to give consent. As a patient advocate, the nurse should verify with the patient that the surgeon has explained the procedure and answered all her questions. The surgeon is responsible for giving the patient the necessary information and determining the patient's competence to make an informed decision about the surgery. If the patient has further questions, the nurse should notify the surgeon and delay sending the patient to surgery until an informed consent is obtained.)

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

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.)

After emergency surgery, the nurse teaches a client how to use an incentive spirometer. What client behavior indicates to the nurse that the spirometer is being used correctly? Inhales deeply through the mouthpiece, relaxes, and then exhales. Inhales deeply, seals the lips around the mouthpiece, and exhales. Uses the incentive spirometer for 10 consecutive breaths per hour. Coughs several times before inhaling deeply through the mouthpiece.

Inhales deeply through the mouthpiece, relaxes, and then exhales. (Inhaling deeply through the mouthpiece, relaxing, and then exhaling are correct techniques; deep inhalation promotes alveolar expansion, and exhalation promotes lung recoil. Inhaling deeply, sealing the lips around the mouthpiece, and exhaling are incorrect techniques; inhalation should occur through the mouthpiece. The breaths should not be taken in succession; they should be spaced by several normal breaths to avoid fatigue. Coughing is done after deep breathing.)

By which action does atorvastatin (Lipitor) decrease lipid levels? Inhibiting HMG-CoA reductase, the enzyme responsible for the biosynthesis of cholesterol in the liver Decreasing the amount of triglycerides produced by the liver and increasing the removal of triglycerides by the liver Binding to bile in the intestinal tract, forming an insoluble complex that is excreted in the feces Stimulating the gallbladder and biliary system to increase excretion of dietary cholesterol

Inhibiting HMG-CoA reductase, the enzyme responsible for the biosynthesis of cholesterol in the liver (Atorvastatin (Lipitor) is an HMG-CoA reductase inhibitor that inhibits HMG-CoA reductase, the enzyme needed to make cholesterol in the liver.)

What is the mechanism of action of ezetimibe (Zetia)? Binds to bile acids in the intestine, inhibiting its reabsorption into the blood. Inhibits absorption of dietary and biliary cholesterol in the small intestine. Decreases the adhesion of cholesterol in the arteries. Inhibits the biosynthesis of cholesterol in the liver.

Inhibits absorption of dietary and biliary cholesterol in the small intestine. (Ezetimibe selectively inhibits absorption of cholesterol in the small intestine.)

Famotidine (Pepcid) is prescribed for a client with peptic ulcer disease. The client asks the nurse what this medication does. Which action does the nurse mention when replying? Increases gastric motility Neutralizes gastric acidity Facilitates histamine release Inhibits gastric acid secretion

Inhibits gastric acid secretion (Famotidine decreases gastric secretion by inhibiting histamine at H₂ receptors. Increases gastric motility, neutralizes gastric acidity, and facilitates histamine release are not actions of famotidine.)

Which task would be best for the charge nurse to assign to the LPN/LVN working in the surgery admitting area? Provide preoperative teaching to a client who needs insertion of a tunneled central venous catheter. Insert a retention catheter in a client who requires a flap graft of a sacral pressure ulcer. Obtain the medical history from a client who is scheduled for a total hip replacement. Assess the client who is being admitted for an elective laparoscopic cholecystectomy.

Insert a retention catheter in a client who requires a flap graft of a sacral pressure ulcer. (Insertion of a catheter is the best task within the scope of skills approved for the LPN/LVN.Preoperative teaching and physical assessment of a preoperative client are under the scope of the RN. History information would be completed by the RN on the unit.)

The nurse is caring for a patient who has cultured positive for Clostridium difficile. Which of the following nursing actions would be appropriate given this organism? Instruct assistive personnel to use soap and water rather than sanitizer to clean hands. Place the patient on Droplet Precautions. Wear an N95 respirator when entering the patient room. Teach the patient cough etiquette.

Instruct assistive personnel to use soap and water rather than sanitizer to clean hands. (Clostridium difficile is a spore-forming organism that can be transmitted through direct and indirect patient contact. Because Clostridium difficile is a spore-forming organism, hand sanitizer is not effective in preventing its transmission. Hands must be washed with soap and water to prevent transmission. This organism is not transmitted via the droplet route; therefore Droplet Precautions are not needed. An N95 respirator is used primarily for patients with airborne illness. All patients should be taught cough etiquette; this action is not one to be take especially because the patient has Clostridium difficile.)

The nurse is caring for a client with ureteral colic. To prevent the development of renal calculi in the future, which strategy should be included in the client's plan of care? Instructing the client to drink 8 to 10 glasses of water daily Interventions to decrease the serum creatinine level A urinary output goal of 2000 mL per 24 hours Excluding milk products from the diet

Instructing the client to drink 8 to 10 glasses of water daily (Increasing fluid intake dilutes the urine, and crystals are less likely to coalesce and form calculi. An elevated serum creatinine has no relationship to the formation of renal calculi. Calcium restriction is necessary only if calculi have a calcium phosphate basis. Producing only 2000 mL of urine per 24 hours is inadequate.)

Which information will the nurse prioritize in planning preoperative teaching for a patient undergoing a Roux-en-Y gastric bypass? Educating the patient about the nasogastric (NG) tube Instructing the patient on coughing and breathing techniques Discussing necessary postoperative modifications in lifestyle Demonstrating passive range-of-motion exercises for the legs

Instructing the patient on coughing and breathing techniques (Coughing and deep breathing can prevent major postoperative complications such as carbon monoxide retention and hypoxemia. Information about passive range of motion, the NG tube, and postoperative modifications in lifestyle will also be discussed, but avoidance of respiratory complications is the priority goal after surgery.)

The health care provider prescribes one tube of glucose gel for the client with type 1 diabetes. The nurse recognizes that this is for treatment of which diabetes complication? Diabetic acidosis Hyperinsulin secretion Insulin-induced hypoglycemia Idiosyncratic reactions to insulin

Insulin-induced hypoglycemia (Glucose gel delivers a measured amount of simple sugars to provide glucose to the blood for rapid action. Acidosis occurs when there is an increased serum glucose level; therefore glucose gel is not indicated. Diabetes mellitus involves a decreased insulin production. Glucose gel is not indicated in idiosyncratic reactions to insulin.)

A primary healthcare provider diagnoses a client with acute cholecystitis with biliary colic. Which clinical findings should the nurse expect when performing a health history and physical assessment? Select all that apply. Diarrhea with black feces Intolerance to foods high in fat Vomiting of coffee-ground emesis Gnawing pain when stomach is empty Pain that radiates to the right shoulder

Intolerance to foods high in fat Pain that radiates to the right shoulder (Interference with bile flow into the intestine will lead to an increasing inability to tolerate fatty foods. Although the gallbladder is in the upper right quadrant of the abdomen, when inflamed it can radiate to the right shoulder or scapula. Diarrhea with melena (black feces) is not associated with cholecystitis. Melena is tarry stools associated with upper gastrointestinal bleeding; diarrhea is associated with increased intestinal motility. Coffee-ground emesis is indicative of gastric bleeding; it is not associated with cholecystitis. Gnawing pain when the stomach is empty is associated with duodenal ulcers, not with cholecystitis.)

The nurse will plan to inject iron dextran by which technique? Subcutaneous injection with a ½-inch, 25-gauge needle Intramuscular (IM) injection using the Z-track method Intradermal injection with a sunburst technique of administration IM injection with a ½-inch, 18-gauge needle

Intramuscular (IM) injection using the Z-track method (Iron dextran should be administered deep in a large muscle mass using the Z-track method and a 23-gauge, 1½-inch needle to prevent skin irritation and potential necrosis.)

A recently admitted client who is in sickle cell crisis requests "something for pain." What medication would the nurse be prepared to administer? Oral ibuprofen (Motrin) Oral morphine sulfate (MS-Contin) Intramuscular (IM) morphine sulfate Intravenous (IV) hydromorphone (Dilaudid)

Intravenous (IV) hydromorphone (Dilaudid) (The client with sickle cell disease needs IV pain relief, and it needs to be administered on a routine schedule (i.e., before the client has to request it).Nonsteroidal anti-inflammatory drugs may be used for clients with SCD for pain relief once their pain is under control. However, in a crisis, this choice of analgesic is not strong enough. Moderate pain may be treated with oral opioids, but this client is in a sickle cell crisis. IV analgesics would be used until his or her condition stabilizes. Morphine is not administered intramuscularly (IM) to clients with sickle cell disease (SCD). In fact, all IM injections are avoided because absorption is impaired by poor perfusion and sclerosed skin.)

What pain management does a client who has been admitted to the post-anesthesia care unit typically receive? Intramuscular nonopioid analgesics Intramuscular opioid analgesics Intravenous nonopioid analgesics Intravenous opioid analgesics

Intravenous opioid analgesics (Intravenous (IV) opioid analgesics are given in small doses to provide pain relief, but not to mask an anesthetic reaction.Intramuscular nonopioid analgesics and opioid analgesics are too long-acting. IV nonopioid analgesics usually are not given within the first 48 hours after surgery.)

The nurse would anticipate an order for which diagnostic test for a patient who has severe flank pain and calcium phosphate crystals revealed on urinalysis? Renal ultrasound Bladder scan KUB x-ray Intravenous pyelogram

Intravenous pyelogram (Flank pain and calcium phosphate crystals are associated with renal calculi. An intravenous pyelogram allows the provider to observe pathological problems such as obstruction of the ureter. A renal ultrasound is performed to identify gross structures. A bladder scan measures the amount of urine in the bladder. A KUB x-ray shows size, shape, symmetry, and location of the kidneys.)

A nurse is assessing two clients. One client has ulcerative colitis, and the other client has Crohn disease. Which is more likely to be identified in the client with ulcerative colitis than in the client with Crohn disease? Inclusion of transmural involvement of the small bowel wall Higher occurrence of fistulas and abscesses from changes in the bowel wall Pathology beginning proximally with intermittent plaques found along the colon Involvement starting distally with rectal bleeding that spreads continuously up the colon

Involvement starting distally with rectal bleeding that spreads continuously up the colon (Ulcerative colitis involvement starts distally with rectal bleeding that spreads continuously up the colon to the cecum. In ulcerative colitis, pathology usually is in the descending colon; in Crohn disease, it is primarily in the terminal ileum, cecum, and ascending colon. Ulcerative colitis, as the name implies, affects the colon, not the small intestine. Intermittent areas of pathology occur in Crohn. In ulcerative colitis, the pathology is in the inner layer and does not extend throughout the entire bowel wall; therefore, abscesses and fistulas are rare. Abscesses and fistulas occur more frequently in Crohn disease.)

A patient is scheduled for abdominal surgery tomorrow. While gathering preoperative data, the nurse learns that the patient takes the following medications daily: an anticoagulant, a multivitamin, and vitamin E 1,500 IU. The patient reports that he stopped taking the anticoagulant 4 days ago as instructed by the surgeon. He has continued to take the multivitamin and vitamin E. Based on the information given, the nurse telephones the surgeon because she: Needs an order to restart the anticoagulant. Is concerned about continued use of the multivitamin. Is concerned about the vitamin E dosage. Thinks the surgery should be delayed until further notice.

Is concerned about the vitamin E dosage. (Both prescribed and over-the-counter medications may increase surgical risk. Many herbs can cause potassium loss and increase the risk for cardiac arrhythmias. High doses of vitamin E may increase the risk for bleeding. This patient's use of 1,500 IU of vitamin E daily exceeds the recommended dosage, so the nurse should inform the surgeon of the vitamin E intake. Generally, the surgeon or anesthesiologist instructs patients to continue or discontinue taking their prescribed medicines. However, it is important to assess use of supplements and over-the-counter medicines. The surgeon would determine if the surgery should be delayed.)

What is the mechanism of action for Famotidine (Pepcid)? It forms a protective coating against gastric acid, pepsin, and bile salts. It competes with histamine for binding sites on the parietal cells. It irreversibly binds to the hydrogen-potassium-adenosine triphosphatase (ATPase) pump. It causes a decrease in stomach pH, reducing stomach acidity.

It competes with histamine for binding sites on the parietal cells. (Histamine receptor-blocking drugs decrease gastric acid by competing with histamine for binding sites on the parietal cells.)

A nurse is assisting a physician during a cesarean section for a client. The client is administered epidural anesthesia. Which of the following is an advantage of epidural anesthesia? It counteracts the effects of conscious sedation. It decreases the risk of gastrointestinal complications. It prevents clients from remembering the initial recovery period. It acts on the central nervous system to produce loss of sensation.

It decreases the risk of gastrointestinal complications. (Epidural anesthesia is a regional anesthesia administered to a client before surgery; it decreases the risk of gastrointestinal complications in clients. Reversal drugs are medications that counteract the effects of those used for conscious sedation. General anesthesia acts on the central nervous system to produce loss of sensation; it prevents clients from remembering their initial recovery period.)

A client admitted to the hospital for chest pain is diagnosed with stable angina. Which information should the nurse include in the teaching session? It is relieved by rest. It is precipitated by light activity. It is described as sharp or knifelike. It is unaffected by the administration of vasodilators.

It is relieved by rest. (Anginal pain commonly is relieved by immediate rest because rest decreases the cardiac workload and oxygen need. Angina usually is precipitated by exertion, emotion, or a heavy meal. Anginal pain usually is described as tightness, indigestion, or heaviness. Nitroglycerin, a vasodilator and a standard treatment for angina, dilates coronary arteries, which increases oxygen to the myocardium, decreasing pain.)

Calcium channel blockers reduce myocardial oxygen demand by decreasing afterload. How would the nurse explain afterload to the patient? It is the total volume of blood in the heart. It is the pressure within the four chambers of the heart. It is the force against which the heart must pump. It is the contractility of the heart muscle.

It is the force against which the heart must pump. (Afterload is the force (systemic vascular resistance) against which the heart must exert itself when delivering blood to the body.)

A student is assessing a postoperative client who has developed pneumonia. The plan of care includes positioning the client in the Fowler's or semi-Fowler's position. What is the rationale for this position? It increases blood flow to the heart. The client will be more comfortable and have less pain. It facilitates nursing assessments of skin color and temperature. It promotes full aeration of the lungs.

It promotes full aeration of the lungs. (Pneumonia may occur in the postoperative client from aspiration, immobilization, depressed cough reflex, infection, increased secretions from anesthesia, or dehydration. Nursing interventions include positioning the client in the Fowler or semi-Fowler position to promote full aeration of the lungs.)

The nurse recognizes that metoclopramide (Reglan) is useful in treating postoperative nausea and vomiting because of what action? It inhibits chemoreceptor stimulation. It promotes motility in the small intestine. It improves the body's response to analgesia. It decreases peristalsis in the intestinal wall.

It promotes motility in the small intestine. (Metoclopramide works by increasing gastrointestinal (GI) motility in the small intestine, thus minimizing gastric distention and accompanying stimulation of the vomiting center.)

What clinical manifestations does a nurse expect a client with systemic lupus erythematosus (SLE) most likely to exhibit? Select all that apply. Joint pain Facial rash Pericarditis Weight gain Hypotension

Joint pain Facial rash Pericarditis (SLE is a chronic, autoimmune disease that affects connective tissue; joint pain is common. A butterfly rash on the face is characteristic of SLE. Pericarditis is the most common cardiac indicator of SLE. Weight loss, not gain, is a classic sign of SLE because of gastrointestinal effects. Renal impairment with SLE may cause hypertension, not hypotension.)

An obese client has been taking orlistat (Xenical) 60 mg orally three times a day for 4 weeks, but has only lost 10 pounds (4.5 kg). The health care provider doubles the dosage and recommends behavioral changes. What behavioral changes does the nurse include in the teaching plan? Select all that apply. Cognitive restructuring to learn negative coping statements Keeping a daily food diary Identifying emotional and situational factors that stimulate eating Increasing exercise Seeking behaviors in others that one can model

Keeping a daily food diary Identifying emotional and situational factors that stimulate eating Increasing exercise (Self-monitoring techniques the nurse includes in the teaching plan are keeping a record of foods eaten (food diary), identifying emotional and situational factors that stimulate eating, and exercise patterns. Stimulus control involves controlling the external cues that promote overeating.Cognitive restructuring involves modifying negative beliefs by learning positive, not negative, coping self-statements. Healthy eating behaviors must be learned or modified by the client as an individual and not through copying or modeling others' behaviors.)

A client with a femoral fracture associated with osteomyelitis is immobilized for 3 weeks. The nurse assesses for the development of renal calculi. What is the rationale for the nurse's assessment? The client's dietary patterns have changed since admission. The client has more difficulty urinating in a supine position. Lack of weight-bearing activity promotes bone demineralization. Fracture healing requires more calcium, which increases total calcium metabolism.

Lack of weight-bearing activity promotes bone demineralization. (All clients who are confined to bed for any considerable period risk losing calcium from bones. Calcium precipitates in the urine, resulting in formation of calculi. There is no indication that the client's diet has changed. Although the client may have more difficulty urinating in a supine position because of an inability to assume the preferred anatomic position and the emotional effects of using a urinal, it usually does not predispose the client to developing renal calculi. The presence of a healing fracture does not increase total calcium metabolism; however, deposition of bone at the fracture site will be increased.)

Which of the following surgical clients will return to activities in their everyday lives more quickly? Vaginal hysterectomy Laparoscopic cholecystectomy Right nephrectomy Open-heart surgery

Laparoscopic cholecystectomy (Clients who have surgery using a laparoscope are able to return to previous activity levels much sooner.)

Upon assessment, a client reports that he drinks five to six bottles of beer every evening after work. Based upon this information, the nurse is aware that the client may require which of the following? Larger doses of anesthetic agents and larger doses of postoperative analgesics Larger doses of anesthetic agents and lower doses of postoperative analgesics Lower doses of anesthetic agents and lower doses of postoperative analgesics Lower doses of anesthetic agents and larger doses of postoperative analgesics

Larger doses of anesthetic agents and larger doses of postoperative analgesics (Clients with a large habitual intake of alcohol require larger doses of anesthetic agents and postoperative analgesics, increasing the risk for drug-related complications.)

The nurse would anticipate administering which medication to clients receiving high-dose methotrexate (Trexall)? Cisplatin (Platinol) Dactinomycin (Cosmegen) Bleomycin (Blenoxane) Leucovorin (Wellcovorin)

Leucovorin (Wellcovorin) (Leucovorin is given to block the systemic toxic effect of high-dose methotrexate. It is a form of folic acid that does not require dihydrofolate reductase to produce folic acid. Therefore, it is used to prevent or treat toxicity induced by methotrexate, a folic acid antagonist. All of the other options are chemotherapeutic drugs, which are not specifically associated with methotrexate.)

Which instructions should the nurse discuss to reduce the gastrointestinal (GI) adverse effects of orlistat (Xenical)? Advise to take vitamin C supplement. Take the medication with an antacid. Limit dietary intake of fat. Increase fluid and fiber in the diet.

Limit dietary intake of fat. (Orlistat is an anorexiant that works by blocking the absorption of fat from the GI tract. Restricting dietary intake of fat reduces the GI adverse effects associated with increased fat content in stool (flatulence, oily spotting, and fecal incontinence).)

A client with a history of sleep apnea has had a same-day surgery procedure that will require the administration of morphine postoperatively to manage pain. This client will be assessed most appropriately by the perioperative nurse for the risk for respiratory complications by frequently: Listening to breath sounds Monitoring pulse oximetry Evaluating spirometer use Counting respirations per minute

Listening to breath sounds (Administration of opioids increases risk for airway obstruction postoperatively. Clients will desaturate as revealed by a drop in oxygen saturation by pulse oximetry. The remaining options are not as specific for this particular client's risk.)

To assess for a potentially serious adverse effect to HMG-CoA reductase inhibitors, the nurse should monitor which laboratory results? Serum electrolytes Urine specific gravity Liver function studies Complete blood count

Liver function studies (HMG-CoA reductase inhibitors can cause hepatic toxicity; thus, liver function studies are often measured every 6 to 8 weeks for the first 6 months of statin therapy and then every 3 to 6 months, depending on the prescriber and the patient situation.)

A client is placed on orlistat (Xenical) as part of a treatment regimen for morbid obesity. What side effects does the nurse tell the client to expect from using this drug? Dry mouth, constipation, and insomnia Insomnia, dry mouth, and blurred vision Loose stools, abdominal cramps, and nausea Palpitations, constipation, and restlessness

Loose stools, abdominal cramps, and nausea (The nurse tells the client to expect loose stools, abdominal cramps, and nausea. These are side effects unique to orlistat (Xenical).Dry mouth, constipation, and insomnia are not side effects of orlistat. Insomnia, dry mouth, blurred vision, palpitations, constipation, and restlessness are all side effects of short-term therapy drugs such as phentermine (Adipex-P), diethylpropion (Tenuate), and phendimetrazine (Bontril).)

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? Balsalazide (Colazal) Loperamide (Imodium) Mesalamine (Asacol) Milk of Magnesia (MOM)

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.)

A nurse is caring for a client with a diagnosis of renal calculi secondary to hyperparathyroidism. Which type of diet should the nurse explore with the client when providing discharge information? Low purine Low calcium High phosphorus High alkaline ash

Low calcium (A low calcium intake is recommended. Calcium and phosphorus are components of these stones; foods high in calcium and phosphorus should be avoided. Low purine and high alkaline ash diets are indicated for clients with gout.)

What information will the nurse include for an overweight 35-year-old woman who is starting a weight-loss plan? Weigh yourself at the same time every morning and evening. Stick to a 600- to 800-calorie diet for the most rapid weight loss. Low carbohydrate diets lead to rapid weight loss but are difficult to maintain. Weighing all foods on a scale is necessary to choose appropriate portion sizes.

Low carbohydrate diets lead to rapid weight loss but are difficult to maintain. (The restrictive nature of fad diets makes the weight loss achieved by the patient more difficult to maintain. Portion size can be estimated in other ways besides weighing. Severely calorie-restricted diets are not necessary for patients in the overweight category of obesity and need to be closely supervised. Patients should weigh weekly rather than daily.)

Enoxaparin sodium (Lovenox) is an anticoagulant used to prevent and treat deep vein thrombosis and pulmonary embolism. This medication is in which drug class? Oral anticoagulant Glycoprotein IIb/IIIa inhibitor Low-molecular-weight heparin Thrombolytic drug

Low-molecular-weight heparin (Enoxaparin is a low-molecular-weight heparin.)

A staff educator is reviewing the causes of gastroesophageal reflux disease (GERD) with new staff nurses. What area of the GI tract should the educator identify as the cause of reduced pressure associated with GERD? Pyloric sphincter Lower esophageal sphincter Hypopharyngeal sphincter Upper esophageal sphincter

Lower esophageal sphincter (The lower esophageal sphincter, also called the gastroesophageal sphincter or cardiac sphincter, is located at the junction of the esophagus and the stomach. An incompetent lower esophageal sphincter allows reflux (backward flow) of gastric contents. The upper esophageal sphincter and the hypopharyngeal sphincter are synonymous and are not responsible for the manifestations of GERD. The pyloric sphincter exists between the stomach and the duodenum.)

An operating room nurse is preparing for a surgical procedure on an infant. The nurse's perioperative care is based on what physiologic factor that puts infants at greater risk from surgery than adults? Increased vascular rigidity Diminished chest expansion Lower total blood volume Decreased peripheral circulation

Lower total blood volume (Infants are at a greater risk from surgery as a result of various physiologic factors. A major factor is that the infant has a lower total blood volume, making even a small loss of blood a serious consideration because of the risk for dehydration and the inability to respond to the need for increased oxygen during surgery.)

For a client with chronic renal failure, the nurse MOST likely will question a prescription for which type of antacid? Aluminum-containing antacids Calcium-containing antacids Sodium-containing antacids Magnesium-containing antacids

Magnesium-containing antacids (Magnesium-containing antacids can cause hypermagnesemia in clients with chronic renal failure. Aluminum-containing antacids may be used as a phosphate binder in clients with chronic renal failure. Sodium- and aluminum-containing antacids are chemically more easily excreted in clients with renal compromise. Although calcium-containing antacids may accumulate in the bloodstream of clients with renal failure, they may also be appropriate because these patients may be hypocalcemic.)

The nurse is caring for an older client with Salmonella food poisoning. Which is the priority action of the nurse? Monitor vital signs. Maintain IV fluids. Provide perineal care. Initiate Isolation Precautions.

Maintain IV fluids. (Dehydration can occur quickly in older clients with Salmonella food poisoning caused by diarrhea, so maintenance of fluid balance is a high priority. Monitoring vital signs and providing perineal care are important nursing actions, but are of lower priority than fluid replacement. Contact Isolation is not regularly instituted for Salmonella infection. Standard Precautions are usually sufficient.)

Which of the following nursing actions provides the greatest assistance in healing? Maintaining a restful environment Providing solid food in the first day Allowing family members to visit often Keeping the client recumbent

Maintaining a restful environment (The nurse should plan for adequate periods of rest and sleep, maintaining a quiet, restful environment.)

The nurse-anesthetist is monitoring his client during surgery. He notices a ventricular dysrhythmia and unstable blood pressure. He notifies the surgeon. The operative team suspects Myocardial infarction Malignant hyperthermia Mitral valve prolapse Major blood loss

Malignant hyperthermia (The symptoms of malignant hyperthermia are masseter muscle rigidity, ventricular dysrhythmia, tachypnea, cyanosis, skin mottling, and unstable blood pressure.)

Which adult will the nurse plan to teach about risks associated with obesity? Man who has a BMI of 18 kg/m² Man with a 42 in waist and 44 in hips Woman who has a body mass index (BMI) of 24 kg/m² Woman with a waist circumference of 34 inches (86 cm)

Man with a 42 in waist and 44 in hips (The waist-to-hip ratio for this patient is 0.95, which exceeds the recommended level of <0.80. A patient with a BMI of 18 kg/m² is considered underweight. A BMI of 24 kg/m² is normal. Health risks associated with obesity increase in women with a waist circumference larger than 35 in (89 cm) and men with a waist circumference larger than 40 in (102 cm).)

The nurse is providing preoperative care for a client who will have an arthroscopy of the left knee. As part of the Joint Commission National Patient Safety Goals (NPSG), what will the nurse be required to do? Ensure that the correct procedure is noted in the client's history. Remind the surgeon that the client will have a left knee arthroscopy. Verify with the client that a left knee arthroscopy will be performed. Mark the left knee site with the client awake and the surgeon present.

Mark the left knee site with the client awake and the surgeon present. (The nurse will be required to mark the left knee site with the client awake and the surgeon present. The Joint Commission NSPG requires that the surgical site be marked by an independent licensed professional and should, when possible, involve the client. The surgeon is accountable and should be present.The EMR should identify the correct procedure, but is not a specific JCAHO requirement. The nurse will verify the procedure with the client when possible, but this is not a requirement. Communication with the surgeon is ideal, but is not specifically required.)

While observing a patient self-administer enoxaparin (Lovenox), the nurse identifies the need for further teaching when the patient performs which self-injection action? Massages the site after administration of the medication Does not aspirate before injecting the medication Administers the medication into subcutaneous (fatty) tissue Injects the medication greater than 2 inches away from the umbilicus

Massages the site after administration of the medication (It is not recommended to massage the area of injection of anticoagulants because of the increased risk of hematoma formation.)

Following an abdominal cholecystectomy, the client refuses to take deep breaths and cough, saying, "It's too painful." What action does the nurse take? Give pain medication regularly as soon as possible. Obtain a prescription to increase the client's pain medication. Medicate the client for pain before coughing and deep breathing. Substitute incentive spirometry for coughing and deep breathing.

Medicate the client for pain before coughing and deep breathing. (Analgesics limit pain, facilitating effective coughing and deep breathing. Although giving pain medication regularly may be necessary, it must be coordinated with the deep breathing and coughing exercises. Opioids depress the central nervous system (CNS), particularly respirations, and increasing the dose should be an option only after other interventions have been unsuccessful. Incentive spirometry will cause pain because it increases intraabdominal pressure, and the client may not cooperate if pain is not relieved.)

A client is admitted to the hospital with a diagnosis of Crohn disease. What is most important for the nurse to include in the teaching plan for this client? Controlling constipation Meeting nutritional needs Preventing increased weakness Anticipating a sexual alteration

Meeting nutritional needs (To avoid gastrointestinal pain and diarrhea, these clients often refuse to eat and become malnourished. The consumption of a high-calorie, high-protein diet is advised. Diarrhea, not constipation, is a problem with Crohn disease. Preventing an increase in weakness is a secondary concern that results from malnutrition; correcting the malnutrition will increase strength. Anticipating a sexual alteration generally is not a problem with Crohn disease.)

What condition will the nurse monitor for with a client using sodium bicarbonate to treat gastric hyperacidity? Hypercalcemia Hyperkalemia Metabolic acidosis Metabolic alkalosis

Metabolic alkalosis (Solutions containing sodium bicarbonate (a base) can cause metabolic alkalosis. Serum potassium and serum calcium would decrease, not increase, with alkalosis.)

The nurse is caring for a patient with opioid addiction. The nurse anticipates that the patient will be prescribed which medication? Meperidine (Demerol) Naloxone (Narcan) Methadone (Dolophine) Morphine (MS Contin)

Methadone (Dolophine) (Methadone is a synthetic opioid analgesic with gentler withdrawal symptoms and is the drug of choice for detoxification treatment.)

Which medication will cause the nurse to monitor the client closely for hemolytic anemia? Tacrolimus Methyldopa Azathioprine Procainamide

Methyldopa (Hemolytic anemia is an autoimmune disorder in which red blood cells are destroyed and removed from the bloodstream before the end of their normal life span. It may result after administration of methyldopa. Tacrolimus may cause adverse effects such as nephrotoxicity, lymphoma, and leukopenia. Azathioprine is administered as an immunosuppressant, which may cause bone marrow suppression. Procainamide can induce the formation of antinuclear antibodies and cause a lupus-like syndrome.)

A client undergoing corticosteroid therapy is admitted with a peptic ulcer, osteoporosis, and hypertension. Which medication may have caused this condition? Everolimus Azathioprine Mycophenolate acid Methylprednisolone

Methylprednisolone (Methylprednisolone is a corticosteroid that suppresses inflammatory responses and inhibits both cytokine production and T-cell activation. This drug may cause a peptic ulcer, osteoporosis, and hypertension. Everolimus may cause urinary tract infections, hyperlipidemia, and peripheral edema. Azathioprine may cause bone marrow suppression, neutropenia, and thrombocytopenia. Mycophenolate acid may cause diarrhea, neutropenia, and increased incidence of malignancies.)

Before administering an intravenous (IV) injection of basiliximab (Simulect), the nurse should anticipate giving which medication? Methylprednisolone (Solu-Medrol) Diphenhydramine (Benadryl) Meperidine (Demerol) Acetaminophen (Tylenol)

Methylprednisolone (Solu-Medrol) (IV methylprednisolone is administered before basiliximab injection to prevent or minimize acute allergic-type reactions associated with this medication.)

A patient with GERD has undergone diagnostic testing and it has been determined that increasing the pace of gastric emptying may help alleviate symptoms. The nurse should anticipate that the patient may be prescribed what drug? Metoclopramide (Reglan) Omeprazole (Prilosec) Lansoprazole (Prevacid) Famotidine (Pepcid)

Metoclopramide (Reglan) (Metoclopramide (Reglan) is useful in promoting gastric motility. Omeprazole and lansoprozole are proton pump inhibitors that reduce gastric acid secretion. Famotidine (Pepcid) is an H₂ receptor antagonist, which has a similar effect.)

A client with mild diarrhea is diagnosed with a Clostridium difficile infection. Which is the first-line drug that would be used to treat this condition? Rifaximin Fidaxomicin Vancomycin Metronidazole

Metronidazole (Metronidazole is the first line of treatment prescribed to clients with a Clostridium difficile infection. Rifaximin is used to treat traveler's diarrhea caused by Escherichia coli. Fidaxomicin is reserved for clients who are at risk for the relapse of or have recurrent Clostridium difficile infections. Vancomycin is preferred for serious Clostridium difficile infections.)

A client has been admitted with suspected Clostridium difficile infection. Which medication does the nurse plan to administer as a priority? Metronidazole (Flagyl) Acetaminophen (Tylenol) Tetracycline (Sumycin) Doxycycline (Vibramycin)

Metronidazole (Flagyl) (Metronidazole and vancomycin are the antibiotics of choice for C. difficile infection. Tylenol might be used if the client is febrile. The other two antibiotics are not appropriate.)

A nurse is admitting a child to the hospital with a diagnosis of giardiasis. Which medication should the nurse expect to be prescribed? Metronidazole (Flagyl) Amoxicillin clavulanate (Augmentin) Clarithromycin (Biaxin) Prednisone (Orapred)

Metronidazole (Flagyl) (The drugs of choice for treatment of giardiasis are metronidazole (Flagyl), tinidazole (Tindamax), and nitazoxanide (Alinia). These are classified as antifungals. Amoxicillin and clarithromycin are antibiotics that treat bacterial infections. Prednisone is a steroid and is used as an anti-inflammatory medication.)

Which client is most likely to have organic erectile dysfunction? Middle-aged man who first had sexual intercourse at age 15 Middle-aged man who has had diabetes mellitus for 25 years Young man who had a myocardial infarction 2 years ago Young man who has a job that causes him high stress levels

Middle-aged man who has had diabetes mellitus for 25 years (Organic erectile dysfunction occurs as a gradual reduction in sexual functioning. Diabetes mellitus causes microvascular and macrovascular complications that decrease the sensation and autonomic nerve activity required for achievement of an erection. The other factors will not increase the client's risk for development of organic erectile dysfunction.)

The nurse reviews a medication history for a patient newly diagnosed with peptic ulcer disease (PUD) who has a history of using ibuprofen (Advil) frequently for chronic knee pain. The nurse anticipates that the primary health care provider will request which medication for this patient? Bismuth subsalicylate (Pepto-Bismol) Magnesium hydroxide (Maalox) Metronidazole (Flagyl) Misoprostol (Cytotec)

Misoprostol (Cytotec) (The nurse expects that the primary health care provider will request that Misoprostol be given to the patient. Misoprostol is a prostaglandin analogue that protects against nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers.Bismuth subsalicylate is an antidiarrheal drug that contains salicylates, which can cause bleeding and would be avoided in patients who have PUD. Magnesium hydroxide is an antacid that may be used to neutralize stomach secretions but is not used specifically to help prevent NSAID-induced ulcers. Metronidazole is an antimicrobial agent used to treat Helicobacter pylori infection.)

After conducting a preoperative health assessment, the nurse documents that the client has physical assessments supporting the medical diagnosis of emphysema. Based on this finding, what postoperative interventions would be included on the plan of care? Perform sterile dressing changes each morning. Administer pain medications as needed. Conduct a head-to-toe assessment each shift. Monitor respirations and breath sounds.

Monitor respirations and breath sounds. (Respiratory disorders, including emphysema, increase the risk for respiratory depression from anesthesia as well as postoperative pneumonia and atelectasis.)

A nurse is taking care of a client during the immediate post-operative period. Which of the following duties performed during the immediate post-operative period is most important? Ensure the safe recovery of surgical clients. Monitor the client for complications. Prepare a room for the client's return. Assess the client's health constantly.

Monitor the client for complications. (The immediate post-operative period refers to the first 24 hours after surgery. During this time, the nurse monitors the client for complications as he or she recovers from anesthesia. Once the client is stable, the nurse prepares a room for the client's return and assesses the client to prevent or minimize potential complications. The nurse ensures the safe recovery of the client after the client has stabilized.)

In the postanesthesia care unit a client received intrathecal morphine intraoperatively to control pain. Considering the administration of this medication, what should the nurse include as part of the client's initial 24-hour postoperative care? Monitoring of respiratory rate hourly Assessing the client for tachycardia Administering naloxone every 3 to 4 hours Observing the client for signs of central nervous system (CNS) excitement

Monitoring of respiratory rate hourly (Intrathecal morphine can depress respiratory function depending on the level it reaches within the spinal column; hourly assessments during the first 12 to 24 hours will allow for early intervention with an antidote if respiratory depression needs to be corrected. Bradycardia, not tachycardia, and hypotension occur. Administering naloxone every 3 to 4 hours is too infrequent if the client's respirations are depressed. The recommended adult dosage usually is 0.4 to 2 mg every 2 to 3 minutes, if indicated. CNS depression occurs secondary to hypoxia.)

A patient needs to switch analgesic drugs secondary to an adverse reaction to the current treatment regimen. The patient is concerned that the new prescription will not provide optimal pain control. The nurse's response is based on knowledge that doses of analgesics are determined using an equianalgesic table with which drug prototype? Fentanyl Meperidine Morphine Codeine

Morphine (An equianalgesic table is a conversion chart for commonly used opioids. It identifies oral and parenteral dosages that provide comparable analgesia. The equianalgesic table identifies dosages of various narcotics that are equal to 10 mg of morphine. It is important to use when changing to a new opioid or different route. Morphine is the drug prototype for all opioid drugs.)

The nurse is providing discharge teaching for a patient about potential serious adverse effects to simvastatin (Zocor). Which symptom may indicate the patient is experiencing a serious adverse effect to this medication? Muscle pain Itching Headache Weight loss

Muscle pain (Unexplained muscle pain and soreness are symptoms of a relatively uncommon but serious adverse effect of rhabdomyolysis associated with statin drugs and must be immediately reported to the health care provider.)

Which medication is used to treat a patient with severe adverse effects of a narcotic analgesic? Flumazenil (Romazicon) Methylprednisolone (Solu-Medrol) Acetylcysteine (Mucomyst) Naloxone (Narcan)

Naloxone (Narcan) (Naloxone is the narcotic antagonist that will reverse the effects, both adverse and therapeutic, of opioid narcotic analgesics.)

A nurse caring for a patient prior to surgery should recognize which of the following factors place a client at risk for obstructive sleep apnea? (Select all that apply.) Heart disease Respiratory tract infections Nasal polyps Obesity

Nasal polyps Obesity (Structural abnormalities, such as a deviated septum, nasal polyps, certain jaw configurations, or enlarged tonsils predispose a client to obstructive apnea. Individuals with mixed apnea often have signs and symptoms of right-sided heart failure. Respiratory tract infections do not predispose a client to obstructive sleep apnea. Clients with obstructive apnea are often middle-age, obese men. Obesity itself does not predispose a client to obstructive sleep apnea.)

A client is admitted with a stroke (brain attack). Which tool does the nurse use to facilitate a focused neurologic assessment of the client? Glasgow Coma Score (GCS) Intracranial pressure monitor Mini-Mental State Examination (MMSE; mini-mental status examination) National Institutes of Health Stroke Scale (NIHSS)

National Institutes of Health Stroke Scale (NIHSS) (The nurse uses the NIHSS tool to perform a focused neurologic assessment. Health care providers and nurses at designated stroke centers use a specialized stroke scale such as the NIHSS to assess clients.The Glasgow Coma Score (GCS) provides a non-specific indication of level of consciousness. An intracranial pressure monitor would be requested by the health care specialist if signs and symptoms indicated increased intracranial pressure. The MMSE is used primarily to differentiate among dementia, psychosis, and affective disorders.)

The nurse provides education about signs and symptoms of hypoglycemia to a client with newly diagnosed type 1 diabetes. The nurse concludes that the teaching was effective when the client acknowledges the need to drink orange juice when experiencing which symptoms? Nervous and weak Thirsty with a headache Flushed and short of breath Nausea and abdominal cramps

Nervous and weak (Nervousness and weakness are the most commonly reported symptoms of hypoglycemia and are related to increased sympathetic nervous system activity. Feeling flushed and short of breath are adaptations of hyperglycemia. Being thirsty, having a headache, being nauseated, or having abdominal cramps are symptoms of hyperglycemia.)

The nurse will teach clients that antacids are effective in the treatment of hyperacidity based on which mechanism of action? Neutralizes gastric acid Decreases gastric pH Decreases stomach motility Decreases duodenal pH

Neutralizes gastric acid (Antacids work by neutralizing gastric acid, which would cause an increase in pH. They do not affect gastric motility.)

Patients prescribed sildenafil (Viagra) should be instructed regarding the potential life-threatening drug interaction with which medication? Aspirin (Acetylsalicylic acid) Acetaminophen (Tylenol) Warfarin (Coumadin) Nitroglycerin (Nitrostat)

Nitroglycerin (Nitrostat) (Sildenafil and other drugs for erectile dysfunction should not be taken with nitroglycerin because it may lead to a significant hypotension that could be life threatening.)

A client with gastroesophageal reflux disease (GERD) receives a prescription for an H₂ receptor antagonist. Which medications are within the classification of an H₂ receptor antagonist? Select all that apply. Nizatidine Ranitidine Famotidine Lansoprazole Metoclopramide

Nizatidine Ranitidine Famotidine (Nizatidine is an H₂ receptor antagonist that reduces gastric acid secretion and provides for symptomatic improvement in GERD. Ranitidine is an H₂ receptor antagonist that reduces gastric acid secretion and provides for symptomatic improvement in GERD. Famotidine is an H₂ receptor antagonist that reduces gastric acid secretion and provides for symptomatic improvement in GERD. Lansoprazole is a proton pump inhibitor that inhibits gastric secretion up to 90% with one dose daily and provides for symptomatic improvement in GERD. Metoclopramide is a prokinetic agent that increases the rate of gastric emptying; it has multiple side effects and is not appropriate for long-term treatment of GERD.)

A 45-year-old obese man arrives in a clinic with complaints of daytime sleepiness, difficulty going to sleep at night, and snoring. The nurse should recognize the manifestations of what health problem? Adenoiditis Chronic tonsillitis Obstructive sleep apnea Laryngeal cancer

Obstructive sleep apnea (Obstructive sleep apnea occurs in men, especially those who are older and overweight. Symptoms include excessive daytime sleepiness, insomnia, and snoring. Daytime sleepiness and difficulty going to sleep at night are not indications of tonsillitis or adenoiditis. This patient's symptoms are not suggestive of laryngeal cancer.)

he healthy adult patient is given a narcotic prior to a surgical procedure. The nurse is completing the chart and notices the consent form was not signed by the patient. Which of the following should the nurse do first? Immediately have the patient sign the consent form. Have the patient's family member sign the consent form. Ask the patient if he still wants to proceed with the procedure. Notify the physician of the oversight.

Notify the physician of the oversight. (Do not administer any medications that might alter judgment or perception before the patient signs the consent form because many drugs commonly administered as preoperative medications, such as narcotics or barbiturates, can alter cognitive abilities and invalidate informed consent.)

The nurse is performing a dressing change on a client who underwent abdominal surgery 6 days prior. The nurse notes a moderate amount of serosanguineous drainage on the old dressing. What will the nurse do? Apply extra gauze to the new dressing. Contact the surgeon to discuss the need for antibiotics. Notify the surgeon about possible wound dehiscence. Perform the dressing change according to unit protocol.

Notify the surgeon about possible wound dehiscence. (Serosanguineous discharge persisting past the 5th postoperative day may indicate wound dehiscence and would be reported to the surgeon.The nurse would not just reinforce the dressing, but would notify the surgeon. Serosanguineous discharge does not indicate infection. Persistent serosanguineous discharge is an abnormal finding and to be reported.)

A female client is scheduled for a hysterectomy. While discussing the preoperative preparations, the nurse determines that the client's understanding of the surgery is inadequate. What is the next nursing intervention? Describing the proposed surgery to the client Proceeding with the preoperative plan Notifying the surgeon that the client needs more information Explaining gently to the client that she should have asked more questions

Notifying the surgeon that the client needs more information (Legally the person performing the surgery is responsible for informing the client adequately; the nurse may clarify information, witness the client's signature, and co-sign the consent form. Describing the proposed surgery to the client is beyond the scope of nursing practice. The nurse could face criminal charges of assault and battery for proceeding when there is a lack of informed consent. Explaining gently that she should have asked more questions places blame on the client; it is the responsibility of the surgeon to impart the vital information required for consent.)

The nurse suspects that which client is at highest risk for developing gallstones? Obese male with chronic obstructive pulmonary disease Obese female receiving hormone replacement therapy Thin male with a history of coronary artery bypass grafting Thin female who has recently given birth

Obese female receiving hormone replacement therapy (The client at highest risk is the obese female receiving hormone replacement therapy. Both obesity and hormone replacement therapy have been found to increase a woman's risk for developing gallstones. Other risk factors for developing gallstones are type 2 diabetes, dyslipidemia, and insulin resistance.Men are at lower risk than women for developing gallstones. Although pregnancy increases the risk for a woman to develop gallstones, a woman's thin frame lessens that risk.)

The nurse assigns a nursing diagnosis of ineffective breathing pattern. Which of the following sleep conditions would support this diagnosis? Insomnia Narcolepsy Obstructive sleep apnea Sleep deprivation

Obstructive sleep apnea (Obstructive sleep apnea (OSA) occurs when the muscles or structures of the oral cavity or throat relax during sleep. The upper airway becomes partially or completely blocked, diminishing airflow or stopping it for as long as 30 seconds. The person still attempts to breathe because chest and abdominal movements continue, resulting in snoring or snorting sounds. With narcolepsy, the person feels an overwhelming wave of sleepiness and falls asleep. Insomnia is characterized by chronic difficulty falling asleep. Sleep deprivation is a condition caused by dyssomnia. OSA is the only one of these conditions that results in blockage of the airway and impacts the ability to breathe.)

Before administering isosorbide mononitrate (Imdur) sustained-release tablet to a patient, what is the priority nursing intervention? Remind the patient to take the tablet before meals. Emphasize that the patient should swallow the tablet whole. Obtain a blood pressure reading. Advise the patient that Tylenol is used to treat headache.

Obtain a blood pressure reading. (Mononitrate is a vasodilator and thus can cause hypotension. It is important to assess blood pressure before administering.)

A client with severe gastroesophageal reflux disease (GERD) is still having symptoms of reflux despite taking omeprazole, (Prilosec) 20 mg daily. What does the nurse do next? Document the finding in the client's chart. Obtain an order for omeprazole twice daily. Instruct the client to double the daily dose. Tell the client to take antacids with omeprazole.

Obtain an order for omeprazole twice daily. (Omeprazole is a proton pump inhibitor that acts to reduce gastric acid secretion. If once-daily dosing fails to control the client's symptoms, the nurse should obtain an order for the client to take omeprazole twice daily for better symptom control. This finding should be documented, but the nurse should do more than merely record the client's symptoms. Doubling the daily dose and adding antacids will not be as effective as obtaining an order for twice-a-day dosing.)

A facility is beginning to perform bariatric surgery on obese clients. Which action by the nursing manager is most important? Obtain appropriately sized equipment for these clients. Select a dedicated group of staff members for these clients. Send personnel to sensitivity training as part of orientation. Establish multidisciplinary rounding for clients in this program.

Obtain appropriately sized equipment for these clients. (All actions might be appropriate and helpful in the care of bariatric clients. However, staff and client safety is a unique priority when working with this group of clients. The manager must ensure appropriately sized equipment, so that neither staff nor clients injure themselves.)

Which task is appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP) working on a medical-surgical unit? Obtain vital signs on a client receiving a blood transfusion Assist a client with folic acid deficiency in making diet choices Administer erythropoietin to a client with myelodysplastic syndrome Assess skin integrity on an anemic client who fell during ambulation

Obtain vital signs on a client receiving a blood transfusion (The appropriate task for the nurse to delegate to a UAP is obtaining vital signs on a client receiving a blood transfusion. This activity is within the scope of practice for UAPs.Assisting with prescribed diet choices, administering medication, and assessing clients are complex actions that must be done by licensed nurses.)

A client with acute cholecystitis is admitted to the medical-surgical unit. Which nursing activity associated with the client's care will be appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? Assessing dietary risk factors for cholecystitis Checking for bowel sounds and distention Determining precipitating factors for abdominal pain Obtaining the admission weight, height, and vital signs

Obtaining the admission weight, height, and vital signs (Obtaining admission height, weight, and vital signs is included in the education for UAPs and usually is included in the job description for these staff members.Assessing for risk factors, checking bowel sounds, and determining precipitating factors for abdominal pain require assessment skills. Assessment skills require broader education and are within the scope of practice of licensed nursing staff and not UAPs.)

A young adult man says that he cannot stay on a diet because of trouble finding one that will incorporate his food preferences. How does the nurse most effectively plan nutritional care for this client? Calculates his body mass index (BMI) Records a 24-hour diary of his physical activities Obtains a 24-hour recall (diary) of his food intake Measures his accurate height and weight measurements

Obtains a 24-hour recall (diary) of his food intake (The most effective way to plan nutritional care for a client is to obtain a 24-hour recall of food intake. This will determine the client's food preferences and eating patterns so that they can be incorporated into the diet.Although calculating a BMI and measuring height and weight are important parts of a nutritional assessment, they do not address the issue of the client's food preferences. Keeping an activity diary will also not reveal any information related to the client's food preferences.)

The health care provider is prescribing medication to treat a client's severe gastroesophageal reflux disease (GERD). Which medication does the nurse anticipate teaching the client about? Magnesium hydroxide (Gaviscon) Ranitidine (Zantac) Nizatidine (Axid) Omeprazole (Prilosec)

Omeprazole (Prilosec) (Proton pump inhibitors such as omeprazole are the main treatment for more severe cases of GERD. Gaviscon, Axid, and Zantac can be used to treat less severe cases.)

A healthcare provider prescribes famotidine and magnesium hydroxide/aluminum hydroxide antacid for a client with a peptic ulcer. The nurse should teach the client to take the antacid at what time? Only at bedtime, when famotidine is not taken Only if famotidine is ineffective At the same time as famotidine, with a full glass of water One hour before or 2 hours after famotidine

One hour before or 2 hours after famotidine (Antacids interfere with complete absorption of famotidine; therefore antacids should be administered at least 1 hour before or 2 hours after famotidine. Magnesium hydroxide/aluminum hydroxide usually is taken 1 hour after meals and at bedtime. Famotidine usually is prescribed once a day at bedtime. The client has received a prescription for both medications; the client should not be instructed to omit one of the medications without checking with the healthcare provider first.)

A patient has been treated for lung cancer for 3 years. Over the past few months, the patient has noticed that the opioid analgesic is not helping as much as it had previously and more medication is needed for the same pain relief. The nurse is aware that this patient is experiencing which of these? Opioid addiction Opioid tolerance Opioid toxicity Opioid abstinence syndrome

Opioid tolerance (Opioid tolerance is a common physiologic result of long-term opioid use. Patients with opioid tolerance require larger doses of the opioid agent to maintain the same level of analgesia. This situation does not describe toxicity (overdose), addiction, or abstinence syndrome (withdrawal).)

A client with cholelithiasis is scheduled for a lithotripsy. What should the nurse include in the client's teaching plan? Opioids will be available for postoperative pain. Fever is a common response to this intervention. Heart palpitations often occur after the procedure. Anesthetics are not necessary during the procedure.

Opioids will be available for postoperative pain. (Painful biliary colic may occur in the postoperative period as a result of the passage of pulverized fragments of the calculi; this may occur three or more days after the lithotripsy. Fever may indicate pancreatitis, which is a rare occurrence. The delivery of shock waves during the procedure is synchronized with the heartbeat to avoid initiation of dysrhythmias. Light sedation may be used to keep the client comfortable and as still as possible.)

When administering ferrous sulfate (iron) to a client, the nurse plans to give this medication with which fluid to increase absorption of the iron? Orange juice Black tea 8 oz of water 4 oz of milk

Orange juice (The absorption of iron can be enhanced when it is given with ascorbic acid (vitamin C), which is present in orange juice.)

Which intervention does the nurse implement for an older adult client to minimize skin breakdown related to surgical positioning? Apply elastic stockings to lower extremities. Monitor for excessive blood loss. Pad bony prominences. Secure joints on a board in anatomic positions.

Pad bony prominences. (Padding bony prominences best minimizes skin breakdown.Elastic stockings assist in increased venous return. Monitoring for blood loss and securing joints do not protect the skin.)

The nurse plans pharmacologic management for a patient with pain. The nurse should administer the pain medication based on what dosage schedule? Pain relief is best obtained by administering analgesics around the clock. Administer the analgesic when the pain level reaches a "6" on a scale of 1 to 10. Opioid analgesics should not be used for more than 24 hours to prevent drug addiction. Analgesics should be administered as needed (prn) to minimize adverse effects.

Pain relief is best obtained by administering analgesics around the clock. (When pain is present for more than 12 hours a day, analgesic dosages are best administered around the clock rather than on an as-needed basis, but dosages should always be within the dosage guidelines for each drug used. The around-the-clock (or "scheduled") dosing maintains steady-state levels of the medication and prevents drug troughs and escalation of pain.)

A nurse is performing the initial history and physical examination of a client with a diagnosis of duodenal ulcer. Which type of pain does the nurse expect the client to describe? Pain that is relieved with eating Pain that is worse with antacids Pain that is relieved with sleep Pain that is worse one hour after eating

Pain that is relieved with eating (Duodenal ulcer pain is relieved with food and antacids and often awakens the client at night when sleeping. Gastric ulcer pain is worse with eating or one hour after eating.)

Colostomy surgery is categorized as what type of surgery? Cosmetic Curative Diagnostic Palliative

Palliative (Colostomy surgery is categorized as palliative. Palliative surgery is performed to relieve symptoms of a disease process, but does not cure the disease.Cosmetic surgery is performed primarily to alter or enhance personal appearance. Curative surgery is performed to resolve a health problem by repairing or removing the cause. Diagnostic surgery is performed to determine the origin and cause of a disorder or the cell type for cancer.)

Identify the type of surgery a terminally ill patient will undergo if the purpose is removal of tissue to relieve pain. Procurement Ablative Palliative Diagnostic

Palliative (Palliative surgery alleviates discomfort or other disease symptoms without producing a cure. Procurement surgery occurs when an organ or tissue is harvested for transplantation into another. Ablative surgery involves removal of a body part. Diagnostic surgery confirms or negates a diagnosis.)

The nurse is performing an assessment on a client with anemia. What are the typical clinical manifestations of anemia? Select all that apply. Pallor Fatigue Tachycardia Dyspnea on exertion Elevated temperature Decreased breath sounds

Pallor Fatigue Tachycardia Dyspnea on exertion (The typical clinical manifestations of anemia are: pallor, fatigue, tachycardia, and dyspnea on exertion. Lowered O2 levels deliver less oxygen to all cells, making clients with anemia pale—especially their ears, nail beds, palms, and conjunctivae and around the mouth. Fatigue is a classic symptom of anemia because lowered O2 levels contribute to a faster pulse (i.e., cardiac rate) and tend to "wear out" a client's energy. Difficulty breathing—especially with activity—is common with anemia. Lower levels of hemoglobin carry less O2 to the cells of the body.Respiratory problems with anemia do not include changes in breath sounds. Skin is cool to the touch, and an intolerance to cold is noted. Elevated temperature would signify something additional, such as infection.)

In the postoperative phase of abdominal surgery, the client complains of severe abdominal pain, and in the second postoperative day, the client's bowel sounds are absent. What does the nurse suspect? Normal response Abdominal infection Hernia development Paralytic ileus

Paralytic ileus (A potential complication after surgery is paralytic ileus, a condition in which there is decreased bowel functioning.)

When an elderly client is brought to the recovery room and presents with irregular, loud respirations, the nurse determines that this most likely a result of Effects of anesthesia Normal return of reflexes Partial airway obstruction Type of surgery

Partial airway obstruction (Loud, irregular respirations may indicate obstruction of the airway, possibly from emesis, accumulated secretions, or client positioning that allows the tongue to fall to the back of the throat.)

A patient had a hiatal hernia repair earlier today and is now in the postanesthesia care unit (PACU). The family asks the nurse why the patient is in the PACU rather than back in his room on the postsurgical unit. The nurse should inform the family that: Patients who have had surgical complications are observed in the PACU until they are stable enough to return to the floor. Patients recover from the effects of anesthesia in the PACU and then return to the postsurgical unit for further care. The PACU is a holding area for patients awaiting a surgical unit bed or awaiting adequate staff to provide care on the postsurgical unit. The nurse will ask the surgeon explain to them why the patient is not on the postsurgical unit, as is the usual procedure.

Patients recover from the effects of anesthesia in the PACU and then return to the postsurgical unit for further care. (A client remains in the PACU until he has recovered from the effects of anesthesia. In the PACU, the client is assessed every 5 to 15 minutes in order to quickly identify surgical or anesthesia-related problems. Most surgical units routinely admit patients to the PACU for a period of observation. Admission to the PACU does not indicate surgical complications nor imply that a holding area is required. There is no reason the surgeon would need to explain this to the family, as the nurse could do it. It is not usual procedure for a patient to be transferred directly from surgery to the postsurgical unit.)

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

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.)

A client recovering from a sickle cell crisis is to be discharged. The nurse says to the client, "You and all clients with sickle cell disease are at risk for infection because of your decreased spleen function. For this reason, you will most likely be prescribed an antibiotic before discharge." Which drug does the nurse anticipate the primary health care provider (PHCP) will prescribe? Cefaclor (Ceclor) Vancomycin (Vancocin) Gentamicin (Garamycin) Penicillin V (Pen-V K)

Penicillin V (Pen-V K) (The nurse expects the PHCP to prescribe Penicillin V for a client recovering from sickle cell crisis who is at risk for infection. Prophylactic therapy with twice-daily oral penicillin reduces the incidence of pneumonia and other streptococcal infections and is the correct drug to use. It is a standard protocol for long-term prophylactic use in clients with sickle cell disease.Cefaclor (Ceclor) and vancomycin (Vancocin) are antibiotics more specific for short-term use and would be inappropriate for this client. Gentamicin (Garamycin) is a drug that can cause liver and kidney damage with long-term use.)

The nurse is caring for a client with erectile dysfunction who has not had success with common treatment modalities. The nurse anticipates that the primary health care provider will recommend which treatment for this client? Penile implants Penile injections Transurethral suppository Vacuum constriction device

Penile implants (Penile implants (prostheses), which require surgery, are used when other modalities fail. Devices include semirigid, flexible, or hydraulic inflatable and multicomponent or one-piece instruments.Penile injections and transurethral suppositories are tried before using the option of last resort. A vacuum constriction device is easy to use and is often the first option that is tried.)

The nurse caring for four clients with diabetes has these activities to perform. Which activity is appropriate to delegate to unlicensed assistive personnel (UAP)? Perform a blood glucose check on a client who requires insulin. Verify the infusion rate on a continuous infusion insulin pump. Assess a client who reports tremors and irritability. Monitor a client who is reporting palpitations and anxiety.

Perform a blood glucose check on a client who requires insulin. (Performing bedside glucose monitoring is a task that may be delegated to UAPs because it does not require extensive clinical judgment to perform. There is no evidence the client is unstable at this time. The nurse will follow up with the results and insulin administration after assessing the less stable clients.Intravenous therapy and medication administration are not within the scope of practice for UAPs. The client with tremors and irritability is displaying symptoms of hypoglycemia requiring further assessment and intervention that are not within the scope of practice for UAPs. The client reporting palpitations and anxiety may have hypoglycemia, requiring further intervention. This client must be assessed by licensed nursing staff.)

The nurse is caring for a client with sickle cell disease. Which nursing action is most effective in reducing the potential for sepsis in this client? Check vital signs every 4 hours Administer prophylactic drug therapy Monitor for abnormal laboratory values Perform frequent and thorough handwashing

Perform frequent and thorough handwashing (The most effective nursing action to reduce the risk for sepsis in a client with sickle cell anemia is to perform frequent and thorough handwashing. Prevention and early detection strategies are used to protect the client in sickle cell crisis from infection. Frequent and thorough handwashing is of the utmost importance.Taking vital signs every 4 hours will help with early detection of infection but is not prevention. Drug therapy is a major defense against infections that develop in the client with sickle cell disease but is not the most effective way that the nurse can reduce the potential for sepsis. Continually assessing the client for infection and monitoring the daily complete blood count with differential white blood cell count is early detection, not prevention.)

A patient is questioning the nurse about circulation and perfusion. What is the nurse's best response? Perfusion assists the body by preventing clots and increasing stamina. Perfusion assists the cell by delivering oxygen and removing waste products. Perfusion assists the heart by increasing the cardiac output. Perfusion assists the brain by increasing mental alertness.

Perfusion assists the cell by delivering oxygen and removing waste products. (Perfusion delivers much needed oxygen to the cells of the body and then helps to remove waste products. Perfusion does not prevent clots, does not increase cardiac output, and does not increase mental alertness.)

Which manifestations may indicate a client has systemic lupus erythematosus (SLE)? Select all that apply. Pericarditis Esophagitis Fibrotic skin Discoid lesions Pleural effusions

Pericarditis Discoid lesions Pleural effusions (SLE is a chronic, progressive inflammatory connective tissue disorder that can cause major organs and systems to fail. Pericarditis is a cardiovascular manifestation of SLE. Discoid lesion is a skin manifestation that is a key indicator of the presence of SLE. Pleural effusion, a pulmonary manifestation, is a key indicator of the presence of SLE. Esophagitis is one of the gastrointestinal manifestations of systemic sclerosis. Fibrotic skin is one of the skin manifestations of systemic sclerosis.)

A cleansing enema is ordered for a client who is scheduled to have colon surgery. What is the rationale for this procedure? Surgical clients routinely are given a cleansing enema. Cleansing enemas are given before surgery at the client's request. There will be less flatus and discomfort postoperatively. Peristalsis does not return for 24 to 48 hours after surgery.

Peristalsis does not return for 24 to 48 hours after surgery. (If the client is scheduled for gastrointestinal tract surgery, a cleansing enema is usually ordered. Peristalsis does not return for 24 to 48 hours after the bowel is handled, so preoperative cleansing helps decrease postoperative constipation.)

Which adverse effect can result if tetracycline is administered to children younger than 8 years of age? Delayed growth development Drug-induced neurotoxicity Permanent discoloration of the teeth Gastrointestinal (GI) and rectal bleeding

Permanent discoloration of the teeth (Tetracycline is contraindicated in children younger than 8 years of age because it can cause permanent discoloration of the adult teeth and tooth enamel, which are still forming in the child.)

A nurse is assessing a patient who presented to the ED with priapism. The student nurse is aware that this condition is classified as a urologic emergency because of the potential for what? Urinary tract infection Chronic pain Permanent vascular damage Future erectile dysfunction

Permanent vascular damage (The ischemic form of priapism, which is described as nonsexual, persistent erection with little or no cavernous blood flow, must be treated promptly to prevent permanent damage to the penis. Priapism has not been indicated in the development of UTIs, chronic pain, or erectile dysfunction.)

If sterile gauze falls to the ground and hits the front of the surgeon's gown on the way down, what does the nurse do to ensure proper infection control? Helps the surgeon change the gown Picks the gauze up with a pair of sterile gloves Picks the gauze up without touching the surgeon Sprays an antimicrobial on the surgeon's gown

Picks the gauze up without touching the surgeon (To ensure proper infection control, the nurse picks up the gauze without touching the surgeon. The surgeon is sterile, but the gauze is now nonsterile and must be removed and counted.A sterile gauze touching a sterile gown does not require a gown change. Sterile gloves are not needed to pick up the gauze. An antimicrobial spray is inappropriate in this situation.)

A nurse is teaching a preoperative client about postoperative breathing exercises. Which information should the nurse include? Select all that apply. Take short, frequent breaths Exhale with the mouth open wide Perform the exercises twice a day Place a hand on the abdomen while feeling it rise Hold the breath for several seconds at the height of inspiration

Place a hand on the abdomen while feeling it rise Hold the breath for several seconds at the height of inspiration (Abdominal breathing improves lung expansion because it makes the contraction of the diaphragm more efficient. Placing the hand on the abdomen to watch it rise provides feedback, ensuring that abdominal rather than intercostal breathing is accomplished. Holding the breath for several seconds at the height of inspiration allows several additional seconds for oxygen and carbon dioxide to exchange in the alveoli. Short breaths do not expand the lungs; deep, slow breaths should be encouraged. Exhalation with pursed lips, not with an open mouth, promotes exhalation of air from the lung and minimizes trapping of air in the alveoli. Breathing exercises should be performed at least every two hours.)

A client states he has a latex allergy. What action should the nurse take? Inform the client to tell the anesthesiologist Have the client take a Benadryl before surgery Send the client to the OR with epinephrine Place an allergy identification band

Place an allergy identification band (Assist client with allergies to medications, food, and latex before the surgical procedure, and clearly mark them on the client record and on the client identification band.)

What nursing action is essential when a client experiences hemianopsia as the result of a left ischemic stroke? Place objects within the visual field. Teach passive range-of-motion exercises. Instill artificial teardrops into the affected eye. Reduce time client is positioned on the left side.

Place objects within the visual field. (A stroke in the left hemisphere will lead to a loss of the right visual field of each eye; objects should be placed within the client's view. Passive range-of-motion exercises, artificial teardrops, and reducing time client is positioned on the left side are not related to hemianopsia.)

A client receives a prescription for nitroglycerin sublingual as needed for anginal pain. What should the nurse include in the teaching about this medication? Place the tablet under the tongue or between the cheek and gum. It takes 30 to 45 minutes for the nitroglycerin to achieve its effect. If dizziness occurs, take a few deep breaths and lean the head back. To facilitate absorption, drink a large glass of water after taking the medication.

Place the tablet under the tongue or between the cheek and gum. (Nitroglycerin sublingual tablets should not be chewed, crushed, or swallowed. They work much faster when absorbed through the lining of the mouth. Clients are instructed to place the tablet under the tongue or between the cheek and gum and let it dissolve. The client should not eat, drink, smoke, or use chewing tobacco while a tablet is dissolving; this will decrease the effectiveness of the drug. If taken with water, the tablet is washed away from the site of absorption or may be swallowed. Nitroglycerin sublingual tablets usually give relief in 1 to 5 minutes. If a client experiences dizziness or lightheadedness, the client is instructed to take several deep breaths and bend forward with the head between the knees. This position promotes blood flow to the head.)

Which is the priority intervention for the dependent client with peptic ulcer disease (PUD) who is vomiting bright red blood? Apply oxygen Place the client in a side-lying position Prepare to administer packed red blood cells Assess the client's pulse and blood pressure

Place the client in a side-lying position (Recall the airway, breathing, and circulation (ABCs) of priority care. The client who needs assistance to manage self-care (dependent) should be placed in the side-lying position when vomiting to prevent aspiration. The use of supplemental oxygen may support oxygen saturation in the client with decreased hemoglobin because of gastrointestinal bleeding. However, in the dependent client who is vomiting, applying oxygen is of lower priority than placing the client in a side-lying position. The nurse should anticipate a prescription for packed red blood cells in the client with a significant gastrointestinal bleed. Restoring circulation, however, is of lower priority than protecting the airway in a dependent client whose airway is at risk. The immediate physical examination of the client with active gastrointestinal bleeding includes evaluation of vital signs as a means of assessing for shock. Assessing for adequate circulation does not take priority over protecting the airway.)

Which action will the nurse include in the plan of care for a 42-year-old patient who is being admitted with Clostridium difficile? Educate the patient about proper food storage. Order a diet with no dairy products for the patient. Place the patient in a private room on contact isolation. Teach the patient about why antibiotics will not be used.

Place the patient in a private room on contact isolation. (Because C. difficile is highly contagious, the patient should be placed in a private room and contact precautions should be used. There is no need to restrict dairy products for this type of diarrhea. Metronidazole (Flagyl) is frequently used to treat C. difficile. Improper food handling and storage do not cause C. difficile.)

After several days of antibiotic therapy, an older hospitalized patient develops watery diarrhea. Which action should the nurse take first? Notify the health care provider. Obtain a stool specimen for analysis. Teach the patient about handwashing. Place the patient on contact precautions.

Place the patient on contact precautions. (The patient's history and new onset diarrhea suggest a C. difficile infection, which requires implementation of contact precautions to prevent spread of the infection to other patients. The other actions are also appropriate but can be accomplished after contact precautions are implemented.)

How does the nurse explain physiologic anemia to a pregnant client? Erythropoiesis decreases. Plasma volume increases. Utilization of iron decreases. Detoxification by the liver increases.

Plasma volume increases. (There is a 30% to 50% increase in maternal plasma volume at the end of the first trimester, leading to hemodilution and a decrease in the concentrations of hemoglobin and erythrocytes. Erythropoiesis increases after the first trimester. Iron utilization is unrelated to the development of physiologic anemia of pregnancy. Detoxification demands are unchanged during pregnancy.)

A client is receiving unfractionated heparin (UFH) by infusion. Of which finding does the nurse notify the primary health care provider (PCP)? Partial thromboplastin time (PTT) 60 seconds Platelets 32,000/mm³ (32 × 109/L) White blood cells 11,000/mm³ (11 × 109/L) Hemoglobin 12.2 g/dL (122 mmol/L)

Platelets 32,000/mm³ (32 × 109/L) (When caring for a client receiving UFH, the nurse notifies the PCP of a platelet level of 32,000/mm³ (32 × 109/L). UFH can decrease platelet counts. The PCP must be notified if the platelet count is below 100,000 to 120,000/mm³ (100 to 120 × 109/L). Heparin-induced thrombocytopenia, an immune disorder, presents with platelets less than 150,000/mm³ (150 × 109/L).A 60-second PTT reflects a therapeutic value within 1.5 to 2 times the normal value. Mild leukocytosis (increased white blood cells) may be expected with deep vein thrombosis. A hemoglobin of 12.2 g/dL (122 mmol/L) reflects a normal reading.)

After gastric surgery, a client arrives in the post-anesthesia care unit. Which nursing action is most appropriate for the RN to delegate to an experienced nursing assistant? Monitor respiratory rate and airway patency. Irrigate the nasogastric tube with saline. Position the client on the left side. Assess the client's pain level.

Position the client on the left side. (Positioning the client on the left side would most likely be delegated to an experienced, unlicensed care provider.Airway patency requires the care of a nurse in case of emergency management requirements. Irrigating the nasogastric tube with saline is a nursing skill and care by a nurse would be required. Pain assessment is also within the scope of a nurse.)

A client presents to the Emergency Department from an assisted living facility after a ground level fall with a head strike. The client has a Glasgow Coma Score (GCS) of 12, which is decreased for this client, and has projectile vomiting. What is the priority intervention for this client? Calling the Stroke Team Establishing an IV Positioning the client to prevent aspiration Preparing for thrombolytic administration

Positioning the client to prevent aspiration (Positioning the client while maintaining cervical spine immobilization to prevent aspiration is the nurse's priority intervention. Maintaining a patent airway is essential especially since this client is vomiting.Calling the Stroke Team would not be necessary. Establishing an IV is important for this client but it is not the first priority. If this client was having a stroke, thrombolytics would be contraindicated because of the fall with head strike.)

An intensive care client with diabetic ketoacidosis (DKA) is receiving an insulin infusion. When the cardiac monitor shows ventricular ectopy, which assessment will the nurse make? Urine output 12-lead electrocardiogram (ECG) Potassium level Rate of IV fluids

Potassium level (After DKA therapy starts, serum potassium levels drop quickly. An ECG shows conduction changes and ectopy related to alterations in potassium. Hypokalemia is a common cause of death in the treatment of DKA. Detecting and treating the underlying cause of the ectopy is essential.Ectopy is not associated with changes in urine output even though hyperglycemia will cause osmotic diuresis. A 12-lead ECG can verify the ectopy, but the priority is to detect and fix the underlying cause, which is most likely hypokalemia. Increased fluids treat the symptoms of dehydration secondary to DKA, but do not treat the hypokalemia.)

A nurse is caring for an older adult who has been experiencing severe Clostridium difficile-related diarrhea. When reviewing the patient's most recent laboratory tests, the nurse should prioritize which of the following? White blood cell level Creatinine level Hemoglobin level Potassium level

Potassium level (In elderly patients, it is important to monitor the patient's serum electrolyte levels closely. Diarrhea is less likely to cause an alteration in white blood cell, creatinine, and hemoglobin levels.)

A patient is admitted for hip surgery. The patient usually takes the following medications daily: an anticoagulant, a multivitamin, and vitamin E 1,500 IU. He stopped taking his anticoagulant 4 days ago as instructed by his surgeon, but has continued to take the multivitamin and vitamin E. An important collaborative problem or nursing diagnosis for this patient is which of the following? Potential complication: anemia Risk for infection related to inadequate anticoagulant dosage Risk for noncompliance related to inability to follow instructions Potential complication: increased bleeding

Potential complication: increased bleeding (The patient is at an increased risk for bleeding due to his intake of vitamin E. He may be at risk for anemia if he experiences a large blood loss in surgery; however, this problem is not appropriate before he experiences the blood loss. This patient does not have a higher-than-average risk for infection because he is not having surgery involving a "contaminated" system (e.g., the gastrointestinal system). There is no evidence to suggest that this is noncompliant simply he because he stopped taking his anticoagulant as ordered.)

The nurse is providing ancillary personnel with instructions regarding the proper methods to implement when caring for a client with a Clostridium difficile infection. Which of the following practices will have the greatest impact on containment of the bacteria and thus prevention of cross-contamination? Frequent in-services on transmission modes of C. difficile Practice of proper hand hygiene by all staff Appropriate handling of contaminated linen Stool cultures on all suspected carriers

Practice of proper hand hygiene by all staff (Poor hand hygiene and erratic disinfection practices result in the transmission of C. difficile. Stool cultures are useful in the diagnosis, not the prevention, of C. difficile. Although the other options are appropriate, they do not have the most impact on preventing the spread of these bacteria.)

A client on immunosuppressive therapy is diagnosed with a peptic ulcer. Which medication might have led to this condition? Prednisone Azathioprine Cyclosporine Cyclophosphamide

Prednisone (Prednisone is a corticosteroid that suppresses inflammatory responses. A side effect of prednisone is the development of peptic ulcers. Azathioprine is an immunosuppressant that may cause anemia. Cyclosporine is an immunosuppressant that may cause nephrotoxicity and hypertension. Cyclophosphamide is an immunosuppressant that may cause hemorrhagic cystitis.)

The focus of nursing activities in the preoperative phase is to: Admit the patient to the surgical suite. Prepare the patient mentally and physically for surgery. Set up the sterile field in the operating room. Perform the primary surgical scrub to the surgical site.

Prepare the patient mentally and physically for surgery. (The nursing focus in the preoperative phase is to prepare the patient mentally and physically for surgery. The patient is in the intraoperative phase when admitted to the surgical suite. The sterile field and the surgical scrub would be performed in the surgery suite during the intraoperative phase.)

The community/public health nurse invites a dietitian to a healthy lifestyles program to discuss fun ways to eat vegetables and fruits as snacks. Which of the following best describes this nursing intervention? Disability limitation Primary prevention Secondary prevention Tertiary prevention

Primary prevention (This intervention would be considered primary prevention, as poor eating habits may lead to obesity and chronic diseases such as diabetes later in life.)

The nurse should teach a client about which antiemetic commonly used to prevent motion sickness? Prochlorperazine (Compazine) Droperidol (Inapsine) Metoclopramide (Reglan) Scopolamine (Transderm-Scōp)

Prochlorperazine (Compazine) (Scopolamine has potent effects on the vestibular nuclei, which are located in the area of the brain that controls balance. These effects make scopolamine one of the most commonly used drugs for the treatment and prevention of nausea and vomiting associated with motion sickness.)

Before emergency surgery, the nurse would anticipate administering which medication to a patient receiving heparin? Vitamin K (Phytonadione) Protamine (Protamine sulfate) Phenytoin (Dilantin) Vitamin E

Protamine (Protamine sulfate) (Protamine sulfate binds with heparin in the bloodstream to inactivate it and thus reverse its effect.)

A client is admitted to the hospital with a diagnosis of deep vein thrombosis, and intravenous (IV) heparin sodium is prescribed. If the client experiences excessive bleeding, what should the nurse be prepared to administer? Vitamin K Oprelvekin Warfarin sodium Protamine sulfate

Protamine sulfate (Protamine sulfate binds with heparin sodium to form a physiologically inert complex; it corrects clotting deficits. Vitamin K counteracts the effects of drugs like warfarin sodium (Coumadin). Oprelvekin is a thrombopoietic growth factor that stimulates the production of platelets. It would not be appropriate for emergency management. Warfarin sodium is an oral anticoagulant that interferes with the synthesis of prothrombin.)

When educating a client in the postoperative period, it is important to educate the client to consume a diet high in Protein Calcium Bicarbonate Potassium

Protein (After surgery, a diet with sufficient amounts of protein and vitamins A and C helps rebuild tissues and promotes wound healing.)

The nurse is caring for a client who is in sickle cell crisis. What action would the nurse perform first? Provide pain medications as needed. Apply cool compresses to the client's forehead. Increase food sources of iron in the client's diet. Encourage the client's use of two methods of birth control.

Provide pain medications as needed. (The action the nurse would perform first for a client in sickle cell crisis is to provide pain medications as needed. Analgesics are needed to treat sickle cell pain.Cool compresses do not help the client in sickle cell crisis. Birth control is not the priority for this client. Increasing iron in the diet is not pertinent for the client in sickle cell crisis.)

A client has undergone bariatric surgery. Which nursing intervention is the highest priority in preventing dehydration in this client? Ambulating the client as quickly as possible after surgery Applying an abdominal binder daily when the client is out of bed Observing for tachycardia, nausea, diarrhea, and abdominal cramping Providing six small feedings daily and offering fluids frequently

Providing six small feedings daily and offering fluids frequently (The nursing intervention with the highest priority to prevent dehydration in a post-operative bariatric client is small daily feedings and adequate fluids. This will prevent the development of dehydration in this client.Ambulation will prevent pulmonary embolism and other circulatory problems. An abdominal binder will help support the abdomen and may prevent dehiscence of the wound. Observing for tachycardia, nausea, diarrhea, and abdominal cramping will prevent the development of postoperative dumping syndrome. All of these interventions are important, but preventing dehydration is the priority.)

Five RNs from other units have been assigned to the post-anesthesia care unit for the day. A 16-year-old client with diabetes has also just arrived from the operating room (OR) after having laparoscopic abdominal surgery. The charge nurse assigns the RN with which kind of experience to care for this new client? RN who usually works on the inpatient pediatric unit RN who provides education to diabetic clients in a clinic RN who has 5 years of experience in the delivery room RN who ordinarily works as a scrub nurse in the OR

RN who has 5 years of experience in the delivery room (The RN with delivery room experience would have experience with abdominal surgery and with postoperative care of clients with diabetes, and would be aware of possible postoperative complications for this client.The RN who usually works on the pediatric unit would not be aware of potential complications and routine assessments for this client. The RN who provides education to diabetic clients in a clinic would be able to provide required care for the client's diabetes but not the postoperative aspect of care. The RN who works as a scrub nurse would not have the knowledge and understanding of routine postoperative care that is needed for this client.)

A client scheduled for major surgery will receive general anesthesia. Why is inhalation anesthesia often used to provide the desired actions? Rapid excretion and reversal of effects Safe administration in the client's own room Involves only the respiratory system and skin Slow onset of action and maintains reflexes

Rapid excretion and reversal of effects (General anesthesia involves the administration of drugs by inhalation and intravenous routes to produce central nervous system depression. Inhalation anesthesia is often used because it has the advantage of rapid excretion and reversal of effects.)

A client came to the clinic with erectile dysfunction. What are some possible causes of this condition that the nurse could discuss with the client during history taking? (Select all that apply.) Recent prostatectomy Long-term hypertension Diabetes mellitus Hour-long exercise sessions Consumption of beer each night

Recent prostatectomy Long-term hypertension Diabetes mellitus Consumption of beer each night (Organic erectile dysfunction can be caused by surgical procedures, hypertension and its treatment, diabetes mellitus, and alcohol consumption. There is no evidence that exercise is related to this problem.)

For a patient receiving an IV infusion of alteplase (Activase), which nursing actions should be taken? (Select all that apply.) Record vital signs and report changes. Assess for cardiac dysrhythmias. Observe for signs and symptoms of bleeding. Administer injections intramuscularly. Monitor for an increase in liver enzymes.

Record vital signs and report changes. Assess for cardiac dysrhythmias. Observe for signs and symptoms of bleeding. (Alteplase can cause bleeding as well as cardiac dysrhythmias. Vital sign changes can alert the nurse to these complications. Alteplase does not directly affect liver enzymes. Injections should not be administered intramuscularly because of the increased risk of bleeding.)

The nurse assesses a client's wound 24 hours postoperatively. Which finding causes the nurse the greatest concern and should be reported to the surgeon? Crusting along the incision line Redness and swelling around the incision Sanguineous drainage at the suture site Serosanguineous drainage on the dressing

Redness and swelling around the incision (The nurse's greatest concern is redness and swelling around the incision. This needs to be reported to the surgeon because these signs could indicate an infection.Crusting along the incision line, sanguineous drainage, and serosanguineous drainage are normal.)

An obese client with a body mass index of 30 and hypertension has been taking prescription orlistat for 4 weeks and reports loose stools, abdominal cramps, and nausea. What does the nurse recommend for this client? Asking the provider to change the medication to phendimetrazine (Bontril). Changing to the lower dose, over-the-counter form of orlistat to reduce these effects. Increasing the daily activity level to improve overall metabolism. Reducing nutritional fat intake to less than 30% of the client's daily food intake.

Reducing nutritional fat intake to less than 30% of the client's daily food intake. (The nurse recommends reducing nutritional fat intake to less than 30% of the client's daily food intake. Loose stools, abdominal cramps, and nausea are common side effects of orlistat and can be reduced by decreasing fat intake.Unless side effects persist or become more severe, it is not necessary to change the medication. Reducing the dose of orlistat does not affect these symptoms, since they are dependent on fat intake. Increasing the daily activity level helps with weight loss, but does not reduce side effects of Orlistat.)

A nurse is caring for a client who recently is diagnosed with a gastric ulcer. The nurse expects that the plan of care will include a prescription for which type of diet? Soft diet Low-fat, high-protein liquid diet Hourly feedings of dairy products Regular diet with foods that are tolerated

Regular diet with foods that are tolerated (No specific diet is recommended; the client is encouraged to avoid meals that overdistend the stomach and foods that cause gastrointestinal (GI) distress. There is no need for a soft diet; a soft diet is appropriate for those who have difficulty with chewing and swallowing. The client does not require a liquid diet. High-fat dairy products increase GI secretions and may not be tolerated by some clients.)

A nurse in the postanesthesia care unit (PACU) is providing care to a client who had an abdominal cholecystectomy and observes serosanguineous drainage on the abdominal dressing. What is the next nursing action? Change the dressing. Reinforce the dressing. Replace the tape with Montgomery ties. Support the incision with an abdominal binder.

Reinforce the dressing. (The nurse should anticipate drainage and reinforce the surgical dressing as needed. Changing a dressing at this time is unnecessary and increases the risk for infection. Montgomery ties are used when frequent dressing changes are anticipated; they are not appropriate at this time. An abdominal binder rarely is prescribed, and it will interfere with assessment of the dressing at this time.)

What nursing action will assist in pain management for a client in the postoperative phase? Client teaching Relaxation techniques Dim lighting Provide food and medication

Relaxation techniques (Nursing interventions vital in helping clients cope with pain include administering medications, positioning, relaxation techniques, psychological support, distraction techniques, and appropriate referrals to other health professionals.)

What does a nurse who is caring for a client experiencing anginal pain expect to observe about the pain? Unchanged by rest Precipitated by light activity Described as a knifelike sharpness Relieved by sublingual nitroglycerin

Relieved by sublingual nitroglycerin (Relief by sublingual nitroglycerin is a classic reaction because it dilates coronary arteries, which increases oxygen to the myocardium, thus decreasing pain. Immediate rest frequently relieves anginal pain. Angina usually is precipitated by exertion, emotion, or a heavy meal. Angina usually is described as tightness, indigestion, or heaviness.)

A patient who has recently undergone ESWL for the treatment of renal calculi has phoned the urology unit where he was treated, telling the nurse that he has a temperature of 101.1ºF (38.4ºC). How should the nurse best respond to the patient? Remind the patient that renal calculi have a noninfectious etiology and that a fever is unrelated to their recurrence. Remind the patient that occasional febrile episodes are expected following ESWL. Tell the patient to report to the ED for further assessment. Tell the patient to monitor his temperature for the next 24 hours and then contact his urologist's office.

Remind the patient that renal calculi have a noninfectious etiology and that a fever is unrelated to their recurrence. (Following ESWL, the development of a fever is abnormal and is suggestive of a UTI; prompt medical assessment and treatment are warranted. It would be inappropriate to delay further treatment.)

A patient with sleep apnea who uses a continuous positive airway pressure (CPAP) device is preparing to have inpatient surgery. Which instructions should the nurse provide to the patient? Remind the patient to take the CPAP device to the hospital. Plan to schedule a nighttime polysomnography (PSG) study before surgery. Discourage the patient from requesting pain medication while hospitalized. Call the hospital to ensure that mechanical ventilation will be available for the patient.

Remind the patient to take the CPAP device to the hospital. (The patient should be told to take the CPAP device to the hospital if an overnight stay is expected. Many patients will be able to use their own CPAP equipment, but hospital policy should be checked to make sure it can be used. Patients should be treated for pain and monitored for respiratory depression. Another PSG is not required before surgery. There is no need to call the hospital if the patient takes the CPAP device to the hospital.)

A 58-year-old woman is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires An access route to administer medications intravenously Replacement of fluids for those lost from vomiting and diarrhea An access route to replace fluids in combination with blood products Intravenous fluids to be administered on an outpatient basis

Replacement of fluids for those lost from vomiting and diarrhea (The therapeutic goal may be maintenance, replacement, treatment, diagnosis, monitoring, palliation, or a combination. This patient requires intravenous fluids for replacement of those lost from vomiting and diarrhea.)

The nurse is assessing a patient who has been admitted to the emergency department for a possible opioid overdose. Which assessment finding is characteristic of an opioid drug overdose? Dilated pupils Restlessness Respiration rate of 6 breaths/min Heart rate of 55 beats/min

Respiration rate of 6 breaths/min (The most serious adverse effect of opioid use is CNS depression, which may lead to respiratory depression. Pinpoint pupils, not dilated pupils, are seen. Restlessness and a heart rate of 55 beats/min are not indications of an opioid overdose.)

Which of the following are potential complications of anesthesia? Choose all that apply. Hypothermia Respiratory depression Cardiovascular compromise Aspiration

Respiratory depression Cardiovascular compromise Aspiration (Hypothermia is a potential complication of surgery. It is not induced by anesthesia.)

When assessing for the MOST serious adverse effect to an opioid analgesic, what does the nurse monitor for in this patient? Blood pressure Respiratory rate Mental status Heart rate

Respiratory rate (The most serious adverse effect of opioid analgesics is respiratory depression.)

Which assessment finding in a postoperative client after general anesthesia requires immediate intervention? Heart rate of 58 beats/min Pale, cool extremities Respiratory rate of 6 breaths/min Suppressed gag reflex

Respiratory rate of 6 breaths/min (The most immediate postoperative assessment is respiratory assessment, and a rate less than 10 breaths/min is too low.A heart rate of 58 beats/min, pale and cool extremities, and a suppressed gag reflex are all normal postoperative findings.)

Which of the following would be most important for the nurse to monitor in a patient who has obstructive sleep apnea? Gastrointestinal function Circulatory status Respiratory status Neurological function

Respiratory status (In obstructive sleep apnea, the upper airway becomes partially or completely blocked, diminishing airflow and stopping it. The person still attempts to breathe because the chest and abdominal movement continue, which results in loud snoring and snorting sounds. According to the ABCs of prioritizing care, airway and respiratory status take priority.)

What should the nurse teach the client with gastroesophageal reflux disease to do after meals? Drink 8 ounces (240 mL) of water Take a walk for 30 minutes Lie down for at least 20 minutes Rest in a sitting position for one hour

Rest in a sitting position for one hour (Gravity facilitates digestion and prevents reflux of stomach contents into the esophagus. Water should not be taken with or immediately after meals because it overdistends the stomach. Exercise immediately after eating may prolong the digestive process. Lying down immediately after eating facilitates reflux of the stomach contents into the esophagus.)

The nurse on a urology unit is working with a patient who has been diagnosed with oxalate renal calculi. When planning this patient's health education, what nutritional guidelines should the nurse provide? Restrict protein intake as ordered. Increase intake of potassium-rich foods. Follow a low-calcium diet. Encourage intake of food containing oxalates.

Restrict protein intake as ordered. (Protein is restricted to 60 g/d, while sodium is restricted to 3 to 4 g/d. Low-calcium diets are generally not recommended except for true absorptive hypercalciuria. The patient should avoid intake of oxalate-containing foods and there is no need to increase potassium intake.)

A patient who had surgery for gallbladder disease has just returned to the postsurgical unit from postanesthetic recovery. The nurse caring for this patient knows to immediately report what assessment finding to the physician? Decreased breath sounds Drainage of bile-colored fluid onto the abdominal dressing Rigidity of the abdomen Acute pain with movement

Rigidity of the abdomen (The location of the subcostal incision will likely cause the patient to take shallow breaths to prevent pain, which may result in decreased breath sounds. The nurse should remind patients to take deep breaths and cough to expand the lungs fully and prevent atelectasis. Acute pain is an expected assessment finding following surgery; analgesics should be administered for pain relief. Abdominal splinting or application of an abdominal binder may assist in reducing the pain. Bile may continue to drain from the drainage tract after surgery, which will require frequent changes of the abdominal dressing. Increased abdominal tenderness and rigidity should be reported immediately to the physician, as it may indicate bleeding from an inadvertent puncture or nicking of a major blood vessel during the surgical procedure.)

A preoperative assessment finds a client to be 75 pounds overweight. The client is to have abdominal surgery. What nursing diagnosis would be appropriate based on the client's weight? Risk for Aspiration Risk for Imbalanced Body Temperature Risk for Infection Risk for Falls

Risk for Infection (Fatty tissue in obese clients has a poor blood supply and, therefore, has less resistance to infections. Postoperative complications of delayed wound healing, wound infection, and disruption of the wound are more common in obese clients.)

Which nursing diagnosis is appropriate for a patient receiving famotidine (Pepcid)? Ineffective peripheral tissue perfusion related to hypertension Risk for infection related to immunosuppression Impaired urinary elimination related to retention Risk for injury related to thrombocytopenia

Risk for injury related to thrombocytopenia (A serious side effect of famotidine is thrombocytopenia, which is manifested by a decrease in platelet count and an increased risk of bleeding. The patient receiving famotidine may experience hypotension as an adverse effect, not hypertension. Famotidine does not cause immunosuppression or urinary retention.)

Which of the following problems is associated with obesity, heavy snoring, and shallow breathing? Sleep apnea Narcolepsy Hypersomnia Hyperpnea

Sleep apnea (Sleep apnea refers to recurrent periods of absence of breathing for 10 seconds or longer, occurring at least five times per hour.)

A nurse is teaching a community group about food poisoning and gastroenteritis. Which statements by the nurse are accurate? (Select all that apply.) Rotavirus is more common among infants and younger children. Escherichia coli diarrhea is transmitted by contact with infected animals. Don't drink water when swimming to prevent E. coli infection. All clients with botulism require hospitalization. Parasitic diseases may not show up for 1 to 2 weeks after infection.

Rotavirus is more common among infants and younger children. Don't drink water when swimming to prevent E. coli infection. All clients with botulism require hospitalization. Parasitic diseases may not show up for 1 to 2 weeks after infection. (Rotavirus is more common among the youngest of clients, not drinking water while swimming can help prevent E. coli infection, people with botulism need to be hospitalized to monitor for respiratory failure and paralysis, and parasitic diseases may take up to 2 weeks to become symptomatic. The other statements are not accurate.)

A client is being discharged following surgery for cancer care. The client will require extensive dressing changes two times per day. The client is on a fixed income and cannot afford to purchase dressing supplies. The nurse contacts the local Peregrine Society to assist in the provision of dressings. This contribution in care will assist in improving the client's Family relationships Return to daily activities Decision making Self-concept

Self-concept (In addition to providing the client with the necessary technical care, teaching, extensive rehabilitation, and emotional support, nursing interventions may also include referral to agencies and support groups that can benefit the client after surgery and discharge from the acute care facility.)

One month after abdominal surgery, a client is readmitted to the hospital with recurrent abdominal pain and fever. The medical diagnosis is fistula formation with peritonitis. The nurse should maintain the client in what position? Supine Right Sims Semi-Fowler The position that the client prefers

Semi-Fowler (Semi-Fowler position promotes localization of purulent material and inflammation and prevents an ascending infection. The risk of an ascending infection may be increased in the supine position because it allows fluid in the abdominal cavity to bathe the entire peritoneum. The risk of an ascending infection may be increased in the right Sims position because it allows fluid in the abdominal cavity to bathe the entire peritoneum. The client may prefer a position that increases the risk of an ascending infection.)

A client with a rigid and painful abdomen is diagnosed with a perforated peptic ulcer. A nasogastric tube is inserted, and surgery is scheduled. Before surgery, the nurse should place the client in what position? Sims Flat-lying Semi-Fowler Dorsal recumbent

Semi-Fowler (The semi-Fowler position will localize the spilled stomach contents in the lower part of the abdominal cavity. The Sims position will exert pressure on the abdomen, which may be uncomfortable for the client. Lying flat in bed exerts pressure against the diaphragm from abdominal organs; this will inhibit breathing and intensify discomfort. Also, it allows spilled stomach contents to spread throughout the abdominal cavity. The dorsal recumbent position exerts pressure against the diaphragm from abdominal organs; this will inhibit breathing and intensify discomfort. Also, this position allows spilled stomach contents to spread throughout the abdominal cavity.)

Which of the following is the most appropriate nursing goal for a 2-year-old who is to have a tonsillectomy? Separation anxiety will be minimal. The child will verbalize understanding of expected pain. The child will tolerate a normal diet 24 hours after surgery. The parent will indicate readiness to assume the child's care.

Separation anxiety will be minimal. (The only concrete information in this question is that the child is 2 years old. Therefore, the only problem the nurse can reasonably predict from this would be developmental in nature. It is developmentally normal for toddlers to experience anxiety with separation from parents or caregivers. Minimizing anxiety by involving the parents or caregivers would be the appropriate goal for separation anxiety. A 2-year-old child would not be expected to verbalize understanding of expected pain. The toddler would take liquids and soft foods within the first 24 hours when her throat is sore during swallowing. She should not eat foods that are rough and crunchy because they may scratch her throat and cause bleeding. Nurses should encourage parental involvement, but parents should not be expected to assume the child's care.)

The client is returned to the surgical unit from the postanesthesia care unit (PACU) after a having a splenectomy. In the immediate postoperative period, the nurse specifically should monitor for which potential complications? Select all that apply. Shock Infection Intestinal obstruction Abdominal distention Pulmonary complications

Shock Abdominal distention Pulmonary complications (Because of its great blood supply and general fragility, the spleen may hemorrhage, causing shock and abdominal distention. Pulmonary complications may occur because the spleen is close to the diaphragm, resulting in defensive shallow breathing and the effects of anesthesia. The immediate postoperative period is too soon for the client to exhibit signs of infection. An intestinal obstruction is not associated with a splenectomy.)

Which symptom reported by a client who has had a total hip replacement requires emergency action? Localized swelling of one of the lower extremities Positive Homans' sign Shortness of breath and chest pain Tenderness and redness at the IV site

Shortness of breath and chest pain (Emergency action is needed when the postoperative total hip replacement client reports shortness of breath and cheat pain. Shortness of breath and chest pain indicate a possible pulmonary embolism (PE), which can be life threatening. Orthopedic procedures create high risk for deep vein thrombosis (DVT) and PE.Although localized swelling is a symptom of DVT, it is not emergent. Pain in the calf on dorsiflexion of the foot (positive Homans' sign) appears in only a small percentage of clients with DVT, and false-positive findings are common, so assessing for Homans' sign is not advised. Tenderness and redness at the IV site indicate phlebitis and are not emergent, but must be attended to after the emergency.)

How does the nurse position a client with postoperative nausea and vomiting? Flat in bed, with the head in alignment with the body Prone, with the head of the bed flat Side-lying, with the head in a neutral position Supine in bed, with the neck flexed

Side-lying, with the head in a neutral position (The side-lying position with the client's head in a neutral position helps reduce postoperative nausea and vomiting.The flat-in-bed position with the head in alignment is not a neutral position. The prone position with the head of the bed flat is unnatural, as is the supine position with the neck flexed.)

A nurse has been asked to ensure informed consent for a surgical procedure. What might be a role of the nurse? Securing informed consent from the client Signing the consent form as a witness Ensuring the client does not refuse treatment Refusing to participate based on legal guidelines

Signing the consent form as a witness (The responsibility for securing informed consent from the client lies with the person who will perform the procedure, usually the physician. The nurse may sign as a witness, signifying that the client signed the consent form without coercion, and was alert and aware of the act.)

Which vascular assessment by the student nurse requires intervention by the supervising nurse? Measuring capillary refill in the fingertips Assessing pedal pulses by Doppler Measuring blood pressure in both arms Simultaneously palpating the bilateral carotids

Simultaneously palpating the bilateral carotids (The vascular assessment by the student that needs intervention by the supervisor nurse is simultaneously palpating the bilateral carotids. Carotid arteries are palpated separately because of the risk for inadequate cerebral perfusion and the risk for causing the client to faint.Prolonged capillary filling generally indicates poor circulation, and is an appropriate assessment. Many clients with vascular disease have poor blood flow. Pulses that are not palpable may be heard with a Doppler probe. Because of the high incidence of hypertension in clients with atherosclerosis, blood pressure is assessed in both arms.)

The nurse is teaching treatment of acute chest pain for a patient prescribed nitroglycerin (Nitrostat) sublingual tablets. Which instructions should the nurse include? Keep the tablets locked in a safe place until you need them. Chew or swallow the tablet for the quickest effect. Take five tablets every 3 minutes for chest pain. Sit or lie down before taking medication.

Sit or lie down before taking medication. (Nitroglycerin is a vasodilator and can cause orthostatic hypotension, resulting in dizziness. It should be kept in a readily accessible location for immediate use should chest pain occur. Three tablets may be taken 5 minutes apart. It should be placed under the tongue and allowed to dissolve.)

The nurse is creating a plan of care for an obese patient who is suffering from fatigue related to ineffective breathing. Which intervention best addresses a short-term goal that the patient could achieve? Running 30 minutes every morning Stopping smoking immediately Sleeping on two to three pillows at night Limiting the diet to 1500 calories a day

Sleeping on two to three pillows at night (To achieve a short-term goal, the nurse should plan a lifestyle change that the patient can make immediately that will have a quick effect. Sleeping on several pillows at night will immediately relieve orthopnea and open the patient's airway, thereby reducing sleep apnea and reducing fatigue. Running 30 minutes a day will improve cardiopulmonary health, but a patient needs to build up exercise tolerance. Smoking cessation is another process that many people have difficulty doing immediately. It often occurs as a slow progression, beginning with reduction of frequency. A more realistic short-term goal would be to gradually reduce the number of cigarettes smoked. Limiting caloric intake can help a patient lose weight, but this is a gradual process and is not reasonable for a short-term goal.)

A client has a large episode of diarrhea during an enteral feeding. What should be the first nursing action? Slow the feeding. Stop the feeding. Call the physician. Administer an antidiarrheal agent.

Slow the feeding. (The most common cause of diarrhea during a feeding is dumping syndrome as a result of rapid feed infusion. Slowing the feeding is the appropriate initial action.)

A nurse is caring for a client who is scheduled for a gastric bypass to treat morbid obesity. Which diet should the nurse teach the client to maintain because it will help minimize clinical manifestations of dumping syndrome? Low-residue, bland diet Fluid intake below 500 mL Small, frequent feeding schedule Low-protein, high-carbohydrate diet

Small, frequent feeding schedule (Small feedings reduce the amount of bulk passing into the jejunum and therefore reduce the fluid that shifts into the jejunum. Although a diet high in roughage may be avoided, a low-residue, bland diet is not necessary. Total fluid intake does not have to be restricted; however, fluids should not be taken immediately before, during, or after a meal because they promote rapid stomach emptying. Concentrated sweets pass rapidly out of the stomach and increase fluid shifts; the diet should be low in carbohydrates. Relatively high protein is needed to promote tissue repair.)

A client has just undergone a surgical procedure with general anesthesia. Which finding indicates that the client needs further assessment in the post-anesthesia care unit? Pain at the surgical site Requirement for verbal stimuli to awaken Snoring sounds when inhaling Sore throat on swallowing

Snoring sounds when inhaling (Snoring sounds when inhaling may indicate respiratory depression.Postsurgical pain at the surgical site is normal. Requiring verbal stimuli to awaken and a sore throat on swallowing are normal post-sedation.)

The nurse is reviewing the medication history for a client diagnosed with rheumatoid arthritis (RA) who has been ordered to start sulfasalazine (Azulfidine) therapy. The nurse plans to contact the health care provider if the client has which condition? Glaucoma Hypertension Hypothyroidism Sulfa allergy

Sulfa allergy (Sulfasalazine contains sulfa and is contraindicated in clients with sulfa allergies.)

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? Administer acetaminophen (Tylenol) 650 mg rectally. Draw blood for a complete blood count and serum electrolytes. Obtain a stool specimen for culture and sensitivity. Start an IV solution of 5% dextrose in 0.45 normal saline at 125 mL/hr.

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 patient is experiencing bleeding related to peptic ulcer disease (PUD). Which nursing intervention is the highest priority? Starting a large-bore IV Administering IV pain medication Preparing equipment for intubation Monitoring the patient's anxiety level

Starting a large-bore IV (The nursing intervention that has the highest priority for a patient with a bleeding peptic ulcer is to start a large-bore IV. A large-bore IV is inserted so that blood products can be administered.IV pain medication is not a recommended treatment for gastrointestinal bleeding. Intubation is also not recommended. The mental status of the patient would be monitored, but it is not necessary to monitor the anxiety level of the patient.)

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? Pain when coughing States, "I am too tired to walk very much" States, "I feel like the incision is splitting open" Temperature of 100.8°F (38.2°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 client newly diagnosed with type 2 diabetes is receiving glyburide and asks the nurse how this drug works. What mechanism of action does the nurse provide? Stimulates the pancreas to produce insulin Accelerates the liver's release of stored glycogen Increases glucose transport across the cell membrane Lowers blood glucose in the absence of pancreatic function

Stimulates the pancreas to produce insulin (Glyburide, an antidiabetic sulfonylurea, stimulates insulin production by the beta cells of the pancreas. Accelerating the liver's release of stored glycogen occurs when serum glucose drops below normal levels. Increasing glucose transport across the cell membrane occurs in the presence of insulin and potassium. Antidiabetic medications of the chemical class of biguanide improve sensitivity of peripheral tissue to insulin, which ultimately increases glucose transport into cells. Beta cells must have some function to enable this drug to be effective.)

A client is scheduled for a cholecystectomy and asks the primary nurse about the function of the gallbladder. What should the nurse identify is the function of the gallbladder when providing preoperative teaching? Stores and concentrates bile Releases bile into the pancreatic duct Connects the common bile duct and the pancreas Controls the flow of fat through the sphincter of Oddi

Stores and concentrates bile (The gallbladder concentrates and stores about 90 mL of bile, which is discharged in response to the entrance of fatty food into the duodenum. The gallbladder releases bile into the cystic duct. The common bile duct is connected directly to the pancreas. The sphincter of Oddi controls the release of bile into the duodenum; dietary fat progresses from the stomach to the duodenum and then to the rest of the intestinal tract.)

A client with type 2 diabetes controlled with Metformin is recovering from surgery. The primary health care provider has placed the client on insulin in addition to the metformin. What is the nurse's best response about why the client needs to take insulin? "Your diabetes is getting worse, so you will need to take insulin." "You can't take your metformin while in the hospital." Stress, such as surgery, increases blood glucose levels. You'll need insulin to control your blood glucose temporarily." "You must take insulin from now on because the surgery will affect your diabetes."

Stress, such as surgery, increases blood glucose levels. You'll need insulin to control your blood glucose temporarily." (The nurse's best response is that due to the stress of surgery and NPO status, short-term insulin therapy may be needed perioperatively for clients with diabetes who use oral antidiabetic agents. For those receiving insulin, dosage adjustments may be required until the stress of surgery subsides.No evidence suggests that the client's diabetes has worsened. However, surgery is stressful and may increase insulin requirements. Metformin may be taken in the hospital, but not on days when the client is NPO for surgery. When the client returns to his or her previous health state, oral agents will be resumed.)

The nurse is assessing a client with chest pain to evaluate whether the client is suffering from angina or myocardial infarction (MI). Which symptom is indicative of an MI? Substernal chest discomfort occurring at rest Chest pain brought on by exertion or stress Substernal chest discomfort relieved by nitroglycerin or rest Substernal chest pressure relieved only by opioids

Substernal chest pressure relieved only by opioids (Substernal chest pressure relieved only by opioids is typically indicative of MI.Substernal chest discomfort that occurs at rest is not necessarily indicative of MI, and it could be a sign of unstable angina. Both chest pain brought on by exertion or stress and substernal chest discomfort relieved by nitroglycerin or rest are indicative of angina.)

Which information should be included in the teaching plan for the elderly client with peptic ulcer disease who is taking an antacid and sucralfate? Antacids should be taken 30 minutes before a meal. Sucralfate should be taken on an empty stomach one hour before meals. Sucralfate is prescribed for the long-term maintenance of peptic ulcer disease. Sodium bicarbonate is an inexpensive over-the-counter antacid with few adverse effects.

Sucralfate should be taken on an empty stomach one hour before meals. (Sucralfate works best in a low pH environment; therefore it should be given on an empty stomach either one hour before or two hours after meals. Sucralfate also should be administered no sooner than 30 minutes before or after an antacid. The acid-neutralizing effects of antacids last approximately 30 minutes when taken on an empty stomach and 3 to 4 hours when taken after meals. When sucralfate and an antacid are both prescribed, they are each most effective when the sucralfate is scheduled an hour before meals and the antacid is scheduled after meals. Sucralfate is prescribed for the short-term treatment of peptic ulcers. Its use is limited to 4 to 8 weeks. The client should follow the recommendations of the primary health care provider with regard to antacid selection. Sodium bicarbonate can produce acid-base imbalances which could be harmful, especially in elderly clients.)

A client with Crohn disease is admitted to the hospital with abdominal pain, fever, poor skin turgor, and diarrhea, with 10 stools in the past 24 hours. Which signs are evidence that the client most likely is dehydrated? Select all that apply. Moist skin Sunken eyes Decreased apical pulse Dry mucous membranes Increased blood pressure

Sunken eyes Dry mucous membranes (Sunken eyes and loss of skin turgor occur because of decreased intracellular and interstitial fluid associated with dehydration. Dry mucous membranes occur because of decreased intracellular and interstitial fluid associated with dehydration. The skin will be dry, not moist, with dehydration. The first sign of dehydration usually is tachycardia. The blood pressure will decrease, not increase, because of hypovolemia.)

A client has an acute case of opioid depression and receives a dose of naloxone (Narcan). Which statement is true about this client? Supplemental pain reduction is needed. One dose is needed. This is an acute emergency. The client will be hostile.

Supplemental pain reduction is needed. (Supplemental pain reduction is needed. The client has breakthrough pain after the opioid antagonist is given, so other interventions to promote comfort are needed.Several doses of naloxone may be needed because the drug has a short half-life. Opioid depression is a manageable situation, not an acute emergency. The client with opioid depression usually is not fully conscious.)

Which of the following members of the operative team use sterile technique during the surgical procedure? Choose all that apply. Surgeon Anesthetist Scrub nurse Registered nurse first assistant

Surgeon Scrub nurse Registered nurse first assistant (The anesthetist is a member of the clean team and remains outside the sterile field. Members of the sterile team include the surgeon, the scrub nurse, and the registered first nurse assistant.)

When planning to administer metoclopramide (Reglan), the nurse is aware that this drug must be given in regards to which fluid or food consideration? Give with a full glass of water in the morning. Take with 8 oz of orange or apple juice. Take 30 minutes before meals and at bedtime. Give with food to decrease GI upset.

Take 30 minutes before meals and at bedtime. (Metoclopramide should be administered 30 minutes before meals and at bedtime. Administering the medication before meals allows time for onset to increase GI motility before food ingestion, thus decreasing stomach distention and resulting nausea and vomiting.)

A client who is taking an oral hypoglycemic daily for type 2 diabetes develops the flu and is concerned about the need for special care. What should the nurse advise the client? Select all that apply. Avoid solid food. Take the oral medication. Drink fluids throughout the day. Monitor capillary glucose levels. Do not take medication until tolerating food.

Take the oral medication. Drink fluids throughout the day. Monitor capillary glucose levels. (Physiologic stress increases gluconeogenesis, requiring continued pharmacologic therapy despite an inability to eat; fluids prevent dehydration; monitoring of glucose levels permits early intervention if necessary. Skipping the oral hypoglycemic agent may precipitate hyperglycemia. Food intake should be attempted to prevent acidosis. Delaying an oral hypoglycemic agent may precipitate hyperglycemia.)

An older client's adult child tells the nurse that the client does not want life support. What does the nurse do first? Call the legal department to draft the paperwork. Document this in the chart. Thank the person and do nothing else. Talk to the client.

Talk to the client. (The nurse would first talk to the client in order to determine the client's wishes and state of mind.The nurse should not call the legal department or document in the client's chart before speaking with the client. Doing nothing is not appropriate.)

A preoperative client smokes a pack of cigarettes a day. What is the nurse's teaching priority for the best physical outcomes? Instruct the client to quit smoking. Teach about the dangers of tobacco. Teach the importance of incentive spirometry. Tell the client that smoking increases postoperative complications.

Teach the importance of incentive spirometry. (The nurse would first teach the importance of incentive spirometry. Incentive spirometry is good for lung hygiene and it encourages deep breathing.The nurse can suggest quitting or advice about the dangers of tobacco, but it is not therapeutic to instruct it at this time. Telling the client that smoking causes increased complications is not helpful or therapeutic just prior to surgery.)

A client is experiencing an exacerbation of systemic lupus erythematosus. To reduce the frequency of exacerbations, what would be important for the nurse to include in the client's teaching plan? Basic principles of hygiene Techniques to reduce stress Measures to improve nutrition Signs of an impending exacerbation

Techniques to reduce stress (Systemic lupus erythematosus is an autoimmune disorder, and physical and emotional stresses have been identified as contributing factors to the occurrence of exacerbations. Although basic principles of hygiene should be performed, inadequate hygiene is not known to produce exacerbations. Although measures to improve nutrition should be done, nutritional status is not significantly correlated to exacerbations. Knowledge of the symptoms will not decrease the occurrence of exacerbations.)

The charge nurse for a hospital operating room is making client assignments for the day. Which client is most appropriate to assign to the least-experienced circulating nurse? The 20-year-old client who has a ruptured appendix and is having an emergency appendectomy The 28-year-old client with a fractured femur who is having an open reduction and internal fixation The 45-year-old client with coronary artery disease who is having coronary artery bypass grafting The 52-year-old client with stage I breast cancer who is having a tunneled central venous catheter placed

The 52-year-old client with stage I breast cancer who is having a tunneled central venous catheter placed (The client with stage I breast cancer who is having a tunneled central venous catheter placed is the most stable client among all scheduled procedures. This assignment would be appropriate for the beginning nurse or one with less experience.The client who has a ruptured appendix is less stable and at high risk for infection/sepsis; a more experienced nurse is required. The client with a fractured femur is at high risk for clotting, infection, and aspiration owing to the surgery; a more experienced nurse would be better. The client with coronary artery disease is having high-risk surgery with risk for multiple complications and requires an experienced operating room nurse.)

Following a surgical procedure, which of the following are generally responsible for moving the patient to the recovery area? The surgeon The orderly The recovery nurses The anesthesiologist, circulating nurse, and surgeon

The anesthesiologist, circulating nurse, and surgeon (After the intraoperative phase of the surgical procedure has been completed, the circulating nurse, the anesthesia provider, and the surgeon safely transport the patient to the PACU, taking care to maintain the patient's airway during this critical time.)

A nurse is preparing to discharge a client who is partially paralyzed following a stroke. What should the nurse teach the client's family about recognizing caregiver role strain? Select all that apply. The caregiver has disturbed sleep patterns. The caregiver has reduced appetite and weight. The caregiver is more concerned about personal appearance. The caregiver engages in leisure activities as often as possible. The caregiver is fearful about administering medications to the client.

The caregiver has disturbed sleep patterns. The caregiver has reduced appetite and weight. The caregiver is fearful about administering medications to the client. (A family should recognize that when the caregiver has disturbed sleep patterns, the caregiver is experiencing strain. Changes in appetite, weight, and sleep patterns are all indicative of caregiver role strain. A caregiver experiences strain while learning about new therapies and administering medications to the client. A caregiver experiencing role strain is not concerned about personal appearance and may withdraw from social groups. A caregiver also does not spend time in any leisure activities if overcome by strain.)

In monitoring a patient for adverse effects related to morphine sulfate (MS Contin), the nurse assesses for stimulation of which area in the central nervous system (CNS)? Autonomic control over circulation Sympathetic baroreceptors The cough reflex center The chemoreceptor trigger zone

The chemoreceptor trigger zone (Morphine sulfate can irritate the gastrointestinal (GI) tract, causing stimulation of the chemoreceptor trigger zone in the brain, which in turn causes nausea and vomiting.)

The nursing instructor is discussing the role of the circulating nurse in the operative suite with the student nurses. Which of the following would the nursing instructor include as duties of the circulating nurse? Select all that apply. The circulating nurse is included in the responsibility of accounting for all sponges and instruments following the surgical procedure. The circulating nurse is responsible for preparing the surgical table for the procedure. The circulating nurse is responsible for assisting the surgeon with instruments during the procedure. The surgical nurse is responsible for maintaining the patient's rights during the surgical procedure.

The circulating nurse is included in the responsibility of accounting for all sponges and instruments following the surgical procedure. The surgical nurse is responsible for maintaining the patient's rights during the surgical procedure. (The circulating nurse ensures that the patient's rights are protected and coordinates patient care in the operating room. The circulating nurse and the scrub person are responsible for accounting for all sponges and instruments at the close of surgery.)

A nurse in an outpatient surgical center is teaching a client about what will be necessary for discharge to home. What information should the nurse include about transportation? The client is not allowed to drive a car home. If the client is not dizzy, driving a car is allowed. Only adults over the age of 25 may drive home. None; this is not necessary information.

The client is not allowed to drive a car home. (After outpatient surgery, clients may go home when they are no longer dizzy or drowsy, have stable vital signs, and have voided. Clients are not allowed to drive a car home.)

The nurse is caring for an overweight client who gained 10 pounds during the previous 2 weeks. The client states that she is hungry all the time and doesn't understand why. Which assessment finding could explain the client's weight gain and hunger? The client started taking dexamethasone (Decadron) daily. The client started taking naproxen sodium (Naprosyn) daily. The client's glycosylated hemoglobin level is 6%. The client's thyroxine (T₄) level is 8 mcg/dL.

The client started taking dexamethasone (Decadron) daily. (Dexamethasone is a corticosteroid. These drugs alter carbohydrate, protein, and lipid metabolism, predisposing the client to obesity when taken on a long-term basis. In addition, corticosteroids increase the client's appetite. Naprosyn is an NSAID, which can lead to gastric upset and ulceration and decreased appetite and weight loss. The client's glycosylated hemoglobin and thyroid levels are within normal limits and would not explain the hunger and weight gain.)

The preoperative phase encompasses which period of time? Entry to the operating suite until admission to postanesthesia care Entry into the operating suite until discharge from the hospital The decision to have surgery until admission to postanesthesia care The decision to have surgery until entry to the operating suite

The decision to have surgery until entry to the operating suite (The preoperative phase begins with the decision to have surgery and ends when the patient enters the operating room. The intraoperative phase begins when the patient enters the operating suite and ends when the patient is admitted to the postanesthesia care unit.)

Which of the following describes the Perioperative Nursing Data Set? Choose all that apply. A standardized tool for assessing high-risk surgical patients A standardized vocabulary encompassing all surgical patient outcomes The first specialized nursing language recognized by the ANA A standardized language designed to describe the care of perioperative patients

The first specialized nursing language recognized by the ANA A standardized language designed to describe the care of perioperative patients (The Perioperative Nursing Data Set (PNDS) is a standardized vocabulary specifically designed to describe the care of perioperative clients. It consists of 74 nursing diagnoses, 133 nursing interventions, and 28 nurse-sensitive patient outcomes appropriate for use in any surgical setting. It was the first specialty language recognized by the ANA.)

Which finding for a patient who has been taking orlistat (Xenical) is most important to report to the health care provider? The patient frequently has liquid stools. The patient is pale and has many bruises. The patient complains of bloating after meals. The patient is experiencing a weight loss plateau.

The patient is pale and has many bruises. (Because orlistat blocks the absorption of fat-soluble vitamins, the patient may not be receiving an adequate amount of vitamin K, resulting in a decrease in clotting factors. Abdominal bloating and liquid stools are common side effects of orlistat and indicate that the nurse should remind the patient that fat in the diet may increase these side effects. Weight loss plateaus are normal during weight reduction.)

The nurse notes a patient's international normalized ratio (INR) value of 2.5. What is the meaning of this reported value? The patient's warfarin dose is within the therapeutic range. The patient needs the subcutaneous heparin dose increased. The patient is not receiving enough warfarin for a therapeutic effect. The patient is receiving too much heparin and is at risk for bleeding.

The patient's warfarin dose is within the therapeutic range. (INR determination is a routine test to evaluate coagulation while patients are taking warfarin, not heparin. A therapeutic INR is 2 to 3.)

The patient has been transported to the operating suite and positioned on the operating table. Suddenly, the patient states, "I don't want to do this. Get me out of here now!" Which of the following actions should occur? The patient should be given the anesthesia. The surgeon should tell the patient to remain calm and the procedure will be over soon. The patient should be told it is too late to change his mind. The procedure should be stopped.

The procedure should be stopped. (The patient has the right to ask any questions and to withdraw consent at any point before the surgery begins.)

Which of the following personnel are legally responsible for obtaining the patient's informed consent for a surgical procedure? The surgeon The registered nurse The admissions clerk The licensed practical nurse Any licensed person

The surgeon (The surgeon is legally responsible for obtaining the patient's informed consent.)

A young woman has been in an automobile crash that resulted in an amputation of her left lower leg. She verbalizes grief and loss. What knowledge by the nurse is used to provide interventions to help the client cope? The client should be grateful to be alive. This is a normal, appropriate response. This is an abnormal, inappropriate response. Tissue healing will help the client adapt.

This is a normal, appropriate response. (Many surgical clients have the same reaction to loss of a body part as they would to a death. A surgical client's grief is a normal, appropriate response. The nurse must be aware of the client's needs and provide interventions to meet those needs in coping with change.)

What is the general action of immunosuppressants? They inhibit T-lymphocytes. They reduce hepatic metabolism of steroids. They increase antibody response. They increase natural killer cellular activity.

They inhibit T-lymphocytes. (Immunosuppressants inhibit T-lymphocyte synthesis, thus preventing an immune response to organ transplants.)

How will the nurse describe the action of proton pump inhibitors (PPIs)? They form a protective barrier that can be thought of as a liquid bandage. They irreversibly bind to the hydrogen-potassium-ATPase pump. They compete with histamine for binding sites on the parietal cells. They help to neutralize acid secretions to promote gastric mucosal defensive mechanisms.

They irreversibly bind to the hydrogen-potassium-ATPase pump. (PPIs work to block the final step in the acid-secreting mechanisms of the proton pump. They do this by irreversibly binding to the ATPase pump, H⁺/K⁺ ATPase, the enzyme for this step.)

he nurse in the endocrine clinic is reviewing type 1 and type 2 diabetes with a group of nursing students. Which explanation by the students indicates their understanding of the types of diabetes? Most clients with type 1 diabetes are born with it. People with type 1 diabetes are often obese. Those with type 2 diabetes make insulin, but in inadequate amounts. People with type 2 diabetes do not develop typical diabetic complications.

Those with type 2 diabetes make insulin, but in inadequate amounts. (The explanation by the students that indicate understanding of the type of diabetes is "Those with type 2 diabetes make insulin, but in inadequate amounts." People with type 2 diabetes may also have resistance to existing insulin.Most clients with type 1 diabetes are not born with it. Although type 1 diabetes may occur early in life, it is considered an autoimmune disorder in which beta cells are destroyed in a genetically susceptible person. Risk for type 1 DM is determined by inheritance of genes coding for the HLA-DR and HLA-DQA and DQB tissue types (McCance et al., 2014). However, inheritance of these genes only increases the risk, and most people with these genes do not develop type 1 DM. Obesity is typically associated with type 2 diabetes. People with type 2 diabetes are at risk for typical diabetic complications, especially cardiovascular diseases.)

A client in the emergency department (ED) has slurred speech, confusion, and visual problems and has been having intermittent episodes of worsening symptoms. The symptoms have a gradual onset. The client also has a history of hypertension and atherosclerosis. What does the nurse suspect that the client is probably experiencing? Embolic stroke Hemorrhagic stroke Thrombotic stroke Transient ischemic attack

Thrombotic stroke (The client's signs and symptoms fit the description of a thrombotic stroke due to its gradual onset.Signs and symptoms of embolic stroke have a sudden onset, unlike this client's symptoms. Hemorrhagic strokes more frequently present with sudden, severe headache. Intermittent episodes of slurred speech, confusion, and visual problems are transient ischemic attacks, which often are warning signs of an impending ischemic stroke.)

What is the rationale for the administration of IV cephalosporin antibiotic before surgery? To prevent the development of strep To prevent the development of pneumonia To allow for decreased level of white blood cells To allow the client high levels of medication

To allow the client high levels of medication (A cephalosporin antibiotic is administered just before the surgical procedure so that the level of medication circulating in the client's blood will be high during surgery.)

What is the rationale for having the client void before surgery? To assess for pregnancy in women To assess for urinary tract infection To prevent bladder distention To prevent electrolyte imbalance

To prevent bladder distention (Having the client void before surgery will assist in the prevention of bladder distention during or after the procedure.)

A nurse working in a PACU is responsible for conducting assessments on immediate postoperative clients. What is the purpose of these assessments? To determine the length of time to recover from anesthesia To use intraoperative data as a basis for comparison To focus on cardiovascular data and findings To prevent complications from anesthesia and surgery

To prevent complications from anesthesia and surgery (Immediate postoperative care in the PACU involves assessing the postoperative client with emphasis on preventing complications from the surgery.)

A client with gastric ulcer disease asks the nurse why the health care provider has prescribed metronidazole. What purpose does the nurse provide? To augment the immune response To potentiate the effect of antacids To treat Helicobacter pylori infection To reduce hydrochloric acid secretion

To treat Helicobacter pylori infection (Approximately two thirds of clients with peptic ulcer disease are found to have Helicobacter pylori infecting the mucosa and interfering with its protective function. Antibiotics do not augment the immune response, potentiate the effect of antacids, or reduce hydrochloric acid secretion.)

A client with a long history of cardiovascular problems, including angina and hypertension, is scheduled to have a cardiac catheterization. During preprocedure teaching, what does the nurse explains to the client is the major purpose for catheterization? To obtain the pressures in the heart chambers To determine the existence of congenital heart disease To visualize the disease process in the coronary arteries To measure the oxygen content of various heart chambers

To visualize the disease process in the coronary arteries (Angina usually is caused by narrowing of the coronary arteries; the lumen of the arteries can be assessed by cardiac catheterization. Although pressures can be obtained, they are not the priority for this client; this assessment is appropriate for those with valvular disease. Determining the existence of congenital heart disease is appropriate for infants and young adults with cardiac birth defects. Measuring the oxygen content of various heart chambers is appropriate for infants and young children with suspected septal defects.)

Which dosage form of nitroglycerin has the longest duration of action? Transdermal patch Sublingual tablet Intravenous (IV) infusion Immediate-release tablet

Transdermal patch (The transdermal patch has an 8- to 12-hour duration of action compared with 3 minutes to 6 hours for the other dosage forms of nitroglycerin.)

The nurse is preparing to teach a client that metabolic syndrome can increase the risk for myocardial infarction (MI). Which signs of metabolic syndrome should the nurse include in the discussion? Select all that apply. Truncal obesity Hypercholesterolemia Elevated homocysteine levels Glucose intolerance Client taking losartan (Cozaar)

Truncal obesity Hypercholesterolemia Glucose intolerance Client taking losartan (Cozaar) (Truncal obesity related to large waist size (excessive abdominal fat causing central obesity)—40 inches (102 cm) or greater for men, 35 inches (89 cm) or greater for women—is a sign of metabolic syndrome. Decreased high-density lipoprotein cholesterol (HDL-C) (usually with high low-density lipoprotein cholesterol)—HDL-C less than 45 mg/dL (1.17 mmol/L) for men or less than 55 mg/dL (1.42 mmol/L) for women—or taking an anticholesterol drug is a sign of metabolic syndrome. Increased fasting blood glucose (caused by diabetes, glucose intolerance, or insulin resistance) is included in the constellation of metabolic syndrome. Blood pressure greater than 130/85 mm Hg or taking antihypertensive medication indicates metabolic syndrome.Although elevated homocysteine levels may predispose to atherosclerosis, they are not part of metabolic syndrome.)

The nurse is teaching a client with gallbladder disease about diet modification. Which meal does the nurse suggest to the client? Steak and French fries Fried chicken and mashed potatoes Turkey sandwich on wheat bread Sausage and scrambled eggs

Turkey sandwich on wheat bread (Turkey is an appropriate low-fat selection for this client. High fiber, from the wheat bread, also helps reduce the risk. Typically, diets high in fat, high in calories, low in fiber, and high in refined white carbohydrates place clients at higher risk for developing gallstones.Steak, French fries, fried chicken and mashed potatoes, and sausage are too fatty. Eggs are too high in cholesterol for a client with gallbladder disease.)

The nurse knows that which assessment finding is characteristic of a deep vein thrombosis in the leg? Bilateral edema of the leg associated with an albumin level of 2 g/dL Unilateral swelling with redness over the swollen area Brisk reflexes in the lower extremities Brownish discoloration of the skin over the lower extremities

Unilateral swelling with redness over the swollen area (A deep vein thrombosis of the leg may be associated with edema in the affected leg and erythema. Bilateral swelling of the legs associated with a low serum albumin level is related to decreased oncotic pressure. Brisk reflexes may be the result of a neurological disorder. Brownish discoloration of the lower extremities may be related to chronic venous insufficiency, not a deep vein thrombosis.)

A patient admitted to the medical unit with impaired renal function is complaining of severe, stabbing pain in the flank and lower abdomen. The patient is being assessed for renal calculi. The nurse recognizes that the stone is most likely in what anatomic location? Meatus Bladder Ureter Urethra

Ureter (Ureteral pain is characterized as a dull continuous pain that may be intense with voiding. The pain may be described as sharp or stabbing if the bladder is full. This type of pain is inconsistent with a stone being present in the bladder. Stones are not normally situated in the urethra or meatus.)

A young adult woman is scheduled for a bilateral breast reduction under general anesthesia. She is normally healthy and takes no daily medications. Identify the preoperative screening tests appropriate for this patient. Choose all that apply. Urinalysis EKG Creatinine clearance CBC

Urinalysis CBC (Preoperative screening tests are ordered to determine if the client has undetected underlying health concerns. Most institutions require a complete blood count (CBC) and urinalysis prior to all surgical procedures. Generally, an electrocardiograph (ECG) is ordered for clients over the age of 50 years or with known cardiac disease. A creatinine clearance is not a routine presurgical screening test.)

The nurse obtains assessment data on a client who had bariatric surgery today. Which finding does the nurse report to the surgeon immediately? Bowel sounds are not audible in all quadrants. Client's skin under the panniculus is excoriated. The client reports pain when being repositioned. Urine output total is 15 mL for the past 2 hours.

Urine output total is 15 mL for the past 2 hours. (The nurse reports a urine output total of 15 mL for the past two hours. Normal urine output needs to be at least 30 mL per hour. Oliguria (scant urine output) may indicate severe postoperative complications such as anastomotic leaks or acute kidney failure.Inaudible bowel sounds would typically require intervention, but on the day of surgery, bowel sounds will probably be absent normally for some time. The other findings, excoriated skin under the panniculus and subjective reports of pain, may require nursing interventions, but do not require an immediate report to the surgeon.)

Which interventions are most important for preventing bleeding in patients with bleeding disorders? Select all that apply. Using a soft-bristle toothbrush Avoiding over-the-counter medications that contain aspirin Using a blade razor Removing obstacles that may result in a fall Giving medication by intramuscular injection

Using a soft-bristle toothbrush Avoiding over-the-counter medications that contain aspirin Removing obstacles that may result in a fall (Use of a soft-bristle toothbrush decreases the trauma to the gums with oral care. Avoid the use of aspirin because of its antiplatelet effect. Decrease the fall risk to prevent bleeding from trauma. Do not use a blade razor because of the risk for nicks when shaving. Intramuscular injections are avoided in bleeding precautions due to the risk of bleeding into muscle from the trauma of the injection.)

A client who has undergone a bariatric surgical procedure is recuperating after surgery. Which nursing intervention most effectively prevents injury to the client who is being re-positioned postoperatively? Administering pain medication Making sure not to move the client's nasogastric (NG) tube Monitoring skinfold areas and keeping them clean and dry Using a weight-rated extra-wide bed for the client

Using a weight-rated extra-wide bed for the client (The most effective way to reposition a post-operative bariatric client and prevent injury is to use a special weight-related extra wide bed. This will allow adequate room for re-positioning the client comfortably without causing the bed rails to touch his or her body, causing pressure and injury.Pain medication and monitoring skinfold areas will not prevent injury to the client that might occur during repositioning. Not moving the client's NG tube will prevent disruption of the suture line, but will not prevent repositioning injuries.)

The nurse is assigned to work with a new nursing assistant. Which action by the nursing assistant requires intervention by the registered nurse? Using an alcohol-based hand rub after caring for a client with diarrhea Washing hands for 20 seconds using warm water and friction Cleaning especially carefully under fingernails and around a wedding band Using chlorhexidine for handwashing when caring for clients on neutropenic precautions

Using an alcohol-based hand rub after caring for a client with diarrhea (Alcohol-based hand rubs are not effective against spore-forming organisms such as Clostridium difficile, which is a common cause of diarrhea among hospitalized clients. The nursing assistant should wash hands with soap after caring for such clients in case they have an undiagnosed infection with this bacterium. The other actions are appropriate.)

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

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.)

The nurse is educating a patient about medications used to treat erectile dysfunction. Which erectile dysfunction medications have the longest therapeutic effect when taken orally? (Select all that apply.) Avanafil (Stendra) Alprostadil (Caverject) Vardenafil (Levitra) Tadalafil (Cialis) Sildenafil (Viagra)

Vardenafil (Levitra) Tadalafil (Cialis) (Phosphodiesterase inhibitors (PDIs) are used in the treatment of erectile dysfunction. Sildenafil (Viagra) was the first oral drug approved for the treatment of erectile dysfunction. Two drugs that are similar but have a longer duration of action are vardenafil (Levitra) and tadalafil (Cialis). Collectively, these drugs are referred to as erectile dysfunction drugs. Avanafil (Stendra) is the newest PDI approved for erectile dysfunction. A second type of drug used to treat erectile dysfunction is the prostaglandin alprostadil (Caverject). This drug must be given by injecting it directly into the erectile tissue of the penis or pushing a suppository form of the drug into the urethra.)

A nurse is preparing to administer preoperative medication to a client scheduled for incision and drainage of a wound abscess. Which action is essential before the nurse administers the medication? Verify the consent. Have the client void. Check the vital signs. Remove the client's dentures.

Verify the consent. (Consent must be acquired when the client is fully oriented and in a clear mental state. Although important, having the client void, checking the vital signs, and removing the client's dentures can be implemented before surgery even if the client has received medication.)

The nurse is caring for a patient admitted with gastrointestinal bleeding who is anticoagulated with warfarin (Coumadin). Which medication should the nurse anticipate administering? Vitamin E Vitamin K (Phytonadione) Protamine (Protamine sulfate) Calcium gluconate

Vitamin K (Phytonadione) (Vitamin K is the antagonist for warfarin.)

A client reports pain as a result of a gastric ulcer. What clinical findings is the nurse most likely to identify during an assessment of the client's pain? Select all that apply. Vomiting relieves pain. Eating food prevents pain. Pain is described as gnawing. Flatulence accompanies pain. Pain occurs half an hour after meals.

Vomiting relieves pain. Pain is described as gnawing. Pain occurs half an hour after meals. (Vomiting removes gastric hydrochloric acid (HCl), which irritates the ulcer and causes pain. Typically, gastric ulcer pain is described as burning or gnawing. Eating causes the secretion of HCl, which increases pain. Eating causes the secretion of HCl, which increases, not relieves, pain. Flatulence is not related to a gastric ulcer.)

The nurse is coaching a community group for individuals who are overweight. Which participant behavior is an example of the best exercise plan for weight loss? Walking for 40 minutes 6 or 7 days/week Lifting weights with friends 3 times/week Playing soccer for an hour on the weekend Running for 10 to 15 minutes 3 times/week

Walking for 40 minutes 6 or 7 days/week (Exercise should be done daily for 30 minutes to an hour. Exercising in highly aerobic activities for short bursts or only once a week is not helpful and may be dangerous in an individual who has not been exercising. Running may be appropriate, but a patient should start with an exercise that is less stressful and can be done for a longer period. Weight lifting is not as helpful as aerobic exercise in weight loss.)

A patient is admitted to the medical unit with pneumonia. When reviewing home medications, which of the following medications would the nurse recognize as a risk for bleeding? Diltiazem (Cardizem) Warfarin (Coumadin) Acetaminophen (Tylenol) Metformin (Glucophage)

Warfarin (Coumadin) (Warfarin (Coumadin) is a medication that interferes with blood clotting by interfering with the vitamin K-dependent clotting factors. Diltiazem is a calcium channel blocker. Acetaminophen is an over-the-counter medication that does not interfere with blood clotting. Metformin is a medication used for diabetes.)

A client has Clostridium difficile. The nurse is providing discharge instructions related to decreasing the risk of transmission to family members. What would be appropriate to include in the client's teaching? Increase fluids. Increase fiber in the diet. Wash hands with soap and water. Wash hands with an alcohol-based hand sanitizer.

Wash hands with soap and water. (Alcohol does not kill C. difficile spores. Use of soap and water is more efficacious than alcohol-based hand rubs. Increased fluids and increased fiber do not decrease the risk of transmission of C. difficile.)

A client who sustained serious burns now has a stress ulcer. Which clinical indicators should the nurse immediately report to the primary healthcare provider? Select all that apply. Weakness Diaphoresis Tachycardia Cold extremities Flushed skin tone

Weakness Diaphoresis Tachycardia Cold extremities (The stress ulcer can bleed, leading to shock. Weakness is related to the decrease in the oxygen-carrying capacity of the blood associated with shock. Diaphoresis and tachycardia are sympathetic nervous system responses associated with shock. Peripheral vasoconstriction is associated with the sympathetic nervous system response associated with shock and leads to cold extremities. The skin will be pale, rather than flushed, because of peripheral vasoconstriction.)

Which precaution is best for the nurse to take to prevent the transmission of Clostridium difficile infection? Carefully wash hands that are visibly soiled. Wear a mask and gloves when the client's body secretions or body fluids are likely to be handled. Wear a mask with eye protection and perform proper handwashing. Wear gloves when contact with body secretions or body fluids is expected.

Wear gloves when contact with body secretions or body fluids is expected. (The nurse must wear gloves and wash hands before and after potential exposure to the client's body secretions or fluids. C. difficile infection requires contact precautions. Hands must be properly washed before and after any contact with the client with C. difficile infection. Alcohol-based hand rubs are not effective for hand hygiene in the care of clients with C. difficile.Hands must be washed even if not visibly soiled. It is not necessary to wear a mask when caring for clients with C. difficile infection. A mask and eye protection are not necessary to prevent transmission of C. difficile.)

A patient returns from surgery with a nasogastric tube and intermittent gastric suction to provide abdominal decompression. Which of the following are correct nursing activities for managing the equipment and drainage? Choose all that apply. Wear nonsterile procedure gloves when emptying the drainage container. When irrigating the nasogastric tube, use sterile water. Wear sterile gloves when irrigating the nasogastric tube. Apply water-soluble lubricant if the patient's lips are dry.

Wear nonsterile procedure gloves when emptying the drainage container. Apply water-soluble lubricant if the patient's lips are dry. (Nonsterile procedure gloves are to protect the nurse and other patients against microorganisms that might be present in body fluids; wearing them is in observance of standard precautions. For patients with an NG tube, frequent oral care, including water-soluble lubricant for dry lips, is important. Sterile gloves are not needed for irrigating the NG tube because the nasal passages, esophagus, and stomach are not sterile. Sterile normal saline and a sterile syringe are used for irrigation, however. Sterile water is not used.)

A client with coronary artery disease is scheduled for a cardiac catheterization. What should the client be able to describe if the nurse's preoperative teaching is considered effective? What will occur if there is an emergency What will be experienced during the procedure The risks associated with this invasive procedure The importance of immediate postoperative exercises

What will be experienced during the procedure (Knowing what to expect reduces fear of the unknown. Knowing what will occur in an emergency may increase fear associated with the experience. Discussing the risks of the procedure is the primary healthcare provider's responsibility. The nurse does not give the risks associated with this invasive procedure; the nurse determines the client's knowledge regarding the procedure and documents the client's signature on the consent form. Exercise is not immediate; bed rest is prescribed with operative site immobilization for several hours.)

The nurse has a prescription to give a series of medications on an "on call" basis. The nurse realizes that these medications will be given: In the postanesthesia recovery unit. At the time specified in the order. On the patient's arrival in the surgery suite. When the OR staff notify the nurse to do so.

When the OR staff notify the nurse to do so. (The anesthesia team may order medications to be given "on call" if the surgery time is likely to vary. The nurse will give "on call" medications when he is notified to do so by the OR staff.)

A client recently admitted with new-onset type 2 diabetes will be discharged with a meter for self-monitoring of blood glucose (SMBG) levels. When is the best time for the nurse to explain to the client the proper use of the glucose monitor? Day of discharge On admission When the client states readiness While performing the test in the hospital

While performing the test in the hospital (Teaching the client about the operation of the machine while performing the test in the hospital is the best time for the nurse to introduce the client to SMBG. The teaching can be reinforced each time testing is performed on the client and again before discharge.Instructing the client on the day of admission or the day of discharge would not allow time for redemonstration and correction of the skill if needed. Other time-consuming activities are done on those days and could distract the client and make the client feel overwhelmed. Also, waiting for the client to state readiness may postpone the instructions too long.)

A client is admitted to the hospital for a laparoscopic cholecystectomy. What should the nurse encourage the client to add to the diet to help normalize bowel function after surgery? Vitamins Whole bran Cod liver oil Amino acids

Whole bran (Whole bran provides bulk that promotes intestinal motility and a regular bowel movement. Vitamins are not related to normalizing bowel function. Cod liver oil is not related to regulating bowel function. Amino acids are not related to regulating bowel function.)

The nurse is preparing to administer an intravenous injection of morphine to a patient. The nurse assesses a respiratory rate of 10 breaths/min. Which action should the nurse perform? Withhold the medication and notify the health care provider. Administer a smaller dose and document in the patient's record. Administer the next prescribed dose intramuscularly. Check the pulse oximeter reading and reevaluate respiratory rate in 1 hour.

Withhold the medication and notify the health care provider. (Respiratory depression is an adverse effect of opioid analgesia. Therefore, because the patient's respiratory rate is below normal, the nurse should withhold the morphine and notify the health care provider.)

Based on nutritional screening findings and assessments, which client will be the preferred candidate for surgical treatment for obesity? Man with a body mass index (BMI) of 40, weight 75% above ideal body weight Man with a BMI of 41, weight 80% above ideal body weight Woman with a BMI of 38, weight 50% above ideal body weight Woman with a BMI of 42, weight 100% above ideal body weight

Woman with a BMI of 42, weight 100% above ideal body weight (The client who will be most successful with surgical intervention is the client with a BMI of 40 or more and a weight 100% above the ideal body weight.The other clients do not have a high enough BMI-to-weight ratio to be considered for surgical intervention.)

Which groups of individuals are at highest risk for development of iron deficiency anemia? (Select all that apply.) Women ages 12 to 40 years Men ages 20 to 40 years Children Men older than age 50 years Pregnant women

Women ages 12 to 40 years Children Pregnant women (Individuals who require the highest amount of iron are women (especially pregnant women) and children, and they are the groups most likely to develop iron-deficiency anemia. For women, this is partly because of ongoing menstrual blood losses. Most vitamin supplements for men contain little or no iron because men are much less likely to develop iron-deficiency anemia.)

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 list of medical supply facilities where wound care supplies may be purchased Proper handwashing techniques to avoid cross-contamination of the patient's wound The amount of pain medication that the patient is allowed to take in each dose Written and oral instructions regarding signs/symptoms to report to the primary health care provider

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 student nurse is caring for clients on the postoperative unit. The student asks the registered nurse why malnutrition can lead to poor surgical outcomes. What responses by the nurse are best? (Select all that apply.) a. "A malnourished client will have fragile skin." b. "Malnourished clients always have other problems." c. "Many drugs are bound to protein in the body." d. "Protein stores are needed for wound healing." e. "Weakness and fatigue are common in malnutrition."

a. "A malnourished client will have fragile skin." c. "Many drugs are bound to protein in the body." d. "Protein stores are needed for wound healing." e. "Weakness and fatigue are common in malnutrition." (Malnutrition can lead to poorer surgical outcomes for several reasons, including fragile skin that might break down, altered pharmacokinetics, poorer wound healing, and weakness or fatigue that can interfere with recovery. Malnutrition can exist without other comorbidities.)

A student is caring for clients in the preoperative area. The nurse contacts the surgeon about a client whose heart rate is 120 beats/min. After consulting with the surgeon, the nurse administers a beta blocker to the client. The student asks why this was needed. What response by the nurse is best? a. "A rapid heart rate requires more effort by the heart." b. "Anesthesia has bad effects if the client is tachycardic." c. "The client may have an undiagnosed heart condition." d. "When the heart rate goes up, the blood pressure does too."

a. "A rapid heart rate requires more effort by the heart." (Tachycardia increases the workload of the heart and requires more oxygen delivery to the myocardial tissues. This added strain is not needed on top of the physical and emotional stress of surgery. The other statements are not accurate.)

The nurse is providing teaching to a patient taking an oral tetracycline antibiotic. Which statement by the nurse is correct? a. "Avoid direct sunlight and tanning beds while on this medication." b. "Milk and cheese products result in increased levels of tetracycline." c. "Antacids taken with the medication help to reduce gastrointestinal distress." d. "Take the medication until you are feeling better."

a. "Avoid direct sunlight and tanning beds while on this medication." (Drug-related photosensitivity occurs when patients take tetracyclines, and it may continue for several days after therapy. Milk and cheese products result in decreased levels of tetracycline when the two are taken together. Antacids also interfere with absorption and should not be taken with tetracycline. Counsel patients to take the entire course of prescribed antibiotic drugs, even if they feel that they are no longer ill.)

A client recently diagnosed with systemic lupus erythematosus (SLE) is in the clinic for a follow-up visit. The nurse evaluates that the client practices good self-care when the client makes which statement? a. "I always wear long sleeves, pants, and a hat when outdoors." b. "I try not to use cosmetics that contain any type of sunblock." c. "Since I tend to sweat a lot, I use a lot of baby powder." d. "Since I can't be exposed to the sun, I have been using a tanning bed."

a. "I always wear long sleeves, pants, and a hat when outdoors." (Good self-management of the skin in SLE includes protecting the skin from sun exposure, using sunblock, avoiding drying agents such as powder, and avoiding tanning beds.)

A nurse cares for a client who has obstructive jaundice. The client asks, "Why is my skin so itchy?" How should the nurse respond? a. "Bile salts accumulate in the skin and cause the itching." b. "Toxins released from an inflamed gallbladder lead to itching." c. "Itching is caused by the release of calcium into the skin." d. "Itching is caused by a hypersensitivity reaction."

a. "Bile salts accumulate in the skin and cause the itching." (In obstructive jaundice, the normal flow of bile into the duodenum is blocked, allowing excess bile salts to accumulate on the skin. This leads to itching, or pruritus. The other statements are not accurate.)

A postoperative client is being discharged with a prescription for oxycodone hydrochloride with acetaminophen (Percocet). What instructions does the nurse give the client? (Select all that apply.) a. "Check all over-the-counter medications for acetaminophen." b. "Do not take more pills each day than you are prescribed." c. "Eat a diet that is high in fiber and drink lots of water." d. "If this gives you diarrhea, loperamide (Imodium) can help." e. "You shouldn't drive while you are taking this medication."

a. "Check all over-the-counter medications for acetaminophen." b. "Do not take more pills each day than you are prescribed." c. "Eat a diet that is high in fiber and drink lots of water." e. "You shouldn't drive while you are taking this medication." (Percocet is a common opioid analgesic that contains acetaminophen. The client should be taught to check all over-the-counter medications for acetaminophen and to not take more than the prescribed amount of Percocet, as the maximum daily dose of acetaminophen is 3000 mg. Percocet, like all opioid analgesics, can cause constipation, and the client can minimize this by eating a high-fiber diet and drinking plenty of water. Since Percocet can cause drowsiness, the client taking it should not drive or operate machinery. The medication is more likely to cause constipation than diarrhea.)

A nurse assesses a client who presents with renal calculi. Which question should 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?"

a. "Do any of your family members have this problem?" (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 client with a urinary tract infection.)

A nurse teaches a client with diabetes mellitus about foot care. Which statements should the nurse include in this client's teaching? (Select all that apply.) a. "Do not walk around barefoot." b. "Soak your feet in a tub each evening." c. "Trim toenails straight across with a nail clipper." d. "Treat any blisters or sores with Epsom salts." e. "Wash your feet every other day."

a. "Do not walk around barefoot." c. "Trim toenails straight across with a nail clipper." (Clients who have diabetes mellitus are at high risk for wounds on the feet secondary to peripheral neuropathy and poor arterial circulation. The client should be instructed to not walk around barefoot or wear sandals with open toes. These actions place the client at higher risk for skin breakdown of the feet. The client should be instructed to trim toenails straight across with a nail clipper. Feet should be washed daily with lukewarm water and soap, but feet should not be soaked in the tub. The client should contact the provider immediately if blisters or sores appear and should not use home remedies to treat these wounds.)

A nurse teaches a client who has viral gastroenteritis. Which dietary instruction should the nurse include in this client's teaching? a. "Drink plenty of fluids to prevent dehydration." b. "You should only drink 1 liter of fluids daily." c. "Increase your protein intake by drinking more milk." d. "Sips of cola or tea may help to relieve your nausea."

a. "Drink plenty of fluids to prevent dehydration." (The client should drink plenty of fluids to prevent dehydration. Milk products may not be tolerated. Caffeinated beverages increase intestinal motility and should be avoided.)

A nurse teaches a client about self-care after experiencing a urinary calculus treated by lithotripsy. Which statements should the nurse include in this client's discharge teaching? (Select all that apply.) a. "Finish the prescribed antibiotic even if you are feeling better." b. "Drink at least 3 liters of fluid each day." c. "The bruising on your back may take several weeks to resolve." d. "Report any blood present in your urine." e. "It is normal to experience pain and difficulty urinating."

a. "Finish the prescribed antibiotic even if you are feeling better." b. "Drink at least 3 liters of fluid each day." c. "The bruising on your back may take several weeks to resolve." (The client should be taught to finish the prescribed antibiotic to ensure that he or she does not get a urinary tract infection. The client should drink at least 3 liters of fluid daily to dilute potential stone-forming crystals, prevent dehydration, and promote urine flow. After lithotripsy, the client should expect bruising that may take several weeks to resolve. The client should also experience blood in the urine for several days. The client should report any pain, fever, chills, or difficulty with urination to the provider as these may signal the beginning of an infection or the formation of another stone.)

A client has been prescribed lorcaserin (Belviq). What teaching is most appropriate? a. "Increase the fiber and water in your diet." b. "Reduce fat to less than 30% each day." c. "Report dry mouth and decreased sweating." d. "Lorcaserin may cause loose stools for a few days."

a. "Increase the fiber and water in your diet." (This drug can cause constipation, so the client should increase fiber and water in the diet to prevent this from occurring. Reducing fat in the diet is important with orlistat. Lorcaserin can cause dry mouth but not decreased sweating. Loose stools are common with orlistat.)

The nurse has taught a client about lifestyle modifications for gastroesophageal reflux disease (GERD). What statements by the client indicate good understanding of the teaching? (Select all that apply.) a. "I just joined a gym, so I hope that helps me lose weight." b. "I sure hate to give up my coffee, but I guess I have to." c. "I will eat three small meals and three small snacks a day." d. "Sitting upright and not lying down after meals will help." e. "Smoking a pipe is not a problem and I don't have to stop."

a. "I just joined a gym, so I hope that helps me lose weight." b. "I sure hate to give up my coffee, but I guess I have to." c. "I will eat three small meals and three small snacks a day." d. "Sitting upright and not lying down after meals will help." (Lifestyle modifications can help control GERD and include losing weight if needed; avoiding chocolate, caffeine, and carbonated beverages; eating frequent small meals or snacks; and remaining upright after meals. Tobacco is a risk factor for GERD and should be avoided in all forms.)

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 liters 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."

a. "I should drink at least 3 liters of fluid every day." (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 should 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.)

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 additional education? a. "If I develop an infection, I should stop taking my corticosteroid." b. "If I have pain over the transplant site, I will call the surgeon immediately." c. "I should avoid people who are ill or who have an infection." d. "I should take my cyclosporine exactly the way I was taught."

a. "If I develop an infection, I should stop taking my corticosteroid." (Immunosuppressive agents should not be stopped without the consultation of the transplantation physician, even if an infection is present. Stopping immunosuppressive therapy endangers the transplanted organ. The other statements are correct. Pain over the graft site may indicate rejection. Anti-rejection drugs cause immunosuppression, and the client should avoid crowds and people who are ill. Changing the routine of anti-rejection medications may cause them to not work optimally.)

A nurse cares for a client with ulcerative colitis. The client states, "I feel like I am tied to the toilet. This disease is controlling my life." How should the nurse respond? a. "Let's discuss potential factors that increase your symptoms." b. "If you take the prescribed medications, you will no longer have diarrhea." c. "To decrease distress, do not eat anything before you go out." d. "You must retake control of your life. I will consult a therapist to help."

a. "Let's discuss potential factors that increase your symptoms." (Clients with ulcerative colitis often express that the disorder is disruptive to their lives. Stress factors can increase symptoms. These factors should be identified so that the client will have more control over his or her condition. Prescription medications and anorexia will not eliminate exacerbations. Although a therapist may assist the client, this is not an appropriate response.)

A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement should the nurse include in this client's plan of care to delay the onset of microvascular and macrovascular complications? a. "Maintain tight glycemic control and prevent hyperglycemia." b. "Restrict your fluid intake to no more than 2 liters a day." c. "Prevent hypoglycemia by eating a bedtime snack." d. "Limit your intake of protein to prevent ketoacidosis."

a. "Maintain tight glycemic control and prevent hyperglycemia." (Hyperglycemia is a critical factor in the pathogenesis of long-term diabetic complications. Maintaining tight glycemic control will help delay the onset of complications. Restricting fluid intake is not part of the treatment plan for clients with diabetes. Preventing hypoglycemia and ketosis, although important, are not as important as maintaining daily glycemic control.)

A client had an embolic stroke and is having an echocardiogram. When the client asks why the provider ordered "a test on my heart," how should the nurse respond? a. "Most of these types of blood clots come from the heart." b. "Some of the blood clots may have gone to your heart too." c. "We need to see if your heart is strong enough for therapy." d. "Your heart may have been damaged in the stroke too."

a. "Most of these types of blood clots come from the heart." (An embolic stroke is caused when blood clots travel from one area of the body to the brain. The most common source of the clots is the heart. The other statements are inaccurate.)

A client is taking warfarin (Coumadin) and asks the nurse if taking St. John's wort is acceptable. What response by the nurse is best? a. "No, it may interfere with the warfarin." b. "There isn't any information about that." c. "Why would you want to take that?" d. "Yes, it is a good supplement for you."

a. "No, it may interfere with the warfarin." (Many foods and drugs interfere with warfarin, St. John's wort being one of them. The nurse should advise the client against taking it. The other answers are not accurate.)

When applying transdermal nitroglycerin patches, which instruction by the nurse is correct? a. "Rotate application sites with each dose." b. "Use only the chest area for application sites." c. "Temporarily remove the patch if you go swimming." d. "Apply the patch to the same site each time."

a. "Rotate application sites with each dose." (Application sites for transdermal nitroglycerin patches need to be rotated. Apply the transdermal patch to any nonhairy area of the body; the old patch should first be removed. The patch may be worn while swimming, but if it does come off, it should be replaced after the old site is cleansed.)

A nurse teaches a community group about food poisoning and gastroenteritis. Which statements should the nurse include in this group's teaching? (Select all that apply.) a. "Rotavirus is more common among infants and younger children." b. "Escherichia coli diarrhea is transmitted by contact with infected animals." c. "To prevent E. coli infection, don't drink water when swimming." d. "Clients who have botulism should be quarantined within their home." e. "Parasitic diseases may not show up for 1 to 2 weeks after infection."

a. "Rotavirus is more common among infants and younger children." c. "To prevent E. coli infection, don't drink water when swimming." e. "Parasitic diseases may not show up for 1 to 2 weeks after infection." (Rotavirus is more common among the youngest of clients. Not drinking water while swimming can help prevent E. coli infection. Parasitic diseases may take up to 2 weeks to become symptomatic. People with botulism need to be hospitalized to monitor for respiratory failure and paralysis. Escherichia coli is not transmitted by contact with infected animals.)

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 additional teaching? a. "The lower abdomen is the best location because it is closest to the pancreas." b. "I can reach my thigh the best, so I will use the different areas of my thighs." c. "By rotating the sites in one area, my chance of having a reaction is decreased." d. "Changing injection sites from the thigh to the arm will change absorption rates."

a. "The lower abdomen is the best location because it is closest to the pancreas." (The abdominal site has the fastest rate of absorption because of blood vessels in the area, not because of its proximity to the pancreas. The other statements are accurate assessments of insulin administration.)

A nurse teaches a young female client who is prescribed amoxicillin (Amoxil) for a urinary tract infection. Which statement should 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."

a. "Use a second form of birth control while on this medication." (The client should use a second form of birth control because penicillin seems to reduce the effectiveness of estrogen-containing contraceptives. She should not experience increased menstrual bleeding, an irregular heartbeat, or blood in her urine while taking the medication.)

A nurse teaches a client how to avoid becoming ill with Salmonella infection again. Which statements should the nurse include in this client's teaching? (Select all that apply.) a. "Wash leafy vegetables carefully before eating or cooking them." b. "Do not ingest water from the garden hose or the pool." c. "Wash your hands before and after using the bathroom." d. "Be sure meat is cooked to the proper temperature." e. "Avoid eating eggs that are sunny side up or undercooked." f. "When eating outdoors, be sure to keep flies off your food."

a. "Wash leafy vegetables carefully before eating or cooking them." c. "Wash your hands before and after using the bathroom." d. "Be sure meat is cooked to the proper temperature." e. "Avoid eating eggs that are sunny side up or undercooked." f. "When eating outdoors, be sure to keep flies off your food." (Salmonella is usually contracted via contaminated eggs, beef, poultry, and green leafy vegetables. It is not transmitted through water in garden hoses or pools. Clients should wash leafy vegetables well, wash hands before and after using the restroom, make sure meat and eggs are cooked properly, and, because it can be transmitted by flies, keep flies off of food.)

A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best? a. Assess the client for anxiety. b. Break the information into smaller bits. c. Give the client written information. d. Review the information again.

a. Assess the client for anxiety. (Anxiety can interfere with learning and cooperation. The nurse should assess the client for anxiety. The other actions are appropriate too, and can be included in the teaching plan, but effective teaching cannot occur if the client is highly anxious.)

A nurse cares for a client with diabetes mellitus who is visually impaired. The client asks, "Can I ask my niece to prefill my syringes and then store them for later use when I need them?" How should the nurse respond? a. "Yes. Prefilled syringes can be stored for 3 weeks in the refrigerator in a vertical position with the needle pointing up." b. "Yes. Syringes can be filled with insulin and stored for a month in a location that is protected from light." c. "Insulin reacts with plastic, so prefilled syringes are okay, but you will need to use glass syringes." d. "No. Insulin syringes cannot be prefilled and stored for any length of time outside of the container."

a. "Yes. Prefilled syringes can be stored for 3 weeks in the refrigerator in a vertical position with the needle pointing up." (Insulin is relatively stable when stored in a cool, dry place away from light. When refrigerated, prefilled plastic syringes are stable for up to 3 weeks. They should be stored in the refrigerator in the vertical position with the needle pointing up to prevent suspended insulin particles from clogging the needle.)

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 should the nurse respond? a. "Your risk of diabetes is higher than the general population, but it may not occur." b. "No genetic risk is associated with the development of type 1 diabetes mellitus." c. "The risk for becoming a diabetic is 50% because of how it is inherited." d. "Female children do not inherit diabetes mellitus, but male children will."

a. "Your risk of diabetes is higher than the general population, but it may not occur." (Risk for type 1 diabetes is determined by inheritance of genes coding for HLA-DR and HLA-DQ tissue types. Clients who have one parent with type 1 diabetes are at increased risk for its development. Diabetes (type 1) seems to require interaction between inherited risk and environmental factors, so not everyone with these genes develops diabetes. The other statements are not accurate.)

A client in sickle cell crisis is dehydrated and in the emergency department. The nurse plans to start an IV. Which fluid choice is best? a. 0.45% normal saline b. 0.9% normal saline c. Dextrose 50% (D50) d. Lactated Ringer's solution

a. 0.45% normal saline (Because clients in sickle cell crisis are often dehydrated, the fluid of choice is a hypotonic solution such as 0.45% normal saline. 0.9% normal saline and lactated Ringer's solution are isotonic. D50 is hypertonic and not used for hydration.)

A nurse assesses clients at a health fair. Which clients should the nurse counsel to be tested for diabetes? (Select all that apply.) a. 56-year-old African-American male b. Female with a 30-pound weight gain during pregnancy c. Male with a history of pancreatic trauma d. 48-year-old woman with a sedentary lifestyle e. Male with a body mass index greater than 25 kg/m² f. 28-year-old female who gave birth to a baby weighing 9.2 pounds

a. 56-year-old African-American male d. 48-year-old woman with a sedentary lifestyle e. Male with a body mass index greater than 25 kg/m² f. 28-year-old female who gave birth to a baby weighing 9.2 pounds (Risk factors for type 2 diabetes include certain ethnic/racial groups (African Americans, American Indians, Hispanics), obesity and physical inactivity, and giving birth to large babies. Pancreatic trauma and a 30-pound gestational weight gain are not risk factors.)

A nurse is providing community screening for risk factors associated with stroke. Which client would the nurse identify as being at highest risk for a stroke? a. A 27-year-old heavy cocaine user b. A 30-year-old who drinks a beer a day c. A 40-year-old who uses seasonal antihistamines d. A 65-year-old who is active and on no medications

a. A 27-year-old heavy cocaine user (Heavy drug use, particularly cocaine, is a risk factor for stroke. Heavy alcohol use is also a risk factor, but one beer a day is not considered heavy drinking. Antihistamines may contain phenylpropanolamine, which also increases the risk for stroke, but this client uses them seasonally and there is no information that they are abused or used heavily. The 65-year-old has only age as a risk factor.)

The circulating nurse reviews the day's schedule and notes clients who are at higher risk of anesthetic overdose and other anesthesia-related complications. Which clients does this include? (Select all that apply.) a. A 75-year-old client scheduled for an elective procedure b. Client who drinks a 6-pack of beer each day c. Client with a serum creatinine of 3.8 mg/dL d. Client who is taking birth control pills e. Young male client with a RYR1 gene mutation

a. A 75-year-old client scheduled for an elective procedure b. Client who drinks a 6-pack of beer each day c. Client with a serum creatinine of 3.8 mg/dL e. Young male client with a RYR1 gene mutation (People at higher risk for anesthetic overdose or other anesthesia-related complications include people with a slowed metabolism (older adults generally have slower metabolism than younger adults), those with kidney or liver impairments, and those with mutations of the RYR1 gene. Drinking a 6-pack of beer per day possibly indicates some liver disease; a creatinine of 3.8 is high, indicating renal disease; and the genetic mutation increases the chance of malignant hyperthermia. Taking birth control pills is not a risk factor.)

A nurse assesses a client with diabetes mellitus and notes the client only responds to a sternal rub by moaning, has capillary blood glucose of 33 g/dL, and has an intravenous line that is infiltrated with 0.45% normal saline. Which action should the nurse take first? a. Administer 1 mg of intramuscular glucagon. b. Encourage the client to drink orange juice. c. Insert a new intravenous access line. d. Administer 25 mL dextrose 50% (D50) IV push.

a. Administer 1 mg of intramuscular glucagon. (The client's blood glucose level is dangerously low. The nurse needs to administer glucagon IM immediately to increase the client's blood glucose level. The nurse should insert a new IV after administering the glucagon and can use the new IV site for future doses of D50 if the client's blood glucose level does not rise. Once the client is awake, orange juice may be administered orally along with a form of protein such as a peanut butter.)

A client in the operating room has developed malignant hyperthermia. The client's potassium is 6.5 mEq/L. What action by the nurse takes priority? a. Administer 10 units of regular insulin. b. Administer nifedipine (Procardia). c. Assess urine for myoglobin or blood. d. Monitor the client for dysrhythmias.

a. Administer 10 units of regular insulin. (For hyperkalemia in a client with malignant hyperthermia, the nurse administers 10 units of regular insulin in 50 mL of 50% dextrose. This will force potassium back into the cells rapidly. Nifedipine is a calcium channel blocker used to treat hypertension and dysrhythmias, and should not be used in a client with malignant hyperthermia. Assessing the urine for blood or myoglobin is important, but does not take priority. Monitoring the client for dysrhythmias is also important due to the potassium imbalance, but again does not take priority over treating the potassium imbalance.)

A nurse assesses a client who has diabetes mellitus and notes the client is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup of orange juice, the client's clinical manifestations have not changed. Which action should the nurse take next? a. Administer another half-cup of orange juice. b. Administer a half-ampule of dextrose 50% intravenously. c. Administer 10 units of regular insulin subcutaneously. d. Administer 1 mg of glucagon intramuscularly.

a. Administer another half-cup of orange juice. (This client is experiencing mild hypoglycemia. For mild hypoglycemic manifestations, the nurse should administer oral glucose in the form of orange juice. If the symptoms do not resolve immediately, the treatment should be repeated. The client does not need intravenous dextrose, insulin, or glucagon.)

A client presents to the emergency department in sickle cell crisis. What intervention by the nurse takes priority? a. Administer oxygen. b. Apply an oximetry probe. c. Give pain medication. d. Start an IV line.

a. Administer oxygen. (All actions are appropriate, but remembering the ABCs, oxygen would come first. The main problem in a sickle cell crisis is tissue and organ hypoxia, so providing oxygen helps halt the process.)

A nurse is preparing to administer pantoprazole (Protonix) intravenously. What actions by the nurse are most appropriate? (Select all that apply.) a. Administer the drug through a separate IV line. b. Infuse pantoprazole using an IV pump. c. Keep the drug in its original brown bag. d. Take vital signs frequently during infusion. e. Use an in-line IV filter when infusing.

a. Administer the drug through a separate IV line. b. Infuse pantoprazole using an IV pump. e. Use an in-line IV filter when infusing. (When infusing pantoprazole, use a separate IV line, a pump, and an in-line filter. A brown wrapper and frequent vital signs are not needed.)

A nursing student planning to teach clients about risk factors for coronary artery disease (CAD) would include which topics? (Select all that apply.) a. Advanced age b. Diabetes c. Ethnic background d. Medication use e. Smoking

a. Advanced age b. Diabetes c. Ethnic background e. Smoking (Age, diabetes, ethnic background, and smoking are all risk factors for developing CAD; medication use is not.)

A postoperative client has just been admitted to the postanesthesia care unit (PACU). What assessment by the PACU nurse takes priority? a. Airway b. Bleeding c. Breathing d. Cardiac rhythm

a. Airway (Assessing the airway always takes priority, followed by breathing and circulation. Bleeding is part of the circulation assessment, as is cardiac rhythm.)

The nurse working in the emergency department assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess? (Select all that apply.) a. Alcohol intake b. Diabetes c. High-fat diet d. Obesity e. Smoking

a. Alcohol intake c. High-fat diet d. Obesity e. Smoking (Alcohol intake, a high-fat diet, obesity, and smoking are all modifiable risk factors for stroke. Diabetes is not modifiable but is a risk factor that can be controlled with medical intervention.)

A client has dumping syndrome. What menu selections indicate the client understands the correct diet to manage this condition? (Select all that apply.) a. Canned unsweetened apricots b. Coffee cake c. Milk shake d. Potato soup e. Steamed broccoli

a. Canned unsweetened apricots d. Potato soup (Canned apricots and potato soup are appropriate selections as they are part of a high-protein, high-fat, low- to moderate-carbohydrate diet. Coffee cake and other sweets must be avoided. Milk products and sweet drinks such as shakes must be avoided. Gas-forming foods such as broccoli must also be avoided.)

A nurse is admitting an older client for surgery to the inpatient surgical unit. The client relates a prior history of acute confusion after a previous operation. What interventions does the nurse include on the client's plan of care to minimize the potential for this occurring? (Select all that apply.) a. Allow family and friends to visit as the client desires. b. Ask the client about coping techniques frequently used. c. Instruct the nursing assistant to ensure the client is bathed. d. Place the client in a room secluded at the end of the hall. e. Provide the client with uninterrupted periods of sleep.

a. Allow family and friends to visit as the client desires. b. Ask the client about coping techniques frequently used. c. Instruct the nursing assistant to ensure the client is bathed. e. Provide the client with uninterrupted periods of sleep. (Older clients may have difficulty adjusting to the stress of the hospital environment and illness or surgery. Techniques that are helpful include allowing liberal visitation, assisting the client to use successful coping techniques, and keeping the client bathed and groomed. Sleep deprivation can contribute to confusion, so the nurse ensures the client receives adequate sleep. Secluding the client at the end of the hall may lead to sensory deprivation and loneliness.)

A client is clearly uncomfortable and anxious in the preoperative holding room waiting for emergent abdominal surgery. What actions can the nurse perform to increase comfort? (Select all that apply.) a. Allow the client to assume a position of comfort. b. Allow the client's family to remain at the bedside. c. Give the client a warm, non-caffeinated drink. d. Provide warm blankets or cool washcloths as desired. e. Pull the curtains around the bed to provide privacy.

a. Allow the client to assume a position of comfort. b. Allow the client's family to remain at the bedside. d. Provide warm blankets or cool washcloths as desired. e. Pull the curtains around the bed to provide privacy. (There are many nonpharmacologic comfort measures the nurse can employ, such as allowing the client to remain in the position that is most comfortable, letting the family stay with the client, providing warmth or cooling measures as requested by the client, and providing privacy. The client in the preoperative holding area is NPO, so drinks should not be provided.)

A circulating nurse has transferred an older client to the operating room. What action by the nurse is most important for this client? a. Allow the client to keep hearing aids in until anesthesia begins. b. Pad the table as appropriate for the surgical procedure. c. Position the client for maximum visualization of the site. d. Stay with the client, providing emotional comfort and support.

a. Allow the client to keep hearing aids in until anesthesia begins. (Many older clients have sensory loss. To help prevent disorientation, facilities often allow older clients to keep their eyeglasses on and hearing aids in until the start of anesthesia. The other actions are appropriate for all operative clients.)

After a stroke, a client has ataxia. What intervention is most appropriate to include on the client's plan of care? a. Ambulate only with a gait belt. b. Encourage double swallowing. c. Monitor lung sounds after eating. d. Perform post-void residuals.

a. Ambulate only with a gait belt. (Ataxia is a gait disturbance. For the client's safety, he or she should have assistance and use a gait belt when ambulating. Ataxia is not related to swallowing, aspiration, or voiding.)

A male patient wants to begin taking tadalifil (Cialis) to treat erectile dysfunction. Which aspect of this patient's history would be of concern? a. Angina pectoris b. Asthma c. Benign prostatic hypertrophy d. Color blindness

a. Angina pectoris (Patient with angina usually are treated with nitrates; phosphodiesterase inhibitors such as tadalifil are contraindicated in patients taking nitrates.)

patient will be taking a 2-week course of combination therapy with omeprazole (Prilosec) and another drug for a peptic ulcer caused by Helicobacter pylori. The nurse expects a drug from which class to be ordered with the omeprazole? a. Antibiotic b. Nonsteroidal anti-inflammatory drug c. Antacid d. Antiemetic

a. Antibiotic (The antibiotic clarithromycin is active against H. pylori and is used in combination with omeprazole to eradicate the bacteria. First-line therapy against H. pylori includes a 10- to 14-day course of a proton pump inhibitor such as omeprazole, plus the antibiotics clarithromycin and either amoxicillin or metronidazole, or a combination of a proton pump inhibitor, bismuth subsalicylate, and the antibiotics tetracycline and metronidazole. Many different combinations are used.)

A client is experiencing pain after leg surgery but cannot yet have more pain medication. What comfort interventions can the nurse provide? (Select all that apply.) a. Apply stimulation to the contralateral leg. b. Assess the client's willingness to try meditation. c. Elevate the client's operative leg and apply ice. d. Reduce the noise level in the client's environment. e. Turn the TV on loudly to distract the client.

a. Apply stimulation to the contralateral leg. b. Assess the client's willingness to try meditation. c. Elevate the client's operative leg and apply ice. d. Reduce the noise level in the client's environment. (There are many nonpharmacologic comfort measures for pain, including applying stimulation to the opposite leg, providing opportunities for meditation, elevation of the leg, applying ice, and reducing noxious stimuli in the environment. Participating in diversional activities is another approach, but simply turning the TV on loudly does not provide a good diversion.)

A client has dumping syndrome after a partial gastrectomy. Which action by the nurse would be most helpful? a. Arrange a dietary consult. b. Increase fluid intake. c. Limit the client's foods. d. Make the client NPO.

a. Arrange a dietary consult. (The client with dumping syndrome after a gastrectomy has multiple dietary needs. A referral to the registered dietitian will be extremely helpful. Food and fluid intake is complicated and needs planning. The client should not be NPO.)

A client is in the family practice clinic. Today the client weighs 186.4 pounds (84.7 kg). Six months ago the client weighed 211.8 pounds (96.2 kg). What action by the nurse is best? a. Ask the client if the weight loss was intentional. b. Determine if there are food allergies or intolerances. c. Perform a comprehensive nutritional assessment. d. Perform a rapid bedside blood glucose test.

a. Ask the client if the weight loss was intentional. (This client has had a 12% weight loss. The nurse first determines if the weight loss was intentional. If not, then the nurse proceeds to a comprehensive nutritional assessment. Food intolerances are part of this assessment. Depending on risk factors and other findings, a blood glucose test may be warranted.)

A nurse is concerned that a preoperative client has a great deal of anxiety about the upcoming procedure. What action by the nurse is best? a. Ask the client to describe current feelings. b. Determine if the client wants a chaplain. c. Reassure the client this surgery is common. d. Tell the client there is no need to be anxious.

a. Ask the client to describe current feelings. (The nurse needs to conduct further assessment of the client's anxiety. Asking open-ended questions about current feelings is an appropriate way to begin. The client may want a chaplain, but the nurse needs to do more for the client. Reassurance can be good, but false hope is not, and simply reassuring the client may not be helpful. Telling the client not to be anxious belittles the client's feelings.)

A client who has had systemic lupus erythematosus (SLE) for many years is in the clinic reporting hip pain with ambulation. Which action by the nurse is best? a. Assess medication records for steroid use. b. Facilitate a consultation with physical therapy. c. Measure the range of motion in both hips. d. Notify the health care provider immediately.

a. Assess medication records for steroid use. (Chronic steroid use is seen in clients with SLE and can lead to osteonecrosis (bone necrosis). The nurse should determine if the client has been taking a steroid. Physical therapy may be beneficial, but there is not enough information about the client yet. Measuring range of motion is best done by the physical therapist. Notifying the provider immediately is not warranted.)

A postoperative nurse is caring for a client whose oxygen saturation dropped from 98% to 95%. What action by the nurse is most appropriate? a. Assess other indicators of oxygenation. b. Call the Rapid Response Team. c. Notify the anesthesia provider. d. Prepare to intubate the client.

a. Assess other indicators of oxygenation. (If a postoperative client's oxygen saturation (SaO2) drops below 95% (or the client's baseline), the nurse should notify the anesthesia provider. If the SaO2 drops by 10% or more, the nurse should call the Rapid Response Team. Since this is approximately a 3% drop, the nurse should further assess the client. Intubation (if the client is not intubated already) is not warranted.)

A nurse is caring for a client on IV infusion of heparin. What actions does this nurse include in the client's plan of care? (Select all that apply.) a. Assess the client for bleeding. b. Monitor the daily activated partial thromboplastin time (aPTT) results. c. Stop the IV for aPTT above baseline. d. Use an IV pump for the infusion. e. Weigh the client daily on the same scale.

a. Assess the client for bleeding. b. Monitor the daily activated partial thromboplastin time (aPTT) results. d. Use an IV pump for the infusion. (Assessing for bleeding, monitoring aPTT, and using an IV pump for the infusion are all important safety measures for heparin to prevent injury from bleeding. The aPTT needs to be 1.5 to 2 times normal in order to demonstrate that the heparin is therapeutic. Weighing the client is not related.)

A client is in the bariatric clinic 1 month after having gastric bypass surgery. The client is crying and says "I didn't know it would be this hard to live like this." What response by the nurse is best? a. Assess the client's coping and support systems. b. Inform the client that things will get easier. c. Re-educate the client on needed dietary changes. d. Tell the client lifestyle changes are always hard.

a. Assess the client's coping and support systems. (The nurse should assess this client's coping styles and support systems in order to provide holistic care. The other options do not address the client's distress.)

A client is having surgery. The circulating nurse notes the client's oxygen saturation is 90% and the heart rate is 110 beats/min. What action by the nurse is best? a. Assess the client's end-tidal carbon dioxide level. b. Document the findings in the client's chart. c. Inform the anesthesia provider of these values. d. Prepare to administer dantrolene sodium (Dantrium).

a. Assess the client's end-tidal carbon dioxide level. (Malignant hyperthermia is a rare but serious reaction to anesthesia. The triad of early signs include decreased oxygen saturation, tachycardia, and elevated end-tidal carbon dioxide (CO2) level. The nurse should quickly check the end-tidal CO2 and then report findings to the anesthesia provider and surgeon. Documentation is vital, but not the most important action at this stage. Dantrolene sodium is the drug of choice if the client does have malignant hyperthermia.)

A client with a history of heart failure and hypertension is in the clinic for a follow-up visit. The client is on lisinopril (Prinivil) and warfarin (Coumadin). The client reports new-onset cough. What action by the nurse is most appropriate? a. Assess the client's lung sounds and oxygenation. b. Instruct the client on another antihypertensive. c. Obtain a set of vital signs and document them. d. Remind the client that cough is a side effect of Prinivil.

a. Assess the client's lung sounds and oxygenation. (This client could be having an exacerbation of heart failure or be experiencing a side effect of lisinopril (and other angiotensin-converting enzyme inhibitors). The nurse should assess the client's lung sounds and other signs of oxygenation first. The client may or may not need to switch antihypertensive medications. Vital signs and documentation are important, but the nurse should assess the respiratory system first. If the cough turns out to be a side effect, reminding the client is appropriate, but then more action needs to be taken.)

A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin (Coumadin). The client is adamant about refusing the drug because "it's dangerous." What action by the nurse is best? a. Assess the reason behind the client's fear. b. Remind the client about laboratory monitoring. c. Tell the client drugs are safer today than before. d. Warn the client about consequences of noncompliance.

a. Assess the reason behind the client's fear. (The first step is to assess the reason behind the client's fear, which may be related to the experience of someone the client knows who took warfarin. If the nurse cannot address the specific rationale, teaching will likely be unsuccessful. Laboratory monitoring once every few weeks may not make the client perceive the drug to be safe. General statements like "drugs are safer today" do not address the root cause of the problem. Warning the client about possible consequences of not taking the drug is not therapeutic and is likely to lead to an adversarial relationship.)

A client with a stroke has damage to Broca's area. What intervention to promote communication is best for this client? a. Assess whether or not the client can write. b. Communicate using "yes-or-no" questions. c. Reinforce speech therapy exercises. d. Remind the client not to use neologisms.

a. Assess whether or not the client can write. (Damage to Broca's area often leads to expressive aphasia, wherein the client can understand what is said but cannot express thoughts verbally. In some instances the client can write. The nurse should assess to see if that ability is intact. "Yes-or-no" questions are not good for this type of client because he or she will often answer automatically but incorrectly. Reinforcing speech therapy exercises is good for all clients with communication difficulties. Neologisms are made-up "words" often used by clients with sensory aphasia.)

A client is having shoulder surgery with regional anesthesia. What actions by the nurse are most important to enhance client safety related to this anesthesia? (Select all that apply.) a. Assessing distal circulation to the operative arm after positioning b. Keeping the client warm during the operative procedure c. Padding the client's shoulder and arm on the operating table d. Preparing to suction the client's airway if the client vomits e. Speaking in a low, quiet voice as anesthesia is administered

a. Assessing distal circulation to the operative arm after positioning c. Padding the client's shoulder and arm on the operating table (After regional anesthesia is administered, the client loses all sensation distally. The nurse ensures client safety by assessing distal circulation and padding the shoulder and arm appropriately. Although awake, the client will not be able to report potential injury. Keeping the client warm is not related to this anesthesia, nor is suctioning or speaking quietly.)

A client in the emergency department is having a stroke and needs a carotid artery angioplasty with stenting. The client's mental status is deteriorating. What action by the nurse is most appropriate? a. Attempt to find the family to sign a consent. b. Inform the provider that the procedure cannot occur. c. Nothing; no consent is needed in an emergency. d. Sign the consent form for the client.

a. Attempt to find the family to sign a consent. (The nurse should attempt to find the family to give consent. If no family is present or can be found, under the principle of emergency consent, a life-saving procedure can be performed without formal consent. The nurse should not just sign the consent form.)

The perioperative nurse manager and the postoperative unit manager are concerned about the increasing number of surgical infections in their hospital. What action by the managers is best? a. Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met. b. Encourage staff on both units to provide peer pressure to adhere to hand hygiene policy. c. Hold educational meetings with the nursing and surgical staff on infection prevention. d. Monitor staff on both units for consistent adherence to established hand hygiene practices.

a. Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met. (The SCIP project contains core measures that are mandatory for all surgical clients and focuses on preventing infection, serious cardiac events, and venous thromboembolism. The managers should start by reviewing charts to see if the guidelines of this project were implemented. The other actions may be necessary too, but first the managers need to assess the situation.)

A patient who recently began having mild symptoms of GERD is reluctant to take medication. What measures will the nurse recommend to minimize this patient's symptoms? (Select all that apply.) a. Avoiding hot, spicy foods b. Avoiding tobacco products c. Drinking a glass of red wine with dinner d. Eating a snack before bedtime e. Taking ibuprofen with food f. Using a small pillow for sleeping g. Wearing well-fitted clothing

a. Avoiding hot, spicy foods b. Avoiding tobacco products e. Taking ibuprofen with food (Hot, spicy foods aggravate gastric upset, tobacco increases gastric secretions, and ibuprofen on an empty stomach increases gastric secretions, so patients should be taught to avoid these actions. Alcohol should be avoided since it increases gastric secretions. Eating at bedtime increases reflux, as does laying relatively flat to sleep, or wearing fitted clothing.)

A patient arrives in the emergency department with severe chest pain. The patient reports that the pain has been occurring off and on for a week now. Which assessment finding would indicate the need for cautious use of nitrates and nitrites? a. Blood pressure of 88/62 mm Hg b. Apical pulse rate of 110 beats/min c. History of renal disease d. History of a myocardial infarction 2 years ago

a. Blood pressure of 88/62 mm Hg (Hypotension is a possible contraindication to the use of nitrates because the medications may cause the blood pressure to decrease. The other options are incorrect.)

A client has a platelet count of 9000/mm3. The nurse finds the client confused and mumbling. What action takes priority? a. Calling the Rapid Response Team b. Delegating taking a set of vital signs c. Instituting bleeding precautions d. Placing the client on bedrest

a. Calling the Rapid Response Team (With a platelet count this low, the client is at high risk of spontaneous bleeding. The most disastrous complication would be intracranial bleeding. The nurse needs to call the Rapid Response Team as this client has manifestations of a sudden neurologic change. The nurse should not delegate the vital signs as the client is no longer stable. Bleeding precautions will not address the immediate situation. Placing the client on bedrest or putting the client back into bed is important, but the critical action is to call for immediate medical attention.)

An older client is hospitalized after an operation. When assessing the client for postoperative infection, the nurse places priority on which assessment? a. Change in behavior b. Daily white blood cell count c. Presence of fever and chills d. Tolerance of increasing activity

a. Change in behavior (Older people have an age-related decrease in immune system functioning and may not show classic signs of infection such as increased white blood cell count, fever and chills, or obvious localized signs of infection. A change in behavior often signals an infection or onset of other illness in the older client.)

A nurse is teaching clients with gastroesophageal reflux disease (GERD) about foods to avoid. Which foods should the nurse include in the teaching? (Select all that apply.) a. Chocolate b. Decaffeinated coffee c. Citrus fruits d. Peppermint e. Tomato sauce

a. Chocolate c. Citrus fruits d. Peppermint e. Tomato sauce (Chocolate, citrus fruits such as oranges and grapefruit, peppermint and spearmint, and tomato-based products all contribute to the reflux associated with GERD. Caffeinated teas, coffee, and sodas should be avoided.)

An older adult patient had gastric surgery due to a gastrointestinal bleed 3 days ago, and he has been stable since the surgery. This evening, his daughter tells the nurse, "He seems to be more confused this afternoon. He's never been like this. What could be the problem?" The nurse reviews the patient's medication record and suspects that which drug could be the cause of the patient's confusion? a. Cimetidine (Tagamet) b. Pantoprazole (Protonix) c. Clarithromycin (Biaxin) d. Sucralfate (Carafate)

a. Cimetidine (Tagamet) (Sometimes H₂ receptor antagonists such as cimetidine may cause adverse effects related to the central nervous system in the older adult, including confusion and disorientation. The nurse needs to be alert for mental status changes when giving these drugs, especially if the changes are new to the patient.)

Maintaining a safe environment is a major responsibility of which surgical team member? a. Circulating nurse b. Scrub nurse c. Surgeon d. Certified registered nurse anesthetist

a. Circulating nurse (The circulating nurse observes the surgical procedure, coordinates the needs of the surgical team, and assists the team in maintaining a safe and comfortable environment. The scrub nurse is within the sterile field and passes instruments and other equipment needed to the surgeon during the surgical procedure. The surgeon performs the surgical procedure. The certified registered nurse anesthetist is a registered nurse who has been trained to deliver anesthesia.)

A 74-year-old professional golfer has chest pain that occurs toward the end of his golfing games. He says the pain usually goes away after one or two sublingual nitroglycerin tablets and rest. What type of angina is he experiencing? a. Classic b. Variant c. Unstable d. Prinzmetal's

a. Classic (Classic, or chronic stable, angina is triggered by either exertion or stress and usually subsides within 15 minutes with either rest or drug therapy.)

A nurse is working with many stroke clients. Which clients would the nurse consider referring to a mental health provider on discharge? (Select all that apply.) a. Client who exhibits extreme emotional lability b. Client with an initial National Institutes of Health (NIH) Stroke Scale score of 38 c. Client with mild forgetfulness and a slight limp d. Client who has a past hospitalization for a suicide attempt e. Client who is unable to walk or eat 3 weeks post-stroke

a. Client who exhibits extreme emotional lability b. Client with an initial National Institutes of Health (NIH) Stroke Scale score of 38 d. Client who has a past hospitalization for a suicide attempt e. Client who is unable to walk or eat 3 weeks post-stroke (Clients most at risk for post-stroke depression are those with a previous history of depression, severe stroke (NIH Stroke Scale score of 38 is severe), and post-stroke physical or cognitive impairment. The client with mild forgetfulness and a slight limp would be a low priority for this referral.)

A nurse assesses a client in the preoperative holding area and finds brittle nails and hair, dry skin turgor, and muscle wasting. What action by the nurse is best? a. Consult the surgeon about a postoperative dietitian referral. b. Document the findings thoroughly in the client's chart. c. Encourage the client to eat more after recovering from surgery. d. Refer the client to Meals on Wheels after discharge.

a. Consult the surgeon about a postoperative dietitian referral. (This client has signs of malnutrition, which can impact recovery from surgery. The nurse should consult the surgeon about prescribing a consultation with a dietitian in the postoperative period. The nurse should document the findings but needs to do more. Encouraging the client to eat more may be helpful, but the client needs a professional nutritional assessment so that the appropriate diet and supplements can be ordered. The client may or may not need Meals on Wheels after discharge.)

A client is hospitalized and on multiple antibiotics. The client develops frequent diarrhea. What action by the nurse is most important? a. Consult with the provider about obtaining stool cultures. b. Delegate frequent perianal care to unlicensed assistive personnel. c. Place the client on NPO status until the diarrhea resolves. d. Request a prescription for an anti-diarrheal medication.

a. Consult with the provider about obtaining stool cultures. (Hospitalized clients who have three or more stools a day for 2 or more days are suspected of having infection with Clostridium difficile. The nurse should inform the practitioner and request stool cultures. Frequent perianal care is important and can be delegated but is not the priority. The client does not necessarily need to be NPO; if the client is NPO, the nurse ensures he or she is getting appropriate IV fluids to prevent dehydration. Anti-diarrheal medication may or may not be appropriate, and the diarrhea serves as the portal of exit for the infection.)

What actions by the circulating nurse are important to promote client comfort? (Select all that apply.) a. Correct positioning b. Introducing one's self c. Providing warmth d. Remaining present e. Removing hearing aids

a. Correct positioning b. Introducing one's self c. Providing warmth d. Remaining present (The circulating nurse can do many things to promote client comfort, including positioning the client correctly and comfortably, introducing herself or himself to the client, keeping the client warm, and remaining present with the client. Removing hearing aids does not promote comfort and, if the client is still awake when they are removed, may contribute to disorientation and anxiety.)

A nurse caring for a client with sickle cell disease (SCD) reviews the client's laboratory work. Which finding should the nurse report to the provider? a. Creatinine: 2.9 mg/dL b. Hematocrit: 30% c. Sodium: 147 mEq/L d. White blood cell count: 12,000/mm3

a. Creatinine: 2.9 mg/dL (An elevated creatinine indicates kidney damage, which occurs in SCD. A hematocrit level of 30% is an expected finding, as is a slightly elevated white blood cell count. A sodium level of 147 mEq/L, although slightly high, is not concerning.)

The nurse on an inpatient rheumatology unit receives a hand-off report on a client with an acute exacerbation of systemic lupus erythematosus (SLE). Which reported laboratory value requires the nurse to assess the client further? a. Creatinine: 3.9 mg/dL b. Platelet count: 210,000/mm3 c. Red blood cell count: 5.2/mm3 d. White blood cell count: 4400/mm3

a. Creatinine: 3.9 mg/dL (Lupus nephritis is the leading cause of death in clients with SLE. The creatinine level is very high and the nurse needs to perform further assessments related to this finding. The other laboratory values are normal.)

A student nurse asks why older adults are at higher risk for complications after surgery. What reasons does the registered nurse give? (Select all that apply.) a. Decreased cardiac output b. Decreased oxygenation c. Frequent nocturia d. Mobility alterations e. Inability to adapt to changes

a. Decreased cardiac output b. Decreased oxygenation c. Frequent nocturia d. Mobility alterations (Older adults have many age-related physiologic changes that put them at higher risk of falling and other complications after surgery. Some of these include decreased cardiac output, decreased oxygenation of tissues, nocturia, and mobility alterations. They also have a decreased ability to adapt to new surroundings, but that is not the same as being unable to adapt.)

A nurse assesses a client who is experiencing diabetic ketoacidosis (DKA). For which manifestations should the nurse monitor the client? (Select all that apply.) a. Deep and fast respirations b. Decreased urine output c. Tachycardia d. Dependent pulmonary crackles e. Orthostatic hypotension

a. Deep and fast respirations c. Tachycardia e. Orthostatic hypotension (DKA leads to dehydration, which is manifested by tachycardia and orthostatic hypotension. Usually clients have Kussmaul respirations, which are fast and deep. Increased urinary output (polyuria) is severe. Because of diuresis and dehydration, peripheral edema and crackles do not occur.)

A nurse working with clients with sickle cell disease (SCD) teaches about self-management to prevent exacerbations and sickle cell crises. What factors should clients be taught to avoid? (Select all that apply.) a. Dehydration b. Exercise c. Extreme stress d. High altitudes e. Pregnancy

a. Dehydration c. Extreme stress d. High altitudes e. Pregnancy (Several factors cause red blood cells to sickle in SCD, including dehydration, extreme stress, high altitudes, and pregnancy. Strenuous exercise can also cause sickling, but not unless it is very vigorous.)

The nurse is aware that which factors are related to the development of gastroesophageal reflux disease (GERD)? (Select all that apply.) a. Delayed gastric emptying b. Eating large meals c. Hiatal hernia d. Obesity e. Viral infections

a. Delayed gastric emptying b. Eating large meals c. Hiatal hernia d. Obesity (Many factors predispose a person to GERD, including delayed gastric emptying, eating large meals, hiatal hernia, and obesity. Viral infections are not implicated in the development of GERD, although infection with Helicobacter pylori is.)

A client is being discharged on warfarin (Coumadin) therapy. What discharge instructions is the nurse required to provide? (Select all that apply.) a. Dietary restrictions b. Driving restrictions c. Follow-up laboratory monitoring d. Possible drug-drug interactions e. Reason to take medication

a. Dietary restrictions c. Follow-up laboratory monitoring d. Possible drug-drug interactions e. Reason to take medication (The Joint Commission's Core Measures state that clients being discharged on warfarin need instruction on follow-up monitoring, dietary restrictions, drug-drug interactions, and reason for compliance. Driving is typically not restricted.)

A nurse assesses a client with Crohn's disease and colonic strictures. Which clinical manifestation should alert the nurse to urgently contact the health care provider? a. Distended abdomen b. Temperature of 100.0° F (37.8° C) c. Loose and bloody stool d. Lower abdominal cramps

a. Distended abdomen (The presence of strictures predisposes the client to intestinal obstruction. Abdominal distention may indicate that the client has developed an obstruction of the large bowel, and the client's provider should be notified right away. Low-grade fever, bloody diarrhea, and abdominal cramps are common symptoms of Crohn's disease.)

A nurse assesses a client with peritonitis. Which clinical manifestations should the nurse expect to find? (Select all that apply.) a. Distended abdomen b. Inability to pass flatus c. Bradycardia d. Hyperactive bowel sounds e. Decreased urine output

a. Distended abdomen b. Inability to pass flatus e. Decreased urine output (A client with peritonitis may present with a distended abdomen, diminished bowel sounds, inability to pass flatus or feces, tachycardia, and decreased urine output secondary to dehydration. Bradycardia and hyperactive bowel sounds are not associated with peritonitis.)

A preoperative nurse assesses a client who has type 1 diabetes mellitus prior to a surgical procedure. The client's blood glucose level is 160 mg/dL. Which action should the nurse take? a. Document the finding in the client's chart. b. Administer a bolus of regular insulin IV. c. Call the surgeon to cancel the procedure. d. Draw blood gases to assess the metabolic state.

a. Document the finding in the client's chart. (Clients who have type 1 diabetes and are having surgery have been found to have fewer complications, lower rates of infection, and better wound healing if blood glucose levels are maintained at between 140 and 180 mg/dL throughout the perioperative period. The nurse should document the finding and proceed with other operative care. The need for a bolus of insulin, canceling the procedure, or drawing arterial blood gases is not required.)

A nurse prepares to administer insulin to a client at 1800. The client's medication administration record contains the following information: -------------------------------- • Insulin glargine: 12 units daily at 1800 • Regular insulin: 6 units QID at 0600, 1200, 1800, 2400 -------------------------------- Based on the client's medication administration record, which action should the nurse take? a. Draw up and inject the insulin glargine first, and then draw up and inject the regular insulin. b. Draw up and inject the insulin glargine first, wait 20 minutes, and then draw up and inject the regular insulin. c. First draw up the dose of regular insulin, then draw up the dose of insulin glargine in the same syringe, mix, and inject the two insulins together. d. First draw up the dose of insulin glargine, then draw up the dose of regular insulin in the same syringe, mix, and inject the two insulins together.

a. Draw up and inject the insulin glargine first, and then draw up and inject the regular insulin. (Insulin glargine must not be diluted or mixed with any other insulin or solution. Mixing results in an unpredictable alteration in the onset of action and time to peak action. The correct instruction is to draw up and inject first the glargine and then the regular insulin right afterward.)

A student nurse observing in the operating room notes that the functions of the Certified Registered Nurse First Assistant (CRNFA) include which activities? (Select all that apply.) a. Dressing the surgical wound b. Grafting new or synthetic skin c. Reattaching severed nerves d. Suctioning the surgical site e. Suturing the surgical wound

a. Dressing the surgical wound d. Suctioning the surgical site e. Suturing the surgical wound (The CRNFA can perform tasks under the direction of the surgeon such as suturing and dressing surgical wounds, cutting away tissue, suctioning the wound to improve visibility, and holding retractors. Reattaching severed nerves and performing grafts would be the responsibility of the surgeon.)

What are functional causes of hypoglycemia? (Select all that apply.) a. Dumping syndrome b. Overdose of insulin c. Addison disease d. Prolonged muscular exercise e. Chronic alcoholism

a. Dumping syndrome c. Addison disease d. Prolonged muscular exercise (Dumping syndrome, Addison disease, and prolonged exercise are functional causes of hypoglycemia. Overdose of insulin and chronic alcoholism are exogenous causes.)

The nursing student observing in the perioperative area notes the unique functions of the circulating nurse, which include which roles? (Select all that apply.) a. Ensuring the client's safety b. Accounting for all sharps c. Documenting all care given d. Maintaining the sterile field e. Monitoring traffic in the room

a. Ensuring the client's safety e. Monitoring traffic in the room (The circulating nurse has several functions, including maintaining client safety and privacy, monitoring traffic in and out of the operating room, assessing fluid losses, reporting findings to the surgeon and anesthesia provider, anticipating needs of the team, and communicating to the family. The circulating nurse and scrub person work together to ensure accurate counts of sharps, sponges, and instruments. The circulating nurse also documents care, but in the perioperative area, the preoperative or holding room nurse would also document care received there. Maintaining the sterile field is a joint responsibility among all members of the surgical team.)

A client is on the phone when the nurse brings a preoperative antibiotic before scheduled surgery. The circulating nurse has requested the antibiotic be started. The client wants the nurse to wait before starting it. What response by the nurse is most appropriate? a. Explain the rationale for giving the medicine now. b. Leave the room and come back in 15 minutes. c. Provide holistic client care and come back later. d. Tell the client you must start the medication now.

a. Explain the rationale for giving the medicine now. (The preoperative antibiotic must be given within 60 minutes of the surgical start time to ensure the proper amount is in the tissues when the incision is made. The nurse should explain the rationale to the client for this timing. The other options do not take this timing into consideration and do not give the client the information needed to be cooperative.)

A client is scheduled for a below-the-knee amputation. The circulating nurse ensures the proper side is marked prior to the start of surgery. What action by the nurse is most appropriate? a. Facilitate marking the site with the client and surgeon. b. Have the client mark the operative site. c. Mark the operative site with a waterproof marker. d. Tell the surgeon it is time to mark the surgical site.

a. Facilitate marking the site with the client and surgeon. (The Joint Commission now recommends that both the client and the surgeon mark the operative site together in order to prevent wrong-site surgery. The nurse should facilitate this process.)

A postoperative client has respiratory depression after receiving midazolam (Versed) for sedation. Which IV-push medication and dose does the nurse prepare to administer? a. Flumazenil (Romazicon) 0.2 to 1 mg b. Flumazenil (Romazicon) 2 to 10 mg c. Naloxone (Narcan) 0.4 to 2 mg d. Naloxone (Narcan) 4 to 20 mg

a. Flumazenil (Romazicon) 0.2 to 1 mg (Flumazenil is a benzodiazepine antagonist and would be the correct drug to use in this situation. The correct dose is 0.2 to 1 mg. Naloxone is an opioid antagonist.)

A client has Crohn's disease. What type of anemia is this client most at risk for developing? a. Folic acid deficiency b. Fanconi's anemia c. Hemolytic anemia d. Vitamin B12 anemia

a. Folic acid deficiency (Malabsorption syndromes such as Crohn's disease leave a client prone to folic acid deficiency. Fanconi's anemia, hemolytic anemia, and vitamin B12 anemia are not related to Crohn's disease.)

A client hospitalized with sickle cell crisis frequently asks for opioid pain medications, often shortly after receiving a dose. The nurses on the unit believe the client is drug seeking. When the client requests pain medication, what action by the nurse is best? a. Give the client pain medication if it is time for another dose. b. Instruct the client not to request pain medication too early. c. Request the provider leave a prescription for a placebo. d. Tell the client it is too early to have more pain medication.

a. Give the client pain medication if it is time for another dose. (Clients with sickle cell crisis often have severe pain that is managed with up to 48 hours of IV opioid analgesics. Even if the client is addicted and drug seeking, he or she is still in extreme pain. If the client can receive another dose of medication, the nurse should provide it. The other options are judgmental and do not address the client's pain. Giving placebos is unethical.)

Which of the following statements is correct about childhood obesity? a. Heredity is an important factor in the development of obesity. b. Childhood obesity in the United States is decreasing. c. Childhood obesity is the result of inactivity. d. Childhood obesity can be attributed to an underlying disease in most cases.

a. Heredity is an important factor in the development of obesity. (Heredity is an important fact that contributes to obesity. Identical twins reared apart tend to resemble their biologic parents to a greater extent than their adoptive parents. It is difficult to distinguish between hereditary and environmental factors.)

The nurse would expect to administer an anticoagulant to a patient following which surgery? a. Hip replacement b. Hysterectomy c. Abdominal aorta aneurism (AAA) repair d. Appendectomy

a. Hip replacement (Prophylactic anticoagulation is used for hip replacement because of the high risk of developing a deep vein thrombosis after hip replacement. Anticoagulants are not routinely administered to patients with hysterectomies, AAA repairs, and appendectomies.)

A patient on an enteral feeding suddenly complains of feeling faint and is sweating. The diastolic blood pressure has dropped 20 points. The nurse recognizes this as signs of the dumping syndrome. What is the cause of dumping syndrome? a. Hypertonic fluid entering the jejunum and pulling large amounts of water from the circulating volume b. Rich enteral feeding causing bowel irritation with severe cramping c. Hypertonic solution rapidly entering the stomach causing pyloric spasm d. Rapid drop in blood glucose as a result of the hypertonic solution pooling in the jejunum

a. Hypertonic fluid entering the jejunum and pulling large amounts of water from the circulating volume (Enteral tube feedings can cause dumping syndrome by pooling feeding in the jejunum, which pulls fluid from the circulating volume and causes hypotension.)

An emergency department nurse assesses a client with ketoacidosis. Which clinical manifestation should the nurse correlate with this condition? a. Increased rate and depth of respiration b. Extremity tremors followed by seizure activity c. Oral temperature of 102° F (38.9° C) d. Severe orthostatic hypotension

a. Increased rate and depth of respiration (Ketoacidosis decreases the pH of the blood, stimulating the respiratory control areas of the brain to buffer the effects of increasing acidosis. The rate and depth of respiration are increased (Kussmaul respirations) in an attempt to excrete more acids by exhalation. Tremors, elevated temperature, and orthostatic hypotension are not associated with ketoacidosis.)

A nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.) a. Lower gastrointestinal bleeding - Erosion of the bowel wall b. Abscess formation - Localized pockets of infection develop in the ulcerated bowel lining c. Toxic megacolon - Transmural inflammation resulting in pyuria and fecaluria d. Nonmechanical bowel obstruction - Paralysis of colon resulting from colorectal cancer e. Fistula - Dilation and colonic ileus caused by paralysis of the colon

a. Lower gastrointestinal bleeding - Erosion of the bowel wall b. Abscess formation - Localized pockets of infection develop in the ulcerated bowel lining d. Nonmechanical bowel obstruction - Paralysis of colon resulting from colorectal cancer (Lower GI bleeding can lead to erosion of the bowel wall. Abscesses are localized pockets of infection that develop in the ulcerated bowel lining. Nonmechanical bowel obstruction is paralysis of the colon that results from colorectal cancer. When the inflammation is transmural, fistulas can occur between the bowel and bladder resulting in pyuria and fecaluria. Paralysis of the colon causing dilation and subsequent colonic ileus is known as a toxic megacolon.)

A nurse is caring for several clients prior to surgery. Which medications taken by the clients require the nurse to consult with the physician about their administration? (Select all that apply.) a. Metformin (Glucophage) b. Omega-3 fatty acids (Sea Omega 30) c. Phenytoin (Dilantin) d. Pilocarpine hydrochloride (Isopto Carpine) e. Warfarin (Coumadin)

a. Metformin (Glucophage) c. Phenytoin (Dilantin) d. Pilocarpine hydrochloride (Isopto Carpine) e. Warfarin (Coumadin) (Although the client will be on NPO status before surgery, the nurse should check with the provider about allowing the client to take medications prescribed for diabetes, hypertension, cardiac disease, seizure disorders, depression, glaucoma, anticoagulation, or depression. Metformin is used to treat diabetes; phenytoin is for seizures; pilocarpine is for glaucoma, and warfarin is an anticoagulant. The omega-3 fatty acids can be held the day of surgery.)

A patient who has severe nausea and vomiting following a case of food poisoning comes to the urgent care center. When reviewing his medication history, the nurse notes that he has an allergy to procaine. The nurse would question an order for which antiemetic drug if ordered for this patient? a. Metoclopramide (Reglan) b. Promethazine (Phenergan) c. Phosphorated carbohydrate solution (Emetrol) d. Palonosetron (Aloxi)

a. Metoclopramide (Reglan) (The use of metoclopramide (Reglan) is contraindicated in patients with a hypersensitivity to procaine or procainamide. There are no known interactions with the drugs listed in the other options.)

The nurse is making a home visit to a patient who was discharged from the hospital on Lovenox and warfarin following replacement of the patient's pacemaker. Which observation indicates excessive bleeding? (Select all that apply.) a. New ecchymosis on the abdomen b. A nosebleed that does not stop with pressure c. Pain of the lower extremity with flexion d. Extreme fatigue e. Pallor f. Sudden onset of severe headache

a. New ecchymosis on the abdomen b. A nosebleed that does not stop with pressure d. Extreme fatigue e. Pallor f. Sudden onset of severe headache (Excessive bleeding includes large bruises that may be increasing in size, nosebleeds, extreme fatigue from decreased tissue oxygenation due to decreased hemoglobin, and sudden onset of a severe headache, which may indicate a cerebral hemorrhage. Pain in the lower extremity may be a result of a deep vein thrombosis. Pain of the legs with flexion may be associated with venous thrombosis.)

A patient in the intensive care unit has a nasogastric tube and is also receiving a proton pump inhibitor (PPI). The nurse recognizes that the purpose of the PPI is which effect? a. Prevent stress ulcers b. Reduce bacteria levels in the stomach c. Reduce gastric gas formation (flatulence) d. Promote gastric motility

a. Prevent stress ulcers (Stress-related mucosal damage is an important issue for critically ill patients. Stress ulcer prophylaxis (or therapy to prevent severe gastrointestinal [GI] damage) is undertaken in almost every critically ill patient in an intensive care unit and for many patients on general medical surgical units. Procedures performed commonly in critically ill patients, such as passing nasogastric tubes, placing patients on ventilators, and others, predispose patients to bleeding of the GI tract. Guidelines suggest that all such patients receive either a histamine receptor-blocking drug or a proton pump inhibitor. The other options are incorrect.)

A patient is receiving a tube feeding through a gastrostomy. The nurse expects that which type of drug will be used to promote gastric emptying for this patient? a. Prokinetic drugs, such as metoclopramide (Reglan) b. Serotonin blockers, such as ondansetron (Zofran) c. Anticholinergic drugs, such as scopolamine (Transderm-Scop) d. Neuroleptic drugs, such as chlorpromazine (Thorazine)

a. Prokinetic drugs, such as metoclopramide (Reglan) (Prokinetic drugs promote the movement of substances through the gastrointestinal tract and increase gastrointestinal motility.)

A patient with elevated lipid levels has a new prescription for nicotinic acid (niacin). The nurse informs the patient that which adverse effects may occur with this medication? a. Pruritus, cutaneous flushing b. Tinnitus, urine with a burnt odor c. Myalgia, fatigue d. Blurred vision, headaches

a. Pruritus, cutaneous flushing (Possible adverse effects of nicotinic acid include pruritus, cutaneous flushing, and gastrointestinal distress. Tinnitus, urine with a burnt odor, and headaches are possible adverse effects of bile acid sequestrants. Headaches are also possible adverse effects of HMG-CoA reductase inhibitors, as are myalgia and fatigue.)

The nurse is conducting a smoking-cessation program. Which statement regarding drugs used in cigarette-smoking-cessation programs is true? a. Rapid chewing of the nicotine gum releases an immediate dose of nicotine. b. Quick relief from withdrawal symptoms is most easily achieved by using a transdermal patch. c. Compliance with treatment is higher with use of the gum rather than the transdermal patch. d. The nicotine gum can be used only up to six times per day.

a. Rapid chewing of the nicotine gum releases an immediate dose of nicotine. (Quick or acute relief from withdrawal symptoms is most easily achieved with the use of the gum because rapid chewing of the gum produces an immediate dose of nicotine. However, treatment compliance is higher with the use of the transdermal patch system. Nicotine gum can be used whenever the patient has a strong urge to smoke.)

A nurse collaborates with the interdisciplinary team to develop a plan of care for a client who is newly diagnosed with diabetes mellitus. Which team members should the nurse include in this interdisciplinary team meeting? (Select all that apply.) a. Registered dietitian b. Clinical pharmacist c. Occupational therapist d. Health care provider e. Speech-language pathologist

a. Registered dietitian b. Clinical pharmacist d. Health care provider (When planning care for a client newly diagnosed with diabetes mellitus, the nurse should collaborate with a registered dietitian, clinical pharmacist, and health care provider. The focus of treatment for a newly diagnosed client would be nutrition, medication therapy, and education. The nurse could also consult with a diabetic educator. There is no need for occupational therapy or speech therapy at this time.)

Methotrexate is ordered for a patient with a malignant tumor, and the nurse is providing education about self-care after the chemotherapy is given. Which statements by the nurse are appropriate for the patient receiving methotrexate? (Select all that apply.) a. Report unusual bleeding or bruising. b. Hair loss is not expected with this drug. c. Prepare for hair loss. d. Avoid areas with large crowds or gatherings. e. Avoid foods that are too hot or too cold or rough in texture. f. Restrict fluid intake to reduce nausea and vomiting.

a. Report unusual bleeding or bruising. c. Prepare for hair loss. d. Avoid areas with large crowds or gatherings. e. Avoid foods that are too hot or too cold or rough in texture. (Counsel patients who are taking methotrexate to expect hair loss and to report any unusual bleeding or bruising. Because of the possibility of infection, avoid areas with large crowds or gatherings. Foods that are too hot or too cold or rough in texture may be irritating to the oral mucosa. Fluid intake is to be encouraged to prevent dehydration.)

A nurse reviews the chart of a client who has Crohn's disease and a draining fistula. Which documentation should alert the nurse to urgently contact the provider for additional prescriptions? a. Serum potassium of 2.6 mEq/L b. Client ate 20% of breakfast meal c. White blood cell count of 8200/mm3 d. Client's weight decreased by 3 pounds

a. Serum potassium of 2.6 mEq/L (Fistulas place the client with Crohn's disease at risk for hypokalemia which can lead to serious dysrhythmias. This potassium level is low and should cause the nurse to intervene. The white blood cell count is normal. The other two findings are abnormal and also warrant intervention, but the potassium level takes priority.)

A nurse assesses a client who has appendicitis. Which clinical manifestation should the nurse expect to find? a. Severe, steady right lower quadrant pain b. Abdominal pain associated with nausea and vomiting c. Marked peristalsis and hyperactive bowel sounds d. Abdominal pain that increases with knee flexion

a. Severe, steady right lower quadrant pain (Right lower quadrant pain, specifically at McBurney's point, is characteristic of appendicitis. Usually if nausea and vomiting begin first, the client has gastroenteritis. Marked peristalsis and hyperactive bowel sounds are not indicative of appendicitis. Abdominal pain due to appendicitis decreases with knee flexion.)

The nurse is providing education about the use of sublingual nitroglycerin tablets. She asks the patient, "What would you do if you experienced chest pain while mowing your yard? You have your bottle of sublingual nitroglycerin with you." Which actions by the patient are appropriate in this situation? (Select all that apply.) a. Stop the activity, and lie down or sit down. b. Call 911 immediately. c. Call 911 if the pain is not relieved after taking one sublingual tablet. d. Call 911 if the pain is not relieved after taking three sublingual tablets in 15 minutes. e. Place a tablet under the tongue. f. Place a tablet in the space between the gum and cheek. g. Take another sublingual tablet if chest pain is not relieved after 5 minutes, up to three total.

a. Stop the activity, and lie down or sit down. c. Call 911 if the pain is not relieved after taking one sublingual tablet. e. Place a tablet under the tongue. g. Take another sublingual tablet if chest pain is not relieved after 5 minutes, up to three total. (With sublingual forms, the medication is taken at the first sign of chest pain, not delayed until the pain is severe. The patient needs to sit down or lie down and take one sublingual tablet. According to current guidelines, if the chest pain or discomfort is not relieved in 5 minutes, after 1 dose, the patient (or family member) must call 911 immediately. The patient can take one more tablet while awaiting emergency care and may take a third tablet 5 minutes later, but no more than a total of three tablets. These guidelines reflect the fact that angina pain that does not respond to nitroglycerin may indicate a myocardial infarction. The sublingual dose is placed under the tongue, and the patient needs to avoid swallowing until the tablet has dissolved. Placing a tablet between the gum and cheek is the buccal route.)

A nurse provides diabetic education at a public health fair. Which disorders should the nurse include as complications of diabetes mellitus? (Select all that apply.) a. Stroke b. Kidney failure c. Blindness d. Respiratory failure e. Cirrhosis

a. Stroke b. Kidney failure c. Blindness (Complications of diabetes mellitus are caused by macrovascular and microvascular changes. Macrovascular complications include coronary artery disease, cerebrovascular disease, and peripheral vascular disease. Microvascular complications include nephropathy, retinopathy, and neuropathy. Respiratory failure and cirrhosis are not complications of diabetes mellitus.)

A patient will be taking oral iron supplements at home. The nurse will include which statements in the teaching plan for this patient? (Select all that apply.) a. Take the iron tablets with meals. b. Take the iron tablets on an empty stomach 1 hour before meals. c. Take the iron tablets with an antacid to prevent heartburn. d. Drink 8 ounces of milk with each iron dose. e. Taking iron supplements with orange juice enhances iron absorption. f. Stools may become loose and light in color. g. Stools may become black and tarry. h. Tablets may be crushed to enhance iron absorption.

a. Take the iron tablets with meals. e. Taking iron supplements with orange juice enhances iron absorption. g. Stools may become black and tarry. (Iron tablets need to be taken with meals to reduce gastrointestinal distress, but antacids and milk interfere with absorption. Orange juice enhances the absorption of iron. Stools may become black and tarry in patients who are on iron supplements. Tablets need to be taken whole, not crushed, and the patient needs to be encouraged to eat foods high in iron.)

A nurse assesses a client with the National Institutes of Health (NIH) Stroke Scale and determines the client's score to be 36. How should the nurse plan care for this client? a. The client will need near-total care. b. The client will need cuing only. c. The client will need safety precautions. d. The client will be discharged home.

a. The client will need near-total care. (This client has severe neurologic deficits and will need near-total care. Safety precautions are important but do not give a full picture of the client's dependence. The client will need more than cuing to complete tasks. A home discharge may be possible, but this does not help the nurse plan care for a very dependent client.)

A patient will be taking dabigatran (Pradaxa) as part of treatment for chronic atrial fibrillation. Which statements about dabigatran are true? (Select all that apply.) a. The dose of dabigatran is reduced in patients with decreased renal function. b. Bleeding is the most common adverse effect. c. Potassium chloride is given as an antidote in cases of overdose. d. Dabigatran levels are monitored by measuring prothrombin time/international normalized ratio (PT/INR) results. e. This drug is a prodrug and becomes activated in the liver.

a. The dose of dabigatran is reduced in patients with decreased renal function. b. Bleeding is the most common adverse effect. e. This drug is a prodrug and becomes activated in the liver. (Dabigatran is excreted extensively in the kidneys, and the dose is dependent upon renal function. The normal dose is 150 mg twice daily, but it must be reduced to 75 mg twice daily if creatinine clearance is less than 30 mL/min. The most common and serious side effect is bleeding. Dabigatran is a prodrug that becomes activated in the liver. There is no antidote to dabigatran. The other options are incorrect.)

A patient is taking gabapentin (Neurontin), and the nurse notes that there is no history of seizures on his medical record. What is the best possible rationale for this medication order? a. The medication is used for the treatment of neuropathic pain. b. The medication is helpful for the treatment of multiple sclerosis. c. The medication is used to reduce the symptoms of Parkinson's disease. d. The medical record is missing the correct information about the patient's history of seizures.

a. The medication is used for the treatment of neuropathic pain. (Gabapentin (Neurontin) is commonly used to treat neuropathic pain. The other options are incorrect.)

A patient is asking advice about which over-the-counter antacid is considered the most safe to use for heartburn. The nurse explains that the reason that calcium antacids are not used as frequently as other antacids is for which of these reasons? a. Their use may result in kidney stones. b. They cause decreased gastric acid production. c. They cause severe diarrhea. d. Their use may result in fluid retention and edema.

a. Their use may result in kidney stones. (Calcium antacids are not used as frequently as other antacids because their use may lead to the development of kidney stones; they also cause increased gastric acid production. The other options are incorrect.)

A nurse is reviewing the drugs taken by a 50-year-old male patient. What medication should the nurse recognize as the most probable cause of erectile dysfunction (ED)? a. Vasodilator for hypertension b. Antibiotic for an upper respiratory infection c. Antihistamine for allergies d. Glucophage for type 2 diabetes

a. Vasodilator for hypertension (Vasodilators taken for the control of hypertension frequently cause ED.)

A good snack for a patient with dumping syndrome is a. cheese and whole grain crackers. b. applesauce and graham crackers. c. nonfat milk and pretzels. d. fig bars and juice.

a. cheese and whole grain crackers. (The complex of symptoms in dumping syndrome constitutes a shock syndrome that results when a meal containing a large portion of readily soluble carbohydrates rapidly enters, or "dumps," into the small intestine. An appropriate food choice for someone with dumping syndrome would include complex carbohydrate and protein as well as fat—in this case, cheese and whole grain crackers. Nonfat milk and pretzels would not provide any fat, plus liquids should be given between rather than with meals, and milk contains some simple carbohydrates, which may not be tolerated.)

A clinical symptom of gallbladder inflammation or gallstones is a. pain and distention after eating. b. jaundice. c. anorexia. d. weakness and apathy.

a. pain and distention after eating. (A clinical symptom of gallbladder inflammation is pain and distention after eating. When infection, stones, or both are present, the normal contraction of the gallbladder, triggered by fat entering the intestine, causes pain.)

After successfully losing 1 lb weekly for several months, a patient at the clinic has not lost any weight for the last month. The nurse should first review the diet and exercise guidelines with the patient. instruct the patient to weigh and record weights weekly. ask the patient whether there have been any changes in exercise or diet patterns. discuss the possibility that the patient has reached a temporary weight loss plateau.

ask the patient whether there have been any changes in exercise or diet patterns. (The initial nursing action should be assessment of any reason for the change in weight loss. The other actions may be needed, but further assessment is required before any interventions are planned or implemented.)

medication: ED tx PDE5 inhibitor (PO) ↑ blood flow to corpus cavernosum contra: nitrate use ADR: h/a, flushing, take 15 min before sexual activity

avanafil (stendra)

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 should the nurse respond? a. "You need to start with multiple injections until you become more proficient at self-injection." b. "A single dose of insulin each day would not match your blood insulin levels and your food intake patterns." c. "A regimen of a single dose of insulin injected each day would require that you eat fewer carbohydrates." d. "A single dose of insulin would be too large to be absorbed, predictably putting you at risk for insulin shock."

b. "A single dose of insulin each day would not match your blood insulin levels and your food intake patterns." (Even when a single injection of insulin contains a combined dose of different-acting insulin types, the timing of the actions and the timing of food intake may not match well enough to prevent wide variations in blood glucose levels. One dose of insulin would not be appropriate even if the client decreased carbohydrate intake. Additional injections are not required to allow the client practice with injections, nor will one dose increase the client's risk of insulin shock.)

A nurse teaches a client with type 2 diabetes mellitus who is prescribed glipizide (Glucotrol). Which statement should the nurse include in this client's teaching? a. "Change positions slowly when you get out of bed." b. "Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs)." c. "If you miss a dose of this drug, you can double the next dose." d. "Discontinue the medication if you develop a urinary infection."

b. "Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs)." (NSAIDs potentiate the hypoglycemic effects of sulfonylurea agents. Glipizide is a sulfonylurea. The other statements are not applicable to glipizide.)

A nurse is giving a client instructions for showering with special antimicrobial soap the night before surgery. What instruction is most appropriate? a. "After you wash the surgical site, shave that area with your own razor." b. "Be sure to wash the area where you will have surgery very thoroughly." c. "Use a washcloth to wash the surgical site; do not take a full shower or bath." d. "Wash the surgical site first, then shampoo and wash the rest of your body."

b. "Be sure to wash the area where you will have surgery very thoroughly." (The entire proposed surgical site needs to be washed thoroughly and completely with the antimicrobial soap. Shaving, if absolutely necessary, should be done in the operative suite immediately before the operation begins, using sterile equipment. The client needs a full shower or bath (shower preferred). The client should wash the surgical site last; dirty water from shampooing will run over the cleansed site if the site is washed first.)

A nurse teaches a client about self-monitoring of blood glucose levels. Which statement should the nurse include in this client's teaching to prevent bloodborne infections? a. "Wash your hands after completing each test." b. "Do not share your monitoring equipment." c. "Blot excess blood from the strip with a cotton ball." d. "Use gloves when monitoring your blood glucose."

b. "Do not share your monitoring equipment." (Small particles of blood can adhere to the monitoring device, and infection can be transported from one user to another. Hepatitis B in particular can survive in a dried state for about a week. The client should be taught to avoid sharing any equipment, including the lancet holder. The client should be taught to wash his or her hands before testing. The client would not need to blot excess blood away from the strip or wear gloves.)

A client admitted for sickle cell crisis is distraught after learning her child also has the disease. What response by the nurse is best? a. "Both you and the father are equally responsible for passing it on." b. "I can see you are upset. I can stay here with you a while if you like." c. "It's not your fault; there is no way to know who will have this disease." d. "There are many good treatments for sickle cell disease these days."

b. "I can see you are upset. I can stay here with you a while if you like." (The best response is for the nurse to offer self, a therapeutic communication technique that uses presence. Attempting to assign blame to both parents will not help the client feel better. There is genetic testing available, so it is inaccurate to state there is no way to know who will have the disease. Stating that good treatments exist belittles the client's feelings.)

After teaching a client with a parasitic gastrointestinal infection, a nurse assesses the client's understanding. Which statements made by the client indicate that the client correctly understands the teaching? (Select all that apply.) a. "I'll have my housekeeper keep my toilet clean." b. "I must take a shower or bathe every day." c. "I should have my well water tested." d. "I will ask my sexual partner to have a stool test." e. "I must only eat raw vegetables from my own garden."

b. "I must take a shower or bathe every day." c. "I should have my well water tested." d. "I will ask my sexual partner to have a stool test." (Parasitic infections can be transmitted to other people. The client himself or herself should keep the toilet area clean instead of possibly exposing another person to the disease. Parasites are transmitted via unclean water sources and sexual practices with rectal contact. The client should test his or her well water and ask sexual partners to have their stool examined for parasites. Raw vegetables are not associated with parasitic gastrointestinal infections. The client can eat vegetables from the store or a home garden as long as the water source is clean.)

After teaching a client with perineal excoriation caused by diarrhea from acute gastroenteritis, a nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching? a. "I'll rinse my rectal area with warm water after each stool and apply zinc oxide ointment." b. "I will clean my rectal area thoroughly with toilet paper after each stool and then apply aloe vera gel." c. "I must take a sitz bath three times a day and then pat my rectal area gently but thoroughly to make sure I am dry." d. "I shall clean my rectal area with a soft cotton washcloth and then apply vitamin A and D ointment."

b. "I will clean my rectal area thoroughly with toilet paper after each stool and then apply aloe vera gel." (Toilet paper can irritate the sensitive perineal skin, so warm water rinses or soft cotton washcloths should be used instead. Although aloe vera may facilitate healing of superficial abrasions, it is not an effective skin barrier for diarrhea. Skin barriers such as zinc oxide and vitamin A and D ointment help protect the rectal area from the excoriating effects of liquid stools. Patting the skin is recommended instead of rubbing the skin dry.)

Which statement by a patient indicates additional teaching is required about the medication warfarin? a. "I will continue my diabetic diet and restrict sugar." b. "I will increase the intake of green, leafy vegetables for a more healthful diet." c. "I will restrict the intake of foods high in vitamin C." d. "I will increase the amount of protein in my diet to protect my kidneys."

b. "I will increase the intake of green, leafy vegetables for a more healthful diet." (Foods such as green, leafy vegetables have high levels of vitamin K. Warfarin is an anticoagulant that acts by interfering with vitamin K-dependent clotting factors. If the amount of vitamin K is increased in the diet, the medication dose may need to be adjusted. A diabetic diet would be continued as indicated for a patient receiving warfarin. Vitamin C is not related to warfarin.)

After teaching a client who is prescribed adalimumab (Humira) for severe ulcerative colitis, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "I will avoid large crowds and people who are sick." b. "I will take this medication with my breakfast each morning." c. "Nausea and vomiting are common side effects of this drug." d. "I must wash my hands after I play with my dog."

b. "I will take this medication with my breakfast each morning." (Adalimumab (Humira) is an immune modulator that must be given via subcutaneous injection. It does not need to be given with food or milk. Nausea and vomiting are two common side effects. Adalimumab can cause immune suppression, so clients receiving the medication should avoid large crowds and people who are sick, and should practice good handwashing.)

Which nursing observation would indicate that the nurse hold the medication warfarin (Coumadin)? a. An INR (international normalize ratio) of 1.8 b. An INR of 4.8 c. A partial thromboplastin time (APTT) level of 25 seconds d. An APTT level of 35 seconds

b. An INR of 4.8 (The INR of 4.8 is too high. The dosage of warfarin is adjusted to maintain an INR between 2 and 3. A level of 4.8 indicates that the patient is at risk for excessive bleeding. An INR of 1.8 is below the therapeutic range and would indicate the need for warfarin. APPT is not used to monitor effectiveness of the dose for warfarin.)

After teaching a client who was hospitalized for Salmonella food poisoning, a nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "I will let my husband do all of the cooking for my family." b. "I'll take the ciprofloxacin until the diarrhea has resolved." c. "I should wash my hands with antibacterial soap before each meal." d. "I must place my dishes into the dishwasher after each meal."

b. "I'll take the ciprofloxacin until the diarrhea has resolved." (Ciprofloxacin should be taken for 10 to 14 days to treat Salmonella infection, and should not be stopped once the diarrhea has cleared. Clients should be advised to take the entire course of medication. People with Salmonella should not prepare foods for others because the infection may be spread in this way. Hands should be washed with antibacterial soap before and after eating to prevent spread of the bacteria. Dishes and eating utensils should not be shared and should be cleaned thoroughly. Clients can be carriers for up to 1 year.)

A nurse is giving a preoperative client a dose of ranitidine (Zantac). The client asks why the nurse is giving this drug when the client has no history of ulcers. What response by the nurse is best? a. "All preoperative clients get this medication." b. "It helps prevent ulcers from the stress of the surgery." c. "Since you don't have ulcers, I will have to ask." d. "The physician prescribed this medication for you."

b. "It helps prevent ulcers from the stress of the surgery." (Ulcer prophylaxis is common for clients undergoing long procedures or for whom high stress is likely. The nurse is not being truthful by saying all clients get this medication. If the nurse does not know the information, it is appropriate to find out, but this is a common medication for which the nurse should know the rationale prior to administering it. Simply stating that the physician prescribed the medication does not give the client any useful information.)

A patient who has recently started therapy on a statin drug asks the nurse how long it will take until he sees an effect on his serum cholesterol. Which statement would be the nurse's best response? a. "Blood levels return to normal within a week of beginning therapy." b. "It takes 6 to 8 weeks to see a change in cholesterol levels." c. "It takes at least 6 months to see a change in cholesterol levels." d. "You will need to take this medication for almost a year to see significant results."

b. "It takes 6 to 8 weeks to see a change in cholesterol levels." (The maximum extent to which lipid levels are lowered may not occur until 6 to 8 weeks after the start of therapy. The other responses are incorrect.)

A nurse reviews the medication list of a client with a 20-year history of diabetes mellitus. The client holds up the bottle of prescribed duloxetine (Cymbalta) and states, "My cousin has depression and is taking this drug. Do you think I'm depressed?" How should the nurse respond? a. "Many people with long-term diabetes become depressed after a while." b. "It's for peripheral neuropathy. Do you have burning pain in your feet or hands?" c. "This antidepressant also has anti-inflammatory properties for diabetic pain." d. "No. Many medications can be used for several different disorders."

b. "It's for peripheral neuropathy. Do you have burning pain in your feet or hands?" (Damage along nerves causes peripheral neuropathy and leads to burning pain along the nerves. Many drugs, including duloxetine (Cymbalta), can be used to treat peripheral neuropathy. The nurse should assess the client for this condition and then should provide an explanation of why this drug is being used. This medication, although it is used for depression, is not being used for that reason in this case. Duloxetine does not have anti-inflammatory properties. Telling the client that many medications are used for different disorders does not provide the client with enough information to be useful.)

A nurse teaches a client with diabetes mellitus about sick day management. Which statement should the nurse include in this client's teaching? a. "When ill, avoid eating or drinking to reduce vomiting and diarrhea." b. "Monitor your blood glucose levels at least every 4 hours while sick." c. "If vomiting, do not use insulin or take your oral antidiabetic agent." d. "Try to continue your prescribed exercise regimen even if you are sick."

b. "Monitor your blood glucose levels at least every 4 hours while sick." (When ill, the client should monitor his or her blood glucose at least every 4 hours. The client should continue taking the medication regimen while ill. The client should continue to eat and drink as tolerated but should not exercise while sick.)

A nurse cares for a client who is diagnosed with acute rejection 2 months after receiving a simultaneous pancreas-kidney transplant. The client states, "I was doing so well with my new organs, and the thought of having to go back to living on hemodialysis and taking insulin is so depressing." How should the nurse respond? a. "Following the drug regimen more closely would have prevented this." b. "One acute rejection episode does not mean that you will lose the new organs." c. "Dialysis is a viable treatment option for you and may save your life." d. "Since you are on the national registry, you can receive a second transplantation."

b. "One acute rejection episode does not mean that you will lose the new organs." (An episode of acute rejection does not automatically mean that the client will lose the transplant. Pharmacologic manipulation of host immune responses at this time can limit damage to the organ and allow the graft to be maintained. The other statements either belittle the client or downplay his or her concerns. The client may not be a candidate for additional organ transplantation.)

After teaching a client with type 2 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "I need to have an annual appointment even if my glucose levels are in good control." b. "Since my diabetes is controlled with diet and exercise, I must be seen only if I am sick." c. "I can still develop complications even though I do not have to take insulin at this time." d. "If I have surgery or get very ill, I may have to receive insulin injections for a short time."

b. "Since my diabetes is controlled with diet and exercise, I must be seen only if I am sick." (Clients with diabetes need to be seen at least annually to monitor for long-term complications, including visual changes, microalbuminuria, and lipid analysis. The client may develop complications and may need insulin in the future.)

A client with peptic ulcer disease asks the nurse about taking slippery elm supplements. What response by the nurse is best? a. "Slippery elm has no benefit for this problem." b. "Slippery elm is often used for this disorder." c. "There is no evidence that this will work." d. "You should not take any herbal remedies."

b. "Slippery elm is often used for this disorder." (There are several complementary and alternative medicine regimens that are used for gastritis and peptic ulcer disease. Most have been tested on animals but not humans. Slippery elm is a common supplement used for this disorder.)

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."

b. "The best source is fish, but pills have benefits too." (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.)

A 38-year-old male patient stopped smoking 6 months ago. He tells the nurse that he still feels strong cigarette cravings and wonders if he is ever going to feel "normal" again. Which statement by the nurse is correct? a. "It's possible that these cravings will never stop." b. "These cravings may persist for several months." c. "The cravings tell us that you are still using nicotine." d. "The cravings show that you are about to experience nicotine withdrawal."

b. "These cravings may persist for several months." (Cigarette cravings may persist for months after nicotine withdrawal. The other statements are false.)

A patient with gastroesophageal reflux disease (GERD) asks the nurse why metoclopramide (Reglan) has been prescribed. What is the nurse's best response? a. "This purpose of this drug for GERD is to prevent nausea." b. "This drug has been prescribed to help move food along through your GI tract." c. "Metoclopramide will prevent vomiting and the risk for aspiration." d. "This drug causes growth of new cells to heal your esophagus."

b. "This drug has been prescribed to help move food along through your GI tract." (Metoclopramide increases stomach and small intestine contractions (peristalsis), helping to move food through the GI system. Moving food quickly into the intestinal system decreases the likelihood of backup into the esophagus.)

The nurse will monitor for myopathy (muscle pain) when a patient is taking which class of antilipemic drugs? a. Niacin b. HMG-CoA reductase inhibitors c. Fibric acid derivatives d. Bile acid sequestrants

b. HMG-CoA reductase inhibitors (Myopathy (muscle pain) is a clinically important adverse effect that may occur with HMG-CoA reductase inhibitors. It may progress to a serious condition known as rhabdomyolysis. Patients receiving statin therapy need to be advised to report any unexplained muscular pain or discomfort to their health care providers immediately. The other drugs and drug classes do not cause muscle pain or myopathy.)

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?" How should the nurse respond? a. "Glucose is the only fuel used by the body to produce the energy that it needs." b. "Your brain needs a constant supply of glucose because it cannot store it." c. "Without a minimum level of glucose, your body does not make red blood cells." d. "Glucose in the blood prevents the formation of lactic acid and prevents acidosis."

b. "Your brain needs a constant supply of glucose because it cannot store it." (Because the brain cannot synthesize or store significant amounts of glucose, a continuous supply from the body's circulation is needed to meet the fuel demands of the central nervous system. The nurse would want to educate the client to prevent hypoglycemia. The body can use other sources of fuel, including fat and protein, and glucose is not involved in the production of red blood cells. Glucose in the blood will encourage glucose metabolism but is not directly responsible for lactic acid formation.)

The nurse is administering intravenous iron dextran for the first time to a patient with anemia. After giving a test dose, how long will the nurse wait before administering the remaining portion of the dose? a. 30 minutes b. 1 hour c. 6 hours d. 24 hours

b. 1 hour (Although anaphylactic reactions usually occur within a few moments after the test dose, it is recommended that a period of at least 1 hour elapse before the remaining portion of the initial dose is given. The other options are incorrect.)

A nurse cares for a client who has diabetes mellitus. The nurse administers 6 units of regular insulin and 10 units of NPH insulin at 0700. At which time should the nurse assess the client for potential problems related to the NPH insulin? a. 0800 b. 1600 c. 2000 d. 2300

b. 1600 (Neutral protamine Hagedorn (NPH) is an intermediate-acting insulin with an onset of 1.5 hours, peak of 4 to 12 hours, and duration of action of 22 hours. Checking the client at 0800 would be too soon. Checking the client at 2000 and 2300 would be too late. The nurse should check the client at 1600.)

A patient is receiving heparin therapy as part of the treatment for a pulmonary embolism. The nurse monitors the results of which laboratory test to check the drug's effectiveness? a. Bleeding times b. Activated partial thromboplastin time (aPTT) c. Prothrombin time/international normalized ratio (PT/INR) d. Vitamin K levels

b. Activated partial thromboplastin time (aPTT) (Ongoing aPTT values are used to monitor heparin therapy. PT/INR is used to monitor warfarin therapy. The other two options are not used to monitor anticoagulant therapy.)

A nurse cares for an older adult client who has Salmonella food poisoning. The client's vital signs are heart rate: 102 beats/min, blood pressure: 98/55 mm Hg, respiratory rate: 22 breaths/min, and oxygen saturation: 92%. Which action should the nurse complete first? a. Apply oxygen via nasal cannula. b. Administer intravenous fluids. c. Provide perineal care with a premedicated wipe. d. Teach proper food preparation to prevent contamination.

b. Administer intravenous fluids. (Dehydration caused by diarrhea can occur quickly in older clients with Salmonella food poisoning, so maintenance of fluid balance is a high priority. Monitoring vital signs and providing perineal care are important nursing actions but are of lower priority than fluid replacement. The nurse should teach the client about proper hand hygiene to prevent the spread of infection, and preparation of food and beverages to prevent contamination.)

A patient is on a chemotherapy regimen in an outpatient clinic and is receiving a chemotherapy drug that is known to be highly emetogenic. The nurse will implement which interventions regarding the pharmacologic management of nausea and vomiting? (Select all that apply.) a. Giving antinausea drugs at the beginning of the chemotherapy infusion b. Administering antinausea drugs 30 to 60 minutes before chemotherapy is started c. For best therapeutic effects, medicating for nausea once the symptoms begin d. Observing carefully for the adverse effects of restlessness and anxiety e. Instructing the patient that the antinausea drugs may cause extreme drowsiness f. Instructing the patient to rise slowly from a sitting or lying position because of possible orthostatic hypotension

b. Administering antinausea drugs 30 to 60 minutes before chemotherapy is started e. Instructing the patient that the antinausea drugs may cause extreme drowsiness f. Instructing the patient to rise slowly from a sitting or lying position because of possible orthostatic hypotension (Antiemetics should be given before any chemotherapy drug is administered, often 30 to 60 minutes before treatment, but not immediately before chemotherapy is administered. Do not wait until the nausea begins. Most antiemetics cause drowsiness, not restlessness and anxiety. Orthostatic hypotension is a possible adverse effect that may lead to injury.)

The nurse is providing patient teaching about antacids. Which statements about antacids are accurate? (Select all that apply.) a. Antacids reduce the production of acid in the stomach. b. Antacids neutralize acid in the stomach. c. Rebound hyperacidity may occur with calcium-based antacids. d. Aluminum-based antacids cause diarrhea. e. Magnesium-based antacids cause diarrhea.

b. Antacids neutralize acid in the stomach. c. Rebound hyperacidity may occur with calcium-based antacids. e. Magnesium-based antacids cause diarrhea. (Antacids neutralize acid in the stomach. Magnesium-based antacids cause diarrhea, and aluminum-based antacids cause constipation. Calcium-based antacids often cause rebound hyperacidity.)

A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)? a. Ambulate the client. b. Apply a warm moist pack. c. Massage the client's leg. d. Provide an ice pack.

b. Apply a warm moist pack. (Warm moist packs will help with the pain of a DVT. Ambulation is not a comfort measure. Massaging the client's legs is contraindicated to prevent complications such as pulmonary embolism. Ice packs are not recommended for DVT.)

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. Which action should 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.

b. Apply an ice pack to the site. (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 nurse is caring for a postoperative client who reports discomfort, but denies serious pain and does not want medication. What action by the nurse is best to promote comfort? a. Assess the client's pain on a 0-to-10 scale. b. Assist the client into a position of comfort. c. Have the client sit up in a recliner. d. Tell the client when pain medication is due.

b. Assist the client into a position of comfort. (Several nonpharmacologic comfort measures can help postoperative clients with their pain, including distraction, music, massage, guided imagery, and positioning. The nurse should help this client into a position of comfort considering the surgical procedure and position of any tubes or drains. Assessing the client's pain is important but does not improve comfort. The client may be more uncomfortable in a recliner. Letting the client know when pain medication can be given next is important but does not improve comfort.)

A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is most important? a. Allow the client to rest. b. Auscultate lung sounds. c. Document the episode. d. Encourage the client to eat dry toast.

b. Auscultate lung sounds. (Vomiting after surgery has several complications, including aspiration. The nurse should listen to the client's lung sounds. The client should be allowed to rest after an assessment. Documenting is important, but the nurse needs to be able to document fully, including an assessment. The client should not eat until nausea has subsided.)

A client is awaiting bariatric surgery in the morning. What action by the nurse is most important? a. Answering questions the client has about surgery b. Beginning venous thromboembolism prophylaxis c. Informing the client that he or she will be out of bed tomorrow d. Teaching the client about needed dietary changes

b. Beginning venous thromboembolism prophylaxis (Morbidly obese clients are at high risk of venous thromboembolism and should be started on a regimen to prevent this from occurring as a priority. Answering questions about the surgery is done by the surgeon. Teaching is important, but safety comes first.)

A client is in stage 2 of general anesthesia. What action by the nurse is most important? a. Keeping the room quiet and calm b. Being prepared to suction the airway c. Positioning the client correctly d. Warming the client with blankets

b. Being prepared to suction the airway (During stage 2 of general anesthesia (excitement, delirium), the client can vomit and aspirate. The nurse must be ready to react to this potential occurrence by being prepared to suction the client's airway. Keeping the room quiet and calm does help the client enter the anesthetic state, but is not the priority. Positioning the client usually occurs during stage 3 (operative anesthesia). Keeping the client warm is important throughout to prevent hypothermia.)

A nurse is caring for a client after a stroke. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assess neurologic status with the Glasgow Coma Scale. b. Check and document oxygen saturation every 1 to 2 hours. c. Cluster client care to allow periods of uninterrupted rest. d. Elevate the head of the bed to 45 degrees to prevent aspiration. e. Position the client supine with the head in a neutral midline position.

b. Check and document oxygen saturation every 1 to 2 hours. e. Position the client supine with the head in a neutral midline position. (The UAP can take and document vital signs, including oxygen saturation, and keep the client's head in a neutral, midline position with correct direction from the nurse. The nurse assesses the Glasgow Coma Scale score. The nursing staff should not cluster care because this can cause an increase in the intracranial pressure. The head of the bed should be minimally elevated, up to 30 degrees.)

A nurse working in the preoperative holding area performs which functions to ensure client safety? (Select all that apply.) a. Allow small sips of plain water. b. Check that consent is on the chart. c. Ensure the client has an armband on. d. Have the client help mark the surgical site. e. Allow the client to use the toilet before giving sedation.

b. Check that consent is on the chart. c. Ensure the client has an armband on. d. Have the client help mark the surgical site. e. Allow the client to use the toilet before giving sedation. (Providing for client safety is a priority function of the preoperative nurse. Checking for appropriately completed consent, verifying the client's identity, having the client assist in marking the surgical site if applicable, and allowing the client to use the toilet prior to sedating him or her are just some examples of important safety measures. The preoperative client should be NPO, so water should not be provided.)

Abatacept (Orencia) is prescribed for a patient with severe rheumatoid arthritis. The nurse checks the patient's medical history, knowing that this medication would need to be used cautiously if which condition is present? a. Coronary artery disease b. Chronic obstructive pulmonary disease c. Diabetes mellitus d. Hypertension

b. Chronic obstructive pulmonary disease (Abatacept must be used cautiously in patients with recurrent infections or chronic obstructive pulmonary disease. The other options are incorrect.)

A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt like his legs were very heavy. Currently the client's neurologic examination is normal. About what drug should the nurse plan to teach the client? a. Alteplase (Activase) b. Clopidogrel (Plavix) c. Heparin sodium d. Mannitol (Osmitrol)

b. Clopidogrel (Plavix) (This client's manifestations are consistent with a transient ischemic attack, and the client would be prescribed aspirin or clopidogrel on discharge. Alteplase is used for ischemic stroke. Heparin and mannitol are not used for this condition.)

A patient is having a conversation with a surgeon. Which perioperative phase should the nurse anticipate will begin once the patient has agreed to have surgery? a. Postoperative b. Preoperative c. Intraoperative d. Interoperative

b. Preoperative (The preoperative phase begins when the patient agrees to have surgery. The postoperative phase begins when the patient is transferred from the operating room to the PACU. The intraoperative phase begins when the patient is transferred to the operating room. Interoperative is not a surgical phase.)

The circulating nurse and preoperative nurse are reviewing the chart of a client scheduled for minimally invasive surgery (MIS). What information on the chart needs to be reported to the surgeon as a priority? a. Allergies noted and allergy band on b. Consent for MIS procedure only c. No prior anesthesia exposure d. NPO status for the last 8 hours

b. Consent for MIS procedure only (All MIS procedures have the potential for becoming open procedures depending on findings and complications. The client's consent should include this possibility. The nurse should report this finding to the surgeon prior to surgery taking place. Having allergies noted and an allergy band applied is standard procedure. Not having any prior surgical or anesthesia exposure is not the priority. Maintaining NPO status as prescribed is standard procedure.)

A patient is receiving an aluminum-containing antacid. The nurse will inform the patient to watch for which possible adverse effect? a. Diarrhea b. Constipation c. Nausea d. Abdominal cramping

b. Constipation (Aluminum-based antacids have a constipating effect as well as an acid-neutralizing capacity. The other options are incorrect.)

What is the most common side effect of drugs used for benign prostate hypertrophy (BPH)? a. Low blood pressure b. Decreased libido c. Light-headedness d. Hair loss

b. Decreased libido (Side effects of drugs used for BPH also include erectile dysfunction, decreased seminal fluid, and reduced fertility. The most common side effect of these drugs is a decreased interest in sexual activity.)

A client has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication. What action by the nurse is best? a. Call the provider to request more analgesia. b. Demonstrate how to splint the incision. c. Have the client take shallower breaths. d. Tell the client a little pain is expected.

b. Demonstrate how to splint the incision. (Splinting an incision provides extra support during coughing and activity and helps decrease pain. If the client is otherwise comfortable, no more analgesia is required. Shallow breathing can lead to atelectasis and pneumonia. The client should know some pain is normal and expected after surgery, but that answer alone does not provide any interventions to help the client.)

A patient on chemotherapy is using ondansetron (Zofran) for treatment of nausea. The nurse will instruct the patient to watch for which adverse effect of this drug? a. Dizziness b. Diarrhea c. Dry mouth d. Blurred vision

b. Diarrhea (Diarrhea is an adverse effect of the serotonin blockers. The other adverse effects listed may occur with anticholinergic drugs.)

A patient is concerned about the adverse effects of the fibric acid derivative she is taking to lower her cholesterol level. Which is an adverse effect of this class of medication? a. Constipation b. Diarrhea c. Joint pain d. Dry mouth

b. Diarrhea (Fibric acid derivatives may cause nausea, vomiting, diarrhea, drowsiness, and dizziness. The other options are not adverse effects of fibric acid derivatives.)

A nurse on the postoperative nursing unit provides care to reduce the incidence of surgical wound infection. What actions are best to achieve this goal? (Select all that apply.) a. Administering antibiotics for 72 hours b. Disposing of dressings properly c. Leaving draining wounds open to air d. Performing proper hand hygiene e. Removing and replacing wet dressings

b. Disposing of dressings properly d. Performing proper hand hygiene e. Removing and replacing wet dressings (Interventions necessary to prevent surgical wound infection include proper disposal of soiled dressings, performing proper hand hygiene, and removing wet dressings as they can be a source of infection. Prophylactic antibiotics are given to clients at risk for infection, but are discontinued after 24 hours if no infection is apparent. Draining wounds should always be covered.)

An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by the nurse is best? a. Answer the questions and document that teaching was done. b. Do not have the client sign the consent and call the surgeon. c. Have the client sign the consent, then call the surgeon. d. Remind the client of what teaching the surgeon has done.

b. Do not have the client sign the consent and call the surgeon. (In order to give informed consent, the client needs sufficient information. Questions about potential complications should be answered by the surgeon. The nurse should notify the surgeon to come back and answer the client's questions before the client signs the consent form. The other actions are not appropriate.)

A client is having robotic surgery. The circulating nurse observes the instruments being inserted, then the surgeon appears to "break scrub" when going to the console and sitting down. What action by the nurse is best? a. Call a "time-out" to discuss sterile procedure and scrub technique. b. Document the time the robotic portion of the procedure begins. c. Inform the surgeon that the scrub preparation has been compromised. d. Report the surgeon's actions to the charge nurse and unit manager.

b. Document the time the robotic portion of the procedure begins. (During a robotic operative procedure, the surgeon inserts the articulating arms into the client, then "breaks scrub" to sit at the viewing console to perform the operation. The nurse should document the time the robotic portion of the procedure began. There is no need for the other interventions.)

After receiving a tube feeding, a nurse assesses the patient to be sweaty with abdominal distention and diarrhea. What is the most likely cause of this response? a. Expected reaction to the tube feeding b. Dumping syndrome c. Gastric reflux syndrome d. Onset of gastroenteritis

b. Dumping syndrome (Dumping syndrome is caused by infusing a tube feeding too fast or infusing a tube feeding that is too rich a formula.)

Antilipemic drug therapy is prescribed for a patient, and the nurse is providing instructions to the patient about the medication. Which instructions will the nurse include? (Select all that apply.) a. Limit fluid intake to prevent fluid overload. b. Eat extra servings of raw vegetables and fruit. c. Report abnormal or unusual bleeding or yellow discoloration of the skin. d. Report the occurrence of muscle pain immediately. e. Drug interactions are rare with antilipemics. f. Take the drug 1 hour before or 2 hours after meals to maximize absorption.

b. Eat extra servings of raw vegetables and fruit. c. Report abnormal or unusual bleeding or yellow discoloration of the skin. d. Report the occurrence of muscle pain immediately. (Instructions need to include preventing constipation by encouraging a diet that is plentiful in raw vegetables, fruit, and bran. Forcing fluids (up to 3000 mL/day unless contraindicated) may also help to prevent constipation. Notify the prescriber if there are any new or troublesome symptoms, abnormal or unusual bleeding, yellow discoloration of the skin, or muscle pain. These drugs are highly protein bound; therefore, they interact with many drugs. Taking these drugs with food may help to reduce gastrointestinal distress.)

A morbidly obese client is admitted to a community hospital that does not typically care for bariatric-sized clients. What action by the nurse is most appropriate? a. Assess the client's readiness to make lifestyle changes. b. Ensure adequate staff when moving the client. c. Leave siderails down to prevent pressure ulcers. d. Reinforce the need to be sensitive to the client.

b. Ensure adequate staff when moving the client. (Many hospitals that see bariatric-sized clients have appropriate equipment for this population. A hospital that does not typically see these clients is less likely to have appropriate equipment, putting staff and client safety at risk. The nurse ensures enough staffing is available to help with all aspects of mobility. It may or may not be appropriate to assess the client's willingness to make lifestyle changes. Leaving the siderails down may present a safety hazard. The staff should be sensitive to this client's situation, but safety takes priority.)

A patient who has been taking cimetidine (Tagamet) for hyperacidity calls the clinic to say that the medication has not been effective. The nurse reviews his history and notes that which factor may be influencing the effectiveness of this drug? a. He takes the cimetidine with meals. b. He smokes two packs of cigarettes a day. c. He drinks a glass of water with each dose. d. He takes an antacid 3 hours after the cimetidine dose.

b. He smokes two packs of cigarettes a day. (Smoking may impair the absorption of H₂ antagonists. The other factors are correct interventions for this medication.)

A nurse is caring for a morbidly obese client. What comfort measure is most important for the nurse to delegate to the unlicensed assistive personnel (UAP)? a. Designating "quiet time" so the client can rest b. Ensuring siderails are not causing excess pressure c. Providing oral care before and after meals and snacks d. Relaying any reports of pain to the registered nurse

b. Ensuring siderails are not causing excess pressure (All actions are good for client comfort, but when dealing with an obese client, the staff should take extra precautions, such as ensuring the siderails are not putting pressure on the client's tissues. The other options are appropriate for any client, and are not specific to obese clients.)

A client who has been taking antibiotics reports severe, watery diarrhea. About which test does the nurse teach the client? a. Colonoscopy b. Enzyme-linked immunosorbent assay (ELISA) toxin A+B c. Ova and parasites d. Stool culture

b. Enzyme-linked immunosorbent assay (ELISA) toxin A+B (Clients taking antibiotics are at risk for Clostridium difficile infection. The most common test for this disorder is a stool sample for ELISA toxin A+B. Colonoscopy, ova and parasites, and stool culture are not warranted at this time.)

A patient is being discharged on anticoagulant therapy. The nurse will include in the patient-education conversation that it is important to avoid herbal products that contain which substance? a. Valerian b. Ginkgo c. Soy d. Saw palmetto

b. Ginkgo (Capsicum pepper, feverfew, garlic, ginger, ginkgo, St. John's wort, and ginseng are some herbals that have potential interactions with anticoagulants, especially with warfarin.)

A client waiting for surgery is very anxious. What intervention can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Assess the client's anxiety. b. Give the client a back rub. c. Remind the client to turn. d. Teach about postoperative care.

b. Give the client a back rub. (A back rub reduces anxiety and can be delegated to the UAP. Once teaching has been done, the UAP can remind the client to turn, but this is not related to relieving anxiety. Assessing anxiety and teaching are not within the scope of practice for the UAP.)

A nurse reviews laboratory results for a client with diabetes mellitus who is prescribed an intensified insulin regimen: -------------------------------- • Fasting blood glucose: 75 mg/dL • Postprandial blood glucose: 200 mg/dL • Hemoglobin A1c level: 5.5% -------------------------------- How should the nurse interpret these laboratory findings? a. Increased risk for developing ketoacidosis b. Good control of blood glucose c. Increased risk for developing hyperglycemia d. Signs of insulin resistance

b. Good control of blood glucose (The client is maintaining blood glucose levels within the defined ranges for goals in an intensified regimen. Because the client's glycemic control is good, he or she is not at higher risk for ketoacidosis or hyperglycemia and is not showing signs of insulin resistance.)

When teaching a patient who is beginning antilipemic therapy about possible drug-food interactions, the nurse will discuss which food? a. Oatmeal b. Grapefruit juice c. Licorice d. Dairy products

b. Grapefruit juice (Taking HMG-CoA reductase inhibitors with grapefruit juice may cause complications. Components in grapefruit juice inactivate CYP3A4 in both the liver and intestines. This enzyme plays a key role in statin metabolism. The presence of grapefruit juice in the body may therefore result in sustained levels of unmetabolized statin drug, which increases the risk for major drug toxicity, possibly leading to rhabdomyolysis. The other foods do not interact with these drugs.)

A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates a priority outcome has been met? a. Ambulates with assistance b. Oxygen saturation of 98% c. Pain of 2/10 after medication d. Verbalizing risk factors

b. Oxygen saturation of 98% (A critical complication of DVT is pulmonary embolism. A normal oxygen saturation indicates that this has not occurred. The other assessments are also positive, but not the priority.)

A client with systemic lupus erythematosus (SLE) was recently discharged from the hospital after an acute exacerbation. The client is in the clinic for a follow-up visit and is distraught about the possibility of another hospitalization disrupting the family. What action by the nurse is best? a. Explain to the client that SLE is an unpredictable disease. b. Help the client create backup plans to minimize disruption. c. Offer to talk to the family and educate them about SLE. d. Tell the client to remain compliant with treatment plans.

b. Help the client create backup plans to minimize disruption. (SLE is an unpredictable disease and acute exacerbations can occur without warning, creating chaos in the family. Helping the client make backup plans for this event not only will decrease the disruption but will give the client a sense of having more control. Explaining facts about the disease is helpful as well but does not engage the client in problem solving. The family may need education, but again this does not help the client to problem-solve. Remaining compliant may help decrease exacerbations, but is not as powerful an intervention as helping the client plan for such events.)

A postanesthesia care unit (PACU) nurse is assessing a postoperative client with a nasogastric (NG) tube. What laboratory values would warrant intervention by the nurse? (Select all that apply.) a. Blood glucose: 120 mg/dL b. Hemoglobin: 7.8 mg/dL c. pH: 7.68 d. Potassium: 2.9 mEq/L e. Sodium: 142 mEq/L

b. Hemoglobin: 7.8 mg/dL c. pH: 7.68 d. Potassium: 2.9 mEq/L (Fluid and electrolyte balance are assessed carefully in the postoperative client because many imbalances can occur. The low hemoglobin may be from blood loss in surgery. The higher pH level indicates alkalosis, possibly from losses through the NG tube. The potassium is very low. The blood glucose is within normal limits for a postsurgical client who has been fasting. The sodium level is normal.)

An oral iron supplement is prescribed for a patient. The nurse would question this order if the patient's medical history includes which condition? a. Decreased hemoglobin b. Hemolytic anemia c. Weakness d. Concurrent therapy with erythropoietics

b. Hemolytic anemia (Hemolytic anemia is a contraindication to the use of iron supplements. Decreased hemoglobin and weakness are related to iron-deficiency anemia. Iron supplements are given with erythropoietic drugs to aid in the production of red blood cells.)

A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select all that apply.) a. Age b. Hypertension c. Obesity d. Smoking e. Stress

b. Hypertension c. Obesity d. Smoking e. Stress (Hypertension, obesity, smoking, and excessive stress are all modifiable risk factors for coronary artery disease. Age is a nonmodifiable risk factor.)

An older female client has been prescribed esomeprazole (Nexium) for treatment of chronic gastric ulcers. What teaching is particularly important for this client? a. Check with the pharmacist before taking other medications. b. Increase intake of calcium and vitamin D. c. Report any worsening of symptoms to the provider. d. Take the medication as prescribed by the provider.

b. Increase intake of calcium and vitamin D. (All of this advice is appropriate for any client taking this medication. However, long-term use is associated with osteoporosis and osteoporosis-related fractures. This client is already at higher risk for this problem and should be instructed to increase calcium and vitamin D intake. The other options are appropriate for any client taking any medication and are not specific to the use of esomeprazole.)

A nurse is designing a community education program to meet the Healthy People 2020 objectives for nutrition and weight status. What information about these goals does the nurse use to plan this event? (Select all that apply.) a. Decrease the amount of fruit to 1.1 cups/1000 calories. b. Increase the amount of vegetables to 1.1 cups/1000 calories. c. Increase the number of adults at a healthy weight by 25%. d. Reduce the number of adults who are obese by 10%. e. Reduce the consumption of saturated fat by nearly 10%.

b. Increase the amount of vegetables to 1.1 cups/1000 calories. d. Reduce the number of adults who are obese by 10%. e. Reduce the consumption of saturated fat by nearly 10%. (Some of the goals in this initiative include increasing fruit consumption to 0.9 cups/1000 calories, increasing vegetable intake to 1.1 cups/1000 calories, increasing the number of people at a healthy weight by 10%, decreasing the number of adults who are obese by 10%, and reducing the consumption of saturated fats by 9.5%.)

A nurse reviews the chart and new prescriptions for a client with diabetic ketoacidosis: -------------------------------- Vital Signs and Assessment: • Blood pressure: 90/62 mm Hg • Respiratory rate: 28 breaths/min • Urine output: 20 mL/hr via catheter Laboratory Results: • Serum potassium: 2.6 mEq/L Medications: • Potassium chloride 40 mEq IV bolus STAT • Increase IV fluid to 100 mL/hr -------------------------------- Which action should the nurse take? a. Administer the potassium and then consult with the provider about the fluid order. b. Increase the intravenous rate and then consult with the provider about the potassium prescription. c. Administer the potassium first before increasing the infusion flow rate. d. Increase the intravenous flow rate before administering the potassium.

b. Increase the intravenous rate and then consult with the provider about the potassium prescription. (The client is acutely ill and is severely dehydrated and hypokalemic. The client requires more IV fluids and potassium. However, potassium should not be infused unless the urine output is at least 30 mL/hr. The nurse should first increase the IV rate and then consult with the provider about the potassium.)

A patient has been taking iron supplements for anemia for 2 months. During a follow-up assessment, the nurse will observe for which therapeutic response? a. Decreased weight b. Increased activity tolerance c. Decreased palpitations d. Increased appetite

b. Increased activity tolerance (Absence of fatigue, increased activity tolerance and well-being, and improved nutrition status are therapeutic responses to iron supplementation. The other options are incorrect.)

A new perioperative nurse is receiving orientation to the surgical area and learns about the Surgical Care Improvement Project (SCIP) goals. What major areas do these measures focus on preventing? (Select all that apply.) a. Hemorrhage b. Infection c. Serious cardiac events d. Stroke e. Thromboembolism

b. Infection c. Serious cardiac events e. Thromboembolism (The SCIP project includes core measures to prevent infection, serious cardiac events, and thromboembolic events such as deep vein thrombosis.)

A student nurse is preparing morning medications for a client who had a stroke. The student plans to hold the docusate sodium (Colace) because the client had a large stool earlier. What action by the supervising nurse is best? a. Have the student ask the client if it is desired or not. b. Inform the student that the docusate should be given. c. Tell the student to document the rationale. d. Tell the student to give it unless the client refuses.

b. Inform the student that the docusate should be given. (Stool softeners should be given to clients with neurologic disorders in order to prevent an elevation in intracranial pressure that accompanies the Valsalva maneuver when constipated. The supervising nurse should instruct the student to administer the docusate. The other options are not appropriate. The medication could be held for diarrhea.)

The nurse is administering liquid oral iron supplements. Which intervention is appropriate when administering this medication? a. Have the patient take the liquid iron with milk. b. Instruct the patient to take the medication through a plastic straw. c. Have the patient sip the medication slowly. d. Have the patient drink the medication, undiluted, from the unit-dose cup.

b. Instruct the patient to take the medication through a plastic straw. (Liquid oral forms of iron need to be taken through a plastic straw to avoid discoloration of tooth enamel. Milk may decrease absorption.)

A patient scheduled for surgery takes several medications. Which medication indicates that the patient's surgical risk is increased? a. Tylenol b. Insulin c. Thyroid medication d. Vitamin C

b. Insulin (Insulin is taken for an elevated glucose level. This person has diabetes, which increases the surgical risk. Tylenol does not increase the risk. Aspirin, steroids, and herbal medications increase surgical risk. Thyroid medication does not increase surgical risk. Vitamin C is needed for normal growth and development. It is also required for the growth and repair of tissues in all parts of the body.)

A patient is receiving high doses of methotrexate and is experiencing severe bone marrow suppression. The nurse expects which intervention to be ordered with this drug to reduce this problem? a. A transfusion of whole blood b. Leucovorin rescue c. Therapy with filgrastim (Neupogen) d. Administration of allopurinol (Zyloprim)

b. Leucovorin rescue (High-dose methotrexate is associated with bone marrow suppression, and it is always given in conjunction with the rescue drug leucovorin, which is an antidote for folic acid antagonists. Basically, leucovorin rescues the healthy cells from methotrexate. The other options are incorrect.)

A patient has started azathioprine (Imuran) therapy as part of renal transplant surgery. The nurse will monitor for which expected adverse effect of azathioprine therapy? (Select all that apply.) a. Tremors b. Leukopenia c. Diarrhea d. Thrombocytopenia e. Hepatotoxicity f. Fluid retention

b. Leukopenia d. Thrombocytopenia e. Hepatotoxicity (Leukopenia is an expected adverse effect of azathioprine therapy, as are thrombocytopenia and hepatotoxicity. The other options are incorrect.)

A nursing instructor is teaching students about different surgical procedures and their classifications. Which examples does the instructor include? (Select all that apply.) a. Hemicolectomy: diagnostic b. Liver biopsy: diagnostic c. Mastectomy: restorative d. Spinal cord decompression: palliative e. Total shoulder replacement: restorative

b. Liver biopsy: diagnostic e. Total shoulder replacement: restorative (A diagnostic procedure is used to determine cell type of cancer and to determine the cause of a problem. An example is a liver biopsy. A restorative procedure aims to improve functional ability. An example would be a total shoulder replacement or a spinal cord decompression (not palliative). A curative procedure either removes or repairs the causative problem. An example would be a mastectomy (not restorative) or a hemicolectomy (not diagnostic). A palliative procedure relieves symptoms but will not cure the disease. An example is an ileostomy. A cosmetic procedure is done to improve appearance. An example is rhinoplasty (a "nose job").)

A nurse recently hired to the preoperative area learns that certain clients are at higher risk for venous thromboembolism (VTE). Which clients are considered at high risk? (Select all that apply.) a. Client with a humerus fracture b. Morbidly obese client c. Client who underwent a prolonged surgical procedure d. Client with severe heart failure e. Wheelchair-bound client

b. Morbidly obese client c. Client who underwent a prolonged surgical procedure d. Client with severe heart failure e. Wheelchair-bound client (All surgical clients should be assessed for VTE risk. Those considered at higher risk include those who are obese; are over 40; have cancer; have decreased mobility, immobility, or a spinal cord injury; have a history of any thrombotic event, varicose veins, or edema; take oral contraceptives or smoke; have decreased cardiac output; have a hip fracture; or are having total hip or knee surgery. Prolonged surgical time increases risk due to mobility and positioning needs.)

A client is receiving an infusion of alteplase (Activase) for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse takes priority? a. Assess the client's neurologic status. b. Notify the Rapid Response Team. c. Prepare to administer vitamin K. d. Turn down the infusion rate.

b. Notify the Rapid Response Team. (Clients on fibrinolytic therapy are at high risk of bleeding. The sudden onset of neurologic signs may indicate the client is having a hemorrhagic stroke. The nurse does need to complete a thorough neurological examination, but should first call the Rapid Response Team based on the client's manifestations. The nurse notifies the Rapid Response Team first. Vitamin K is not the antidote for this drug. Turning down the infusion rate will not be helpful if the client is still receiving any of the drug.)

The nurse is caring for a client with peptic ulcer disease who reports sudden onset of sharp abdominal pain. On palpation, the client's abdomen is tense and rigid. What action takes priority? a. Administer the prescribed pain medication. b. Notify the health care provider immediately. c. Percuss all four abdominal quadrants. d. Take and document a set of vital signs.

b. Notify the health care provider immediately. (This client has manifestations of a perforated ulcer, which is an emergency. The priority is to get the client medical attention. The nurse can take a set of vital signs while someone else calls the provider. The nurse should not percuss the abdomen or give pain medication since the client may need to sign consent for surgery.)

A nurse wants to provide community service that helps meet the goals of Healthy People 2020 (HP2020) related to cardiovascular disease and stroke. What activity would best meet this goal? a. Teach high school students heart-healthy living. b. Participate in blood pressure screenings at the mall. c. Provide pamphlets on heart disease at the grocery store. d. Set up an "Ask the nurse" booth at the pet store.

b. Participate in blood pressure screenings at the mall. (An important goal of HP2020 is to increase the proportion of adults who have had their blood pressure measured within the preceding 2 years and can state whether their blood pressure was normal or high. Participating in blood pressure screening in a public spot will best help meet that goal. The other options are all appropriate but do not specifically help meet a goal.)

The nurse is teaching a patient about regional anesthesia. Which statement is accurate about this type of anesthesia? a. Patients will be awake but disoriented during the surgery. b. Patients are awake with loss of sensation in an area of the body. c. Patients will be asleep but may feel some pressure during the surgery. d. Patients are asleep and won't be able to remember the surgery.

b. Patients are awake with loss of sensation in an area of the body. (Regional anesthesia allows for the patient to remain awake. The patient will not feel any sensations during the surgery. The patient will not be disoriented. Many patients may be asked to follow instructions during the surgery. The patient will remain awake and he or she should not feel any pressure. The patient should have full memory of the surgical experience.)

A client has a serum ferritin level of 8 ng/mL and microcytic red blood cells. What action by the nurse is best? a. Encourage high-protein foods. b. Perform a Hemoccult test on the client's stools. c. Offer frequent oral care. d. Prepare to administer cobalamin (vitamin B12).

b. Perform a Hemoccult test on the client's stools. (This client has laboratory findings indicative of iron deficiency anemia. The most common cause of this disorder is blood loss, often from the GI tract. The nurse should perform a Hemoccult test on the client's stools. High-protein foods may help the condition, but dietary interventions take time to work. That still does not determine the cause. Frequent oral care is not related. Cobalamin injections are for pernicious anemia.)

A nurse answers a call light on the postoperative nursing unit. The client states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action should the nurse take first? a. Assess the client's blood pressure. b. Perform hand hygiene and apply gloves. c. Reinforce the dressing with a clean one. d. Remove the dressing to assess the wound.

b. Perform hand hygiene and apply gloves. (Prior to assessing or treating the drainage from the wound, the nurse performs hand hygiene and dons gloves to protect both the client and nurse from infection.)

A nurse orienting to the postoperative area learns which principles about the postoperative period? (Select all that apply.) a. All phases require the client to be in the hospital. b. Phase I care may last for several days in some clients. c. Phase I requires intensive care unit monitoring. d. Phase II ends when the client is stable and awake. e. Vital signs may be taken only once a day in phase III.

b. Phase I care may last for several days in some clients. d. Phase II ends when the client is stable and awake. e. Vital signs may be taken only once a day in phase III. (There are three phases of postoperative care. Phase I is the most intense, with clients coming right from surgery until they are completely awake and hemodynamically stable. This may take hours or days and can occur in the intensive care unit or the postoperative care unit. Phase II ends when the client is at a presurgical level of consciousness and baseline oxygen saturation, and vital signs are stable. Phase III involves the extended care environment and may continue at home or in an extended care facility if needed.)

A client has received intravenous anesthesia during an operation. What action by the postanesthesia care nurse is most important? a. Assist with administering muscle relaxants to the client. b. Place the client on a cardiac monitor and pulse oximeter. c. Prepare to administer intravenous antiemetics to the client. d. Prevent the client from experiencing postoperative shivering.

b. Place the client on a cardiac monitor and pulse oximeter. (Intravenous anesthetic agents have the potential to cause respiratory and circulatory depression. The nurse should ensure the client is on a cardiac monitor and pulse oximeter. Muscle relaxants are not indicated for this client at this time. Intravenous anesthetics have a lower rate of postoperative nausea and vomiting than other types. Shivering can occur in any client, but is more common after inhalation agents.)

The psychologic effects of being obese during adolescence include which of the following? a. Sexual promiscuity b. Poor body image c. Feelings of contempt for thin peers d. Accurate body image but self-deprecating attitude

b. Poor body image (Common emotional consequences of obesity include poor body image, low self- esteem, social isolation, and feelings of depression and isolation.)

A nurse assesses a client with diabetes mellitus. Which clinical manifestation should alert the nurse to decreased kidney function in this client? a. Urine specific gravity of 1.033 b. Presence of protein in the urine c. Elevated capillary blood glucose level d. Presence of ketone bodies in the urine

b. Presence of protein in the urine (Renal dysfunction often occurs in the client with diabetes. Proteinuria is a result of renal dysfunction. Specific gravity is elevated with dehydration. Elevated capillary blood glucose levels and ketones in the urine are consistent with diabetes mellitus but are not specific to renal function.)

A nurse develops a dietary plan for a client with diabetes mellitus and new-onset microalbuminuria. Which component of the client's diet should the nurse decrease? a. Carbohydrates b. Proteins c. Fats d. Total calories

b. Proteins (Restriction of dietary protein to 0.8 g/kg of body weight per day is recommended for clients with microalbuminuria to delay progression to renal failure. The client's diet does not need to be decreased in carbohydrates, fats, or total calories.)

A client has been given hydroxyzine (Atarax) in the preoperative holding area. What action by the nurse is most important for this client? a. Document giving the drug. b. Raise the siderails on the bed. c. Record the client's vital signs. d. Teach relaxation techniques.

b. Raise the siderails on the bed. (All actions are appropriate for a preoperative client. However, for client safety, the nurse should raise the siderails on the bed because hydroxyzine can make the client sleepy.)

When reviewing the health history of a patient who will be receiving antacids, the nurse recalls that antacids containing magnesium need to be used cautiously in patients with which condition? a. Peptic ulcer disease b. Renal failure c. Hypertension d. Heart failure

b. Renal failure (Both calcium- and magnesium-based antacids are more likely to accumulate to toxic levels in patients with renal disease and are commonly avoided in this patient group. The other options are incorrect.)

A nurse cares for a client who is prescribed pioglitazone (Actos). After 6 months of therapy, the client reports that his urine has become darker since starting the medication. Which action should the nurse take? a. Assess for pain or burning with urination. b. Review the client's liver function study results. c. Instruct the client to increase water intake. d. Test a sample of urine for occult blood.

b. Review the client's liver function study results. (Thiazolidinediones (including pioglitazone) can affect liver function; liver function should be assessed at the start of therapy and at regular intervals while the client continues to take these drugs. Dark urine is one indicator of liver impairment because bilirubin is increased in the blood and is excreted in the urine. The nurse should check the client's most recent liver function studies. The nurse does not need to assess for pain or burning with urination and does not need to check the urine for occult blood. The client does not need to be told to increase water intake.)

A patient has an order for the monoclonal antibody adalimumab (Humira). The nurse notes that the patient does not have a history of cancer. What is another possible reason for administering this drug? a. Severe anemia b. Rheumatoid arthritis c. Thrombocytopenia d. Osteoporosis

b. Rheumatoid arthritis (Monoclonal antibodies are used for the treatment of cancer, rheumatoid arthritis and other inflammatory diseases, multiple sclerosis, and organ transplantation.)

Using a behavioral health risk survey and identifying the factors leading to obesity in the family is an example of which level of prevention? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Assessment

b. Secondary prevention (Secondary prevention focuses on early detection and prompt treatment of disease, injury, or disability.)

A patient is taking chemotherapy with a drug that has a high potential for causing nausea and vomiting. The nurse is preparing to administer an antiemetic drug. Which class of antiemetic drugs is most commonly used to prevent nausea and vomiting for patients receiving chemotherapy? a. Prokinetic drugs, such as metoclopramide (Reglan) b. Serotonin blockers, such as ondansetron (Zofran) c. Anticholinergic drugs, such as scopolamine d. Neuroleptic drugs, such as promethazine (Phenergan)

b. Serotonin blockers, such as ondansetron (Zofran) (Serotonin blockers are used to prevent chemotherapy-induced and postoperative nausea and vomiting. The other options are incorrect.)

A 73-year-old male patient is in the clinic for a yearly physical and is asking for a prescription for sildenafil (Viagra). He has listed on his health history that he is taking a nitrate for angina. The nurse is aware that which problem may occur if sildenafil is taken with a nitrate? a. Significant increase in pulse rate b. Significant decrease in blood pressure c. Increased risk of bleeding d. Reduced effectiveness of the sildenafil

b. Significant decrease in blood pressure (In patients with pre-existing cardiovascular disease, especially those on nitrates, erectile dysfunction drugs such as sildenafil lower blood pressure substantially, potentially leading to more serious adverse events. The other options are incorrect.)

A nurse plans care for a client with Crohn's disease who has a heavily draining fistula. Which intervention should the nurse indicate as the priority action in this client's plan of care? a. Low-fiber diet b. Skin protection c. Antibiotic administration d. Intravenous glucocorticoids

b. Skin protection (Protecting the client's skin is the priority action for a client who has a heavily draining fistula. Intestinal fluid enzymes are caustic and can cause skin breakdown or fungal infections if the skin is not protected. The plan of care for a client who has Crohn's disease includes adequate nutrition focused on high-calorie, high-protein, high-vitamin, and low-fiber meals, antibiotic administration, and glucocorticoids.)

A patient who has been receiving continuous enteral nutrition has had several large, watery stools. The nurse will contact the provider to discuss which intervention? a. Administering antidiarrheal medications b. Slowing the rate of infusion c. Starting total parenteral nutrition d. Thickening the nutrition solution

b. Slowing the rate of infusion (The most common cause of diarrhea during a feeding is dumping syndrome as a result of rapid feed infusion. Slowing the feeding is the appropriate initial action. Antidiarrheal medications are not indicated unless slowing the infusion fails. Total parenteral nutrition is not indicated for patients with a functioning gastrointestinal tract. Thickening the solution will increase the solute load and increase the risk for diarrhea.)

Several nurses have just helped a morbidly obese client get out of bed. One nurse accesses the client's record because "I just have to know how much she weighs!" What action by the client's nurse is most appropriate? a. Make an anonymous report to the charge nurse. b. State "That is a violation of client confidentiality." c. Tell the nurse "Don't look; I'll tell you her weight." d. Walk away and ignore the other nurse's behavior.

b. State "That is a violation of client confidentiality." (Ethical practice requires the nurse to speak up and tell the other nurse that he or she is violating client confidentiality rules. The other responses do not address this concern.)

A patient is scheduled for surgery. Which should the nurse include in the preoperative teaching? a. Side effects of postoperative pain medication b. The importance of stopping smoking before the surgery c. The different types of wound drainage d. Advice to call the doctor if having severe pain while in the hospital

b. The importance of stopping smoking before the surgery (A patient should stop smoking once he or she has made the decision to have surgery. Smoking can increase the risk for respiratory complications. At this time the nurse may not know what will be ordered for postoperative pain management. The patient should be given information to help him or her understand signs of infection. Giving information on all the types of drainage is unnecessary. The patient would not be responsible for calling the doctor for inpatient pain management.)

A nurse is notified when a patient, newly admitted with liver and gallbladder disease, complains of pain in the right middle back and asks for some pain medication. What is the best interpretation of this reported assessment by the nurse? a. The patient is just complaining to see whether the staff will give out pain medications. b. The patient has referred pain sensations. The nurse should follow orders for administering pain medication. c. The patient has an injury on the back from an unknown cause that needs immediate assessment. d. The patient is a chronic complainer with anxieties about his condition.

b. The patient has referred pain sensations. The nurse should follow orders for administering pain medication. (Referred pain is a very real physical complaint, and the nurse should give the patient the pain medication as ordered.)

A patient who has been newly diagnosed with vertigo will be taking an antihistamine antiemetic drug. The nurse will include which information when teaching the patient about this drug? a. The patient may skip doses if the patient is feeling well. b. The patient will need to avoid driving because of possible drowsiness. c. The patient may experience occasional problems with taste. d. It is safe to take the medication with a glass of wine in the evening to help settle the stomach.

b. The patient will need to avoid driving because of possible drowsiness. (Drowsiness may occur because of central nervous system (CNS) depression, and patients should avoid driving or working with heavy machinery because of possible sedation. These drugs must not be taken with alcohol or other CNS depressants because of possible additive depressant effects. The medication should be taken as instructed and not skipped unless instructed to do so.)

A postoperative client has an abdominal drain. What assessment by the nurse indicates that goals for the priority client problems related to the drain are being met? a. Drainage from the surgical site is 30 mL less than yesterday. b. There is no redness, warmth, or drainage at the insertion site. c. The client reports adequate pain control with medications. d. Urine is clear yellow and urine output is greater than 40 mL/hr.

b. There is no redness, warmth, or drainage at the insertion site. (The priority client problem related to a surgical drain is the potential for infection. An insertion site that is free of redness, warmth, and drainage indicates that goals for this client problem are being met. The other assessments are normal, but not related to the drain.)

A patient on a medical surgical unit has a platelet count of 90,000 per mm3. The nurse knows to include which of the following precautions in discharge instructions? a. Use a standard safety razor for shaving. b. Use a soft bristle toothbrush. c. Have aggressive dental care immediately to prevent dental caries. d. Do not eat fresh fruit.

b. Use a soft bristle toothbrush. (The use of a soft bristle toothbrush will help prevent bleeding of the gums in a patient with thrombocytopenia. The blade of a safety razor can nick or cut the skin and cause bleeding. Dental care can cause gum bleeding. The consumption of fresh fruit is not part of bleeding precautions.)

A patient who has been anticoagulated with warfarin (Coumadin) has been admitted for gastrointestinal bleeding. The history and physical examination indicates that the patient may have taken too much warfarin. The nurse anticipates that the patient will receive which antidote? a. Vitamin E b. Vitamin K c. Protamine sulfate d. Potassium chloride

b. Vitamin K (Vitamin K is given to reverse the anticoagulation effects of warfarin toxicity. Protamine sulfate is the antidote for heparin overdose. The other options are incorrect.)

A patient tells the nurse that he likes to eat large amounts of garlic "to help lower his cholesterol levels naturally." The nurse reviews his medication history and notes that which drug has a potential interaction with the garlic? a. Acetaminophen (Tylenol) b. Warfarin (Coumadin) c. Digoxin (Lanoxin) d. Phenytoin (Dilantin)

b. Warfarin (Coumadin) (When using garlic, it is recommended to avoid any other drugs that may interfere with platelet and clotting function. These drugs include antiplatelet drugs, anticoagulants, nonsteroidal anti-inflammatory drugs, and aspirin. The other drugs listed do not have known interactions with garlic.)

When monitoring a patient who is on immunosuppressant therapy with azathioprine (Imuran), the nurse will monitor which laboratory results? a. Serum potassium levels b. White blood cell (leukocyte) count c. Red blood cell count d. Serum albumin levels

b. White blood cell (leukocyte) count (Leukopenia is a potential adverse effect of azathioprine therapy, so white blood cells need to be monitored. The other options are incorrect.)

The nurse is teaching a patient about being discharged after an elective surgery. The procedure is being performed at an ambulatory surgical center. What information should the nurse include about transportation? a. You will be able to drive home. b. You will need someone to drive you home. c. You can drive home if someone is in the car with you. d. If you are lightheaded or dizzy, you will not be able to drive home.

b. You will need someone to drive you home. (Patients undergoing surgery in an ambulatory center will need someone to drive them home because of the effects of anesthesia, pain medication, and the surgery itself. Patients are instructed not to drive home. A patient cannot drive home with or without feeling lightheaded or dizzy. Patients should not drive even if someone is in the car with them. Driving is not allowed because of the medications given during the surgical procedure.)

The presence of gallstones in the gallbladder is called a. cholecystitis. b. cholelithiasis. c. cholecystectomy. d. cholecystokinin.

b. cholelithiasis. (Cholelithiasis refers to the presence of gallstones in the gallbladder. When continued infection alters the solubility of the bile ingredients, cholesterol separates out and forms gallstones.)

A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values should the nurse identify as potential ketoacidosis in this client? a. pH 7.38, HCO₃⁻ 22 mEq/L, PCO₂ 38 mm Hg, PO₂ 98 mm Hg b. pH 7.28, HCO₃⁻ 18 mEq/L, PCO₂ 28 mm Hg, PO₂ 98 mm Hg c. pH 7.48, HCO₃⁻ 28 mEq/L, PCO₂ 38 mm Hg, PO₂ 98 mm Hg d. pH 7.32, HCO₃⁻ 22 mEq/L, PCO₂ 58 mm Hg, PO₂ 88 mm Hg

b. pH 7.28, HCO₃⁻ 18 mEq/L, PCO₂ 28 mm Hg, PO₂ 98 mm Hg (When the lungs can no longer offset acidosis, the pH decreases to below normal. A client who has diabetic ketoacidosis would present with arterial blood gas values that show primary metabolic acidosis with decreased bicarbonate levels and a compensatory respiratory alkalosis with decreased carbon dioxide levels.)

A patient has had recent mechanical heart valve surgery and is receiving anticoagulant therapy. While monitoring the patient's laboratory work, the nurse interprets that the patient's international normalized ratio (INR) level of 3 indicates that: a. the patient is not receiving enough warfarin to have a therapeutic effect. b. the patient's warfarin dose is at therapeutic levels. c. the patient's intravenous heparin dose is dangerously high. d. the patient's intravenous heparin dose is at therapeutic levels.

b. the patient's warfarin dose is at therapeutic levels. (A normal INR (without warfarin) is 1.0. A therapeutic INR for patients who have had mechanical heart valve surgery ranges from 2.5 to 3.5, with a middle value of 3.)

A 68-year-old male patient with a stroke is unconscious and unresponsive to stimuli. After learning that the patient has a history of gastroesophageal reflux disease (GERD), the nurse will plan to do frequent assessments of the patient's apical pulse. bowel sounds. breath sounds. abdominal girth.

breath sounds. (Because GERD may cause aspiration, the unconscious patient is at risk for developing aspiration pneumonia. Bowel sounds, abdominal girth, and apical pulse will not be affected by the patient's stroke or GERD and do not require more frequent monitoring than the routine.)

When evaluating a patient who is taking orlistat (Xenical), which is an intended therapeutic effect? a. Increased wakefulness b. Increased appetite c. Decreased weight d. Decreased hyperactivity

c. Decreased weight (Orlistat (Xenical) is a nonstimulant drug that is used as part of a weight loss program. The other options are incorrect.)

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? a. "I should increase my intake of vegetables with higher amounts of dietary fiber." b. "My intake of saturated fats should be no more than 10% of my total calorie intake." c. "I should decrease my intake of protein and eliminate carbohydrates from my diet." d. "My intake of water is not restricted by my treatment plan or medication regimen."

c. "I should decrease my intake of protein and eliminate carbohydrates from my diet." (The client should not completely eliminate carbohydrates from the diet, and should reduce protein if microalbuminuria is present. The client should increase dietary intake of complex carbohydrates, including vegetables, and decrease intake of fat. Water does not need to be restricted unless kidney failure is present.)

A patient with gastroesophageal reflux disease is prescribed ranitidine (Zantac). Which statement by the patient indicates to the nurse a need for additional teaching? a. "If I need to use ranitidine for more than 2 weeks, I will notify my prescriber." b. "I will look into a smoking cessation program when I go home." c. "I will take the ranitidine first thing in the morning so that its effect will last all day and night." d. "I will not drive until I know how the ranitidine affects me."

c. "I will take the ranitidine first thing in the morning so that its effect will last all day and night." (To prolong the effects of histamine H₂ blockers like ranitidine, they should be taken with meals. If a patient takes this drug once a day, giving it at bedtime prolongs the effects when there is no food in the stomach and reflux may be worse.)

A client has newly diagnosed systemic lupus erythematosus (SLE). What instruction by the nurse is most important? a. "Be sure you get enough sleep at night." b. "Eat plenty of high-protein, high-iron foods." c. "Notify your provider at once if you get a fever." d. "Weigh yourself every day on the same scale."

c. "Notify your provider at once if you get a fever." (Fever is the classic sign of a lupus flare and should be reported immediately. Rest and nutrition are important but do not take priority over teaching the client what to do if he or she develops an elevated temperature. Daily weights may or may not be important depending on renal involvement.)

A nurse is teaching a client about magnesium hydroxide with aluminum hydroxide (Maalox). What instruction is most appropriate? a. "Aspirin must be avoided." b. "Do not worry about black stools." c. "Report diarrhea to your provider." d. "Take 1 hour before meals."

c. "Report diarrhea to your provider." (Maalox can cause hypermagnesemia, which causes diarrhea, so the client should be taught to report this to the provider. Aspirin is avoided with bismuth sulfate (Pepto-Bismol). Black stools can be caused by Pepto-Bismol. Maalox should be taken after meals.)

A nurse is caring for a client who has sleep apnea and is prescribed modafinil (Provigil). The client asks, "How will this medication help me?" How should the nurse respond? a. "This medication will treat your sleep apnea." b. "This sedative will help you to sleep at night." c. "This medication will promote daytime wakefulness." d. "This analgesic will increase comfort while you sleep."

c. "This medication will promote daytime wakefulness." (Modafinil is helpful for clients who have narcolepsy (uncontrollable daytime sleep) related to sleep apnea. This medication promotes daytime wakefulness.)

A patient will begin using sildenafil citrate (Viagra) to treat erectile dysfunction. The nurse will instruct the patient to take the medication a. daily in the morning. b. just prior to sexual activity. c. 30 minutes to 4 hours before sexual activity. d. twice daily.

c. 30 minutes to 4 hours before sexual activity. (Sildenafil should be taken at least 30 minutes and less than 4 hours prior to sexual activity. It is not taken daily or twice daily. If taken just prior to sexual activity, it does not have time to take effect.)

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea? a. A 26-year-old woman who is 8 months pregnant b. A 42-year-old man with gastroesophageal reflux disease c. A 55-year-old woman who is 50 pounds overweight d. A 73-year-old man with type 2 diabetes mellitus

c. A 55-year-old woman who is 50 pounds overweight (The client at highest risk would be the one who is extremely overweight. None of the other clients have risk factors for sleep apnea.)

At 4:45 p.m., a nurse assesses a client with diabetes mellitus who is recovering from an abdominal hysterectomy 2 days ago. The nurse notes that the client is confused and diaphoretic. The nurse reviews the assessment data provided in the chart below: -------------------------------- Capillary Blood Glucose Testing (AC/HS): • At 0630: 95 • At 1130: 70 • At 1630: 47 Dietary Intake: • Breakfast: 10% eaten - client states she is not hungry • Lunch: 5% eaten - client is nauseous; vomits once -------------------------------- After reviewing the client's assessment data, which action is appropriate at this time? a. Assess the client's oxygen saturation level and administer oxygen. b. Reorient the client and apply a cool washcloth to the client's forehead. c. Administer dextrose 50% intravenously and reassess the client. d. Provide a glass of orange juice and encourage the client to eat dinner.

c. Administer dextrose 50% intravenously and reassess the client. (The client's symptoms are related to hypoglycemia. Since the client has not been tolerating food, the nurse should administer dextrose intravenously. The client's oxygen level could be checked, but based on the information provided, this is not the priority. The client will not be reoriented until the glucose level rises.)

A nurse cares for a client who is prescribed mesalamine (Asacol) for ulcerative colitis. The client states, "I am having trouble swallowing this pill." Which action should the nurse take? a. Contact the clinical pharmacist and request the medication in suspension form. b. Empty the contents of the capsule into applesauce or pudding for administration. c. Ask the health care provider to prescribe the medication as an enema instead. d. Crush the pill carefully and administer it in applesauce or pudding.

c. Ask the health care provider to prescribe the medication as an enema instead. (Asacol is the oral formula for mesalamine and is produced as an enteric-coated pill that should not be crushed, chewed, or broken. Asacol is not available as a suspension or elixir. If the client is unable to swallow the Asacol pill, a mesalamine enema (Rowasa) may be administered instead, with a provider's order.)

A patient who has been on methotrexate therapy is experiencing mild pain. The patient is asking for aspirin for the pain. The nurse recognizes that which of these is true in this situation? a. The aspirin will aggravate diarrhea. b. The aspirin will masks signs of infection. c. Aspirin can lead to methotrexate toxicity. d. The aspirin will cause no problems for the patient on methotrexate.

c. Aspirin can lead to methotrexate toxicity. (Methotrexate interacts with weak organic acids, such as aspirin, and can lead to toxicity by displacing the methotrexate from protein-binding sites.)

The nurse will teach a patient who is receiving oral iron supplements to watch for which expected adverse effects? a. Palpitations b. Drowsiness and dizziness c. Black, tarry stools d. Orange-red discoloration of the urine

c. Black, tarry stools (Black, tarry stools and other gastrointestinal disturbances may occur with the administration of iron preparations. The other options are incorrect.)

For which client would the nurse suggest the provider not prescribe misoprostol (Cytotec)? a. Client taking antacids b. Client taking antibiotics c. Client who is pregnant d. Client over 65 years of age

c. Client who is pregnant (Misoprostol can cause abortion, so pregnant women should not take this drug. The other clients have no contraindications to taking misoprostol.)

The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client should the nurse assess first? a. Client with a blood pressure of 100/50 mm Hg b. Client with a pulse of 118 beats/min c. Client with a respiratory rate of 6 breaths/min d. Client with a temperature of 96° F (35.6° C)

c. Client with a respiratory rate of 6 breaths/min (The respiratory rate is the most critical vital sign for any client who has undergone general anesthesia or moderate sedation, or has received opioid analgesia. This respiratory rate is too low and indicates respiratory depression. The nurse should assess this client first. A blood pressure of 100/50 mm Hg is slightly low and may be within that client's baseline. A pulse of 118 beats/min is slightly fast, which could be due to several causes, including pain and anxiety. A temperature of 96° F is slightly low and the client needs to be warmed. But none of these other vital signs take priority over the respiratory rate.)

A nurse assesses a client with diabetes mellitus 3 hours after a surgical procedure and notes the client's breath has a "fruity" odor. Which action should the nurse take? a. Encourage the client to use an incentive spirometer. b. Increase the client's intravenous fluid flow rate. c. Consult the provider to test for ketoacidosis. d. Perform meticulous pulmonary hygiene care.

c. Consult the provider to test for ketoacidosis. (The stress of surgery increases the action of counterregulatory hormones and suppresses the action of insulin, predisposing the client to ketoacidosis and metabolic acidosis. One manifestation of ketoacidosis is a "fruity" odor to the breath. Documentation should occur after all assessments have been completed. Using an incentive spirometer, increasing IV fluids, and performing pulmonary hygiene will not address this client's problem.)

A client just returned to the surgical unit after a gastric bypass. What action by the nurse is the priority? a. Assess the client's pain. b. Check the surgical incision. c. Ensure an adequate airway. d. Program the morphine pump.

c. Ensure an adequate airway. (All actions are appropriate care measures for this client; however, airway is always the priority. Bariatric clients tend to have short, thick necks that complicate airway management.)

A nurse assesses a client who has a 15-year history of diabetes and notes decreased tactile sensation in both feet. Which action should the nurse take first? a. Document the finding in the client's chart. b. Assess tactile sensation in the client's hands. c. Examine the client's feet for signs of injury. d. Notify the health care provider.

c. Examine the client's feet for signs of injury. (Diabetic neuropathy is common when the disease is of long duration. The client is at great risk for injury in any area with decreased sensation because he or she is less able to feel injurious events. Feet are common locations for neuropathy and injury, so the nurse should inspect them for any signs of injury. After assessment, the nurse should document findings in the client's chart. Testing sensory perception in the hands may or may not be needed. The health care provider can be notified after assessment and documentation have been completed.)

A nurse attempted to assist a morbidly obese client back to bed and had immediate pain in the lower back. What action by the nurse is most appropriate? a. Ask another nurse to help next time. b. Demand better equipment to use. c. Fill out and file a variance report. d. Refuse to assist the client again.

c. Fill out and file a variance report. (The nurse should complete a variance report per agency policy. Asking another nurse to help and requesting better equipment are both good ideas, but the nurse may have an injury that needs care. It would be unethical to refuse to care for this client again.)

The circulating nurse is plugging in a piece of equipment and notes that the cord is frayed. What action by the nurse is best? a. Call maintenance for repair. b. Check the machine before using. c. Get another piece of equipment. d. Notify the charge nurse.

c. Get another piece of equipment. (The circulating nurse is responsible for client safety. If an electrical cord is frayed, the risk of fire or sparking increases. The nurse should obtain a replacement. The nurse should also tag the original equipment for repair as per agency policy. Checking the equipment is not important as the nurse should not even attempt to use it. Calling maintenance or requesting maintenance per facility protocol is important, but first ensure client safety by having a properly working piece of equipment for the procedure about to take place. The charge nurse probably does need to know of the need for equipment repair, but ensuring client safety is the priority.)

0900, the nurse is about to give morning medications, and the patient has asked for a dose of antacid for severe heartburn. Which schedule for the antacid and medications is correct? a. Give both the antacid and medications at 0900. b. Give the antacid at 0900, and then the medications at 0930. c. Give the medications at 0900, and then the antacid at 1000. d. Give the medications at 0900, and then the antacid at 0915.

c. Give the medications at 0900, and then the antacid at 1000. (Medications are not to be taken, unless prescribed, within 1 to 2 hours of taking an antacid because of the impact on the absorption of many medications in the stomach.)

A nurse assesses a client who is being treated for hyperglycemic-hyperosmolar state (HHS). Which clinical manifestation indicates to the nurse that the therapy needs to be adjusted? a. Serum potassium level has increased. b. Blood osmolarity has decreased. c. Glasgow Coma Scale score is unchanged. d. Urine remains negative for ketone bodies.

c. Glasgow Coma Scale score is unchanged. (A slow but steady improvement in central nervous system functioning is the best indicator of therapy effectiveness for HHS. Lack of improvement in the level of consciousness may indicate inadequate rates of fluid replacement. The Glasgow Coma Scale assesses the client's state of consciousness against criteria of a scale including best eye, verbal, and motor responses. An increase in serum potassium, decreased blood osmolality, and urine negative for ketone bodies do not indicate adequacy of treatment.)

A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that a priority goal for this problem has been met? a. Chooses preferred items from the menu b. Eats 75% to 100% of all meals and snacks c. Has clear lung sounds on auscultation d. Gains 2 pounds after 1 week

c. Has clear lung sounds on auscultation (Impaired swallowing can lead to aspiration, so the priority goal for this problem is no aspiration. Clear lung sounds is the best indicator that aspiration has not occurred. Choosing menu items is not related to this problem. Eating meals does not indicate the client is not still aspirating. A weight gain indicates improved nutrition but still does not show a lack of aspiration.)

A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment should the nurse complete first? a. Inspection of oral mucosa b. Recent dietary intake c. Heart rate and rhythm d. Percussion of abdomen

c. Heart rate and rhythm (Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client should have her or his electrolyte levels monitored, and electrolyte replacement may be necessary. Oral mucosa inspection, recent dietary intake, and abdominal percussion are important parts of physical assessment but are lower priority for this client than heart rate and rhythm.)

A client has a platelet count of 25,000/mm3. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assist with oral hygiene using a firm toothbrush. b. Give the client an enema if he or she is constipated. c. Help the client choose soft foods from the menu. d. Shave the male client with an electric razor. e. Use a lift sheet when needed to re-position the client.

c. Help the client choose soft foods from the menu. d. Shave the male client with an electric razor. e. Use a lift sheet when needed to re-position the client. (This client has thrombocytopenia and requires bleeding precautions. These include oral hygiene with a soft-bristled toothbrush or swabs, avoiding rectal trauma, eating soft foods, shaving with an electric razor, and using a lift sheet to re-position the client.)

A nurse assesses a client who is hospitalized with an exacerbation of Crohn's disease. Which clinical manifestation should the nurse expect to find? a. Positive Murphy's sign with rebound tenderness to palpitation b. Dull, hypoactive bowel sounds in the lower abdominal quadrants c. High-pitched, rushing bowel sounds in the right lower quadrant d. Reports of abdominal cramping that is worse at night

c. High-pitched, rushing bowel sounds in the right lower quadrant (The nurse expects high-pitched, rushing bowel sounds due to narrowing of the bowel lumen in Crohn's disease. A positive Murphy's sign is indicative of gallbladder disease, and rebound tenderness often indicates peritonitis. Dullness in the lower abdominal quadrants and hypoactive bowel sounds are not commonly found with Crohn's disease. Nightly worsening of abdominal cramping is not consistent with Crohn's disease.)

A patient has been diagnosed with angina and will be given a prescription for sublingual nitroglycerin tablets. When teaching the patient how to use sublingual nitroglycerin, the nurse will include which instruction? a. Take up to 5 doses at 15-minute intervals for an angina attack. b. If the tablet does not dissolve quickly, chew the tablet for maximal effect. c. If the chest pain is not relieved after one tablet, call 911 immediately. d. Wait 1 minute between doses of sublingual tablets, up to 3 doses.

c. If the chest pain is not relieved after one tablet, call 911 immediately. (According to current guidelines, if the chest pain or discomfort is not relieved in 5 minutes, after 1 dose, the patient (or family member) must call 911 immediately. The patient may take one more tablet while awaiting emergency care and may take a third tablet 5 minutes later, but no more than a total of three tablets. The sublingual dose is placed under the tongue, and the patient needs to avoid swallowing until the tablet has dissolved.)

What can men who have sustained spinal cord injuries with resultant ED use to aid in the ability to have sexual intercourse? a. Testosterone injections b. Papaverine penile injections c. Inflatable penile implants d. Oral sildenafil (Viagra)

c. Inflatable penile implants (Penile implants may be prescribed for patients with the inability to initiate, fill, or restore an erection.)

The circulating nurse is in the operating room and sees the surgeon don gown and gloves using appropriate sterile procedure. The surgeon then folds the hands together and places them down below the hips. What action by the nurse is most appropriate? a. Ask the surgeon to change the sterile gown. b. Do nothing; this is acceptable sterile procedure. c. Inform the surgeon that the sterile field has been broken. d. Obtain a new pair of sterile gloves for the surgeon to put on.

c. Inform the surgeon that the sterile field has been broken. (The surgical gown is considered sterile from the chest to the level of the surgical field. By placing the hands down by the hips, the surgeon has broken sterile field. The circulating nurse informs the surgeon of this breach. Changing only the gloves or only the gown does not "restore" the sterile sections of the gown. Doing nothing is unacceptable.)

A patient is to receive iron dextran injections. Which technique is appropriate when the nurse is administering this medication? a. Intravenous administration mixed with 5% dextrose b. Intramuscular injection in the upper arm c. Intramuscular injection using the Z-track method d. Subcutaneous injection into the abdomen

c. Intramuscular injection using the Z-track method (Intramuscular iron is given using the Z-track method deep into a large muscle mass. If given intravenously, it is given with normal saline, not 5% dextrose.)

A client has a sickle cell crisis with extreme lower extremity pain. What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)? a. Apply ice packs to the client's legs. b. Elevate the client's legs on pillows. c. Keep the lower extremities warm. d. Place elastic bandage wraps on the client's legs.

c. Keep the lower extremities warm. (During a sickle cell crisis, the tissue distal to the occlusion has decreased blood flow and ischemia, leading to pain. Due to decreased blood flow, the client's legs will be cool or cold. The UAP can attempt to keep the client's legs warm. Ice and elevation will further decrease perfusion. Elastic bandage wraps are not indicated and may constrict perfusion in the legs.)

The nurse is caring for a client with systemic sclerosis (SSc). What comfort measures can the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Collaborate with a registered dietitian for appropriate foods. b. Inspect the skin and note any areas of ulceration. c. Keep the room at a comfortably warm temperature. d. Place a foot cradle at the end of the bed to lift sheets. e. Remind the client to elevate the head of the bed after eating.

c. Keep the room at a comfortably warm temperature. d. Place a foot cradle at the end of the bed to lift sheets. e. Remind the client to elevate the head of the bed after eating. (The client with SSc should avoid cold temperatures, which may lead to vasospasms and Raynaud's phenomenon. The UAP can adjust the room temperature for the client's comfort. Keeping the sheets off the feet will help prevent injury; the UAP can apply a foot cradle to the bed to hold the sheets up. Because of esophageal problems, the client should remain in an upright position for 1 to 2 hours after meals. The UAP can remind the client of this once he or she has been taught. The other actions are performed by the registered nurse.)

A nurse assesses a client who has cholecystitis. Which clinical manifestation indicates that the condition is chronic rather than acute? a. Temperature of 100.1° F (37.8° C) b. Positive Murphy's sign c. Light-colored stools d. Upper abdominal pain after eating

c. Light-colored stools (Jaundice, clay-colored stools, and dark urine are more commonly seen with chronic cholecystitis. The other symptoms are seen equally with both chronic and acute cholecystitis.)

A client had a surgical procedure with spinal anesthesia. The nurse raises the head of the client's bed. The client's blood pressure changes from 122/78 mm Hg to 102/50 mm Hg. What action by the nurse is best? a. Call the Rapid Response Team. b. Increase the IV fluid rate. c. Lower the head of the bed. d. Nothing; this is expected.

c. Lower the head of the bed. (A client who had epidural or spinal anesthesia may become hypotensive when the head of the bed is raised. If this occurs, the nurse should lower the head of the bed to its original position. The Rapid Response Team is not needed, nor is an increase in IV rate.)

A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein thrombosis. The client has lost 20 pounds since the last visit. What action by the nurse is best? a. Ask if the weight loss was intended. b. Encourage a high-protein, high-fiber diet. c. Measure for new compression stockings. d. Review a 3-day food recall diary.

c. Measure for new compression stockings. (Compression stockings must fit correctly in order to work. After losing a significant amount of weight, the client should be re-measured and new stockings ordered if needed. The other options are appropriate, but not the most important.)

A 75-year-old woman comes into the clinic with complaints of muscle twitching, nausea, and headache. She tells the nurse that she has been taking sodium bicarbonate five or six times a day for the past 3 weeks. The nurse will assess for which potential problem that may occur with overuse of sodium bicarbonate? a. Constipation b. Metabolic acidosis c. Metabolic alkalosis d. Excessive gastric mucus

c. Metabolic alkalosis (Excessive use of sodium bicarbonate may lead to systemic alkalosis. The other options are incorrect.)

A client who collapsed during dinner in a restaurant arrives in the emergency department. The client is going to surgery to repair an abdominal aortic aneurysm. What medication does the nurse prepare to administer as a priority for this client? a. Hydroxyzine (Atarax) b. Lorazepam (Ativan) c. Metoclopramide (Reglan) d. Morphine sulfate

c. Metoclopramide (Reglan) (Reglan increases gastric emptying, an important issue for this client who was eating just prior to the operation. The other drugs are appropriate for any surgical client.)

A patient calls the clinic office saying that the cholestyramine (Questran) powder he started yesterday clumps and sticks to the glass when he tries to mix it. The nurse will suggest what method for mixing this medication for administration? a. Mix the powder in a carbonated soda drink to dissolve it faster. b. Add the powder to any liquid, and stir vigorously to dissolve it quickly. c. Mix the powder with food or fruit, or at least 4 to 6 ounces of fluid. d. Sprinkle the powder into a spoon and take it dry, followed by a glass of water.

c. Mix the powder with food or fruit, or at least 4 to 6 ounces of fluid. (Mix the powder with food or at least 4 to 6 ounces of fluid. The powder may not mix completely at first, but patients should be sure to mix the dose as much as possible and then dilute any undissolved portion with additional fluid. The powder should be dissolved for at least 1 full minute. Powder and granule dosages are never to be taken in dry form.)

A patient asks about his cancer treatment with monoclonal antibodies. The nurse tells him that which is the major advantage of treating certain cancers with monoclonal antibodies? a. They will help the patient improve more quickly than will other antineoplastic drugs. b. They are more effective against metastatic tumors. c. Monoclonal antibodies target certain tumor cells and bypass normal cells. d. There are fewer incidences of opportunistic infections with monoclonal antibodies.

c. Monoclonal antibodies target certain tumor cells and bypass normal cells. (Monoclonal antibodies can target cancer cells specifically and have minimal effects on healthy cells, unlike conventional cancer treatments. As a result, there are fewer adverse effects when compared to traditional antineoplastic therapy. The other options are incorrect.)

The nurse caring for clients with gastrointestinal disorders should understand that which category best describes the mechanism of action of sucralfate (Carafate)? a. Gastric acid inhibitor b. Histamine receptor blocker c. Mucosal barrier fortifier d. Proton pump inhibitor

c. Mucosal barrier fortifier (Sucralfate is a mucosal barrier fortifier (protector). It is not a gastric acid inhibitor, a histamine receptor blocker, or a proton pump inhibitor.)

A nurse works on the postoperative floor and has four clients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the health care team for post-discharge care? a. Married young adult who is the primary caregiver for children b. Middle-aged client who is post knee replacement, needs physical therapy c. Older adult who lives at home despite some memory loss d. Young client who lives alone, has family and friends nearby

c. Older adult who lives at home despite some memory loss (The older adult has the most potentially complex discharge needs. With memory loss, the client may not be able to follow the prescribed home regimen. The client's physical abilities may be limited by chronic illness. This client has several safety needs that should be assessed. The other clients all have evidence of a support system and no known potential for serious safety issues.)

A client has gastroesophageal reflux disease (GERD). The provider prescribes a proton pump inhibitor. About what medication should the nurse anticipate teaching the client? a. Famotidine (Pepcid) b. Magnesium hydroxide (Maalox) c. Omeprazole (Prilosec) d. Ranitidine (Zantac)

c. Omeprazole (Prilosec) (Omeprazole is a proton pump inhibitor used in the treatment of GERD. Famotidine and ranitidine are histamine blockers. Maalox is an antacid.)

A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery. Which result warrants immediate communication with the surgical team? a. Creatinine: 1.2 mg/dL b. Hemoglobin: 14.8 mg/dL c. Potassium: 2.9 mEq/L d. Sodium: 134 mEq/L

c. Potassium: 2.9 mEq/L (A potassium of 2.9 mEq/L is critically low and can affect cardiac and respiratory status. The nurse should communicate this laboratory value immediately. The creatinine is at the high end of normal, the hemoglobin is normal, and the sodium is only slightly low (normal low being 136 mEq/L), so these values do not need to be reported immediately.)

The nurse notes in the patient's medication orders that the patient will be starting anticoagulant therapy. What is the primary goal of anticoagulant therapy? a. Stabilizing an existing thrombus b. Dissolving an existing thrombus c. Preventing thrombus formation d. Dilating the vessel around a clot

c. Preventing thrombus formation (Anticoagulants prevent thrombus formation but do not dissolve or stabilize an existing thrombus, nor do they dilate vessels around a clot.)

A patient has received an overdose of intravenous heparin, and is showing signs of excessive bleeding. Which substance is the antidote for heparin overdose? a. Vitamin E b. Vitamin K c. Protamine sulfate d. Potassium chloride

c. Protamine sulfate (Protamine sulfate is a specific heparin antidote and forms a complex with heparin, completely reversing its anticoagulant properties. Vitamin K is the antidote for warfarin (Coumadin) overdose. The other options are incorrect.)

A client tells the nurse about losing weight and regaining it multiple times. Besides eating and exercising habits, for what additional data should the nurse assess as the priority? a. Economic ability to join a gym b. Food allergies and intolerances c. Psychosocial influences on weight d. Reasons for wanting to lose weight

c. Psychosocial influences on weight (While all topics might be important to assess, people who lose and gain weight in cycles often are depressed or have poor self-esteem, which has a negative effect on weight-loss efforts. The nurse assesses the client's psychosocial status as the priority.)

When the nurse is administering topical nitroglycerin ointment, which technique is correct? a. Apply the ointment on the skin on the forearm. b. Apply the ointment only in the case of a mild angina episode. c. Remove the old ointment before new ointment is applied. d. Massage the ointment gently into the skin, and then cover the area with plastic wrap.

c. Remove the old ointment before new ointment is applied. (The old ointment should be removed before a new dose is applied. The ointment should be applied to clean, dry, hairless skin of the upper arms or body, not below the elbows or below the knees. The ointment is not massaged or spread on the skin, and it is not indicated for the treatment of acute angina.)

A registered nurse (RN) is watching a nursing student change a dressing and perform care around a Penrose drain. What action by the student warrants intervention by the RN? a. Cleaning around the drain per agency protocol b. Placing a new sterile gauze under the drain c. Securing the drain's safety pin to the sheets d. Using sterile technique to empty the drain

c. Securing the drain's safety pin to the sheets (The safety pin that prevents the drain from slipping back into the client's body should be pinned to the client's gown, not the bedding. Pinning it to the sheets will cause it to pull out when the client turns. The other actions are appropriate.)

A client with peptic ulcer disease is in the emergency department and reports the pain has gotten much worse over the last several days. The client's blood pressure when lying down was 122/80 mm Hg and when standing was 98/52 mm Hg. What action by the nurse is most appropriate? a. Administer ibuprofen (Motrin). b. Call the Rapid Response Team. c. Start a large-bore IV with normal saline. d. Tell the client to remain lying down.

c. Start a large-bore IV with normal saline. (This client has orthostatic changes to the blood pressure, indicating fluid volume loss. The nurse should start a large-bore IV with isotonic solution. Ibuprofen will exacerbate the ulcer. The Rapid Response Team is not needed at this point. The client should be put on safety precautions, which includes staying in bed, but this is not the priority.)

A patient reports having adverse effects with nicotinic acid (niacin). The nurse can suggest performing which action to minimize these undesirable effects? a. Take the drug on an empty stomach. b. Take the medication every other day until the effects subside. c. Take an aspirin tablet 30 minutes before taking the drug. d. Take the drug with large amounts of fiber.

c. Take an aspirin tablet 30 minutes before taking the drug. (The undesirable effects of nicotinic acid can be minimized by starting with a low initial dose, taking the drug with meals, and taking small doses of aspirin with the drug to minimize cutaneous flushing. Fiber intake has no effect on niacin's adverse effects, and it is not within the nurse's scope of practice to suggest a change of medication dosage.)

A nurse is giving instructions to a patient who will be receiving oral iron supplements. Which instructions will be included in the teaching plan? a. Take the iron tablets with milk or antacids. b. Crush the pills as needed to help with swallowing. c. Take the iron tablets with meals if gastrointestinal distress occurs. d. If black tarry stools occur, report it to the doctor immediately.

c. Take the iron tablets with meals if gastrointestinal distress occurs. (Although taking iron tablets with food may decrease absorption, doing so helps to reduce gastrointestinal distress. Antacids and milk may cause decreased iron absorption; iron tablets must be taken whole and not crushed. Black, tarry stools are expected adverse effects of oral iron supplements.)

A patient has been instructed to take one enteric-coated low-dose aspirin a day as part of therapy to prevent strokes. The nurse will provide which instruction when providing patient teaching about this medication? a. Aspirin needs to be taken on an empty stomach to ensure maximal absorption. b. Low-dose aspirin therapy rarely causes problems with bleeding. c. Take the medication with 6 to 8 ounces of water and with food. d. Coated tablets may be crushed if necessary for easier swallowing.

c. Take the medication with 6 to 8 ounces of water and with food. (Enteric-coated aspirin is best taken with 6 to 8 ounces of water and with food to help decrease gastrointestinal upset. Enteric-coated tablets should not be crushed. Risk for bleeding increases with aspirin therapy, even at low doses.)

A patient will be receiving a thrombolytic drug as part of the treatment for acute myocardial infarction. The nurse explains to the patient that this drug is used for which purpose? a. To relieve chest pain b. To prevent further clot formation c. To dissolve the clot in the coronary artery d. To control bleeding in the coronary vessels

c. To dissolve the clot in the coronary artery (Thrombolytic drugs lyse, or dissolve, thrombi. They are not used to prevent further clot formation or to control bleeding. As a result of dissolving of the thrombi, chest pain may be relieved, but that is not the primary purpose of thrombolytic therapy.)

When teaching a patient who has a new prescription for transdermal nitroglycerin patches, the nurse tells the patient that these patches are most appropriately used for which situation? a. To prevent low blood pressure b. To relieve shortness of breath c. To prevent the occurrence of angina d. To keep the heart rate from rising too high during exercise

c. To prevent the occurrence of angina (Transdermal dosage formulations of nitroglycerin are used for the long-term prophylactic management (prevention) of angina pectoris. Transdermal nitroglycerin patches are not appropriate for the relief of shortness of breath, to prevent palpitations, or to control the heart rate during exercise.)

A client has been treated for a deep vein thrombus and today presents to the clinic with petechiae. Laboratory results show a platelet count of 42,000/mm3. The nurse reviews the client's medication list to determine if the client is taking which drug? a. Enoxaparin (Lovenox) b. Salicylates (aspirin) c. Unfractionated heparin d. Warfarin (Coumadin)

c. Unfractionated heparin (This client has manifestations of heparin-induced thrombocytopenia. Enoxaparin, salicylates, and warfarin do not cause this condition.)

Of the following, the food item most likely to lead to dumping syndrome is a. lean meat. b. butter. c. chocolate cookies. d. whole wheat toast.

c. chocolate cookies. (The complex of symptoms in dumping syndrome constitutes a shock syndrome that results when a meal containing a large portion of readily soluble carbohydrates rapidly enters, or "dumps" into the small intestine.)

Nutrition therapy for gallbladder disorders includes a. reducing cholesterol intake. b. eliminating gas-forming foods. c. lowering fat intake. d. increasing caloric intake.

c. lowering fat intake. (A low-fat intake may help avoid pain and discomfort because the presence of fat entering the small intestine stimulates the contraction of the gallbladder.)

Which precaution is most important for the nurse to teach an older patient who is starting histamine H₂ blockers for gastroesophageal reflux disease (GERD)? a. "Do not drink caffeine while taking this drug." b. "Elevate the head of your bed by 6 to 10 inches." c. "Take this drug with meals and before going to bed." d. "Avoid driving until you know how this drug affects you."

d. "Avoid driving until you know how this drug affects you." (Older adults are more likely to experience drowsiness and acute confusion when taking these drugs. They should avoid driving or operating dangerous equipment until they know how the drug affects them. Although the drug should be taken with a meal or before bedtime, the safety issue with the confusion and drowsiness has the highest priority. Avoiding caffeine and elevating the head of the bed are helpful for GERD but are not related to drug therapy.)

A nurse teaches a client who is prescribed an insulin pump. Which statement should the nurse include in this client's discharge education? a. "Test your urine daily for ketones." b. "Use only buffered insulin in your pump." c. "Store the insulin in the freezer until you need it." d. "Change the needle every 3 days."

d. "Change the needle every 3 days." (Having the same needle remain in place through the skin for longer than 3 days drastically increases the risk for infection in or through the delivery system. Having an insulin pump does not require the client to test for ketones in the urine. Insulin should not be frozen. Insulin is not buffered.)

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? a. "At my age, I should continue seeing the ophthalmologist as I usually do." b. "I will see the eye doctor when I have a vision problem and yearly after age 40." c. "My vision will change quickly. I should see the ophthalmologist twice a year." d. "Diabetes can cause blindness, so I should see the ophthalmologist yearly."

d. "Diabetes can cause blindness, so I should see the ophthalmologist yearly." (Diabetic retinopathy is a leading cause of blindness in North America. All clients with diabetes, regardless of age, should be examined by an ophthalmologist (rather than an optometrist or optician) at diagnosis and at least yearly thereafter.)

During drug therapy with a tetracycline antibiotic, a patient complains of some nausea and decreased appetite. Which statement is the nurse's best advice to the patient? a. "Take it with cheese and crackers or yogurt." b. "Take each dose with a glass of milk." c. "Take an antacid with each dose as needed." d. "Drink a full glass of water with each dose."

d. "Drink a full glass of water with each dose." (Oral doses should be given with at least 8 ounces of fluids and food to minimize gastrointestinal upset; however, antacids and dairy products will bind with the tetracycline and make it inactive.)

After teaching a client who has diabetes mellitus and proliferative 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? a. "I have so many complications; exercising is not recommended." b. "I will exercise more frequently because I have so many complications." c. "I used to run for exercise; I will start training for a marathon." d. "I should look into swimming or water aerobics to get my exercise."

d. "I should look into swimming or water aerobics to get my exercise." (Exercise is not contraindicated for this client, although modifications based on existing pathology are necessary to prevent further injury. Swimming or water aerobics will give the client exercise without the worry of having the correct shoes or developing a foot injury. The client should not exercise too vigorously.)

After teaching a client with type 2 diabetes mellitus who is prescribed nateglinide (Starlix), the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the prescribed therapy? a. "I'll take this medicine during each of my meals." b. "I must take this medicine in the morning when I wake." c. "I will take this medicine before I go to bed." d. "I will take this medicine immediately before I eat."

d. "I will take this medicine immediately before I eat." (Nateglinide is an insulin secretagogue that is designed to increase meal-related insulin secretion. It should be taken immediately before each meal. The medication should not be taken without eating as it will decrease the client's blood glucose levels. The medication should be taken before meals instead of during meals.)

A patient has been taking a beta blocker for 4 weeks as part of his antianginal therapy. He also has type II diabetes and hyperthyroidism. When discussing possible adverse effects, the nurse will include which information? a. "Watch for unusual weight loss." b. "Monitor your pulse for increased heart rate." c. "Use the hot tub and sauna at the gym as long as time is limited to 15 minutes." d. "Monitor your blood glucose levels for possible hypoglycemia or hyperglycemia."

d. "Monitor your blood glucose levels for possible hypoglycemia or hyperglycemia." (Beta blockers can cause both hypoglycemia and hyperglycemia. They may also cause weight gain if heart failure is developing, and decreased pulse rate. The use of hot tubs and saunas is not recommended because of the possibility of hypotensive episodes.)

An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice clinic nurse. What statement by the client may indicate a barrier to proper foot care? a. "I nearly always wear comfy sweatpants and house shoes." b. "I'm glad I get energy assistance so my house isn't so cold." c. "My daughter makes sure I have plenty of lotion for my feet." d. "My hands shake when I try to do things requiring coordination."

d. "My hands shake when I try to do things requiring coordination." (Clients with PVD need to pay special attention to their feet. Toenails need to be kept short and cut straight across. The client whose hands shake may cause injury when trimming toenails. The nurse should refer this client to a podiatrist. Comfy sweatpants and house shoes are generally loose and not restrictive, which is important for clients with PVD. Keeping the house at a comfortable temperature makes it less likely the client will use alternative heat sources, such as heating pads, to stay warm. The client should keep the feet moist and soft with lotion.)

A nurse cares for a client who has type 1 diabetes mellitus. The client asks, "Is it okay for me to have an occasional glass of wine?" How should the nurse respond? a. "Drinking any wine or alcohol will increase your insulin requirements." b. "Because of poor kidney function, people with diabetes should avoid alcohol." c. "You should not drink alcohol because it will make you hungry and overeat." d. "One glass of wine is okay with a meal and is counted as two fat exchanges."

d. "One glass of wine is okay with a meal and is counted as two fat exchanges." (Under normal circumstances, blood glucose levels will not be affected by moderate use of alcohol when diabetes is well controlled. Because alcohol can induce hypoglycemia, it should be ingested with or shortly after a meal. One alcoholic beverage is substituted for two fat exchanges when caloric intake is calculated. Kidney function is not impacted by alcohol intake. Alcohol is not associated with increased hunger or overeating.)

An older adult has been transferred to the postoperative inpatient unit after surgery. The family is concerned that the client is not waking up quickly and states "She needs to get back to her old self!" What response by the nurse is best? a. "Everyone comes out of surgery differently." b. "Let's just give her some more time, okay?" c. "She may have had a stroke during surgery." d. "Sometimes older people take longer to wake up."

d. "Sometimes older people take longer to wake up." (Due to age-related changes, it may take longer for an older adult to metabolize anesthetic agents and pain medications, making it appear that they are taking too long to wake up and return to their normal baseline cognitive status. The nurse should educate the family on this possibility. While everyone does react differently, this does not give the family any objective information. Saying "Let's just give her more time, okay?" sounds patronizing and again does not provide information. While an intraoperative stroke is a possibility, the nurse should concentrate on the more common occurrence of older clients taking longer to fully arouse and awake.)

A nurse teaches a client with type 1 diabetes mellitus. Which statement should the nurse include in this client's teaching to decrease the client's insulin needs? a. "Limit your fluid intake to 2 liters a day." b. "Animal organ meat is high in insulin." c. "Limit your carbohydrate intake to 80 grams a day." d. "Walk at a moderate pace for 1 mile daily."

d. "Walk at a moderate pace for 1 mile daily." (Moderate exercise such as walking helps regulate blood glucose levels on a daily basis and results in lowered insulin requirements for clients with type 1 diabetes mellitus. Restricting fluids and eating organ meats will not reduce insulin needs. People with diabetes need at least 130 grams of carbohydrates each day.)

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 should the nurse respond? a. "I can give your injections to you while you are here in the hospital." b. "Everyone gets used to giving themselves injections. It really does not hurt." c. "Your disease will not be managed properly if you refuse to administer the shots." d. "Tell me what it is about the injections that are concerning you."

d. "Tell me what it is about the injections that are concerning you." (Devote as much teaching time as possible to insulin injection and blood glucose monitoring. Clients with newly diagnosed diabetes are often fearful of giving themselves injections. If the client is worried about giving the injections, it is best to try to find out what specifically is causing the concern, so it can be addressed. Giving the injections for the client does not promote self-care ability. Telling the client that others give themselves injections may cause the client to feel bad. Stating that you don't know another way to manage the disease is dismissive of the client's concerns.)

A patient is taking omeprazole (Prilosec) for the treatment of gastroesophageal reflux disease (GERD). The nurse will include which statement in the teaching plan about this medication? a. "Take this medication once a day after breakfast." b. "You will be on this medication for only 2 weeks for treatment of the reflux disease." c. "The medication may be dissolved in a liquid for better absorption." d. "The entire capsule must be taken whole, not crushed, chewed, or opened."

d. "The entire capsule must be taken whole, not crushed, chewed, or opened." (Omeprazole needs to be taken before meals, and an entire capsule must be taken whole, not crushed, chewed, opened, or dissolved in liquid when treating GERD. This medication is used on a long-term basis to maintain healing.)

A client asks the nurse about drugs for weight loss. What response by the nurse is best? a. "All weight-loss drugs can cause suicidal ideation." b. "No drugs are currently available for weight loss." c. "Only over-the-counter medications are available." d. "There are three drugs currently approved for this."

d. "There are three drugs currently approved for this." (There are three drugs available by prescription for weight loss, including orlistat (Xenical), lorcaserin (Belviq), and phentermine-topiramate (Qsymia). Suicidal thoughts are possible with lorcaserin and phentermine-topiramate. Orlistat is also available in a reduced-dose over-the-counter formulation.)

Ten hours after surgery, a postoperative client reports that the antiembolism stockings and sequential compression devices itch and are too hot. The client asks the nurse to remove them. What response by the nurse is best? a. "Let me call the surgeon to see if you really need them." b. "No, you have to use those for 24 hours after surgery." c. "OK, we can remove them since you are stable now." d. "To prevent blood clots you need them a few more hours."

d. "To prevent blood clots you need them a few more hours." (According to the Surgical Care Improvement Project (SCIP), any prophylactic measures to prevent thromboembolic events during surgery are continued for 24 hours afterward. The nurse should explain this to the client. Calling the surgeon is not warranted. Simply telling the client he or she has to wear the hose and compression devices does not educate the client. The nurse should not remove the devices.)

A nurse teaches a client with diabetes mellitus who is experiencing numbness and reduced sensation. Which statement should the nurse include in this client's teaching to prevent injury? a. "Examine your feet using a mirror every day." b. "Rotate your insulin injection sites every week." c. "Check your blood glucose level before each meal." d. "Use a bath thermometer to test the water temperature."

d. "Use a bath thermometer to test the water temperature." (Clients with diminished sensory perception can easily experience a burn injury when bathwater is too hot. Instead of checking the temperature of the water by feeling it, they should use a thermometer. Examining the feet daily does not prevent injury, although daily foot examinations are important to find problems so they can be addressed. Rotating insulin and checking blood glucose levels will not prevent injury.)

A nurse is preparing a client for discharge after surgery. The client needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important? a. "Be sure you keep all your postoperative appointments." b. "Call your surgeon if you have any questions at home." c. "Eat a diet high in protein, iron, zinc, and vitamin C." d. "Wash your hands before touching the drain or dressing."

d. "Wash your hands before touching the drain or dressing." (All options are appropriate for the client being discharged after surgery. However, for this client who is changing a dressing and managing a drain, infection control is the priority. The nurse should instruct the client to wash hands often, including before and after touching the dressing or drain.)

A nurse assesses clients who are at risk for diabetes mellitus. Which client is at greatest risk? a. A 29-year-old Caucasian b. A 32-year-old African-American c. A 44-year-old Asian d. A 48-year-old American Indian

d. A 48-year-old American Indian (Diabetes is a particular problem among African Americans, Hispanics, and American Indians. The incidence of diabetes increases in all races and ethnic groups with age. Being both an American Indian and middle-aged places this client at highest risk.)

A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. Which action should the nurse take? a. Administration of oxygen via face mask b. Intravenous administration of 10% glucose c. Implementation of seizure precautions d. Administration of intravenous insulin

d. Administration of intravenous insulin (The rapid, deep respiratory efforts of Kussmaul respirations are the body's attempt to reduce the acids produced by using fat rather than glucose for fuel. Only the administration of insulin will reduce this type of respiration by assisting glucose to move into cells and to be used for fuel instead of fat. The client who is in ketoacidosis may not experience any respiratory impairment and therefore does not need additional oxygen. Giving the client glucose would be contraindicated. The client does not require seizure precautions.)

A nurse assesses a client who reports waking up feeling very tired, even after 8 hours of good sleep. Which action should the nurse take first? a. Contact the provider for a prescription for sleep medication. b. Tell the client not to drink beverages with caffeine before bed. c. Educate the client to sleep upright in a reclining chair. d. Ask the client if he or she has ever been evaluated for sleep apnea.

d. Ask the client if he or she has ever been evaluated for sleep apnea. (Clients are usually unaware that they have sleep apnea, but it should be suspected in people who have persistent daytime sleepiness and report waking up tired. Causes of the problem should be assessed before the client is offered suggestions for treatment.)

The nurse is reviewing new postoperative orders and notes that the order reads, "Give hydroxyzine (Vistaril) 50 mg IV PRN nausea or vomiting." The patient is complaining of slight nausea. Which action by the nurse is correct at this time? a. Hold the dose until the patient complains of severe nausea. b. Give the dose orally instead of intravenously. c. Give the patient the IV dose of hydroxyzine as ordered. d. Call the prescriber to question the route that is ordered.

d. Call the prescriber to question the route that is ordered. (The nurse needs to question the route. Hydroxyzine (Vistaril) is an antihistamine-class antiemetic that is only to be given either by oral or intramuscular routes. It may be easy to make the mistake of giving hydroxyzine intravenously because many other antiemetics are given by that route. It is important to note that intravenous, intra-arterial, or subcutaneous administration of hydroxyzine may result in significant tissue damage, thrombosis, and gangrene. The nurse cannot change the route of an ordered medication without a prescriber's order. Antiemetic drugs are best given before the patient's nausea become severe.)

The nurse is reviewing new medication orders for a patient who has an epidural catheter for pain relief. One of the orders is for enoxaparin (Lovenox), a low-molecular-weight heparin (LMWH). What is the nurse's priority action? a. Give the LMWH as ordered. b. Double-check the LMWH order with another nurse, and then administer as ordered. c. Stop the epidural pain medication, and then administer the LMWH. d. Contact the prescriber because the LMWH cannot be given if the patient has an epidural catheter.

d. Contact the prescriber because the LMWH cannot be given if the patient has an epidural catheter. (LMWHs are contraindicated in patients with an indwelling epidural catheter; they can be given 2 hours after the epidural is removed. This is very important to remember, because giving an LMWH with an epidural has been associated with epidural hematoma.)

A patient states that his/her legs have pain with walking that decreases with rest. The nurse observes absence of hair on the patient's lower leg and the patient has a thready posterior tibial pulse. How would the nurse position the patient's legs? a. Elevated b. Crossed at the knee c. Slightly bent with a pillow under the knees d. Dependent position

d. Dependent position (A patient with arterial insufficiency is taught to position their legs in a dependent position to use gravity to help perfuse the tissues. Crossing legs at the knee may interfere with blood flow. Slightly bent legs do not enhance blood flow.)

A woman who is planning to become pregnant should ensure that she receives adequate levels of which supplement to reduce the risk for fetal neural tube defects? a. Vitamin B12 b. Vitamin D c. Iron d. Folic acid

d. Folic acid (It is recommended that administration of folic acid be begun at least 1 month before pregnancy and continue through early pregnancy to reduce the risk for fetal neural tube defects.)

A home health nurse is assigned to follow-up on a patient recently diagnosed with gastroesophageal reflux disease (GERD). Which primary symptom should the nurse take into consideration when updating the nursing interventions on this patient's care plan? a. Nausea b. Vomiting c. Anorexia d. Heartburn

d. Heartburn (The onset of GERD symptoms may be sudden or gradual. Patients typically report a painful burning sensation that moves up and down, commonly occurs after meals, and is relieved by antacids. Acid regurgitation, intermittent dysphagia, and belching are also common.)

A patient has been prescribed warfarin (Coumadin) in addition to a heparin infusion. The patient asks the nurse why he has to be on two medications. The nurse's response is based on which rationale? a. The oral and injection forms work synergistically. b. The combination of heparin and an oral anticoagulant results in fewer adverse effects than heparin used alone. c. Oral anticoagulants are used to reach an adequate level of anticoagulation when heparin alone is unable to do so. d. Heparin is used to start anticoagulation so as to allow time for the blood levels of warfarin to reach adequate levels.

d. Heparin is used to start anticoagulation so as to allow time for the blood levels of warfarin to reach adequate levels. (This overlap therapy is required in patients who have been receiving heparin for anticoagulation and are to be switched to warfarin so that prevention of clotting is continuous. This overlapping is done purposefully to allow time for the blood levels of warfarin to rise, so that when the heparin is eventually discontinued, therapeutic anticoagulation levels of warfarin will have been achieved. Recommendations are to continue overlap therapy of the heparin and warfarin for at least 5 days; the heparin is stopped after day 5 when the international normalized ratio (INR) is above 2.)

A patient with coronary artery disease asks the nurse about the "good cholesterol" laboratory values. The nurse knows that "good cholesterol" refers to which lipids? a. Triglycerides b. Low-density lipoproteins (LDLs) c. Very-low-density lipoproteins (VLDLs) d. High-density lipoproteins (HDLs)

d. High-density lipoproteins (HDLs) (HDLs are responsible for the "recycling" of cholesterol. HDLs are sometimes referred to as the "good" lipid (or good cholesterol) because they are believed to be cardioprotective. LDLs are known as the "bad" cholesterol.)

The nurse is conducting a class about antilipemic drugs. The antilipemic drug ezetimibe (Zetia) works by which mechanism? a. Inhibiting HMG-CoA reductase b. Preventing resorption of bile acids from the small intestines c. Activating lipase, which breaks down cholesterol d. Inhibiting cholesterol absorption in the small intestine

d. Inhibiting cholesterol absorption in the small intestine (Ezetimibe selectively inhibits absorption in the small intestine of cholesterol and related sterols. The other options are incorrect.)

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. Which action should the nurse take? a. Apply ice to the site to reduce inflammation. b. Consult the provider for a new administration route. c. Assess the client for other signs of cellulitis. d. Instruct the client to rotate sites for insulin injection.

d. Instruct the client to rotate sites for insulin injection. (The client's tissue has been damaged from continuous use of the same site. The client should be educated to rotate sites. The damaged tissue is not caused by cellulitis or any type infection, and applying ice may cause more damage to the tissue. Insulin can only be administered subcutaneously and intravenously. It would not be appropriate or practical to change the administration route.)

A patient is receiving thrombolytic therapy, and the nurse monitors the patient for adverse effects. What is the most common undesirable effect of thrombolytic therapy? a. Dysrhythmias b. Nausea and vomiting c. Anaphylactic reactions d. Internal and superficial bleeding

d. Internal and superficial bleeding (Bleeding, both internal and superficial, as well as intracranial, is the most common undesirable effect of thrombolytic therapy. The other options list possible adverse effects of thrombolytic drugs, but they are not the most common effects.)

A patient with the diagnosis of Clostridium difficile infection asks what has caused the diarrhea. What is the best response by the nurse? a. It is caused by a protozoal infection. b. It is caused by a fecal-oral contamination. c. It is caused by an inflammatory response. d. It is caused by a long-term antibiotic therapy.

d. It is caused by a long-term antibiotic therapy. (Superinfections such as Clostridium difficile infections are caused by long-term antibiotic therapy, which kills all the natural flora of the bowel and causes diarrhea.)

The nurse is reviewing the medication orders for a patient who will be taking an H₂ antagonist. Which drug may have an interaction if taken along with the H₂ antagonist? a. Ibuprofen (Motrin) b. Ranitidine (Zantac) c. Tetracycline (Doryx) d. Ketoconazole (Nizoral)

d. Ketoconazole (Nizoral) (All H₂ receptor antagonists may inhibit the absorption of certain drugs, such as the antifungal ketoconazole, that require an acidic gastrointestinal environment for gastric absorption. The other options are incorrect.)

While a patient is receiving antilipemic therapy, the nurse knows to monitor the patient closely for the development of which problem? a. Neutropenia b. Pulmonary problems c. Vitamin C deficiency d. Liver dysfunction

d. Liver dysfunction (Antilipemic drugs may adversely affect liver function; therefore, liver function studies need to be closely monitored. The other options do not reflect problems that may occur with antilipemic drugs.)

The nurse is teaching a patient who will be taking a proton pump inhibitor as long-term therapy about potential adverse effects. Which statement is correct? a. Proton pump inhibitors can cause diarrhea. b. These drugs can cause nausea and anorexia. c. Proton pump inhibitors cause drowsiness. d. Long-term use of these drugs may contribute to osteoporosis.

d. Long-term use of these drugs may contribute to osteoporosis. (New concerns have arisen over the potential for long-term users of proton pump inhibitors (PPIs) to develop osteoporosis. This is thought to be due to the inhibition of stomach acid, and it is speculated that PPIs speed up bone mineral loss. The other options are incorrect.)

During an admission assessment, the patient tells the nurse that he has been self-treating his heartburn for 1 year with over-the-counter Prilosec OTC (omeprazole, a proton pump inhibitor). The nurse is aware that this self-treatment may have which result? a. No serious consequences b. Prevention of more serious problems, such as an ulcer c. Chronic constipation d. Masked symptoms of serious underlying diseases

d. Masked symptoms of serious underlying diseases (Long-term self-medication with antacids may mask symptoms of serious underlying diseases, such as bleeding ulcer or malignancy. Patients with ongoing symptoms need to undergo regular medical evaluations, because additional medications or other interventions may be needed.)

A nurse reviews the medication list of a client recovering from a computed tomography (CT) scan with IV contrast to rule out small bowel obstruction. Which medication should alert the nurse to contact the provider and withhold the prescribed dose? a. Pioglitazone (Actos) b. Glimepiride (Amaryl) c. Glipizide (Glucotrol) d. Metformin (Glucophage)

d. Metformin (Glucophage) (Glucophage should not be administered when the kidneys are attempting to excrete IV contrast from the body. This combination would place the client at high risk for kidney failure. The nurse should hold the metformin dose and contact the provider. The other medications are safe to administer after receiving IV contrast.)

The nurse is giving intravenous nitroglycerin to a patient who has just been admitted because of an acute myocardial infarction. Which statement is true regarding the administration of the intravenous form of this medication? a. The solution will be slightly colored green or blue. b. The intravenous form is given by bolus injection. c. It can be given in infusions with other medications. d. Non-polyvinylchloride (non-PVC) plastic intravenous bags and tubing must be used.

d. Non-polyvinylchloride (non-PVC) plastic intravenous bags and tubing must be used. (The non-PVC infusion kits are used to avoid absorption and/or uptake of the nitrate by the intravenous tubing and bag and/or decomposition of the nitrate. The medication is given by infusion via an infusion pump and not with other medications. It is not given by bolus injection. If the parenteral solution is discolored blue or green, it should be discarded.)

The nurse is teaching a patient with iron-deficiency anemia about foods to increase iron intake. Which food may enhance the absorption of oral iron forms? a. Milk b. Yogurt c. Antacids d. Orange juice

d. Orange juice (Orange juice contains ascorbic acid, which enhances the absorption of oral iron forms; antacids, milk, and yogurt may interfere with absorption.)

A client has arrived in the postoperative unit. What action by the circulating nurse takes priority? a. Assessing fluid and blood output b. Checking the surgical dressings c. Ensuring the client is warm d. Participating in hand-off report

d. Participating in hand-off report (Hand-offs are a critical time in client care, and poor communication during this time can lead to serious errors. The postoperative nurse and circulating nurse participate in hand-off report as the priority. Assessing fluid losses and dressings can be done together as part of the report. Ensuring the client is warm is a lower priority.)

Which outcome is most necessary for a patient diagnosed with renal calculi? a. Patient states an awareness of signs and symptoms of kidney stones and knows where to find pain relief. b. Patient will measure intake and output so that they will be approximately equal. c. Patient will avoid infections and situations that would increase stress. d. Patient is able to describe measures to prevent recurrence of calculi.

d. Patient is able to describe measures to prevent recurrence of calculi. (Recurrence of renal calculi is common. The patient needs to possess the information necessary to understand the formation of stones to reduce the risk of their recurrence.)

In which order will the nurse take the following actions when caring for a patient who develops watery diarrhea and a fever after prolonged omeprazole (Prilosec) therapy? a. Contact the health care provider. b. Assess blood pressure and heart rate. c. Give the PRN acetaminophen (Tylenol). d. Place the patient on contact precautions.

d. Place the patient on contact precautions. b. Assess blood pressure and heart rate. a. Contact the health care provider. c. Give the PRN acetaminophen (Tylenol). (Proton pump inhibitors including omeprazole (Prilosec) may increase the risk of Clostridium difficile-associated colitis. Because the patient's history and symptoms are consistent with C. difficile infection, the initial action should be initiation of infection control measures to protect other patients. Assessment of blood pressure and pulse is needed to determine whether the patient has symptoms of hypovolemia and/or shock. The health care provider should be notified so that actions such as obtaining stool specimens and antibiotic therapy can be started. Tylenol may be administered, but is the lowest priority of the actions.)

A client on the postoperative nursing unit has a blood pressure of 156/98 mm Hg, pulse 140 beats/min, and respirations of 24 breaths/min. The client denies pain, has normal hemoglobin, hematocrit, and oxygen saturation, and shows no signs of infection. What should the nurse assess next? a. Cognitive status b. Family stress c. Nutrition status d. Psychosocial status

d. Psychosocial status (After ensuring the client's physiologic status is stable, these manifestations should lead the nurse to assess the client's psychosocial status. Anxiety especially can be demonstrated with elevations in vital signs. Cognitive and nutrition status are not related. Family stress is a component of psychosocial status.)

A circulating nurse wishes to provide emotional support to a client who was just transferred to the operating room. What action by the nurse would be best? a. Administer anxiolytics. b. Give the client warm blankets. c. Introduce the surgical staff. d. Remain with the client.

d. Remain with the client. (The nurse can provide emotional support by remaining with the client until anesthesia has been provided. An extremely anxious client may need anxiolytics, but not all clients require this for emotional support. Physical comfort and introductions can also help decrease anxiety.)

What action is often recommended to help reduce tolerance to transdermal nitroglycerin therapy? a. Omit a dose once a week. b. Leave the patch on for 2 days at a time. c. Cut the patch in half for 1 week until the tolerance subsides. d. Remove the patch at bedtime, and then apply a new one in the morning.

d. Remove the patch at bedtime, and then apply a new one in the morning. (To prevent tolerance, remove the transdermal patch at night for 8 hours, and apply a new patch in the morning. Transdermal patches must never be cut or left on for 2 days, and doses must not be omitted.)

A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain? a. Loss of bladder control b. Other medical conditions c. Progression of symptoms d. Time of symptom onset

d. Time of symptom onset (The time limit for initiating fibrinolytic therapy for a stroke is 3 to 4.5 hours, so the exact time of symptom onset is the most important information for this client. The other information is not as critical.)

A nurse receives a report on a client who had a left-sided stroke and has homonymous hemianopsia. What action by the nurse is most appropriate for this client? a. Assess for bladder retention and/or incontinence. b. Listen to the client's lungs after eating or drinking. c. Prop the client's right side up when sitting in a chair. d. Rotate the client's meal tray when the client stops eating.

d. Rotate the client's meal tray when the client stops eating. (This condition is blindness on the same side of both eyes. The client must turn his or her head to see the entire visual field. The client may not see all the food on the tray, so the nurse rotates it so uneaten food is now within the visual field. This condition is not related to bladder function, difficulty swallowing, or lack of trunk control.)

A nurse reviews laboratory results for a client with diabetes mellitus who presents with polyuria, lethargy, and a blood glucose of 560 mg/dL. Which laboratory result should the nurse correlate with the client's polyuria? a. Serum sodium: 163 mEq/L b. Serum creatinine: 1.6 mg/dL c. Presence of urine ketone bodies d. Serum osmolarity: 375 mOsm/kg

d. Serum osmolarity: 375 mOsm/kg (Hyperglycemia causes hyperosmolarity of extracellular fluid. This leads to polyuria from an osmotic diuresis. The client's serum osmolarity is high. The client's sodium would be expected to be high owing to dehydration. Serum creatinine and urine ketone bodies are not related to the polyuria.)

A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which should alert the nurse to intervene immediately? a. Serum chloride level of 98 mmol/L b. Serum calcium level of 8.8 mg/dL c. Serum sodium level of 132 mmol/L d. Serum potassium level of 2.5 mmol/L

d. Serum potassium level of 2.5 mmol/L (Insulin activates the sodium-potassium ATPase pump, increasing the movement of potassium from the extracellular fluid into the intracellular fluid, resulting in hypokalemia. In hyperglycemia, hypokalemia can also result from excessive urine loss of potassium. The chloride level is normal. The calcium and sodium levels are slightly low, but this would not be related to hyperglycemia and insulin administration.)

The nurse is reviewing the medical record of a patient before giving a new order for iron sucrose (Venofer). Which statement regarding the administration of iron sucrose is correct? a. The medication is given with food to reduce gastric distress. b. Iron sucrose is contraindicated if the patient has renal disease. c. A test dose will be administered before the full dose is given. d. The nurse will monitor the patient for hypotension during the infusion.

d. The nurse will monitor the patient for hypotension during the infusion. (Iron sucrose (Venofer) is an injectable iron product indicated for the treatment of iron-deficiency anemia in patients with chronic renal disease. It is also used for patients without kidney disease. Its risk of precipitating anaphylaxis is much less than that of iron dextran, and a test dose is not required. Hypotension is the most common adverse effect and appears to be related to infusion rate. Low-weight elderly patients appear to be at greatest risk for hypotension.)

A patient who started taking orlistat (Xenical) 1 month ago calls the clinic to report some "embarrassing" adverse effects. She tells the nurse that she has had episodes of "not being able to control my bowel movements." Which statement is true about this situation? a. These are expected adverse effects that will eventually diminish. b. The patient will need to stop this drug immediately if these adverse effects are occurring. c. The patient will need to increase her fat intake to prevent these adverse effects. d. The patient will need to restrict fat intake to less than 30% to help reduce these adverse effects.

d. The patient will need to restrict fat intake to less than 30% to help reduce these adverse effects. (Restricting dietary intake of fat to less than 30% of total calories can help reduce some of the GI adverse effects, which include oily spotting, flatulence, and fecal incontinence. The other options are incorrect.)

The nurse is administering folic acid to a patient with a new diagnosis of anemia. Which statement about treatment with folic acid is true? a. Folic acid is used to treat any type of anemia. b. Folic acid is used to treat iron-deficiency anemia. c. Folic acid is used to treat pernicious anemia. d. The specific cause of the anemia needs to be determined before treatment.

d. The specific cause of the anemia needs to be determined before treatment. (Folic acid should not be used to treat anemias until the underlying cause and type of anemia have been identified. Administering folic acid to a patient with pernicious anemia may correct the hematologic changes of anemia, but the symptoms of pernicious anemia (which is due to a vitamin B12 deficiency, not a folic acid deficiency) may be deceptively masked. The other options are incorrect.)

A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical team? a. Allergy to bee and wasp stings b. History of lactose intolerance c. No previous experience with surgery d. Use of multiple herbs and supplements

d. Use of multiple herbs and supplements (Some herbs and supplements can interact with medications, so this information needs to be reported as the priority. An allergy to bee and wasp stings should not affect the client during surgery. Lactose intolerance should also not affect the client during surgery but will need to be noted before a postoperative diet is ordered. Lack of experience with surgery may increase anxiety and may require higher teaching needs, but is not the priority over client safety.)

When a patient with sleep apnea says, "I'm not wearing that silly mask. I look like something out of Star Wars," what should the nurse remind the patient about the function of the mask? a. Increases oxygen intake b. Stimulates regular respirations c. Sounds an alarm when the oxygen concentration drops d. Uses positive pressure to keep the airway open

d. Uses positive pressure to keep the airway open (The sleep apnea mask, through positive pressure, keeps the airway open during sleep.)

When administering heparin subcutaneously, the nurse will follow which procedure? a. Aspirating the syringe before injecting the medication b. Massaging the site after injection c. Applying heat to the injection site d. Using a ½-⅝-inch 25-to 28-gauge needle

d. Using a ½-⅝-inch 25-to 28-gauge needle (A ½-⅝-inch 25- to 28-gauge needle is the correct needle to use for a subcutaneous heparin injection. The other options would encourage hematoma formation at the injection site.)

A client with sickle cell disease (SCD) takes hydroxyurea (Droxia). The client presents to the clinic reporting an increase in fatigue. What laboratory result should the nurse report immediately? a. Hematocrit: 25% b. Hemoglobin: 9.2 mg/dL c. Potassium: 3.2 mEq/L d. White blood cell count: 38,000/mm3

d. White blood cell count: 38,000/mm3 (Although individuals with SCD often have elevated white blood cell (WBC) counts, this extreme elevation could indicate leukemia, a complication of taking hydroxyurea. The nurse should report this finding immediately. Alternatively, it could indicate infection, a serious problem for clients with SCD. Hematocrit and hemoglobin levels are normally low in people with SCD. The potassium level, while slightly low, is not as worrisome as the WBCs.)

Ms. Jones has recently had gastric surgery and 45 minutes after eating her regular diet she feels cramping and full with waves of weakness and dizziness. Ms. Jones is most likely experiencing a. a heart attack. b. a gallbladder attack. c. a pulmonary embolus. d. dumping syndrome.

d. dumping syndrome. (Dumping syndrome is a frequently encountered complication after extensive gastric resection. After the initial recovery from surgery, when the patient begins to feel better and eats a regular diet in greater volume and variety, discomfort may occur 30 to 60 minutes after meals. A cramping and full feeling develops, the pulse becomes rapid, and a wave of weakness, cold sweating, and dizziness may follow.)

Bacterial food poisoning is caused by a. ingestion of toxic bacteria. b. toxins produced by bacteria in the intestines. c. toxins produced by bacteria in the bloodstream. d. ingestion of toxins produced by bacteria in the food before it is eaten.

d. ingestion of toxins produced by bacteria in the food before it is eaten. (Bacterial food poisoning is caused by the ingestion of bacterial toxins that have been produced in the food by the growth of specific kinds of bacteria before the food is eaten.)

The nurse is teaching a patient who has just been prescribed prazosin (Minipres) for hypertension. The nurse immediately notifies the prescriber and questions the order upon discovering that the patient is also taking which drug? a. aspirin b. atenolol (Tenormin) c. chlorothiazide (Diuril) d. sildenafil (Viagra)

d. sildenafil (Viagra) (Sildenafil is a drug for erectile dysfunction and works by dilating blood vessels. When taken with an alpha blocker, sildenafil can cause a very rapid drop in blood pressure to the extent that the patient may fall or pass out.)

Physiologic symptoms of dumping syndrome result from a. the intestinal contents being absorbed too quickly. b. the ingested food remaining in the stomach too long. c. the stomach emptying too quickly into the intestine. d. water being drawn from the blood into the intestine and decreasing the blood volume.

d. water being drawn from the blood into the intestine and decreasing the blood volume. (Dumping syndrome results when a meal containing a large portion of readily soluble carbohydrates rapidly enters, or "dumps," into the small intestine. This rapidly entering food mass is a concentrated solution in relation to the surrounding circulation of blood. To achieve an osmotic balance, water is drawn from the blood into the intestine. This water shift rapidly shrinks the vascular fluid volume. As a result, blood pressure drops and signs of rapid heart action to rebuild the blood volume appear.)

A nurse counsels a client who smokes cigarettes and uses alcohol daily that he should be aware that these substances have been known to cause decreased erectile ability. decreased sperm count. gynecomastia. increased ejaculatory ability.

decreased erectile ability. (Recreational drugs, alcohol, and smoking cause erectile dysfunction. They are not related to the other three problems.)

Metoclopramide (Reglan) is prescribed for a client with GERD. The nurse realizes that teaching about this drug has been effective when the client says "I understand metoclopramide acts as an antacid to reduce gastric acidity." decreases the time food and fluids are in my stomach." has a local anesthetic effect on the esophagus and stomach." helps to promote movement in the esophagus."

decreases the time food and fluids are in my stomach." (Metoclopramide may be prescribed because it increases LES pressure by stimulating the smooth muscle of the gastrointestinal tract and increasing the rate of gastric emptying. It has no effect on gastric acidity, no anesthetic effects, and does not work in the esophagus.)

The recovery nurse is caring for a surgical patient in the PACU. The patient's blood pressure is dropping and their heart rate is increasing. The nurse suspects the patient is: overmedicated. experiencing normal adaptation to the postoperative period. allergic to the anesthesia. developing shock.

developing shock. (Decreasing blood pressure and an increased pulse rate in the postoperative patient are significant because they may signify hemorrhage or shock.)

medication: ↓ wt (3) sympathomimetic appetite suppressant contra: hyperthyroid, glaucoma, drug abuse hx, MAOIs ADR: palpitations, restlessness, insomnia, dry mouth, diarrhea, constipation, libido △

diethylpropion HCl phendimetrazone tartrate phentermine HCl

The nurse teaches a 64-year-old woman to prevent the recurrence of renal calculi by using a filter to strain all urine. avoiding dietary sources of calcium. choosing diuretic fluids such as coffee. drinking 2000 to 3000 mL of fluid a day.

drinking 2000 to 3000 mL of fluid a day. (A fluid intake of 2000 to 3000 mL daily is recommended to help flush out minerals before stones can form. Avoidance of calcium is not usually recommended for patients with renal calculi. Coffee tends to increase stone recurrence. There is no need for a patient to strain all urine routinely after a stone has passed, and this will not prevent stones.)

A client is taking a 3-week diving vacation in a foreign country and will be staying at a local hotel known for its native food. The nurse cautions the client that a common traveler's infection is giardiasis, and that the client should be cautious about eating food and drinking beverages prepared in the foreign country. flying on an airplane in close contact with other persons. swimming in the coastal waters of the foreign country. taking the necessary inoculations required to travel.

eating food and drinking beverages prepared in the foreign country. (Giardiasis results from a Giardia organism that attacks the gastrointestinal system. It is contracted from ingesting contaminated food and water in areas where sanitation is suspect.)

A client has frequent bouts of laryngitis. When assessing the client the nurse should specifically ask questions regarding the presence of a family history of idiopathic hoarseness. frequent upper respiratory tract infections. gastroesophageal reflux disorder. a history of stomach cancer.

gastroesophageal reflux disorder. (In GERD, the cardiac sphincter relaxes, allowing gastric acid to enter the esophagus. The secretions may be allowed to enter the larynx, causing chemical irritation. Chronic irritation can lead to bouts of laryngitis. The other three options are not related.)

A patient receiving narcotic analgesics for chronic pain can minimize the GI side effects by: eating foods high in lactobacilli. taking Lomotil with each dose. taking the medication on an empty stomach. increasing fluid and fiber in the diet.

increasing fluid and fiber in the diet. (Narcotic analgesics decrease intestinal motility, leading to constipation. Increasing fluid and fiber in the diet can prevent constipation.)

A client admitted for evaluation of gastroesophageal reflux disease (GERD) begins to complain of severe "heartburn" in the chest that radiates to the jaw. The client asks for the nitroglycerin (NTG) tablets brought in from home. The nurse realizes that the clinical manifestations demonstrated by the client are classic manifestations of a myocardial infarction, and the physician should be paged immediately. greatly influenced by fear related to the location of the pain, and the use of NTG should be discouraged. indications that a thorough pain assessment should be done to determine the etiology of the pain, and the NTG should be given at once. specifically associated with GERD and not myocardial infarction, but the NTG should be allowed if the client wants to use it.

indications that a thorough pain assessment should be done to determine the etiology of the pain, and the NTG should be given at once. (Responses to pain-relieving measures (e.g., NTG) help to differentiate between esophagitis and problems of cardiac origin (e.g., angina pectoris). If the nitroglycerin does relieve the pain, the physician should be notified because the patient indeed may be having a cardiac event.)

A 52-year-old man tells the nurse that he decided to seek treatment for erectile dysfunction (ED) because his wife "is losing patience with the situation." The most appropriate nursing diagnosis for the patient is situational low self-esteem related to effects of ED. ineffective role performance related to effects of ED. anxiety related to inability to have sexual intercourse. ineffective sexuality patterns related to infrequent intercourse.

ineffective role performance related to effects of ED. (The patient's statement indicates that the relationship with his wife is his primary concern. Although anxiety, low self-esteem, and ineffective sexuality patterns may also be concerns, the patient information suggests that addressing the role performance problem will lead to the best outcome for this patient.)

medication: ↓ wt sympathomimetic, anticonvulsant (PO) appetite suppressant ADR: tachycardia, paresthesias, insomnia, dizziness, dry mouth, constipation, SI monitor for SI

phentermine/topiramate (qsymia)

medication: ↓ wt antidiabetic (IM) activates appetite regulation contra: insulin use ADR: thyroid carcinoma, ↓ BG, renal impairment, SI, acute pancreatitis

liraglutide (saxenda)

medication: ↓ wt anorexigenic (PO) appetite suppressant, creates sense of fullness ADR: h/a, dizziness, dry mouth, constipation monitor for SI, serotonin syndrome, LOC △

lorcaserin (belviq)

A patient who has severe nausea and vomiting following a case of food poisoning comes to the urgent care center. When reviewing his medication history, the nurse notes that he has an allergy to procaine. The nurse would question an order for which antiemetic drug if ordered for this patient? metoclopramide (Reglan) promethazine (Phenergan) phosphorated carbohydrate solution (Emetrol) palonosetron (Aloxi)

metoclopramide (Reglan) (The use of metoclopramide (Reglan) is contraindicated in patients with a hypersensitivity to procaine or procainamide. There are no known interactions with the drugs listed in the other options.)

medication: ↓ wt lipase inhibitor (PO) triglyceride hydrolysis ADR: loose stool, gas, fecal urgency, cramping, nausea reduce fat intake to <30% of diet to avoid GI problems

orlistat (xenical)

medication: ↓ wt opioid antagonist, antidepressant appetite suppressant contra: uncontrolled htn, seizures ADR: SI, neuropsychiatric reactions

naltrexone HCl/bupropion HCl (contrave)

The nurse will anticipate teaching a patient experiencing frequent heartburn about a barium swallow. radionuclide tests. endoscopy procedures. proton pump inhibitors.

proton pump inhibitors. (Because diagnostic testing for heartburn that is probably caused by gastroesophageal reflux disease (GERD) is expensive and uncomfortable, proton pump inhibitors are frequently used for a short period as the first step in the diagnosis of GERD. The other tests may be used but are not usually the first step in diagnosis.)

A client is being prepared for gastrointestinal surgery and undergoes a bowel preparation. This preoperative procedure is done to decrease expected blood loss during surgery. eliminate any risk of infection. ensure that the bowel is sterile. reduce the number of intestinal bacteria.

reduce the number of intestinal bacteria. (Bowel or intestinal preparations are performed to empty the bowel to minimize the leaking of bowel contents, prevent injury to the colon, and reduce the number of intestinal bacteria.Decreasing expected blood loss and sterilizing the bowel are not the goals of a bowel preparation. While the bowel prep may reduce the number of intestinal bacteria, it will not completely eliminate the risk of infection.)

To prevent recurrence of uric acid renal calculi, the nurse teaches the patient to avoid eating milk and cheese. sardines and liver. legumes and dried fruit. spinach, chocolate, and tea.

sardines and liver. (Organ meats and fish such as sardines increase purine levels and uric acid. Spinach, chocolate, and tomatoes should be avoided in patients who have oxalate stones. Milk, dairy products, legumes, and dried fruits may increase the incidence of calcium-containing stones.)

A patient has a new prescription for tamsulosin (Flomax) as treatment for benign prostatic hyperplasia. The nurse is checking his current medication list and will contact the prescriber regarding a potential interaction if the patient is also taking which drug? levothyroxine (Synthroid) for hypothyroidism sildenafil (Viagra), an erectile dysfunction medication omeprazole (Prilosec), a proton pump inhibitor low-dose aspirin for stroke prevention

sildenafil (Viagra), an erectile dysfunction medication (Drugs that interact with alpha blockers such as tamsulosin include erectile dysfunction drugs; additive hypotensive effects may occur. The other drugs do not interact with tamsulosin.)

medication: ED tx PDE5 inhibitor (PO) ↑ blood flow to corpus cavernosum contra: nitrate use ADR: h/a, dyspepsia, flushing, MYOCARDIAL INFARCTION, SUDDEN DEATH take 30 min-4 hr before sexual activity

sildenafil (viagra)

medication: ED tx PDE5 inhibitor (PO) ↑ blood flow to corpus cavernosum contra: nitrate use ADR: h/a, flushing take at least 30 min before sexual activity

tadalafil (cialis)

During a health interview, the nurse informs a client with GERD that of all the drugs the client is presently taking, the drug that will aggravate the clinical manifestations of GERD is digoxin (Lanoxin). furosemide (Lasix). rofecoxib (Vioxx). theophylline (Theo-Dur).

theophylline (Theo-Dur). (Anticholinergic drugs, calcium-channel blockers, and theophylline should be avoided, if possible, because they delay gastric emptying and can initiate manifestations of GERD.)

medication: ED tx PDE5 inhibitor (PO) ↑ blood flow to corpus cavernosum contra: nitrate use ADR: h/a, flushing, HEARING LOSS, VISION LOSS take 30 min-4 hr before sexual activity

vardenafil (levitra)