ATI focused assessments and pharm

A nurse in an outpatient clinic is teaching a client who has a diabetic foot ulcer about foot care. Which of the following statements by the client indicates an understanding of the teaching?

"I will apply lotion to the dry areas of my feet but not between my toes." Lotion can be used for dry areas of the feet, but the client should avoid applying lotion between the toes, as this area is prone to bacterial growth.

a nurse is teaching a client who has multiple sclerosis and has a new prescription for glatiramer acetate. Which of the following statements indicates that the client understands the teaching?

"I will avoid going to the store when it is crowded."

a nurse is providing discharge teaching to a client who has pulmonary TB and a new prescription for rifampin. which of the following instructions should the nurse include?

"Expect your urine and other secretions to be orange while taking this medication." rationale: The nurse should inform the client that rifampin will turn urine and other secretions orange. Rifampin is hepatotoxic, so the nurse should also instruct the client to notify the provider if manifestations of hepatitis occur, including jaundice, fatigue, or malaise.

A nurse is reviewing postoperative instructions with a client following cataract surgery. Which of the following client statements indicates an understanding of the instructions?

"I should call my doctor if my vision gets worse."

A nurse is teaching a client who has Parkinson's disease and is prescribed carbidopa-levodopa. Which of the following client statements indicates an understanding of the teaching?

"I should expect that this medication can cause me to be drowsy."

A nurse is teaching a client who has type 1 diabetes mellitus about how to prevent complications during illness. Which of the following statements by the client indicates an understanding of the teaching?

"I will call my doctor if my blood sugar is more than 250." The client should call the provider if their blood glucose levels exceed 250 mg/dL during illness.

A nurse is developing a teaching plan for a client who has Ménière's disease. Which of the following instructions should the nurse include?

"Move your head slowly to decrease vertigo."

A nurse is teaching a client who has osteoporosis and has a new prescription for alendronate. Which of the following information should the nurse include in the teaching?

"Remain upright for 30 minutes after taking this medication."

A nurse is providing discharge teaching to a client who has diabetes insipidus and a new prescription for desmopressin nasal spray. Which of the following instructions should the nurse include in the teaching?

"blow your nose gently prior to using the nasal spray." The nurse should instruct the client to blow his nose gently prior to using the spray. This action prevents dilution of the medication with nasal secretions.

A nurse is assessing a client who has a new diagnosis of osteoarthritis. Which of the following findings should the nurse expect?

-Crepitus with joint movement -decreased range of motion of the affected joint -joint pain that resolves with rest

A nurse is providing dietary teaching to a client who has heart failure and is receiving furosemide. Which of the following foods should the nurse recommend as containing the greatest amount of potassium? a. 1/2 cup chopped celery b. 1 cup plain yogurt c. 1 slice whole grain bread d. 1/2 cup cooked tofu

1 cup plain yogurt One cup of plain yogurt contains 380 g of potassium. Therefore, the nurse should recommend this food as containing the greatest amount of potassium.

A nurse is providing dietary teaching to a client who has kidney disease. Which of the following food choices should the nurse include in the teaching as containing the lowest amount of magnesium? a. 1 large hard-boiled egg b. 1 cup bran cereal c. 1/2 cup almond d. 1 cup cooked spinach

1 large hard-boiled eggs One large hard-boiled egg contains 5 mg of magnesium. Therefore, the nurse should recommend this food as containing the lowest amount of magnesium.Cereal has 112 mg. Almonds 193 mg and spinach 157 mg.

Presence of inspiratory stridor The nurse should report inspiratory stridor to the provider because it is a manifestation of tracheal edema and requires intervention.

A nurse in a PACU is assessing a client who is postoperative. Which of the following findings should the nurse report to the provider?

"I can expect to feel sleepy for several hours after the procedure." The nurse should instruct the client to expect to feel drowsy for several hours following moderate sedation and to avoid any activities which require concentration.

A nurse is providing teaching for a client who is scheduled to undergo moderate sedation for a bronchoscopy. Which of the following client statements indicates an understanding of the teaching?

A client who is postoperative following a thoractomy and has a chest tube with 150 mL of bright-red blood in the collection chamber from the past 1 hr. When using the airway, breathing, circulation approach to client care, the first client the nurse should assess is the client who has 150 mL of blood in the collection chamber because this finding is above the expected reference range and can be an indication of hemorrhage.

A nurse is receiving evening shift report on four clients who returned from the PACU that morning. Which of the following clients should the nurse assess first?

Potassium 2.8 mEq/L The nurse should identify that the client's potassium level is below the expected reference range of 3.5 to 5 mEq/L, which places the client at risk for cardiac dysrhythmias. Therefore, the nurse should report this finding to the provider. Sodium 140 mEq/L The nurse should identify that the client's sodium level is within the expected reference range of 136 to 145 mEq/L. INR 1.5 The nurse should identify that the client's INR is within the expected reference range of 0.7 to 1.8. BUN 12 mg/dL The nurse should identify that the client's BUN level is within the expected reference range of 10 to 20 mg/dL.

A nurse is reviewing the medical record for a client who has a prescription for general anesthesia prior to surgery. Which of the following findings should the nurse report to the provider? BUN 12 mg/dL INR 1.5 Sodium 140 mEq/L Potassium 2.8 mEq/L

A nurse is providing teaching to a group of clients regarding skin cancer prevention. Which of the following risk factors should the nurse include in the teaching? A. Light skin pigmentation B. Psoriasis C. History of frostbite D. Immunodeficiency disorder

A. Light skin pigmentation The nurse should inform the clients that light skin pigmentation is a risk factor for the development of skin cancer

A nurse is caring for a client who is receiving furosemide daily. During the morning assessment, the client tells the nurse that he is "feeling weak in the legs." Which of the following actions should the nurse take first? a. Monitor the client's bowel sounds. b. Review the client's daily laboratory results. c. Auscultate the client's lungs. d. Palpate the client's peripheral pulses.

Auscultate the client's lungs Using the airway, breathing, circulation approach to client care, the first action the nurse should take is to auscultate the client's lungs to assess for respiratory changes due to weakness of the respiratory muscles.

A nurse is reviewing the laboratory report for a client who has hodgkin's lymphoma. Which of the following findings should the nurse expect? A. overgrowth of B-lymphocyte plasma cells B. Reed-Sternberg cells C. Epstein-Barr virus D. Overproduction of blast phase cells

B. Reed sternberg cells The nurse should expect to find Reed-Sternberg cells, which are cancer cells specific to a client who has Hodgkin's lymphoma, in the client's lymph nodes.

A nurse is performing a breast examination on a female client who is pregnant. Which of the following findings should the nurse report to the provider? A. Slight asymmetrical breast size B. Breast tissue with an orange-peel appearance C. Nipple inversion of one breast since puberty D. Elevated Montgomery's glands

B. Breast tissue with an orange-peel appearance The nurse should report an orange-peel appearance of the client's skin because this can indicate a blockage of lymph channels which is a manifestation of advanced breast cancer

A nurse is providing teaching to a client who is scheduled for a papanicolaou (pap) test. The nurse should inform the client that the Pap test is used to screen for which of the following? A. uterine cancer B. cervical cancer C. ovarian cysts D.fibroids

B. Cervical cancer the nurse should inform the client that a pap test is used to screen for cervical cancer

A nurse is assessing a client who has systemic lupus erythematosus. which of the following findings should the nurse expect? select all that apply A. subcutaneous nodules B. Decreased urine output C. Renal calculi D. Butterfly rash E. Joint inflammation

B. Decreased urine output D. Butterfly rash is correct E. Joint inflammation

A nurse in an emergency department is assessing a newly admitted client. Which of the following actions places the client at increased risk for contracting hepatitis B? A. residing in an institutional setting B. Engaging in unprotected sexual intercourse C. Working with hazardous chemical waste materials D. Traveling to a foreign country

B. Engaging in unprotected sexual intercourse A client who engages in unprotected sexual intercourse is at increased risk because hepatitis B is transmitted by sexual contact.

a nurse is providing discharge teaching to a client who has HIV. Which of the following statements by the client indicates an understanding of the teaching? A. I will clean the bathroom surfaces with full strength bleach B. I should discard open beverages that have been unrefrigerated for 1 hr C. I should wash laundry that is soiled with a body fluid in cool water D. I will work in the garden for exercise

B. I should discard open beverages that have been unrefrigerated for 1 hr The nurse should instruct the client to discard beverages that have been unrefrigerated for 1 hr. Bacteria can grow in open, unrefrigerated beverages, which places the client at risk for infection.

A nurse is caring for a client who has viral pneumonia. Which of the following findings should the nurse report to the provider immediately? A. Negative blood culture B. Left shift in WBC differential C. Oxygen saturation 93% D. Crackles heard on auscultation

B. Left shift in WBC differential When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a left shift in the client's WBC differential, which indicates that the pneumonia is of bacterial origin, rather than viral. The left shift can be a manifestation of sepsis, and the nurse should report this finding to the provider.

A nurse is caring for a client who had dehydration and is receiving IV fluids. Which assessing for complications, the nurse should recognize which of the following manifestations as a sign of fluid overload? a. Increased urine specific gravity b. Hypoactive bowel sounds c. Bounding peripheral pulses d. Decreased respiratory rate

Bounding peripheral pulses Fluid overload results in increased vascular volume and places a greater workload on the heart. Thus, an expected finding is bounding peripheral pulses.

A nurse is planning discharge teaching for a client who is receiving chemotherapy and has bone marrow suppression. Which of the following instructions should the nurse plan to include in the teaching? A. Take aspirin for minor aches and pains B. Clean your toothbrush with warm water weekly C. Bathe with an antimicrobial soap twice per day D. Wear clothing that will minimize sun exposure

C. Bathe with an antimicrobial soap twice per day The nurse should instruct the client to bathe twice per day with an antimicrobial soap to decrease their exposure to micro-organisms. A client who has bone marrow suppression is at increased risk for infection

A nurse is providing teaching to a client who has an allergy to peanuts. Which of the following instructions is the priority to include in the teaching? A. Inform other health care professionals of the allergy B. Wear a medical identification tag C. Carry an emergency anaphylaxis kit D. Keep a food diary

C. Carry an emergency anaphylaxis kit the greatest risk to the client is injury or death from an anaphylactic reaction. therefore, the priority instruction for the client is to be prepared for emergency treatment carrying an emergency anaphylaxis kit

A nurse is caring for a client who has an elevated prostate-specific antigen level. The nurse should anticipate that the client will undergo which of the following diagnostic tests? A. palpation of testes B. Human chorionic gonadotropin level C. Digital rectal examination D. Pelvic ultrasound

C. Digital rectal examination The nurse should recognize that a digital rectal examination is used to determine the size and consistency of the prostate, assisting with the differentiation between benign prostatic hypertrophy and prostate cancer

A nurse is caring for a client who is admitted with enlarged lymph nodes and a fever. To confirm a diagnosis of bacterial pharyngitis, the nurse should anticipate which of the following diagnostic tests? A. indirect laryngoscopy B. Chest xray C. Throat culture D. Monospot test

C. Throat culture Nurse should recongnize that a throat culture is used to confirm a diagnosis of bacterial pharyngitis by identifying specific micro-organisms present in the pharynx

A nurse is caring for a client who has HIV. Which of the following laboratory findings should suggest to the nurse that medication therapy is effective? A. WBC count 3500 B. Lymphocyte 1,400 C. Decreased viral load D. Low CD4/CD8 ratio

C. decreased viral load The nurse should recognize that a client who has HIV and is receiving medication therapy should display a decreasing viral protein amount in the blood, indicating a positive response to the medication therapy.

A nurse is assessing a client who has a serum calcium level of 8.1 mg/dL. Which of the following findings is the priority for the nurse to assess? a. Deep-tendon reflexes b. Cardiac rhythm c. Peripheral sensation d. Bowel sounds

Cardiac rhythm When using the airway, breathing, circulation approach to client care, the nurse should determine that assessing the cardiac rhythm is the priority. Calcium levels below the expected reference range can cause ECG changes, bradycardia, or tachycardia.

A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse except? a. Confusion b. Peripheral edema c. Facial flushing d. Hyperreflexia

Confusion A client who has respiratory acidosis will experience confusion from a lack of cerebral perfusion. If acidosis is not reversed, the client's level of consciousness will decrease and coma may occur. Facial flushing and warmth are manifestations of metabolic acidosis. Pale, cyanotic, dry skin is a manifestation of respiratory acidosis as ineffective breathing causes a lack of perfusion to the tissues. Hyporeflexia, not hyperreflexia, is a manifestation of respiratory acidosis. As acidosis increases, hyperkalemia can occur, causing muscle weakness, flaccid paralysis, and hyporeflexia.

a nurse is caring for a client who has a chest tube following a lobectomy. which of the following items should the nurse keep easily accessible for the client? A.) Extra drainage system B.) Suture removal kit C.) Container of sterile water D.) Non adherent pads

Container of sterile water rationale: The nurse should have a container of sterile water in a location that is easily accessible for this client. The nurse should plan to place the open end of the tubing into the sterile water if the tubing becomes disconnected to prevent a pneumothorax.

A nurse is caring for four clients. Which of the following clients is at the greatest risk for pneumonia? A. A school-age child who has a history of asthma B. a young adult client who is living in a college dormitory C. A middle adult client who is using an incentive spirometer following surgery D. An older adult client who has dysphagia

D. An older adult client who has dysphagia An older adult client who has dysphagia is at the greatest risk for pneumonia due to the increased risk for aspiration when eating

A nurse is providing teaching to a client who has rheumatoid arthritis and reports persistent pain. Which of the following responses should the nurse make? A. Take a cool bath in the evening B. Exercise every other day C. Use pillows to support your joints while in bed D. Ask a friend or a family member to help with household chores

D. Ask a friend or a family member to help with household chores The nurse should

A nurse is providing teaching to a client who has Hodkin's lymphoma and is undergoing external radiation treatment. Which of the following instructions should the nurse include? A. Use an antibacterial soap to cleanse the skin B. Wash the ink marking off when showering C. Rub the skin with a towel when drying D. Avoid direct sun exposure to the skin

D. Avoid direct sun exposure to the skin The nurse should instruct the client to avoid sun exposure because the client's skin is sensitive to sunburn due to the external radiation.

A nurse is caring for a client who has non-Hodgkin's lymphoma and is receiving chemotherapy. which of the following is the priority assessment finding? A. Loss of body hair B. Report of anorexia C. Mucositis of the oral cavity D. Erythema at the IV insertion site

D. Erythema at the IV insertion site The greatest risk to the client is injury to the tissue due to extravasation of chemotherapy. Erythema at the IV insertion site can indicate extravasation is occurring, which can lead to infection and tissue loss. This is the priority assessment finding.

A nurse is reviewing the laboratory report of a client who has fluid volume excess. Which of the following laboratory values should the nurse expect? a. Hemoglobin 20 g/dL b. Hematocrit 34% c. BUN 25 mg/dL d. Urine specific gravity 1.050

Hematocrit 34% This hematocrit level is below the expected reference range. A 2+ pitting edema indicates fluid overload, which can cause hemodilution and a decreased hematocrit.

a nurse is caring for a newly admitted client who has emphysema. the nurse should place the client in which of the following positions to promote effective breathing? A.) Lateral position with a pillow at the back and over the chest to support the arm B.) High-Fowler's position with the arms supported on the overbed table C.) Semi-Fowler's position with pillows supporting both arms D.) Supine position with the head of the bed elevated to 15°

High-Fowler's position with the arms supported on the overbed table rationale: The nurse should place the client in a position that allows for greater expansion of the chest, such as sitting upright and leaning slightly forward while supporting both arms with pillows for comfort on the overbed table.

A nurse is assessing a client who has hypomagnesemia. Which of the following findings should the nurse expect? a. Hyperactive deep-tendon reflexes b. Increased bowel sounds c. Drowsiness d. Decreased blood pressure

Hyperactive deep-tendon reflexes Hyperactive deep-tendon reflexes are an expected finding for a client who has hypomagnesemia, along with muscle cramps, numbness, and tingling.

a nurse is caring for a client who's in respiratory distress. which of the following low-flow delivery devices should the nurse use to provide the client w/ highest level of oxygen? A.) Nasal cannula B.) Nonrebreather mask C.) Simple face mask D.) Partial rebreather mask

Nonrebreather mask rationale: The nurse should use a nonrebreather mask for a client who is in respiratory distress to provide the highest oxygen level. A nonrebreather mask is made up of a reservoir bag from which the client obtains the oxygen, a one-way valve to prevent exhaled air from entering the reservoir bag, and exhalation ports with flaps that prevent room air from entering the mask. This device delivers greater than 90% FiO2.

A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His respiratory rate is 36/min and he appears very restless. Which of the following values should the nurse anticipate to be outside the expected reference range if the client is experiencing respiratory alkalosis? a. PaO2 b. PaCO2 c. Sodium d. Bicarbonate

PaCo2 With respiratory alkalosis, the PaCO2 level is decreased.

a nurse in an ED is caring for a client who's experiencing acute respiratory failure. which of the following lab findings should the nurse expect? A.) Arterial pH 7.50 B.) PaCO2 25 mm Hg C.) SaO2 92% D.) PaO2 58 mm Hg

PaO2 58 mm Hg rationale: The nurse should expect the client to have lower partial pressures of oxygen.

A nurse is teaching an assistive personnel (AP) about providing care to a client following a total hip arthroplasty. Which of the following instructions should the nurse include?

Place an abductor pillow between the client's legs when turning the client

A nurse is assessing a client who is using PCA following a thoracotomy. The client is short of breath, appears restless, and has a respiratory rate of 28/min. The client's ABG results are pH 7.52, PoO2 89 mm hg, and HCO3- 24 mEq/L. Which of the following actions should the nurse take? a. Instruct the client to cough forcefully. b. Assist the client with ambulation. c. Provide calming interventions. d. Discontinue the PCA.

Provide calming interventions The client's respiratory rate is above the expected range. Calming the client should decrease the respiratory rate, which will cause the client's carbon dioxide levels to increase. This will help correct the pH imbalance.

A nurse is admitting a client who has status asthmaticus. The client's ABG results are pH 7.32, PaO2 74 mmhg, PaC02 56 mm hg, and HCO3- 26 mEq/L. The nurse should interpret these laboratory values as which of the following imbalances. a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

Respiratory acidosis Status asthmaticus causes inadequate gas exchange, resulting in a low pH and PaO2, an elevated PaCO2, and an HCO3- within the expected reference range. These laboratory values indicate respiratory acidosis.

A nurse is reviewing the medical record of a client who had diabetes mellitus and is recieving regular insulin by continous IV infustion to treat diabetic ketoacidosis. Which of the following findings should the nurse report to the provider? a. Urine output of 30 mL/hr b. Blood glucose of 180 mg/dL c. Serum potassium 3.0 mEq/L d. BUN 18 mg/dL

Serum potassium 3.0 mEq/L This serum potassium level is outside the expected reference range. The nurse should report this finding to the provider.

A nurse is evaluating a client who is receiving IV fluids to treat isotonic dehydration. Which of the following laboratory findings indicates that the fluid therapy has been effective? a. BUN 26 mg/dL b. Serum sodium 138 mEq/L c. Hct 56% d. Urine specific gravity 1.035

Serum sodium 142 mEq/L Isotonic dehydration includes loss of water and electrolytes due to a decrease in oral intake of water and salt. A serum sodium level of 142 mEq/L is within the expected reference range and indicates that the fluid therapy has been effective.BUN is elevated. HCT is elevated and USG is elevated.

A nurse is assessing a client who has a phosphorus level of 2.4 mg/dL. Which of the following findings should the nurse expect? a. Hepatic failure b. Abdominal pain c. Slow peripheral pulses d. Increase in cardiac output

Slow peripheral pulses Hypophosphatemia causes slow peripheral pulses that are difficult to detect and can eventually result in cardiac muscle damage.

A nurse is planning to teaching a client who has epilepsy and a new prescription for phenytoin. Which of the following instructions should the nurse plan to include?

Take medication at a consistent time each day to maintain therapeutic blood levels

a nurse working in an ED is caring for a client following an acute chest trauma. which of the following findings should indicate to the nurse that the client is possibly experiencing a tension pneumothorax? A.) Collapsed neck veins on the affected side B.) Collapsed neck veins on the unaffected side C.) Tracheal deviation to the affected side D.) Tracheal deviation to the unaffected side

Tracheal deviation to the unaffected side rationale: The nurse should recognize that deviation of the trachea to the unaffected side is a possible indicator that the client is experiencing a tension pneumothorax. A tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side.

A nurse is preparing to administer oral potassium for a client who has a potassium level of 5.5 mEq/L. Which of the following actions should the nurse take first? a. Administer a hypertonic solution. b. Repeat the potassium level. c. Withhold the medication. d. Monitor for paresthesia.

Withhold the medication The greatest risk to this client is injury from hyperkalemia. Therefore, the priority action is to withhold the oral potassium and notify the provider.

A nurse is managing the care of a client who is postoperative and has acute adrenal insufficiency. Which of the following actions should the nurse take?

administer IV hydrocortisone sodium Hydrocortisone sodium is necessary to replace the cortisol deficiency that occurs with adrenal insufficiency.

a nurse is caring for a client who's receiving mechanical ventilation when the low-pressure alarm sounds. which of the following situations should the nurse recognize as a possible cause of the alarm? A.) Excess secretions B.) Kinks in the tubing C.) Artificial airway cuff leak D.) Biting on the endotracheal tube

artificial airway cuff leak rationale: An artificial airway cuff leak interferes with oxygenation and causes the low-pressure alarm to sound.

a nurse is assessing a client who has lung cancer. which of the following manifestations should the nurse expect? A.) Blood-tinged sputum B.) Decreased tactile fremitus C.) Resonance with percussion D.) Peripheral edema

blood-tinged sputum rationale: The nurse should expect blood-tinged sputum secondary to bleeding from the tumor.

a nurse is assessing a client who has adrenal insufficiency. Which of the following findings should the nurse expect?

calcium 12.8 mg/dL A client who has adrenal insufficiency will have a calcium level above the expected reference range of 4.5 to 5.6 mg/dL.

A nurse is caring for a client who has viral meningitis. Which of the following actions should the nurse take?

check capillary refill at least every 4 hr

A nurse is caring for a client who is in balanced suspension skeletal traction and reports intermittent muscle spasms. Which of the following actions should the nurse take first?

check the position of the weights and ropes

A nurse is caring for a client who has a basilar skull fracture following a fall from a ladder. Which of the following assessment findings should the nurse report to the provider?

clear drainage from nose

A nurse is performing a pain assessment for a client who is postoperative. Which of the following findings should the nurse use to determine the severity of the client's pain?

client's report of pain on a pain scale

A nurse is planning care for a client following a lumbar puncture. Which of the following actions should the nurse plan to take?

ensure that the client lies flat for up to 12 hr

A home health nurse is assessing a client who requires lifelong hormone replacement therapy for the treatment of hypothyroidism. The client has not been taking the medication regularly. Which of the following findings should the nurse expect?

hypotension Hypotension is an expected finding of hypothyroidism, along with bradypnea, dysrhythmias, cold intolerance, and cool, dry skin.

A nurse is assessing a client who had a right hemispheric stroke. Which of the following neurologic deficits should the nurse expect?

impulsive behavior

A nurse is assessing a client who has diabetes insipidus. The nurse should expect which of the following findings?

increased hematocrit Increased hematocrit is an expected finding of diabetes insipidus due to dehydration.

A nurse is caring for a client who requires nasogastric suctioning. Which of the following set of laboratory results indicates that the client has metabolic alkalosis? a. pH 7.51, PaO2 94 mm Hg, PaCO2 36 mm Hg, HCO3- 31 mEq/L b. pH 7.48, PaO2 89 mm Hg, PaCO2 30 mm Hg, HCO3- 26 mEq/L c. pH 7.31, PaO2 77 mm Hg, PaCO2 52 mm Hg, HCO3- 23 mEq/L d. pH 7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L

pH 7.51, Pa02 94 mm Hg, PaC02 36 mm Hg, HCO3- 31 mEq/L An elevated pH and HCO3- with a PaCO2 within the expected reference range indicates metabolic alkalosis.

a nurse is preparing a client for discharge following a bronchoscopy with the use of moderate sedation. the nurse should identify that which of the following assessments if the priority? A.) presence of gag reflex B.) pain level rating using 0 to 10 scale C.) hydration status D.) appearance of the IV insertion site

presence of gag reflex rationale: The greatest risk to the client is aspiration due to a depressed gag reflex. Therefore, the priority assessment by the nurse is to determine the return of the gag reflex.

A nurse is assessing a client who has rheumatoid arthritis. Which of the following findings should the nurse expect?

ulnar deviation

a nurse is caring for a client who was admitted for treatment of left-sided heart failure with intravenous loop diuretics and digitalis therapy. the client is experiencing weakness and an irregular heart rate. which of the following actions should the nurse take first?

✓ review serum electrolyte values Weakness and irregular heart rate indicate that the client is at the greatest risk for electrolyte imbalance, an adverse effect of loop diuretics. The first action the nurse should take is to review the client's electrolyte values, particularly the potassium level, because the client is at risk for dysrhythmias from hypokalemia.

a nurse is caring for a client who is receiving heparin therapy and develops hematuria. which of the following actions should the nurse take if the client's aPTT is 96 seconds?

✓ stop the heparin infusion The nurse should identify that the client's aPTT is above the critical value and the client is displaying manifestations of bleeding. Therefore, the nurse should discontinue the heparin infusion immediately and notify the provider to reduce the risk of client injury.

A nurse is monitoring a client's ECG monitor and notes the client's rhythm has changed from normal sinus rhythm to supraventricular tachycardia. The nurse should prepare to assist with which of the following interventions?

✓ vagal stimulation The nurse should identify that vagal stimulation might temporarily convert the client's heart rate to normal sinus rhythm. The nurse should have a defibrillator and resuscitation equipment at the client's bedside because vagal stimulation can cause bradydysrhythmias, ventricular dysrhythmias, or asystole.

a nurse is caring for a client who has endocarditis. which of the following findings should the nurse recognize as a potential complication?

✓ valvular disease Valvular disease or damage often occurs as a result of inflammation or infection of the endocardium.

a nurse is providing discharge teaching for a client who has heart failure. the nurse should instruct the client to report which of the following findings immediately to the provider?

✓ weight gain of 0.9 kg (2 lb) in 24 hr When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a weight gain of 0.5 to 0.9 kg (1.1 to 2 lb) in 1 day. This weight gain is an indication of fluid retention resulting from worsening heart failure. The client should report this finding immediately.

A nurse is assessing a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings should the nurse report to the provider?

sodium 110 mEq/L A client who has SIADH retains fluids, which causes dilutional hyponatremia.

a nurse is caring for a client who has a spastic bladder following a spinal cord injury. Which of the following actions should the nurse take to help stimulate micturition?

stroke the client's inner thigh

A nurse in an emergency department is caring for a client who suddenly lost consciousness and fell while at home. The provider determines that the client had an embolic stroke. Which of the following medications should the nurse expect to adminster?

tissue plasminogen activator

a nurse is providing discharge teaching to a client who has a temporary tracheostomy. which of the following statements by the client indicates an understanding of the teaching? A.) "Ringing in the ears is an adverse effect of this medication." B.) "Have your skin test repeated in 4 months to show a positive result." C.) "Expect your urine and other secretions to be orange while taking this medication." D.) "Remember to take this medication with a sip of water just before your first bite of each meal."

"I should remove the old twill ties after the new ties are in place." rationale: As a safety measure, the nurse should teach the client to wait until the new ties are in place to remove the old ties. This practice can prevent accidental decannulation.

A nurse is teaching nutritional strategies to a client who has a low serum calcium level and an allergy to milk. Which of the following statements by the client indicates an understanding of the teaching? a. "I will eat more cheese because I can't drink milk." b. "I need to avoid foods with vitamin D because I am allergic to milk." c. "I will stop taking my calcium supplements if they irritate my stomach."" d. I will add broccoli and kale to my diet."

"I will add broccoli and kale to my diet." The nurse should recommend broccoli and kale, which are good sources of calcium as alternatives to milk products.

A nurse is providing teaching for a client who is at risk for developing respiratory acidosis following surgery. Which of the following statements by the client indicates an understanding of the teaching? a. "I should conserve energy by limiting my physical activity." b. "I will wait until my pain is at least six out of ten before I use the PCA." c. "I will limit my daily fluid intake to two to three glasses." d. "I will use the incentive spirometer every hour."

"I will use the incentive spirometer every hour." Respiratory depression and limited chest expansion are both causes of respiratory acidosis. Using an incentive spirometer will promote adequate chest expansion. The nurse should identify this statement as indicating an understanding of the teaching.

A nurse is teaching a client and her family about the diagnosis and treatment of Alzheimer's disease. Which of the following statements should the nurse identify as an indication that the family understands the teaching?

"The medications that treat Alzheimer's disease can help delay cognitive changes."

Warfarin The nurse should anticipate that the provider will instruct the client to discontinue warfarin, an anticoagulant, because it increases the risk of bleeding during and following surgery.

A nurse is reviewing the medical record of a client who is scheduled for an elective surgery. Which of the following medications should the nurse expect the provider to discontinue prior to surgery to minimize the risk for complications?

"Do not allow visitors to push the PCA button if you are sleeping." The nurse should instruct the client that they should be awake when receiving a dose of the medication and that they are the only authorized user of the PCA pump. Allowing visitors to push the button is a safety risk for the client

A nurse is teaching a client who is in the immediate postoperative period about the use of a PCA pump. Which of the following statements should the nurse include in the teaching?

The scrub tech is wearing a watch under their scrubs. Finger and wrist jewelry are likely contaminated with micro-organisms and bacteria. Therefore, the scrub technologist should remove jewelry before handling sterile objects.

A surgical nurse enters a surgical suite to ensure surgical asepsis is maintained. For which of the following findings should the nurse intervene?

A nurse is teaching a client about the adrenocorticotropic hormone (ACTH) stimulation test. The nurse should explain that the purpose of the test is to assess for which of the following disorders?

Addison's disease The nurse should instruct the client that the ACTH stimulation test is the standard test for Addison's disease. It measures the cortisol response to ACTH. The response is absent or very decreased in clients who have primary adrenal insufficiency.

a nurse is caring for a client who has pulmonary embolism. which of the following interventions is the nurse's priority? A.) Provide a quiet environment B.) Encourage use of incentive spirometer every 1-2 hrs C.) Obtain blood sample for electrolyte study D.) Administer heparin via continuous IV infusion

Administer heparin via continuous IV infusion. rationale: When using the airway, breathing, circulation approach to client care, the nurse should place priority on stabilizing circulation to the lungs by administering heparin to prevent further clot formation. Therefore, this is the priority intervention.

a nurse developing a plan of care for a client who has active TB. which of the following isolation precautions should the nurse include in the plan? A.) Airborne B.) Neutropenic C.) Contact D.) Droplet

Airborne rationale: The nurse should initiate airborne precautions for a client who has tuberculosis because tuberculosis is a respiratory infection that is spread through the air. The client should be placed in a room with negative airflow pressure that is filtered through a high-efficiency particulate air (HEPA) filter. Members of the health care team should not enter the client's room without wearing an N95 respirator mask.

a nurse is planning care for a client who has asthma. which of the following meds should the nurse plan to administer during an acute asthma attack? A.) cromolyn sodium B.) prednisone C.) fluticasone/salmeterol D.) albuterol

Albuterol rationale: The nurse should administer albuterol because it acts quickly to produce bronchodilation during an acute asthma attack.

a nurse in an ED is caring for a client who's experiencing a pulmonary embolism. which of the following actions should the nurse take first? A.) Apply supplemental oxygen. B.) Increase the rate of IV fluids. C.) Administer pain medication. D.) Initiate cardiac monitoring.

Apply supplemental oxygen. rationale: When using the airway, breathing, circulation approach to client care, the greatest risk to the client is severe hypoxemia. Therefore, the first action the nurse should take is to apply supplemental oxygen.

a nurse is caring for a client who's in acute respiratory failure and is receiving mechanical ventilation. which of the following assessments is the best method for the nurse to use to determine the effectiveness of the current treatment regimen? A.) BP B.) Cap refill C.) ABGs D.) HR

Arterial blood gases rationale: When using the airway, breathing, circulation approach to client care, the nurse should place priority on evaluating arterial blood gases to determine serum oxygen saturation and acid-base balance.

A nurse is planning an education program about testicular cancer for a group of male adolescents. which of the following information should the nurse include? A. Testicular cancer is more common in males who are older than 65 B. With early treatment, the survival rate is 50% C. Examine the testicles immediately after showing D. Schedule an annual ultrasound to screen for testicular cancer

C. Examine the testicles immediately after showing The client should perform a testicular self-examination on a monthly basis by examining the testicles after a bath or shower to allow for easier palpatation

A nurse is providing teaching to a client who has systemic lupus erythematosus. Which of the following statements by the client indicates an understanding of the teaching? A.. I should use a sunscreen with a SPF of at least 15 B. Long-term immunosuppressive therapy could cure this disease C. I should wear gloves when it is cold outside D. SLE should not affect my lungs or breathing

C. I should wear gloves when it is cold outside Raynaud's phenomenon commonly accompanies SLE and can cause painful vasoconstriction in the client's fingers when exposed to cold temperatures

A nursing is educating a client who is scheduled for a kidney transplant. Which of the following information about hyperacute rejection should the nurse include in the teaching? A. Hyperacute rejection can occur during the first few weeks after the transplant B. If hyperacute rejection occurs, the kidney can become enlarged C. The organ will need to be removed if hyperacute rejection occurs D. Immunosuppressive therapy is given to reverse hyperacute rejection

C. The organ will need to be removed if hyperacute rejection occurs Removing the transplanted organ is the only treatment for hyperacute rejection, due to the widespread clotting cascade that leads to ischemic necrosis of the transplant kidney

A nurse is planning care for a client who has leukemia and a platelet count of 48,000. Which of the following interventions should the nurse include in the plan? A. Provide the client with a diet that is low in vitamin K B. Place the client on contact precautions C. Administer subcutaneous epoetin alfa D. Test the client's urine and stool for occult blood

D. Test the client's urine and stool for occult blood A client who is thrombocytopenic is at risk for occult bleeding. Therefore, the nurse should test the client's urine and stool for occult blood

A nurse is admitting a client who has hyperthyroidism. When assessing the client, the nurse should expect which of the following findings?

tremors Findings of hyperthyroidism include tremors, diaphoresis, and insomnia.

A nurse is planning on education program for a group of high school teachers who will be taking students on a hike. Which of the following information should the nurse include regarding Lyme Disease? A. If bitten by a tick, you should be tested immediately. B. Ifyou have a tick embedded in your skin, apply a lit match to remove it C. You should wear dark colored clothing to deter ticks from biting D. If you develop pain and stiffness in your joints, you should see your doctor

D. If you develop pain and stiffness in your joints, you should see your doctor The nurse should inform the group that manifestations of stage 1 Lyme disease include influenza-like manifestations, a "bull's-eye" rash, muscle and joint pain, and stiffness. The nurse should instruct the group to report these findings to a provider.

a nurse is caring for a client who's 1 hr postoperative following a thoracentesis. which of the following is the priority assessment finding? A.) Pallor B.) Insertion site pain C.) Persistent cough D.) Temperature 37.3° C (99.1° F)

Persistent cough rationale: When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding is a persistent cough because this can indicate a tension pneumothorax, which is a medical emergency.

A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect? a. Decreased muscle strength b. Decreased gastric motility c. Increased heart rate d. Increased blood pressure

Decreased muscle strength Hyperkalemia can cause muscle weakness. The nurse should monitor the client's muscle strength.

a nurse in a provider's office is assessing a client who has COPD. which of the following findings is the priority for the nurse to report to the provider? A.) Increased anterior-posterior chest diameter B.) Productive cough with green sputum C.) Clubbing of the fingers D.) Pursed-lip breathing with exertion

Productive cough with green sputum rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a productive cough with green sputum. The nurse should report this finding to the provider because it can indicate infection.

a nurse is creating a plan of care for a client who has COPD. which of the following interventions should the nurse include? A.) Schedule respiratory treatments following meals. B.) Have the client sit up in a chair for 2-hr periods three times per day. C.) Provide a diet that is high in calories and protein. D.) Combine activities to allow for longer rest periods between activities.

Provide a diet that is high in calories and protein. rationale: The nurse should provide a client who has COPD with a diet that is high in calories and protein and low in carbohydrates.

A nurse in an emergency department is assessing a client who reports sudden, severe eye pain with blurry vision. The provider determines that the client has primary angle-closure glaucoma. Which of the following medications should the nurse expect to administer?

osmotic diuretics via IV bolus

a nurse is caring for a client who is being treated for heart failure and has a prescription for furosemide. the nurse should plan to monitor for which of the following as an adverse effect of this medication?

✓ lightheadedness Furosemide can cause a substantial drop in blood pressure, resulting in lightheadedness or dizziness.

a nurse is providing health teaching for a group of clients. which of the following clients is at risk for developing peripheral arterial disease?

✓ patient who has diabetes Diabetes mellitus places the client at risk for microvascular damage and progressive peripheral arterial disease.

a nurse is providing discharge teaching for a client who has a prescription for the transdermal nitroglycerin patch. which of the following instructions should the nurse include in the teaching?

✓ place the patch on an area of skin away from skin folds and joints The nurse should instruct the client to apply the patch to an area of intact skin with enough room for the patch to fit smoothly.

a nurse is preparing a client for coronary angiography. the nurse should report which of the following findings to the provider prior to the procedure?

✓ previous allergic reaction to shellfish The contrast medium used for coronary angiography is iodine-based. Clients who have a history of allergic reaction to shellfish often react to iodine and might need a steroid or antihistamine prior to the procedure.

a nurse is providing teaching to a client who has chronic asthma and a new prescription for montelukast. which of the following client statements indicates an understanding of the teaching? A.) "I will monitor my heart rate every day while taking this medication." B.) "I will make sure I have this medication with me at all times." C.) "I will need to carefully rinse my mouth after I take this medication." D.) "I will take this medication every night even if I don't have symptoms."

"I will take this medication every night even if I don't have symptoms." rationale: Montelukast is used for the prophylactic treatment of asthma and is taken on a daily basis in the evening.

Muscle rigidity Muscle rigidity is a manifestation of neuroleptic malignant syndrome, which is a potentially life-threatening adverse effect of metoclopramide. Other manifestations include hyperthermia, blood pressure irregularities, tachycardia, and diaphoresis. The nurse should report this finding to the provider.

A nurse is assessing a client who received a preoperative IV dose of metoclopramide 1 hr ago. For which of the following findings should the nurse notify the provider?

Obtain vital signs to assess for shock The nurse should obtain vital signs to assess the client's current status.

A nurse is caring for a client who had an open transverse colectomy 5 days ago. The nurse enters the client's room and recognizes that the wound has eviscerated. After covering the wound with a sterile, saline soaked dressing, which of the following actions should the nurse take?

Use the sterile technique when performing dressing changes The nurse should change the Penrose drain dressing using the surgical aseptic technique.

A nurse is caring for a client who has a surgical wound with a Penrose drain in place. Which of the following interventions should the nurse plan to perform?

Epinephrine The nurse should plan to administer epinephrine, a vasopressor, to increase the client's heart rate and prevent cardiac arrest.

A nurse is caring for a client who has bradycardia following a surgical procedure using spinal anesthesia. The nurse should plan to administer which of the following medications to the client?

Gastric distension Gastric distention is an indication that the NG tube is not patent. The nurse should check the tubing for kinks, blockages, and loose connections. The nurse should also reposition the client to facilitate drainage and avoid removing or irrigating the tube unless directed to do so by the provider.

A nurse is caring for a client who is 12 hr postoperative from a gastrectomy and has an NG tube set to continuous low suction. Which of the following findings requires intervention by the nurse?

Flumazenil The client's respiratory rate and oxygen saturation level indicate increased sedation caused by a benzodiazepine. The nurse should administer flumazenil, a benzodiazepine agonist, to reverse the sedative effects of the medication.Atropine Atropine- is an anticholinergic that is used to treat cholinesterase inhibitor toxicity. Acetylcysteine- is an antidote that is used to treat acetaminophen toxicity. Protamine sulfate- is administered to treat heparin toxicity.

A nurse is caring for a client who is receiving moderate (conscious) sedation with midazolam. The client's respiratory rate decreases from 16/min to 6/min, and their oxygen saturation decreases from 92% to 85%. Which of the following medications should the nurse administer? A. Atropine B. Acetylcysteine C. Flumazenil D. Protamine sulfate

Determine if the client's faith conflicts with the treatment plan

A nurse is creating a plan of care for a client who is preoperative for a total hip arthroplasty. The client informs the nurse that they practice Judaism and adhere to a kosher diet. Which of the following interventions is the nurse's priority?

Administer dantrolene The nurse should administer dantrolene by IV bolus at 2 to 5 mg/kg to reverse the manifestations for a client who has malignant hyperthermia.

A nurse is monitoring a client who received succinylcholine during a surgical procedure. Which of the following actions should the nurse take if the client develops manifestations of malignant hyperthermia?

Cleanse the drain plug with alcohol after emptying After emptying the drain, the nurse should compress the top and bottom of the device together with one hand, while cleansing the plug with the other. The nurse should check the amount, color, and type of drainage at least every 8 hr. The purpose of a closed-wound drainage system is to provide continuous suction. Therefore, the nurse should not clamp the drain while the client is ambulating. The nurse should secure the drain to the client's gown to prevent dislodgement.

A nurse is planning care for a client who is postoperative and has a closed-wound drainage system in place. Which of the following interventions should the nurse plan to include?

A nurse is assessing a client who has a new diagnosis of Cushing's disease. Which of the following findings should the nurse expect?

Hirsutism Increased hair growth, or hirsutism, is an expected finding of Cushing's disease due to increased androgen production.

a nurse is providing teaching for a client who is 2 days postoperative following a heart transplant. which of the following statements should the nurse include in the teaching?

✓ "you might no longer be able to feel chest pain" Heart transplant clients usually are no longer able to feel chest pain due to the denervation of the heart.

A nurse is caring for a client who is 8 hr postoperative following a coronary artery bypass graft (CABG). Which of the following client findings should the nurse report?

✓ Blood pressure 160/80 The nurse should report an elevated blood pressure following a CABG because increased vascular pressure can cause bleeding at the incision sites.

A nurse is caring for a client who has a retinal detachment. Which of the following findings should the nurse expect?

flashes of bright light

a nurse is reviewing the laboratory results of a client undergoing screening for primary cushing's disease. The nurse should expect an elevation in which of the following laboratory findings?

glucose Blood glucose is elevated in a client who has Cushing's disease.

A nurse is assessing a client who is taking propylthiouracil. the nurse should identify which of the following findings as an indication that the medication has been effective?

increased body weight Propylthiouracil suppresses the production of thyroid hormones and allows for weight gain. However, excessive weight gain could indicate that the dose of propylthiouracil is too high.

A nurse is planning teaching for a client who has type 1 diabetes mellitus. Which of the following instructions should the nurse plan to include?

ingest food with alcohol to reduce alcohol-induced hypoglycemia Alcohol inhibits the liver's production of glucose. Consuming carbohydrates while drinking alcoholic beverages helps prevent hypoglycemia.

A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect?

intention tremors

a nurse is monitoring a client who is 24 hr postoperative after a total thyroidectomy. Which of the following findings should the nurse report to the provider?

laryngeal stridor Laryngeal stridor is a harsh, high-pitched sound with inspiration that indicates respiratory obstruction. The nurse should take immediate action to preserve the client's airway.

A nurse is planning care for a client who has. closed traumatic brain injury from a fall and is receiving mechanical ventilation. Which of the following interventions is the nurses priority?

maintain a PaCO2 of approximately 35 mmHg

A nurse is caring for a client who has advancing amyotrophic lateral sclerosis. Which of the following interventions is the nurse's priority?

monitor pulse oximetry findings

A nurse is caring for a client who has diabetes mellitus and has developed peripheral neuropathy. Which of the following measures should the nurse recommend to prevent injuries to the clients feet?

monitor the temperature of bath water with a thermometer Peripheral neuropathy makes it difficult to determine if bath water is too hot. Therefore, to prevent injury, the client should use a bath thermometer to ensure a water temperature below 43.3° C (110° F).

a nurse is assessing a client who has a history of deep vein thrombosis and is receiving warfarin. the nurse should identify that which of the following findings indicates the medication is effective?

✓ INR 2.0 The nurse should identify that an INR of 2.0 is within the desired reference range of 2.0 to 3.0 for a client who has a deep-vein thrombosis and is receiving warfarin to reduce the risk of new clot formation and a stroke.

a charge nurse is reviewing the care of a client who has a chest tube connected to a water seal drainage system in a place following thoracic surgery w/ newly licensed nurse. which of the following statements by the newly licensed nurse indicates an understanding of when to notify the provider? A.) "I will notify the provider if there is a fluctuation of drainage in the tubing with inspiration." B.) "I will notify the provider if there is continuous bubbling in the water seal chamber." C.) "I will notify the provider if there is drainage of 60 milliliters in the first hour after surgery." D.) "I will notify the provider if there are several small, dark-red blood clots in the tubing."

"I will notify the provider if there is continuous bubbling in the water seal chamber." rationale: Continuous bubbling in the water seal chamber suggests an air leak and requires notification of the provider. The nurse should check the system for external, correctable leaks while waiting for instructions from the provider.

a charge nurse is providing an in-service to a group of staff nurses about endotracheal suctioning. which of the following statements by a staff nurse indicates an understanding of the teaching? A.) "I will use clean technique when suctioning a client's endotracheal tube." B.) "I will use a rotating motion when removing the suction catheter." C.) "I will suction the oropharyngeal cavity prior to suctioning the endotracheal tube." D.) "I will suction a client's endotracheal tube every 2 hours."

"I will use a rotating motion when removing the suction catheter." rationale: The nurse should rotate the suction catheter during withdrawal to remove secretions from the sides of the airway.

a nurse is teaching a client who is scheduled for a vanillylmandelic acid test to screen for pheochromocytoma. Which of the following statements should the nurse include in the teaching?

"Restrict coffee intake 2 to 3 days prior to the test." The client should avoid coffee and tea, even if they are decaffeinated, bananas, chocolate, and vanilla for 2 to 3 days prior to the test.

a nurse is developing a teaching plan for a client who had a thyroidectomy and takes a thyroid hormone replacement. which of the following instructions should the nurse plan to include?

"Take this medication on an empty stomach." To promote proper absorption, the client should take the medication on an empty stomach and not eat or drink anything for 30 to 60 min after.

A nurse is teaching a client about glycosylated hemoglobin (HbA1c) testing. Which of the following client statements indicates an understanding of the teaching?

"This test's result is a good indicator of my average blood glucose levels." HbA1c reflects the client's glucose levels over a 120-day period, which is the life span of RBCs.

A nurse is providing teaching for a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates an understanding of the teaching? a. "If my stockings feel tight, I'll just roll them down for a while." b. "I'll put on my elastic stockings at the first sign of swelling." c. "When I sit down to watch television, I'll be sure to put my feet up." d. "It's okay to cross my legs as long as it's for less than an hour."

"When I sit down to watch television, I'll be sure to put my feet up." Venous insufficiency makes it difficult for blood flow to return to the heart. Elevating the feet will increase the return. The client should elevate them for at least 20 min several times per day.

A nurse is preparing a teaching plan for a client who has diabetes insipidus and requires intranasal desmopressin. Which of the following information should the nurse include?

"report nocturia because it requires a dosage adjustment." The client should take the initial dose of desmopressin in the evening. The provider will increase the dosage until the client no longer has nocturia.

A nurse is planning care for a client who has experienced excessive fluid loss. Which of the following interventions should the nurse include in the plan of care? a. Administer IV fluids to the client evenly over 24 hr. b. Provide the client with a salt substitute. c. Assess the client for pitting edema. d. Encourage the client to rise slowly when standing up. e. Weigh the client every 8 hr.

-Administer IV fluids to the client evenly over 24 hr -Encourage the client to rise slowly when standing up -Weigh the client every 8 hr Administer IV fluids to the client evenly over 24 hr is correct. A client who has excessive fluid loss is typically prescribed IV replacement fluids. Administering IV fluids rapidly over a short period of time places the client at risk for fluid volume overload. Provide the client with a salt substitute is incorrect. There is no reason to limit the client's sodium intake. The client might require electrolyte replacement, depending on the cause of fluid loss. Assess for pitting edema is incorrect. This action is appropriate for a client who has fluid overload. Encourage the client to rise slowly when standing up is correct. This action can prevent injury from falls caused by orthostatic hypotension. Weigh the client every 8 hr is correct. Weighing the client every 8 hr will provide information regarding fluid balance.

A nurse is caring for a client who has a sodium level of 155 mEq/L. Which of the following IV fluids should the nurse anticipate the provider to prescribe? a. Dextrose 5% in 0.9% sodium chloride b. Dextrose 5% in lactated Ringer's c. 3% sodium chloride d. 0.45% sodium chloride

0.45% sodium chloride A sodium level of 155 mEq/L is an indication of hypernatremia. The nurse should anticipate a prescription for a hypotonic solution. The 0.45% sodium chloride is a hypotonic solution used to provide free water and treat cellular dehydration, which promotes waste elimination by the kidneys.Dextrose 5% in 0.9% sodium chloride is a hypertonic solution. The 3% sodium chloride is a hypertonic solution. Lactated Ringer's solution contains sodium and other electrolytes and is not indicated for hypernatremia.

A nurse is admitting a client who takes 40 mg furosemide daily for heart failure and has experienced 3 days of vomiting. The nurse suspects hypokalemia. Which of the following medications should the nurse prepare to administer? a. Sodium polystyrene sulfonate 30 g/day b. 0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr c. Bumetanide 8 mg/day d. 100 mL of dextrose 10% in water with 10 units of insulin

0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr This IV solution will provide adequate fluid and potassium replacement to offset the losses from vomiting. The typical amount of potassium chloride to administer IV is 5 to 10 mEq/hr and not to exceed 20 mEq/hr. The dilution should be 1 mEq to 10 mL of 0.9% sodium chloride.

Infection The nurse should identify that a cool room temperature with humidity between 30% and 60%, along with a proper air exchange and filtering system, reduces the risk of infection for clients during surgery.

A circulating nurse is monitoring the temperature in a surgical suite. The nurse should identify that cool temperatures reduce a client's risk for which of the following potential complications of surgery?

Use the head-tilt, chin-lift method to open the airway The first action the nurse should take when using the airway, breathing, circulation approach to client care is to establish a patent airway by tilting the client's head back and pushing the lower jaw forward.

A client is transferred from the surgical suite to the PACU following oral surgery. While monitoring the client's vital signs, the nurse finds that the client's tongue has become swollen and is obstructing the airway. Which of the following actions should the nurse take first?

a nurse receives prescriptions from the provider for performing nasopharyngeal suctioning on 4 clients. for which of the following clients should the nurse clarify the provider's prescription? A.) pt w/ epistaxis B.) pt w/ amyotrophic lateral sclerosis C.) pt w/ pneumonia D.) pt w/ emphysema

A client who has epistaxis rationale: The nurse should avoid providing nasopharyngeal suctioning for a client who has nasal bleeding because this intervention might cause an increase in bleeding.

a nurse is caring for 4 clients. which of the following clients is at greatest risk for a pulmonary embolism? A.) A client who is 48 hr postoperative following a total hip arthroplasty B.) A client who is 8 hr postoperative following an open surgical appendectomy C.) A client who is 2 hr postoperative following an open reduction external fixation of the right radius D.) A client who is 4 hr postoperative following a laparoscopic cholecystectomy

A client who is 48 hr postoperative following a total hip arthroplasty rationale: The nurse should identify that a client who has undergone a total hip arthroplasty surgery is at greatest risk for a pulmonary embolus because of decreased mobility of the affected extremity and an increased amount of blood clots forming in the veins of the thigh following hip surgery. Deep-vein thromboses are most likely to occur 48 to 72 hr following the arthroplasty. The nurse should intervene to reduce the risk by applying sequential compression devices or antiembolic stockings and by administering anticoagulant medications.

Elevate the client's right extremity (These findings suggest the client has deep-vein thrombosis. The nurse should keep the client's right extremity elevated to promote venous return.) Apply an ice pack to the client's right calf. (Applying an ice pack to the client's right calf can result in injury because it can cause vasoconstriction. The nurse should apply warm, moist packs to the client's right calf.) Gently massage the client's right calf (The nurses should avoid massaging the client's right calf because it could dislodge the thrombus and result in injury.).

A nurse is assessing a client who is 2 days postoperative following a total prostatectomy. The nurse notes that the client's right calf is red, edematous, and warm to the touch. Which of the following actions should the nurse take? Apply an ice pack to the client's right calf. Elevate the client's right extremity. Administer testosterone to the client. Gently massage the client's right calf.

Urine output of 20 mL/hr The nurse should notify the provider if the client's urine output is less than 30 mL/hr. Decreased urine output can indicate hypovolemia and decreased perfusion of the kidneys.

A nurse is assessing a client who is 2 hr postoperative following an appendectomy. Which of the following findings should the nurse report to the provider?

Long-term use of corticosteroids The nurse should identify that the use of corticosteroids inhibits leukocyte response, which increases the client's risk for infection.

A nurse is assessing a client who is preoperative. The nurse should identify that which of the following factors reported by the client increases the risk for a postoperative infection?

Touch Following spinal anesthesia, the first sensation the nurse should expect the client to feel is the sense of touch. Pain 2 Warmth 3 Cold 4

A nurse is assessing a client who is recovering from spinal anesthesia. Which of the following sensations should the nurse expect to return to the client first?

Insert an NG tube The greatest risk to the client is fluid and electrolyte imbalance as a result of accumulated fluid and gas in the gastrointestinal tract. The first action the nurse should take is to insert an NG tube to begin decompression of the bowel.

A nurse is caring for a client who is 2 days postoperative following a cholecystectomy. The client has been vomiting for the past 24 hr and reports a pain level of 8 on a 0 to 10 scale. The nurse notes a hard, distended abdomen and absent bowel sounds. After conferring with the provider, which of the following actions should the nurse take first?

Advise the client to splint the surgical incision when coughing and deep breathing Splinting the incision supports the surgical site and decreases pain during coughing and deep breathing.

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following interventions should the nurse perform to prevent respiratory complications?

Ask the surgeon to speak to the client for clarification. The nurse should notify the surgeon that the client has questions about the procedure. It is the responsibility of the surgeon to explain the risks and benefits of the surgery. Explain the risks and benefits of the surgery to the client. It is not the nurse's responsibility to explain the risks and benefits of the surgery. The nurse should verify that the client signs the consent form prior to transfer to surgery. Reassure the client that the procedure is necessary for recovery. This response dismisses the client's concerns and is an example of false reassurance. Notify the circulating nurse that the client has questions about the procedure. The nurse should verify that the client signs the consent form prior to transfer to surgery. The circulating nurse is not responsible for explaining the risks and benefits of the procedure to the client. This action

A nurse is caring for a client who is preoperative and is asking multiple questions about the risks of the procedure. Which of the following actions should the nurse take? A. Explain the risks and benefits of the surgery to the client. B. Ask the surgeon to speak to the client for clarification. C. Reassure the client that the procedure is necessary for recovery. D. Notify the circulating nurse that the client has questions about the procedure.

"I will eat foods that are high in protein and vitamin C during my recovery." The nurse should instruct the client to increase intake of foods with protein and vitamin C to promote wound healing.

A nurse is providing discharge instructions for a client who is postoperative following abdominal surgery. Which of the following client statements indicates an understanding of the teaching?

"Use a cool compress on your eyes, nose, and face." The nurse should instruct the client to place cool compresses on his face to reduce swelling and ecchymosis.

A nurse is providing discharge teaching for a client who is postoperative following a rhinoplasty using general anesthesia. Which of the following instructions should the nurse include?

"Your surgeon might prescribe an antibiotic before surgery." A client who has a surgical amputation of an extremity is at risk for infection. Therefore, the provider often prescribes a broad-spectrum, prophylactic antibiotic to reduce the risk of infection.

A nurse is providing preoperative teaching for a client who is scheduled to have a below-the-knee amputation. Which of the following instructions should the nurse include?

Provide concise, factual information Providing concise, factual information allows for open communication and gives the nurse the opportunity to address the client's anxiety.

A nurse is providing preoperative teaching to a client who is scheduled for a gastrectomy in 1 week. The client expresses anxiety about the upcoming surgery. Which of the following actions should the nurse take?

"I will be able to shower after the doctor removes the drain." A client who has had a mastectomy with reconstructive surgery can shower after the provider removes the drain.

A nurse is providing preoperative teaching to a client who is scheduled to have a mastectomy with reconstructive surgery. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who reports a skin change. Which of the following findings should the nurse report to the provider? A. an asymmetrical papule that is pigmented B. A patch of silvery-white scales with a red epidermal base C. A collection of irregular, dry papules that are black D. An elevated red lesion that arises from a scar

A. An asymmetrical papule that is pigmented The nurse should identify an asymmetrical papule that is pigmented as an indication of malignant melanoma. The nurse should report the client's skin change to the provider.

A nurse is providing teaching to a client who has rheumatoid arthritis and a new prescription for methotrexate. Which of the following client statements indicates an understanding of the teaching? A. I will avoid being in large crowds while taking this medication B. I should expect symptoms to subside in 1 to 2 weeks after starting this medication C. I will increase my intake of vitamin D while taking this meedication D. I should expect experience constipation while taking this medication

A. I will avoid being in large crowds while taking this medication The nurse should instruct the client to avoid crowds when taking methotrexate. Methotrexate can cause leukopenia due to bone marrow suppression, which can increase the client's risk for infection.

A nurse is providing teaching to a client who takes an oral contraceptive and has a new prescription for amoxicillin. Which of the following statements by the client indicates an understanding of the teaching? A. I will use a backup method of birth control while I am taking this medication B. I should take this medication on an empty stomach C. I should expect to have constipation while taking this medication D. I will keep taking this medication until I feel better

A. I will use a backup method of birth control while I am taking this medication The nurse should inform the client that antibiotics accelerate the elimination of oral contraceptives, making them less effective.

A nurse is assessing a client who has HIV which of the following findings should cause the nurse to suspect that the client's diagnosis has progressed to AIDS? A. small, purple colored skin lesions B. Fever and diarrhea lasting longer than 1 month C. Persistent, generalized lymphandenopathy D. CD4-T cells decreased to 750 cells

A. Small purple colored skin lesions the nurse should identify the presence of small, purple-colored skin lesions as an indication that the client has acquired Kaposi's sarcoma, which is an AIDS-defining illness

A nurse is caring for a client who has neutropenia. Which of the following findings indicates a need for intervention? A. The client's grandchild is visiting and telling the client about the first day of kindergarten B. The client has a grilled ham and cheese sandwich, a banana, and yogurt on their lunch tray C. The client's family brings in a silk flower arrangement D. The client's assistive personnel places paper cups and plastic utensils in the client's room

A. The client's grandchild is visiting and telling the client about the first day of kindergarten The nurse should limit the client's visitors to healthy adults. A visit from a child who is attending school can place the client at risk for infection due to the client's immunocompromised status.

A nurse is reviewing the daily laboratory results for a female client who has acute leukemia. Which of the following values is an expected findings? A. WBC count 21000 B. Hgb 14 C. Hct 40% D. Platelets 170,000

A. WBC count 21000 The nurse should expect a client who has acute leukemia to have an elevated WBC count

A nurse is assessing a client who has a new prescription for clindamycin to treat acute pelvic inflammatory disease. the nurse should report which of the following findings to the provider immediately? A. watery diarrhea B. Vaginitis C. Furry tongue D. Nausea and vomiting

A. Watery diarrhea The greatest risk to this client is pseudomembranous colitis, which is manifested by watery diarrhea. Therefore, the priority finding is diarrhea. The nurse should report this finding to the provider immediately and discontinue the medication.

A nurse is teaching the parent of a child about administration guidelines for the human papilloma virus vaccine. Which of the following information should the nurse include? A. One dose is administered at birth and another is administered at age 5 B. The vaccine does not protect males C. The vaccine protects against chlamydia D. Three doses are administered to adolescents who start the series after age 15

D. Three doses are administered to adolescents who start the series after age 15 The nurse should inform the parent that the HPV vaccine is recommended for children beginning at age 11 or 12 years. Children who receive the first dose before age 15 should receive two doses of the HPV vaccine. Adolescents who receive the first dose after age 15 should receive three doses of the HPV vaccine.

a nurse is assessing a client who's 4 hr postoperative following a total laryngectomy. which of the following findings is the priority for the nurse to report to the provider? A.) Bleeding at the surgical site B.) Decreased oxygen saturation C.) Urinary retention D.) Increased pain level

Decreased oxygen saturation rationale: When using the airway, breathing, circulation approach to client care, the nurse should identify decreased oxygen saturation as the priority finding to address and report to the provider. A client who is postoperative following a total laryngectomy is at higher risk for hypoxia because of airway obstruction.

a nurse is assessing a client who has emphysema. which of the following findings should the nurse report to the provider? A.) Rhonchi on inspiration B.) Elevated temperature C.) Barrel-shaped chest D.) Diminished breath sounds

Elevated temperature rationale: The nurse should report an elevated temperature to the provider because it can indicate a possible respiratory infection. Clients who have emphysema are at risk for the development of pneumonia and other respiratory infections.

While reviewing a client's laboratory results, a nurse notes a serum calcium level of 0.8 mg/dL. Which of the following actions should the nurse take? a. Implement seizure precautions. b. Administer phosphate. c. Initiate diuretic therapy. d. Prepare the client for hemodialysis.

Implement seizure precautions The client is at risk for seizures due to low excitation threshold as a result of the client's decreased calcium level. The nurse should initiate seizure precautions to prevent injury.

A nurse is caring for a client who is experiencing respiratory distress as a result of pulmonary edema. Which of the following actions should the nurse take first? a. Assist with intubation. b. Initiate high-flow oxygen therapy. c. Administer a rapid-acting diuretic. d. Provide cardiac monitoring.

Initiate high-flow oxygen therapy The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to administer high-flow oxygen therapy by face mask at 5 to 6 L/min to keep the client's oxygen saturation above 90%.

a nurse is assessing a client who has acute respiratory distress syndrome (ARDS). which of the following findings should the nurse report to the provider? A.) Decreased bowel sounds B.) Oxygen saturation 92% C.) CO2 24 mEq/L D.) Intercostal retractions

Intercostal retractions rationale: The nurse should report intercostal retractions to the provider because this finding indicates increasing respiratory compromise in a client who has ARDS.

A nurse is assessing a client who has dehydration. Which of the following assessments is the priority? a. Skin turgor b. Urine output c. Weight d. Mental status

Mental status The greatest risk to this client is injury from declining mental status or a fall from worsened dehydration. Therefore, assessing the client's mental status is the priority.

A nurse is teaching a client who is postoperative following a right hip arthroplasty. Which of the following images indicates the position the nurse should teach the client to take when sitting in a chair?

feet flat on the floor

A nurse is planning care for a client who has a serum potassium level of 3.0 mEq/L. The nurse should plan to monitor the client for which of the following findings? a. Hyperactive deep-tendon reflexes b. Orthostatic hypotension c. Rapid, deep respirations d. Strong, bounding pulse

Orthostatic hypotension Hypokalemia can lead to hypotension. The nurse should monitor the client for orthostatic hypotension.

A nurse is caring for a client who requires continuous cardiac monitoring. The nurse identifies a prolonged PR interval and a widened QRS complex. Which of the following laboratory values supports this finding? a. Sodium 152 mEq/L b. Chloride 102 mEq/L c. Magnesium 1.8 mEq/L d. Potassium 6.1 mEq/L

Potassium 6.1 mEq/L Hyperkalemia can cause a prolonged PR interval; a wide QRS complex; flat or absent P waves; and tall, peaked T waves.

A nurse is assessing a client who is receiving hydrochlorothiazide and notes that the client is confused and lethargic. Which of the following laboratory values should the nurse report to the provider? a. Sodium 128 mEq/L b. Potassium 4.8 mEq/L c. Calcium 9.1 mg/dL d. Magnesium 2.0 mEq/L

Sodium 128 mEq/L This level is below the expected reference range and is the likely cause of the client's altered mental status. The nurse should report this finding to the provider and monitor the client for weakened respiratory effort.

a nurse is caring for a client who has asthma and is receiving albuterol. for which of the following adverse effects should the nurse monitor the client? A.) Hyperkalemia B.) Dyspnea C.) Tachycardia D.) Candidiasis

Tachycardia rationale: The nurse should monitor the client for tachycardia, which is a common adverse effect of this medication, especially if the client uses albuterol on a regular basis.

a nurse is assessing a client who has bacterial pneumonia. which of the following manifestations should the nurse expect? A.) decreased fremitus B.) SaO2 95% on room air C.) temperature 38.8° C (101.8° F) D.) bradypnea

Temperature 38.8° C (101.8° F) rationale: An elevated temperature is an expected finding for a client who has bacterial pneumonia.

a nurse is assisting a provider who's performing a thoracentesis at the beside of a client. which of the following actions should the nurse take? a.) Wear goggles and a mask during the procedure. b.) Cleanse the procedure area with an antiseptic solution. c.) Instruct the client to take deep breaths during the procedure. d.) Position the client laterally on the affected side before the procedure. e.) Apply pressure to the site after the procedure.

a.) Wear goggles and a mask during the procedure. b.) Cleanse the procedure area with an antiseptic solution. e.) Apply pressure to the site after the procedure. rationale: a.) Wear goggles and a mask during the procedure is correct. The nurse and provider should both wear goggles and a mask to reduce the risk for exposure to pleural fluid. b.) Cleanse the procedure area with an antiseptic solution is correct. The use of an antiseptic solution decreases the risk for infection, which is increased due to the invasive nature of the procedure. c.) Instruct the client to take deep breaths during the procedure is incorrect. The nurse should instruct the client to remain as still as possible during the procedure to reduce the risk for puncturing the pleura or lung. d.) Position the client laterally on the affected side before the procedure is incorrect. The nurse should position the client in a sitting position leaning over the bedside table or laterally on the unaffected side to promote access to the site and encourage drainage of pleural fluid. e.) Apply pressure to the site after the procedure is correct. The application of pressure decreases the risk for bleeding at the procedure site.

A nurse is teaching a client who has diabetes mellitus. Which of the following should the nurse include as an expected finding of diabetic ketoacidosis (DKA)?

blood glucose levels above 300 mg/dL Blood glucose levels above 300 mg/dL are an expected finding of DKA. Levels above 600 mg/dL are an expected finding in a client who is in a hyperglycemic-hyperosmolar state.

A nurse is assessing a client who has diabetes mellitus and reports feeling anxious. Which of the following findings should the nurse expect if the client is hypoglycemic?

cool, clammy skin Hypoglycemia causes cool, clammy skin, in addition to anxiety, nervousness, tachycardia, and confusion.

A nurse is teaching a client who has diabetes mellitus about insulin injections. The client's prescription includes evening doses of insulin glargine and regular insulin. Which of the following instructions should the nurse include?

draw the insulins into separate syringes The nurse should instruct the client to draw up the insulins into separate syringes because insulin glargine is not compatible with other insulins.

a nurse is caring for a client who has a pheochromocytoma. Which of the following actions should the nurse take?

elevate the head of the client's bed The nurse should elevate the head of the client's bed to reduce blood pressure and abdominal pressure.

A nurse is assessing a client who is quadriplegic following a cervical fracture at vertebral level C5. The client reports a throbbing headache and nausea. The nurse notes facial flushing and a blood pressure of 220/110 mmHg. Which of the following actions should the nurse take first?

elevated the head of the client's bed

A nurse is caring for a client who has a history of status epilepticus and requires seizure precautions. Which of the following actions should the nurse take?

establish IV access

A nurse is monitoring the laboratory values of a client who has diabetes mellitus and is taking insulin. Which of the following results indicates a therapeutic outcome of insulin therapy?

fasting blood glucose 96 mg/dL This is within the expected reference range of 70 to 110 mg/dL for a fasting blood glucose level and indicates that insulin therapy is effective.

A nurse is teaching a client who has an autoimmune disease about the adverse effects of long-term corticosteroid therapy. Which of the following adverse effects should the nurse include? (SATA)

osteoporosis moon-shaped face increased risk of infection -Osteoporosis is correct. Osteoporosis is an adverse effect of long-term corticosteroid therapy due to the suppression of bone formation and the acceleration of bone resorption that corticosteroid therapy can cause. -Moon-shaped face is correct. Long-term corticosteroid therapy causes characteristics of iatrogenic Cushing's syndrome, including a moon-shaped face, a potbelly, and a buffalo hump. -Increased risk of infection is correct. Increased risk of infection is an adverse effect of long-term corticosteroid therapy. Corticosteroid therapy reduces the phagocytic actions of macrophages and neutrophils, suppressing the immune system.

A nurse is reviewing the ABG results for four clients. Which of the following findings should the nurse identify as metabolic acidosis? a. pH 7.51, PaO2 94 mm Hg, PaCO2 38 mm Hg, HCO3- 29 mEq/L b. pH 7.48, PaO2 89 mm Hg, PaCO2 30 mm Hg, HCO3- 24 mEq/L c. pH 7.36, PaO2 77 mm Hg, PaCO2 52 mm Hg, HCO3- 26 mEq/L d. pH 7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L

pH 7.26, Pa02 84mm hg, PaC02 38 mmhg, HCO3- 20 mEq/L When pH and HCO3- are both above or below the expected reference range, a metabolic imbalance is present. A pH of 7.26 indicates acidosis and a HCO3- of 20 mEq/L indicates the acidosis is due to a metabolic cause. Therefore, the nurse should identify these findings as metabolic acidosis.

a nurse is caring for a client who's postoperative and has an RR of 9/min secondary to general anesthesia effects na incisional pain. which of the following ABG values indicates the client is experiencing respiratory acidosis? A.) pH 7.50, PO2 95 mm Hg, PaCO2 25 mm Hg, HCO3- 22 mEq/L B.) pH 7.50, PO2 87 mm Hg, PaCO2 35 mm Hg, HCO3- 30 mEq/L C.) pH 7.30, PO2 90 mm Hg, PaCO2 35 mm Hg, HCO3- 20 mEq/L D.) pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3- 22 mEq/L

pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3- 22 mEq/L rationale: These ABG values indicate respiratory acidosis. The pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg, which indicates respiratory acidosis.

A nurse is reviewing laboratory values for a client who has diabetic ketoacidosis (DKA). Which of the following results should the nurse expect?

pH 7.32, PaCO2 36 mmHg, HCO3 14 mEq/L Metabolic acidosis is a common manifestation of DKA, with a low pH, carbon dioxide within the expected reference range, and low bicarbonate.

A nurse has administered propranolol by IV bolus to a client who is having a thyroid storm. Which of the following findings indicates that the client is having a therapeutic response?

reduction of the effects of thyroid hormone on the heart Propranolol is a beta2-adrenergic blocking agent that decreases the rapid heart rate caused by excessive thyroid stimulation.

A nurse is caring for a client who is recovering from a stroke and has right-sided homonymous hemianopsia. To help the client adapt to the hemianopsia, the nurse should take which of the following actions?

remind the client to look consciously at both sides of their meal tray

A nurse a caring for a client who is 72 hr postoperative following an above-the-knee amputation and reports phantom limb pain. Which of the following actions should the nurse take?

request a prescription for gabapentin for the client.

A nurse is assessing a client who has a head injury following a motor-vehicle crash. The nurse should identify that which of the following findings indicates increasing intracranial pressure?

restlessness

a nurse is caring for a client who has type 2 diabetes mellitus and is experiencing a hyperglycemic-hyperosmolar state (HHS). Which of the following laboratory findings should the nurse expect?

serum pH 7.45 A client who is experiencing HHS produces enough insulin to prevent ketosis but not enough to prevent hyperglycemia. Therefore, the serum pH is within the expected reference range. Glucose levels will be above 600 mg/dL.

A nurse in an emergency department is caring for a client who has sustained a fracture of the femur following a motor-vehicle crash. Which of the following images should the nurse recognize as a comminuted fracture?

several pieces

A nurse is caring for a client following a thyroidectomy. The nurse should assess for which of the following findings as an indication of hypocalcemia?

tingling and numbness of the hands and feet Hypocalcemia causes paresthesia, which usually starts in the hands and feet.

a nurse is caring for a client following insertion of a permanent pacemaker. which of the following statements indicates a potential complication of the insertion procedure?

✓ "I can't get rid of these hiccups" Hiccups can indicate that the pacemaker is stimulating the chest wall or diaphragm, which can occur as a result of a lead wire perforation.

a nurse is caring for a client who is scheduled for a coronary artery bypass graft (CABG) in 2 hr. which of the following client statements indicates a need for further clarification by the nurse?

✓ "I took warfarin last night according to my usual schedule" clients who are scheduled for a CABG should not take anticoagulants, such as warfarin, for several days prior to the surgery to prevent excessive bleeding.

A nurse is caring for a client who had an onset of chest pain 24 hr ago. The nurse should recognize that an increase in which of the following is diagnostic of a myocardial infarction (MI)?

✓ Creatine kinase-MB is the isoenzyme specific to the myocardium. Elevated creatine kinase-MB indicates myocardial muscle injury.

a nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. the nurse should plan to monitor for and report which of the following findings to the provider immediately?

✓ Slurred speech The greatest risk to this client is injury from an embolus caused by the pooling of blood that can occur with atrial fibrillation. Slurred speech can indicate inadequate circulation to the brain because of an embolus. Therefore, the nurse should report this finding to the provider immediately.

a nurse is caring for a client who has a history of angina and is scheduled for exercise electrocardiography at 1100. which of the following statements by the client requires the nurse to contact the provider for possible rescheduling?

✓ Smoking prior to this test can change the outcome and places the client at additional risk. The procedure should be rescheduled if the client has smoked before the test.

a nurse is caring for a postop client 1 hr following an aortic aneurysm repair. which of the following findings can indicate shock and should be reported to the provider?

✓ Urine output less than 30 mL/hr is a manifestation of shock. Urine output is decreased due to a compensatory decreased blood flow to the kidneys, hypovolemia, or graft thrombosis or rupture.

a nurse is assessing a client who has pulmonary edema related to heart failure. which of the following findings indicates effective treatment of the client's condition?

✓ absence of adventitious breath sounds Adventitious breath sounds occur when there is fluid in the lungs. The absence of adventitious breath sounds indicates that the pulmonary edema is resolving.

a nurse in an emergency department is caring for a client who had an anterior myocardial infarction. the client's history reveals she is 1 week postop following an open cholecystectomy. the nurse should recognize that which of the following interventions is contraindicated?

✓ assisting with thrombolytic therapy The nurse should recognize that major surgery within the previous 3 weeks is a contraindication for thrombolytic therapy.

a nurse is reviewing the lab results of several male clients who have peripheral arterial disease. the nurse should plan to provide dietary teaching for the client who has which of the following lab values?

✓ cholesterol 190 mg/dL, HDL 25 mg/dL, LDL 160 mg/dL These laboratory values for HDL and LDL are outside of the expected reference range and indicate that the nurse should provide dietary teaching to the client. The expected reference range for cholesterol is less than 200 mg/dL; for HDL is above 45 mg/dL for males and above 55 mg/dL for females; and for LDL is less than 130 mg/dL.

a nurse in an emergency room is assessing a client who has a bradydysrhythmia. which of the following findings should the nurse monitor for?

✓ confusion Bradydysrhythmia can cause decreased systemic perfusion, which can lead to confusion. Therefore, the nurse should monitor the client's mental status.

A nurse is assessing a client who has dilated cardiomyopathy. Which of the following findings should the nurse expect?

✓ dyspnea on exertion The nurse should identify dyspnea on exertion as an expected manifestation of dilated cardiomyopathy. Dyspnea on exertion is due to ventricular compromise and reduced cardiac output.

a nurse in an emergency department is caring for a client who has a BP of 254/139. the nurse recognizes that the client is in a hypertensive crisis. which of the following actions should the nurse take first?

✓ elevate the head of the client's bed The greatest risk to this client is organ injury due to severe hypertension. Therefore, the first action the nurse should take is to elevate the head of the client's bed to reduce blood pressure and promote oxygenation.

a nurse is admitting a client who has a leg ulcer and a history of diabetes mellitus. the nurse should use which of the following focused assessments to help differentiate between an arterial ulcer and a venous stasis ulcer?

✓ inquire about the presence or absence of claudication Knowing if the client is experiencing claudication helps differentiate venous from arterial ulcers. Clients who have arterial ulcers experience claudication, but those who have venous ulcers do not.