Cellular Regulation Practice NCLEX Questions, Practice Perfusion NCLEX Questions, clinical decision making practice questions, Inflammation NCLEX Questions, LPN to ADN Study Guide

MRSA (methicillin-resistant Staphylococcus aureus)

-an infection caused by specific bacteria that has become resistant to many antibiotics -contact precautions: gown and mask

5) A client seen in an urgent care clinic is complaining of abdominal pain and believes that the food eaten the previous evening was tainted. What should the nurse do after the client states that the food was tainted? A) Ask the client open-ended questions to further assess the situation. B) Tell the client the physician does not need to assess the client. C) Call an ambulance before assessing the client any further. D) Advise the client to take an antacid.

A

10) A nurse enters a client's room to check on the client's response to IV pain medication she gave on request 20 minutes earlier. She finds the client on her side lying very still and not wanting to move, and asks the client about her current pain level. Which aspect(s) of the nursing process does this action represent? Select all that apply. A) Assessment B) Diagnosis C) Planning D) Implementation E) Evaluation

A,D,E

The nurse evaluates which of the following clients to be at risk for developing hypernatremia? A. 50-year-old with pneumonia, diaphoresis, and high fevers B. 62-year-old with congestive heart failure taking loop diuretics C. 39-year-old with diarrhea and vomiting D. 60-year-old with lung cancer and syndrome of inappropriate antidiuretic hormone (SIADH)

A. 50-year-old with pneumonia, diaphoresis, and high fevers

A nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is at risk for deficient fluid volume? A. A client with a colostomy B. A client with congestive heart failure C. A client with decreased kidney function D. A client receiving frequent wound irrigations

A. A client with a colostomy

The physician has ordered that a client with hypertension begin receiving a thiazide diuretic. The nurse will now closely monitor the client for: A. Hypokalemia B. Hyponatremia C. Hypercalcemia D. Hypermagnesemia

A. Hypokalemia

The nurse provides instructions to a client with a low magnesium level about the foods that are high in magnesium and tells the client to consume which foods? Select all that apply. A. Peas B. Oranges C. Cauliflower D. Peanut butter E. Canned white tuna

A. Peas C. Cauliflower E. Canned white tuna

The client is NPO and is receiving total parenteral nutrition (TPN) via a subclavian line. Which precautions should the nurse implement? Select all that apply. A. Place the solution on an IV pump at the prescribed rate. B. Monitor blood glucose every six (6) hours. C. Weigh the client weekly, first thing in the morning. D. Change the IV tubing every three (3) days. E. Monitor intake and output every shift.

A. Place the solution on an IV pump at the prescribed rate. B. Monitor blood glucose every six (6) hours. E. Monitor intake and output every shift.

An elderly woman was admitted to the medical unit with dehydration. A clinical indication of this problem is A. weight loss. B. full bounding pulse. C. engorged neck veins. D. Kussmaul respiration.

A. weight loss.

Meniere's disease

Abnormal condition within the labyrinth of the inner ear that can lead to a progressive loss of hearing. The symptoms are dizziness or vertigo, hearing loss, and tinnitus (ringing in the ears).

Hyperthermia

Abnormally high body temperature

BPH (benign prostatic hyperplasia)

Age-associated prostate gland enlargement that can cause urination difficulty.

contact dermatitis

An inflammation of the skin caused by having contact with certain chemicals or substances; many of these substances are used in cosmetology.

Which nursing action is most likely to detect early signs of infection in a patient who is taking immunosuppressive medications? a. Monitor white blood cell count. b. Check the skin for areas of redness. c. Check the temperature every 2 hours. d. Ask about fatigue or feelings of malaise.

Ask about fatigue or feelings of malaise

4) The nurse is collecting data about a client's current health status. Which statement would assist in gathering subjective data about the client? A) "Your eyelid is red and swollen." B) "Your skin appears to be dry and irritated." C) "I see that you have bruises on your legs." D) "Tell me why you have difficulty sleeping."

D

6) An older client with heart failure is experiencing activity intolerance due to dyspnea on exertion. Which nursing intervention is a priority for the client? A) Complete all nursing care at the end of the shift. B) Delegate care for the client to an aide. C) Complete all nursing care in the morning. D) Pace nursing care throughout the shift.

D

7) A client recovering from knee surgery is being prepared to ambulate for the first time. Prior to getting the client up, what should the nurse do? A) Ask the client about readiness to walk. B) Call for a wheelchair to start the process. C) Conduct a breathing assessment. D) Evaluate the client's level of pain.

D

Dry mucous membranes are a clinical sign of dehydration. Weight loss can be associated with dehydration but is not a confirming sign. Engorged neck vessels and bounding pulse are signs of fluid overload. The nurse anticipates that the physician will order which intravenous (IV) fluid for a client who is dehydrated? A. Ringer's lactate B. 3% Sodium chloride C. 0.9% Sodium chloride D. 0.45% Sodium chloride

D. 0.45% Sodium chloride

The nurse is evaluating the serum laboratory results on the following four clients. Which of the following laboratory results is a priority for the nurse to report first? A. A client with osteoporosis and a calcium level of 10.6 mg/dl B. A client with renal failure and a magnesium level of 2.5 mEq/L C. A client with bulimia and a potassium level of 3.6 mEq/L D. A client with dehydration and a sodium level of 149 mEq/L

D. A client with dehydration and a sodium level of 149 mEq/L

A client with chronic renal failure reports a 10 pound weight loss over 3 months and has had difficulty taking calcium supplements. The total calcium is 6.9 mg/dl. Which of the following would be the first nursing action? A. Assess for depressed deep tendon reflexes B. Call the physician to report calcium level C. Place an intravenous catheter in anticipation of administering calcium gluconate D. Check to see if a serum albumin level is available

D. Check to see if a serum albumin level is available

Which of the following should the nurse include when preparing to teach a class on the regulation and functions of electrolytes? A. Sodium is essential to maintain intracellular fluid water balance B. Magnesium is essential to the function of muscle, red blood cells, and nervous system C. Less calcium is excreted with aging D. Chloride is lost in hydrochloride acid

D. Chloride is lost in hydrochloride acid

A nurse caring for a client who has been receiving intravenous diuretics suspects that the client is experiencing a deficient fluid volume. Which assessment finding would the nurse note in a client with this condition? A. Lung congestion B. Decreased hematocrit C. Increased blood pressure D. Decreased central venous pressure (CVP)

D. Decreased central venous pressure (CVP)

Hypovelemic shock

shock resulting from blood or fluid loss

Peptic Ulcer Disease (PUD)

sore on the mucous membrane of the stomach, duodenum, or any other part of the gastrointestinal system exposed to gastric juices; commonly caused by infection with Helicobacter pylori bacteria

colon cancer

Cancer of the large intestine

A patient who is confined to bed and who has a stage II pressure ulcer is being cared for in the home by family members. To prevent further tissue damage, the home care nurse instructs the family members that it is most important to a. change the patient's bedding frequently. b. use a hydrocolloid dressing over the ulcer. c. record the size and appearance of the ulcer weekly. d. change the patient's position at least every 2 hours.

Change patient's position at least every two hours

A 24-year-old patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C). Which action by the nurse is most appropriate? a. Apply a cooling blanket. b. Notify the health care provider. c. Give the prescribed PRN aspirin (Ascriptin) 650 mg. d. Check the patient's oral temperature again in 4 hours.

Check the patient's oral temperature again in 4 hours

metabolic acidosis

-buildup of acid in the body due to kidney disease or kidney failure -low pH, normal PaCO2, low HCO3

respiratory alkalosis

-condition marked by a low level of carbon dioxide in the blood due to breathing excessively -high pH, low CO2 -PaCO2 less than 40 and pH greater than 7.4 high HCO3

Hypocalcemia

-deficient calcium in the blood -blood levels less than 4

Hypercalcemia

-excessive calcium in the blood -blood levels greater than 13

Hyperkalemia

-high levels of potassium in the blood -blood level greater than 5.0

Hypernatremia

-high sodium -sodium blood levels greater than 145

pneumonia

-inflammation of the lungs -droplet: glove gown mask

Hypokalemia

-low potassium -blood level less than 3.5

Hyponatremia

-low sodium -sodium blood levels less than 135

metabolic alkalosis

-occurs when digestive issues disrupt the blood's acid-base balance -high pH, high HCO3, normal PaCO2

respiratory acidosis

-occurs when your lungs can't remove all of the carbon dioxide produced by your body. This causes the blood and other body fluids to become too acidic -low pH, high PaCO2 -ABG will show an elevated PCO2 (>45 mmHg), elevated HCO3- (>30 mmHg), and decreased pH (<7.35)

Influenza

-respiratory tract infection caused by an influenza virus -droplet: glove gown mask

A patient diagnosed with ulcerative colitis is prescribed the aminosalicylate sulfasalazine. When teaching the patient about this medication, which of the following statements is a priority for the healthcare provider include? Please choose from one of the following options. "Be sure to limit your intake of fluids during therapy." "Avoid exposure to sunlight while taking this medication." "Call our office immediately if your urine turns an orangish color." "You may crush the enteric-coated tablet and mix it with applesauce."

"Avoid exposure to sunlight while taking this medication"

Tuberculosis

-An infectious disease that may affect almost all tissues of the body, especially the lungs -droplet: gown glove N95 mask

Diabetes Type 1

no insulin produced

5) The nurse is prioritizing care activities that are to be completed for a group of clients. From highest to lowest priority, list the order in which the nurse should complete the listed activities. 1. Measure blood pressure before administering antihypertensive medication. 2. Request dietary consult for gluten-free diet. 3. Remove an intravenous access device infusing chemotherapy. 4. Change a dressing on an arm wound. 5. Call a family member to bring in shoes. 6. Ambulate to the bathroom using a walker.

3,1,4,6,2,5

3) The nurse is prioritizing care for a client based upon nursing diagnoses. If following Maslow's hierarchy of needs, list the order in which the nurse should provide care to the client. 1. Fatigue 2. Anxiety 3. Alteration in Perfusion 4. Self-Care Deficit 5. Deficient Knowledge 6. Diarrhea

3,6,4,2,1,5

Parkinson's disease

A disorder of the central nervous system that affects movement, often including tremors.

COPD (chronic obstructive pulmonary disease)

A group of lung diseases that block airflow and make it difficult to breathe.

7) The home health nurse is visiting a client who is 2 weeks postoperative from a coronary artery bypass surgery. The client has lost 10 pounds, is continuing to experience pain, and is not eating. What should be the nurse's next action? A) Examine the current interventions for pain relief. B) Refer the client to social services. C) Contact Meals on Wheels so that the client will eat. D) Revise the goals in the current plan of care.

A

Diabetes Type 2

A chronic condition where the body does not use insulin properly and becomes insulin resistant.

open angle glaucoma

A condition in which pressure is elevated in the eye because of obstruction of the outflow of aqueous humor.

osteroporosis

A condition in which the body's bones become weak and break easily.

3) The nursing instructor is evaluating a concept map created by a student for a client's plan of care. What characteristic or characteristics on the map indicate that the student created the map appropriately? Select all that apply. A) Legend created identifying nursing process phases and client information categories B) Lines drawn between assessment data and associated nursing diagnoses C) Different colors used to represent the phases of the nursing process D) A column entitled "evaluation" located on the outer edge of the document E) A checklist located at the bottom of the document

A,B,C

7) After receiving the morning report, the nurse prioritizes care needed by several clients. What factors should the nurse keep in mind when creating this priority list? Select all that apply. A) Client condition B) Safety C) Time available D) Client preferences E) Time of day

A,B,C,D

1) The nurse decides to use a standardized plan of care to address a client's health problems. What criterion differentiates this plan of care from other types? Select all that apply. A) Preprinted B) Has blank lines C) Has various shapes connected with lines D) Has checklists E) Includes different colors

A,B,D

12) The nurse is taking the time to reflect on a care situation in which a client sustained a cardiac arrest and died. On which area(s) should the nurse focus when performing this reflection? Select all that apply. A) Things that could have been done differently B) Gut reactions to the situation C) Things that were done well D) Resources that were used at the time E) Resources that were needed but not available

A,C,D,E

6) A client with aspiration pneumonia is diaphoretic, pale, and taking gasping breaths. What should the nurse do first? A) Notify the physician. B) Complete a thorough cardiopulmonary assessment. C) Administer 10 L of oxygen per face mask. D) Reposition the client to help with breathing.

B

11) A construction worker admitted to the unit with a chest injury and broken ribs from a fall from a ladder has nursing diagnoses of "Disturbed Sleep Pattern," "Ineffective Breathing Pattern," and "Risk for Infection." Because he also keeps saying "I've never been sick a day in my life and am really worried about how I can support my family while I'm out of work," the nurse also identifies "Anxiety" as another nursing diagnosis. Which diagnosis would receive priority for nursing intervention? A) Risk for Infection B) Ineffective Breathing Pattern C) Disturbed Sleep Pattern D) Anxiety

B

inflammatory response

nonspecific defense against infection, characterized by redness, heat, swelling, and pain

A patient who has an infected abdominal wound develops a temperature of 104° F (40° C). All the following interventions are included in the patient's plan of care. In which order should the nurse perform the following actions? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Sponge patient with cool water. b. Administer intravenous antibiotics. c. Perform wet-to-dry dressing change. d. Administer acetaminophen (Tylenol).

B, D, A, C

4) The nurse is prioritizing care needed for a group of clients according to urgency. Which care should the nurse identify as being medium priority? Select all that apply. A) Instructing on changing ostomy appliance B) Performing passive range of motion every 4 hours C) Removing splints and providing complete skin care every 2 hours D) Administering 2 units of fresh frozen plasma E) Performing endotracheal suction

B,C

A client is admitted with diabetic ketoacidosis who, with treatment, has a normal blood glucose, pH, and serum osmolality. During assessment, the client complains of weakness in the legs. Which of the following is a priority nursing intervention? A. Request a physical therapy consult from the physician B. Ensure the client is safe from falls and check the most recent potassium level C. Allow uninterrupted rest periods throughout the day D. Encourage the client to increase intake of dairy products and green leafy vegetables.

B. Ensure the client is safe from falls and check the most recent potassium level

A client recently diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) complains of headache, weight gain, and nausea. Which of the following is an appropriate nursing diagnosis for this client? A. Deficient fluid volume related to decreased fluid intake B. Excess fluid volume related to increased water retention C. Deficient fluid volume related to excessive fluid loss D. Risk for injury related to fluid volume loss

B. Excess fluid volume related to increased water retention

A client with hypoparathyroidism complains of numbness and tingling in his fingers and around the mouth. The nurse would assess for what electrolyte imbalance? A. Hyponatremia B. Hypocalcemia C. Hyperkalemia D. Hypermagnesemia

B. Hypocalcemia

A client who is post-gallbladder surgery has a nasogastric tube, decreased reflexes, pulse of 110 weak and irregular, and blood pressure of 80/50 and is weak, mildly confused, and has a serum of potassium of 3.0 mEq/L. Based on the assessment data, which of the following is the priority intervention? A. Withhold furosemide (Lasix) B. Notify the physician C. Administer the prescribed potassium supplement D. Instruct the client on foods high in potassium

B. Notify the physician

The nurse is caring for a client who has been in good health up to the present and is admitted with cellulitis of the hand. The client's serum potassium level was 4.5 mEq/L yesterday. Today the level is 7 mEq/L. Which of the following is the next appropriate nursing action? A. Call the physician and report results B. Question the results and redraw the specimen C. Encourage the client to increase the intake of bananas D. Initiate seizure precautions

B. Question the results and redraw the specimen

A nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client was at risk for developing the potassium deficit because the client: A. Has renal failure. B. Requires nasogastric suction. C. Has a history of Addison's disease. D. Is taking a potassium-sparing diuretic.

B. Requires nasogastric suction.

The nurse should include which of the following instructions to assist in controlling phosphorus levels for a client in renal failure? A. Increase intake of dairy products and nuts B. Take aluminum-based antacids such as aluminum hydroxide (Amphojel) with or after meals C. Reduce intake of chocolate, meats, and whole grains D. Avoid calcium supplements

B. Take aluminum-based antacids such as aluminum hydroxide (Amphojel) with or after meals

The client post-thyroidectomy complains of numbness and tingling around the mouth and the tips of the fingers. Which intervention should be implemented first? A. Notify the health care provider immediately. B. Tap the cheek about two (2) centimeters anterior to the ear lobe. C. Check the serum calcium and magnesium levels. D. Prepare to administer calcium gluconate IVP.

B. Tap the cheek about two (2) centimeters anterior to the ear lobe.

A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a sodium value at this level? A. The client with renal failure B. The client who is taking diuretics C. The client with hyperaldosteronism D. The client who is taking corticosteroids

B. The client who is taking diuretics

11) A graduate nurse is planning care for an older client with a wound infection and systemic blood infection. The nurse completes the plan of care and decides to complete which action to enhance the skill of critical thinking? A) Discuss the plan with the physician. B) Request that the client review the plan. C) Request a review of the plan with the nurse's preceptor. D) Place the plan on the client's chart.

C

4) The nurse is assigned two clients. One client needs postoperative teaching in preparation for discharge and the other client with pneumonia has a PaCO2 of 85. Why does the nurse decide to see the client with pneumonia first? A) The nurse can delegate postoperative teaching to unlicensed assistive personnel (UAP). B) The client with pneumonia needs more care than the client needing postoperative teaching. C) The client with pneumonia may be experiencing respiratory distress. D) The room of the client with pneumonia is closer than that of the client needing postoperative teaching.

C

8) The nurse is caring for a female client with decreased energy who needs to get up to prevent the development of pressure ulcers. The client is unable to ambulate and wants to be alone. What should the nurse do? A) Notify the physician of the client's noncompliance. B) Leave the client alone until ready to get out of bed. C) Gain knowledge about the client from family to gain compliance. D) Proceed to get help to get the client out of bed.

C

9) The nurse is caring for a 10-year-old client who is sleeping when the menu choices for dinner are brought to the room. Which intervention should the nurse use to meet the dietary needs of this client? A) Wake the child to choose a meal for dinner. B) Order chicken nuggets because most children like this meal. C) Ask the dietary worker to come back later. D) Ask the parents to bring dinner from home for the client.

C

The nurse is teaching a client about clopidogrel (Plavix). What is important information to include? a. Constipation may occur. b. Hypotension may occur. c. Bleeding may increase when taken with aspirin. d. Normal dose is 25 mg tablet per day.

C

The client diagnosed with diabetes insipidus weighed 180 pounds when the daily weight was taken yesterday. This morning's weight is 175.6 pounds. One liter of fluid weighs approximately 2.2 pounds. How much fluid has the client lost (in milliliters)? A. 500 mL B. 1000 mL C. 2000 mL D. 4400 mL

C. 2000 mL

The nurse and an unlicensed nursing assistant are caring for a group of clients. Which nursing intervention should the nurse perform? A. Measure the client's output from the indwelling catheter. B. Record the client's intake and output on the I & O sheet. C. Instruct the client on appropriate fluid restrictions. D. Provide water for a client diagnosed with diabetes insipidus.

C. Instruct the client on appropriate fluid restrictions.

acute renal failure

Condition that occurs when something, such as a blockage, toxins, or sudden loss of blood flow causes a change in the filtering function of the kidneys

1) A nurse has just received a shift report and is preparing to care for clients assigned on a medical-surgical unit. Which client should the nurse plan to assess first? A) The client who needs assistance with activities of daily living B) The client who needs help ambulating to the bathroom C) The client with a pain rating of 3/10 D) The client experiencing shortness of breath

D

2) A client with congestive heart failure is having difficulty breathing. Before leaving the room the nurse ensures the client has an over-bed table to lean on when awake if needed to ease breathing. Which technique did the nurse use to make this decision? A) Delegating a task B) Priority-setting C) Conflict resolution D) Critical thinking

D

2) The nurse is conducting a class for a group of expectant mothers regarding basic infant care techniques. Upon completion of the class, what should the nurse expect the participants to do? A) Set goals for the next class session. B) Pass a written test on how to bathe a newborn infant. C) Review the major points of the class. D) Provide a return demonstration of a bath on a newborn doll.

D

3) A postoperative client prescribed pain medication every 4 to 6 hours is requesting medication every 6 hours. At 4 hours the client's pain level is 8 on a rating scale of 1 to 10. The nurse decides to give the pain medication now. What does this nurse's action exemplify? A) Meeting a client goal B) Time management skills C) Prioritizing the client's care D) A response to a change in the client's condition

D

A client with COPD feels short of breath after walking to the bathroom on 2 liters of oxygen nasal cannula. The morning's ABGs were pH of 7.36, PaCO2 of 62, HCO3 of 35 mEq/L, O2 at 88% on 2 liters. Which of the following should be the nurse's first intervention? A. Call the physician and report the change in client's condition B. Turn the client's O2 up to 4 liters nasal cannula C. Encourage the client to sit down and to take deep breaths D. Encourage the client to rest and to use pursed-lip breathing technique

D. Encourage the client to rest and to use pursed-lip breathing technique

The parent asks the nurse to explain which type of drugs will not be used in the medical treatment of their child's allergic reaction to bee stings. A. Diuretics and sedatives B. Antihistamines and salicylates C. Cardiotonics and anticholinergics D. Bronchodilators and corticosteroids

Diuretics and sedatives

The nurse assess a patient the morning of the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate? a. Obtain wound culture b. Document assessment c. Notify health care provide d. Assess the wound every 2 hours

Document assessment

A patient arrives in the emergency department with a swollen ankle after an injury incurred while playing soccer. Which action by the nurse is appropriate? a. Elevate the ankle above heart level. b. Remove the patient's shoe and sock. c. Apply a warm moist pack to the ankle. d. Assess the ankle's range of motion (ROM).

Elevate the ankle above the heart level

appendicitis

inflammation of the appendix

Increased Cranial Pressure (ICP)

Headaches, vomiting, altered mental status (drowsiness to coma), visual changes (blurred, double, photophobia, optic disc edema, optic atrophy) EXTREMELY important to monitor and identify ASAP to prevent herniation and death

increases blood flow in the area of the injury.

Hyperemia

A patient diagnosed with inflammatory bowel disease experiences an obstruction in the small bowel. When assessing the patient, which of the following will the healthcare provider anticipate? Please choose from one of the following options. Scaphoid abdomen Hypovolemia Increased flatus Passage of melena

Hypovolemia

A patient is admitted to the hospital with a pressure ulcer on the left buttock. The base of the wound is yellow and involves subcutaneous tissue. The nurse classifies the pressure ulcer as stage a. I. b. II. c. III. d. IV.

III

Which immunoglobin crosses the placenta? A. IgE B. IgA C. IgG D. IgM

IgG is the only immunoglobulin that crosses the placenta. IgE is found in the plasma and interstitial fluids. IgA lines the mucous membranes and protects body surfaces. IgM is found in plasma; this immunoglobulin activates due to the invasion of ABO blood antigens.

Which wound care is given to a client with severe burn injuries during the acute phase? A. Assess the depth and type of burn B. Provide daily shower and wound care C. Remove dead and contaminated tissue D. Assess the wound daily and adjust the dressing

In the acute phase, wound care is given by assessing the wound daily and adjusting the dressing if necessary according to the protocols. Assessing the extent and depth of burns is performed in the emergent phase. Providing a daily shower and removing the dead and contaminated tissue (debride) is performed in the emergent phase.

pressure ulcer

Inflammation, sore, or ulcer in the skin over a bony prominence.

Conjunctivitis

inflammation of the conjunctiva (pink eye)

glomerulonephritis

inflammation of the glomeruli of the kidney

otitis media

inflammation of the middle ear

Peri-operative Nursing

Involves providing care to surgical patients before, during, and after a surgical procedure. Nursing activities include assessment (physical and emotional), teaching, planning, coordination of care, implementation, as well as creating and maintaining a sterile and safe surgical environment.

A client is admitted to the hospital with a history of cancer of the liver and jaundice. In relation to the jaundice, the nurse expects the client to report the presence of what symptom? A. Pertussis B. Diarrhea C. Blurred vision D. bleeding gums

Itching associated with jaundice is believed to be caused by accumulating bile salts in the skin. Diarrhea, blurred vision, and bleeding gums are not related to jaundice.

The healthcare provider is assessing a patient diagnosed with ulcerative colitis. The patient has an altered level of consciousness, fever, and lower abdominal distension. Which of these additional findings would confirm a diagnosis of toxic megacolon? Please choose from one of the following options. Bradycardia Splenomegaly Leukocytosis Constipation

Leukocytosis

neuro assessment

MSE, cranial nerves, LOC, Glasgow, sensory, motor

When caring for a diabetic patient who had abdominal surgery one week ago, the nurse obtains these data. Which finding should be reported immediately to the health care provider? a. Blood glucose 136 mg/dl b. Oral temperature 101° F (38.3° C) c. Patient complaint of increased incisional pain d. New 5-cm separation of the proximal wound edges

New 5-cm separation of the proximal wound edges

What medication is used to prevent preterm labor? A. Oxytocin B. Nifedipine C. Raloxifene D. Clomiphene

Nifedipine is used to prevent preterm labor because it inhibits myometrial activity by blocking the influx of calcium. Oxytocin may be used to induce labor. Raloxifene is used to prevent postmenopausal osteoporosis. Clomiphene is used to cause ovulation.

pancreatitis

inflammation of the pancreas that occurs when pancreatic enzymes that digest food are activated in the pancreas instead of the duodenum and attack pancreatic tissue, causing damage to the gland

acute angle closure glaucoma

Pain Dilated pupil Shallow anterior chamber Halos around lights Most common in adults >50

A patient diagnosed with ulcerative colitis is admitted to the medical unit. When assessing the patient, which of these findings would be of the most concern? Borborygmi Oral temperature of 99.0 F (37.2 C) Bloody diarrhea Rebound tenderness

Rebound tenderness

anaphylactic shock

Severe allergic reaction

septic shock

Shock caused by severe infection, usually a bacterial infection.

kidney stones

Solid crystalline masses formed in the kidney, resulting from an excess of insoluble salts or uric acid crystallizing in the urine; may become trapped anywhere along the urinary tract.

What nursing care should be included for a client who is receiving doxorubicin for acute myelogenous leukemia? A. Serving hot liquids with each meal B. Providing frequent oral hygiene C. Emphasizing that the disease will be cured with treatment D. Administering medications intramuscularly and encouraging activity

Stomatitis and hyperuricemia are possible complications of therapy; therefore, oral care and hydration are important. Food and fluids with extremes in temperature should be avoided because of the common occurrence of stomatitis. Emphasizing that the disease will be cured with this treatment may provide false reassurance. Abnormal bleeding is a common problem, and thus injections are contraindicated; rest is important for increased fatigability.

stroke

Sudden loss of consciousness, sensation, and voluntary motion caused by rupture or obstruction (as by a clot) of a blood vessel of the brain.

lupus

a chronic autoimmune disease characterized by inflammation of various parts of the body

rheumatoid arthritis

a chronic autoimmune disorder in which the joints and some organs of other body systems are attacked

Liver disease

The effects of liver disease includes metabolic disturbances, blood abnormalities, fluid/electrolyte imbalances, decreased resistance to infection, accumulation of drugs/toxins, obstruction of blood vessels/bike duct of the liver. *Check bilirubin levels for improvement- should lower*

When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing? a. The patient states that the ulcers are very painful. b. The patient has had the heel ulcers for the last 6 months. c. The patient has several old incisions that have formed keloids. d. The patient takes corticosteroids daily for rheumatoid arthritis.

The patient takes corticosteriods daily for rheumatoid arthritis

The nurse has just received change-of-shift report about the following four patients. Which patient will the nurse assess first? a. The patient who has multiple black wounds on the feet and ankles. b. The newly admitted patient with a stage IV pressure ulcer on the coccyx. c. The patient who needs to be medicated with multiple analgesics before a scheduled dressing change. d. The patient who has been receiving immunosuppressant medications and has a temperature of 102° F.

The patient who has been receiving immunosuppressant medications and has a temperature of 102F

A patient with an inflammation has a high eosinophil count. The nurse recognizes that this finding most likely indicates that A. The inflammatory response has been stimulated by infection B. The inflammation has become chronic with persistent tissue damage C. Humoral and cell-mediated immunity is being stimulated D. Tissue damage has been caused by an allergen-antibody reaction

Tissue damage has been caused by an allergen-antibody reaction. Eosinophil= allergies

Angina

a condition of episodes of severe chest pain due to inadequate blood flow to the myocardium

A client with a diagnosis of anemia is receiving packed red blood cells. What is the most important action by the nurse when administering the transfusion? A. Warning the client about the possibility of fluid overload B. Monitoring the client's response, particularly within the first 10 minutes C. Adjusting the client's transfusion flow rate so that it infuses at a consistent rate during the procedure D. Having the client tested for human immunodeficiency virus (HIV) before administering the blood transfusion

Transfusion reactions usually occur early during the administration of a blood transfusion (first 30 mL of blood); early detection of a transfusion reaction will permit a quick termination of the infusion. The risk of fluid overload is unlikely, and this information can be frightening. The donor's, not the recipient's, blood is tested for HIV. The flow rate should be slower during the first 10 to 15 minutes of the infusion to limit the amount of blood infused; this allows time to assess the client's response for signs and symptoms of a transfusion reaction before too much of the blood is infused.

cystic fibrosis (CF)

inherited disorder of exocrine glands resulting in thick mucinous secretions in the respiratory tract that do not drain normally

GI assessment

inspection, auscultation, percussion, palpation

A nurse is caring for a client who is taking an angiotensin-converting enzyme inhibitor and develops a dry, nonproductive cough. What is the nurse's priority action? a. Call the health care provider to switch the medication. b. Assess the client for other symptoms of upper respiratory infection. c. Instruct the client to take antitussive medication until the symptoms subside. d. Tell the client that the cough will subside in a few days.

a. Angiotensin-converting enzyme inhibitors prevent the breakdown of bradykinin, frequently causing a nonproductive cough. Angiotensin receptor blocking agents do not block this breakdown, thus minimizing this annoying side effect. The client should be switched to a different medication if the side effect cannot be tolerated.

Which client assessment would assist the nurse in evaluating therapeutic effects of a calcium channel blocker? a. Client states that she has no chest pain. b. Client states that the swelling in her feet is reduced. c. Client states the she does not feel dizzy. d. Client states that she feels stronger.

a. The workload in the heart should be decreased with the vasodilatation from the calcium channel blocker. With less strain, the client should have fewer incidences of angina as afterload is decreased.

Hypothermia

abnormally low body temperature

A client's serum lipids are cholesterol 197 mg/dl, low-density lipoprotein (LDL) 110 mg/dl, and high-density lipoprotein (HDL) 35 mg/dl. The nurse knows what about these values? a. Serum lipids are within desirable values. b. Cholesterol is within desirable value, but LDL and HDL are not. c. Cholesterol is not within desirable value, though LDL and HDL are. d. Cholesterol, LDL, and HDL are not within desirable values.

b

The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive highest priority? a. BP 110/62, atrial fibrillation with HR 82, bibasilar crackles b. Confusion, urine output 15mL over the last 2 hours, orthopnea. c. SpO2 92 on 2 liters nasal cannula, respirations 20, 1+ edema of lower extremities. d. Weight gain of 1kg in 3 days, BP 130/80, mild dyspnea with exercise.

b. A low urine output and confusion are signs of decreased tissue perfusion. Orthopnea is a sign of left-sided heart failure. Crackles, edema and weight gain should be monitored closely, but the levels are not as high a priority. With atrial fibrillation there is a loss of atrial kick, but the blood pressure and heart rate are stable

Which laboratory test results may be associated with peaked or tall, tented T waves on a client's electrocardiogram (ECG)? a. Chloride level of 98 mEq/L b. Sodium level of 135 mEq/L c. Potassium level of 6.8 mEq/L d. Magnesium level of 1.6 mEq/L

c. Potassium level of 6.8 mEq/L

Leukemia

cancer of white blood cells

heart failure (HF)

condition in which there is an inability of the heart to pump enough blood through the body to supply the tissues and organs with nutrients and oxygen

Cellulitis

diffuse, acute infection of the skin marked by local heat, redness, pain, and swelling

The nurse is admitting a client with a potassium level of 6.0 mEq/L. The nurse reports this finding as a result of A. acute renal failure. B. malabsorption syndrome. C. nasogastric drainage. D. laxative abuse

A. acute renal failure.

The nurse anticipates that the patient with hyperphosphatemia secondary to renal failure will require A. calcium supplements. B. potassium supplements. C. magnesium supplements. D. fluid replacement therapy.

A. calcium supplements.

2) The nurse is prioritizing care for a client with several problems. List the order in which the nurse should address the client's needs. 1. Bleeding through nasogastric tube 2. Audible wheezes 3. Not understanding how to complete the menu 4. Requesting medication for arthritis pain 5. Dyspnea 6. Asking questions about teaching provided the other day

2,5,1,4,6,3

1) During a health history a client becomes upset because the nurse is asking many questions. What should the nurse respond to the client? A) "I use the answers you provide to determine what your current health needs are." B) "I am sorry the questions disturb you." C) "I will skip the questions that bother you." D) "I cannot help you if you do not answer me."

A

10) A client asks the student nurse to explain the pathophysiology of diabetes. The student nurse does not know the answer to this question. What should the student respond to the client? A) "I do not know, but I will find out." B) "You'll have to ask the doctor that question." C) "Why do you need to know that?" D) "I do not know."

A

3) A goal of care for a client with congestive heart failure is for serum sodium levels to be within normal limits. What information should the nurse expect to see documented in the medical record? A) The client is experiencing dependent edema. B) The client experiences joint pain. C) The client is constipated. D) The client is experiencing wheezing respirations.

A

5) An older client is experiencing confusion, a temperature of 101.5°F, bruising to the arms and legs, and decreased urine output. The medical diagnosis is a urinary tract infection. What is the most appropriate nursing diagnosis for this client? A) Risk for Injury B) Ineffective Breathing Pattern C) Activity Intolerance D) Impaired Memory

A

Hemophilia

A hereditary disease where blood does not coagulate to stop bleeding

Implementation of nursing care for the patient with hyponatremia includes A. fluid restriction. B. administration of hypotonic IV fluids. C. administration of a cation exchange resin. D. increased water intake for patients on nasogastric suction.

A. fluid

8) The nurse manager is concerned that a staff nurse is having difficulty prioritizing client care needs. What did the manager observe the nurse perform that caused these concerns? Select all that apply. A) Relying upon another nurse's assessment B) Reviewing the medication administration record C) Not completing an assessment D) Doing easiest tasks first E) Asking unlicensed assistive personnel to perform complicated care

A,C,D,E

1) The nurse is preparing to provide care to a group of clients. On which specific area(s) should the nurse focus in order to prioritize the clients' care needs? Select all that apply. A) Asking if any clients have complex issues B) Noting number of licensed staff assigned for the shift C) Noting time when the attending physicians make rounds D) Identifying clients with specific medication times E) Noting which clients have particular safety needs

A,D,E

The 65-year-old client with congestive heart failure is at the greatest risk for problems from fluid volume excess. Fluid overload in this client could quickly cause life-threatening problems. The 50-year-old client with second degree burns is at risk for fluid volume deficit. The nurse assesses four clients. Which client is at greatest risk for the development of hypocalcemia? A. 56-year-old client with acute renal failure B. 40-year-old client with systemic lupus erythematosus C. 28-year-old client who has just undergone a total thyroidectomy D. 65-year-old client with hypertension taking beta-adrenergic blockers

A. 56-year-old client with acute renal failure

A client admitted with squamous cell carcinoma of the lung has a serum calcium level of 14 mg/dl. The nurse should instruct the client to avoid which of the following foods upon discharge? Select all that apply. A. Eggs B. Broccoli C. Organ meats D. Nuts E. Canned salmon

B. Broccoli D. Nuts

The registered nurse is delegating client assignments to unlicensed assistive personnel. Which of the following clients does not require additional monitoring and assessment and may be delegated to unlicensed assistive personnel? A. A client who has been experiencing diarrhea and has a serum chloride level of 100 mEq/L B. A client with renal failure who has a serum magnesium level of 3.0 mEq/L C. A client who has experienced a fracture of the femur and has a serum phosphate of 5.0 mg/dl D. A client with dehydration who has a serum sodium level of 128 mEq/L

A. A client who has been experiencing diarrhea and has a serum chloride level of 100 mEq/L

A client is receiving an intravenous magnesium infusion to correct a serum level of 1.4 mEq/L. Which of the following assessments would alert the nurse to immediately stop the infusion? A. Absent patellar reflex B. Diarrhea C. Premature ventricular contractions D. Increase in blood pressure

A. Absent patellar reflex

A nurse reviews a client's laboratory report and notes that the client's serum phosphorus level is 2.0 mg/dL. Which condition most likely caused this serum phosphorus level? A. Alcoholism B. Renal insufficiency C. Hypoparathyroidism D. Tumor lysis syndrome

A. Alcoholism

A nurse instructs a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse determines that the client understands the food sources of potassium if the client states that the food item lowest in potassium is: A. Apples B. Carrots C. Spinach D. Avocado

A. Apples

The nurse assists a client with a serum potassium of 3.2 mEq/L to make which of the following menu selections? Select all that apply. A. Baked cod B. Ham and cheese omelet C. Fried eggs D. Baked potato E. Spinach

A. Baked cod D. Baked potato E. Spinach

Which of the following assessment findings would indicate to the nurse that a client's diabetic ketoacidosis is deteriorating? A. Deep tendon reflexes decreasing from +2 to +1 B. Bicarbonate rising from 20 mEq/L to 22 mEq/L C. Urine pH less than 6 D. Serum potassium decreasing from 6.0 mEq/L to 4.5 mEq/L

A. Deep tendon reflexes decreasing from +2 to +1

A nurse is reviewing a client's laboratory report and notes that the serum calcium level is 4.0 mg/dL. The nurse understands that which condition most likely caused this serum calcium level? A. Prolonged bed rest B. Renal insufficiency C. Hyperparathyroidism D. Excessive ingestion of vitamin D

A. Prolonged bed rest

The nurse is caring for a bedridden client admitted with multiple myeloma and a serum calcium level of 13 mg/dl. Which of the following is the most appropriate nursing action? A. Provide passive ROM exercises and encourage fluid intake B. Teach the client to increase intake of whole grains and nuts C. Place a tracheostomy tray at the bedside D. Administer calcium gluconate IM as ordered

A. Provide passive ROM exercises and encourage fluid intake

The telemetry monitor technician notifies the nurse of the morning telemetry readings. Which client should the nurse assess first? A. The client in normal sinus rhythm with a peaked T wave. B. The client diagnosed with atrial fibrillation with a rate of 100. C. The client diagnosed with a myocardial infarction who has occasional PVC. D. The client with a first-degree AV block and a rate of 92.

A. The client in normal sinus rhythm with a peaked T wave.

A nurse is reading a physician's progress notes in the client's record and reads that the physician has documented "insensible fluid loss of approximately 800 mL daily." The nurse understands that this type of fluid loss can occur through: A. The skin B. Urinary output C. Wound drainage D. The gastrointestinal tract

A. The skin

A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following clinical manifestations would the nurse expect to note in the client? A. Twitching B. Negative Trousseau's sign C. Hypoactive bowel sounds D. Hypoactive deep tendon reflexes

A. Twitching

A nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 3.2 mEq/L. Which of the following would the nurse note on the electrocardiogram as a result of the laboratory value? A. U waves B. Absent P waves C. Elevated T waves D. Elevated ST segment

A. U waves

The lungs act as an acid-base buffer by A. increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load. B. increasing respiratory rate and depth when CO2 levels in the blood are low, reducing base load. C. decreasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load. D. decreasing respiratory rate and depth when CO2 levels in the blood are low, increasing acid load.

A. increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load

If the blood plasma has a higher osmolality than the fluid within a red blood cell, the mechanism involved in equalizing the fluid concentration is A. osmosis. B. diffusion. C. active transport. D. facilitated diffusion.

A. osmosis.

A client with chronic renal failure receiving dialysis complains of frequent constipation. When performing discharge teaching, which over-the-counter products should the nurse instruct the client to avoid at home? A. Bisacodyl (Dulcolax) suppository B. Fiber supplements C. Docusate sodium D. Milk of magnesia

D. Milk of magnesia

The client has received IV solutions for three (3) days through a 20-gauge IV catheter placed in the left cephalic vein. On morning rounds the nurse notes the IV site is tender to palpation and a red streak has formed. Which action should the nurse implement first? A. Start a new IV in the right hand. B. Discontinue the intravenous line. C. Complete an incident record. D. Place a warm washrag over the site.

B. Discontinue the intravenous line.

6) The nurse is preparing to triage victims of a train derailment who are being transported to the Emergency Department. Which victim(s) would need immediate care? Select all that apply. A) Holding broken arm, sitting in a chair B) Respiratory rate of 8 and irregular C) Bleeding from fractured limb with a blood pressure of 78/40 mmHg D) Bleeding from superficial facial wounds and talking to family E) Walking with a slight limp, asking for something to drink

B,C

9) Which statement or statements accurately reflect the distinction between nursing diagnoses arrived at as part of the nursing process and medical diagnoses? Select all that apply. A) A nursing diagnosis is determined following an assessment and analysis of data gathered only by registered nurses; a medical diagnosis is determined following an assessment and analysis of data gathered only by physicians. B) A nursing diagnosis changes as the client's responses to an illness or health situation change; a medical diagnosis remains the same as long as the disease process persists. C) A nursing diagnosis describes a client's physical, sociocultural, psychological, and spiritual responses to an illness or health condition; a medical diagnosis refers to disease processes. D) A nursing diagnosis considers the etiology of the health problem to give direction to required nursing care; a medical diagnosis does not consider the etiology of the health problem to give direction to medical care.

B,C

4) The nurse is selected to participate on a committee to write critical pathways for a specific set of medical diagnoses. What will be the advantage(s) of using this approach when providing client care? Select all that apply. A) Link nursing diagnoses with specific assessment data B) Sequence the care that is to be given on a particular day C) Identify interventions, time frames, and expected outcomes D) List medical treatments to be performed by other providers E) Provide specific columns for diagnosis, interventions, and evaluation

B,C,D

2) The nurse is creating a four-column plan of care for a client. For which area(s) should the nurse prepare to document when creating this care plan? Select all that apply. A) Medications B) Nursing diagnosis C) Goals D) Interventions E) Evaluation

B,C,D,E

8) A client who has just been diagnosed with diabetes mellitus is being instructed by the nurse regarding diet and exercise. Which client statement or statements indicate that further teaching is required? Select all that apply. A) "I should talk to the doctor about an exercise program." B) "I don't need to watch my diet as long as I take my insulin." C) "I need to limit the amount of fat in my diet." D) "I should eat a candy bar when my energy is low." E) "I will test my blood sugar before meals and at bedtime."

B,D

13) A client begins to vomit blood. The nurse immediately measures the blood pressure and prepares to insert a nasogastric tube while directing others to notify the physician and prepare to perform iced saline lavage. Which feature(s) of the Tanner Clinical Judgment Model did this nurse demonstrate? Select all that apply. A) Presencing B) Noticing C) Empowerment D) Interpreting E) Responding

B,D,E

A client who had a recent surgery has been vomiting and becomes dizzy while standing up to go to the bathroom. After assisting the client back to bed, the nurse notes that the blood pressure is 55/30 and the pulse is 140. The nurse hangs which of the following IV fluids to correct this condition? A. D5.45 NS at 50 ml/hr B. 0.9 NS at an open rate C. D5W at 125 ml/hr D. 0.45 NS at open rate

B. 0.9 NS at an open rate

The nurse should monitor for clinical manifestations of hypophosphatemia in which of the following clients? A. A client with osteoporosis taking vitamin D and calcium supplements B. A client who is alcoholic receiving total parenteral nutrition C. A client with chronic renal failure awaiting the first dialysis run D. A client with hypoparathyroidism secondary to thyroid surgery

B. A client who is alcoholic receiving total parenteral nutrition

Which of the following should the nurse include in the diet teaching for a client with a sodium level of 158 mEq/L? A. Pretzels B. Baked chicken C. Chicken bouillon D. Baked potato E. Baked ham

B. Baked chicken D. Baked potato

The nurse writes the nursing problem of "fluid volume excess" (FVE). Which intervention should be included in the plan of care? A. Change the IV fluid from 0.9% NS to D5W. B. Restrict the client's sodium in the diet. C. Monitor blood glucose levels. D. Prepare the client for hemodialysis.

B. Restrict the client's sodium in the diet.

Thiazide diuretics cause the loss of water and potassium through the kidneys. Thus, if the client is not consuming sufficient potassium in the diet, a hypokalemic state could occur. Hypokalemia can cause muscle weakness and dysrhythmias. Hyponatremia is not usually a problem because there is an abundance of sodium in the body and the additional regulation of sodium by aldosterone would compensate for sodium loss due to diuretics Calcium level would be unaffected by thiazide diuretics. If magnesium were to be affected by thiazide diuretics, it would be excreted along with potassium, but the imbalance would be hypomagnesemia, not hypermagnesemia. The nurse is assisting a physician in obtaining a sample for blood gas analysis from a client's left wrist. After drawing the sample into the syringe, the nurse: A. Adds a drop of heparin to the sample to prevent clotting B. Seals the end of the syringe and places it in a cup of crushed ice water C. Places the syringe of blood in a dark bag to protect the specimen from light D. Seals the syringe in a zip-lock bag and places the specimen in the out box for laboratory pickup

B. Seals the end of the syringe and places it in a cup of crushed ice water

A nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is at risk for excess fluid volume? A. The client taking diuretics B. The client with renal failure C. The client with an ileostomy D. The client who requires gastrointestinal suctioning

B. The client with renal failure

The typical fluid replacement for the patient with an ICF fluid volume deficit is A. isotonic. B. hypotonic. C. hypertonic. D. a plasma expander.

B. hypotonic.

Tissue injury can cause an increase in WBC The majority of the body's water is contained in which of the following fluid compartments? A. interstitial B. intracellular C. extracellular D. intravascular

B. intracellular

An older adult with a history of small cell lung carcinoma reports muscle cramping, thirst, and fatigue. The primary healthcare provider diagnoses the client with a pituitary disorder and is treating the client accordingly. Which is an effective outcome of the treatment? A. Urine output of 10 L/day B. Urine specific gravity less than 1.025 C. Urine osmolarity of 80 mOsm/kg (80 mmol/kg) D.Serum osmolarity of 600 mOsm/kg (600 mmol/kg)

Because the specific gravity is less than 1.025 after treatment, the outcome is considered positive. In syndrome of inappropriate antidiuretic hormone (SIADH), the specific gravity is greater than 1.025. Small cell lung cancer is a risk factor of SIADH. Muscle cramping, thirst, and fatigue are clinical manifestations of SIADH. A serum osmolarity of 600 mOsm/kg indicates central diabetes insipidus. A urine output 10 L/day and a urine osmolarity of 80 mOsm/kg indicate diabetes insipidus.

A client with heart failure is complaining of nausea. The client has received IV furosemide (Lasix), and the urine output has been 2500 ml over the past 12 hours. The client's home drugs include metoprolol (Lopressor), digoxin (Lanoxin), furosemide, and multivitamins. Which of the following are the appropriate nursing actions before administering the digoxin? Select all that apply. A. Administer an antiemetic prior to giving the digoxin B. Encourage the client to increase fluid intake C. Call the physician D. Report the urine output E. Report indications of nausea

C. Call the physician D. Report the urine output E. Report indications of nausea

A client who is admitted with malnutrition and anorexia secondary to chemotherapy is also exhibiting generalized edema. The client asks the nurse for an explanation for the edema. Which of the following is the most appropriate response by the nurse? A. "The fluid is an adverse reaction to chemotherapy." B. "A decrease in activity has allowed extra fluid to accumulate in the tissues." C. "Poor nutrition has caused decreased blood protein levels, and fluid has moved from the blood vessels into the tissues." D. "Chemotherapy has increased your blood pressure, and fluid was forced out into the tissues."

C. "Poor nutrition has caused decreased blood protein levels, and fluid has moved from the blood vessels into the tissues."

An older adult client admitted with heart failure and a sodium level of 113 mEq/L is behaving aggressively toward staff and does not recognize family members. When the family expresses concern about the client's behavior, the nurse would respond most appropriately by stating A. "The client may be suffering from dementia, and the hospitalization has worsened the confusion." B. "Most older adults get confused in the hospital." C. "The sodium level is low, and the confusion will resolve as the levels normalize." D. "The sodium level is high and the behavior is a result of dehydration."

C. "The sodium level is low, and the confusion will resolve as the levels normalize."

Which of the following patients would be at greatest risk for the potential development of hypermagnesemia? A. 83-year-old man with lung cancer and hypertension B. 65-year-old woman with hypertension taking -adrenergic blockers C. 42-year-old woman with systemic lupus erythematosus and renal failure D. 50-year-old man with benign prostatic hyperplasia and a urinary tract infection

C. 42-year-old woman with systemic lupus erythematosus and renal failure

Individuals taking potassium-wasting diuretics are at risk for hypokalemia. Evaluating blood glucose level when the client reports weakness is important to ensure that low blood glucose level is not an issue. Levels of the other substances would not be affected by a potassium-wasting diuretic. The following four clients are all at risk for fluid volume excess. Which of the clients should the nurse see first? A. 88-year-old client with a fractured femur scheduled for surgery B. 20-year-old client with a 5-year history of type 1 diabetes mellitus C. 65-year-old client recently diagnosed with congestive heart failure D. 50-year-old client with second-degree burns on the ankles and feet

C. 65-year-old client recently diagnosed with congestive heart failure

The nurse evaluates which of the following clients to have hypermagnesemia? A. A client who has chronic alcoholism and a magnesium level of 1.3 mEq/L B. A client who has hyperthyroidism and a magnesium level of 1.6 mEq/L C. A client who has renal failure, takes antacids, and has a magnesium level of 2.9 mEq/L D. A client who has congestive heart disease, takes a diuretic, and has a magnesium level of 2.3 mEq/L

C. A client who has renal failure, takes antacids, and has a magnesium level of 2.9 mEq/L

The nurse is caring for a client with congestive heart failure. On assessment, the nurse notes that the client is dyspneic and that crackles are audible on auscultation. The nurse suspects excess fluid volume. What additional signs would the nurse expect to note in this client if excess fluid volume is present? A. Weight loss B. Flat neck and hand veins C. An increase in blood pressure D. A decreased central venous pressure (CVP)

C. An increase in blood pressure

A client with a serum sodium of 115 mEq/L has been receiving 3% NS at 50 ml/hr for 16 hours. This morning the client feels tired and short of breath. Which of the following interventions is a priority? A. Turn down the infusion B. Check the latest sodium level C. Assess for signs of fluid overload D. Place a call to the physician

C. Assess for signs of fluid overload

The client is admitted to a nursing unit from a long-term care facility with a hematocrit of 56% and a serum sodium level of 152 mEq/L. Which condition would be a cause for these findings? A. Overhydration. B. Anemia. C. Dehydration. D. Renal failure.

C. Dehydration.

A nurse caring for a client with severe malnutrition reviews the laboratory results and notes a magnesium level of 1.0 mg/dL. Which electrocardiographic change would the nurse expect to note based on the magnesium level? A. Prominent U waves B. Prolonged PR interval C. Depressed ST segment D. Widened QRS complexes

C. Depressed ST segment

The client with acute renal failure is at the highest risk of hypocalcemia. While the patient who underwent a thyroidectomy is at risk, the client with acute renal failure is at a higher risk. Clinical assessment of dehydration would be confirmed if the nurse identified: A. 1-lb weight loss B. Engorged neck vessels C. Dry mucous membranes D. Full bounding radial pulse

C. Dry mucous membranes

A nurse is caring for a client with acute congestive heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia were present? A. Dry skin B. Decreased urinary output C. Hyperactive bowel sounds D. Increased specific gravity of the urine

C. Hyperactive bowel sounds

A client with a small bowel obstruction has had an NG tube connected to low intermittent suction for two days. The nurse should monitor for clinical manifestations of which acid-base disorder? A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis

C. Metabolic alkalosis (

The nurse is conducting an assessment of a client receiving intravenous (IV) fluids via a central line. Today is March 9. The tubing is dated March 5. The nurse determines that the tubing: A. Is good for 3 more days, for a total of 7 days B. Can remain in place as long as there is not a disconnection C. Needs changing because it is beyond the 3-day recommended limit D. Needs changing, along with the IV port, because they have been in place for 4 days

C. Needs changing because it is beyond the 3-day recommended limit

The registered nurse is delegating nursing tasks for the day. WHich of the following tasks may the nurse delegate to a licensed practical nurse? A. Assess a client for metabolic acidosis B. Evaluate the blood gases of a client with respiratory alkalosis C. Obtain a glucose level on a client admitted with diabetes mellitus D. Perform a neurological assessment on a client suspected of having hypocalcemia

C. Obtain a glucose level on a client admitted with diabetes mellitus

The client who has undergone an exploratory laparotomy and subsequent removal of a large intestinal tumor has a nasogastric tube (NGT) in place and an IV running at 150 mL/hr via an IV pump. Which data should be reported to the health care provider? A. The pump keeps sounding an alarm that the high pressure has been reached. B. Intake is 1800 mL, NGT output is 550 mL, and Foley output 950 mL. C. On auscultation, crackles and rales in all lung fields are noted. D. Client has negative pedal edema and an increasing level of consciousness.

C. On auscultation, crackles and rales in all lung fields are noted.

A client with pneumonia presents with the following arterial blood gases: pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and PO2 of 45, which of the following is the most appropriate nursing intervention? A. Administer a sedative B. Place client in left lateral position C. Place client in high-Fowler's position D. Assist the client to breathe into a paper bag

C. Place client in high-Fowler's position

A client with a recent thyroidectomy complains of numbness and tingling around the mouth. Which of the following findings indicates the serum calcium is low? A. Bone pain B. Depressed deep tendon reflexes C. Positive Chvostek's sign D. Nausea

C. Positive Chvostek's sign

A client with a history of cardiac disease is taking a potassium-wasting diuretic (furosemide) and is seen in the emergency department for complaints of weakness. The nurse expects to evaluate which laboratory values? A. Albumin and protein levels B. Sodium and chloride levels C. Potassium and blood glucose levels D. Hemoglobin level and hematocrit

C. Potassium and blood glucose levels

A nurse caring for a client with hypocalcemia would expect to note which of the following changes on the electrocardiogram? A. Widened T wave B. Prominent U wave C. Prolonged QT interval D. Shortened ST segment

C. Prolonged QT interval

The client has been vomiting and has had numerous episodes of diarrhea. Which laboratory test should the nurse monitor? A. Serum calcium. B. Serum phosphorus. C. Serum potassium. D. Serum sodium.

C. Serum potassium.

A nurse is caring for a client with a nasogastric tube. Nasogastric tube irrigations are prescribed to be performed once every shift. The client's serum electrolyte results indicate a potassium level of 4.5 mEq/L and a sodium level of 132 mEq/L. Based on these laboratory findings, the nurse selects which solution to use for the nasogastric tube irrigation? A. Tap water B. Sterile water C. Sodium chloride D. Distilled water

C. Sodium chloride

Which statement best explains the scientific rationale for Kussmaul's respirations in the client diagnosed with diabetic ketoacidosis (DKA)? A. The kidneys produce excess urine and the lungs try to compensate. B. The respirations increase the amount of carbon dioxide in the bloodstream. C. The lungs speed up to release carbon dioxide and increase the pH. D. The shallow and slow respirations will increase the HCO3 in the serum.

C. The lungs speed up to release carbon dioxide and increase the pH.

A client with a potassium level of 5.5 mEq/L is to receive sodium polystyrene sulfonate (Kayexalate) orally. After administering the drug, the priority nursing action is to monitor A. urine output. B. blood pressure. C. bowel movements. C. ECG for tall, peaked T waves.\

C. bowel movements.

A client with renal failure enters the emergency room after skipping three dialysis treatments to visit family out of town. Which set of ABGs would indicate to the nurse that the client is in a state of metabolic acidosis? A. pH of 7.43, PCO2 of 36, HCO3 of 26 B. pH of 7.41, PCO2 of 49, HCO3 of 30 C. pH of 7.33, PCO2 of 35, HCO3 of 17 D. pH of 7.25, PCO2 of 56, HCO3 of 28

C. pH of 7.33, PCO2 of 35, HCO3 of 17

It is especially important for the nurse to assess for which of the following in a patient who has just undergone a total thyroidectomy? A. weight gain B. depressed reflexes C. positive Chvostek's sign D. confusion and personality changes

C. positive Chvostek's sign

A patient is receiving a loop diuretic. The nurse should be alert to which of the following symptoms? A. restlessness and agitation B. paresthesias and irritability C. weak, irregular pulse and poor muscle tone D. increased blood pressure and muscle spasms

C. weak, irregular pulse and poor muscle tone

What is important nursing care for pediatric clients with leukemia on chemotherapeutic protocols? A. Preventing physical activity B. Taking vitals every 2 hours C. Having them avoid contact with infected persons D. Reduce unnecessary environmental stimuli

Chemotherapy and acute lymphoblastic leukemia (ALL) cause immunosuppression (low white blood cells), thus increasing the risk for infection. Avoiding contact with infected persons is a necessary precaution. The client should maintain physical activity that can be tolerated. Although vital signs must be checked to assess for changes in pulse or blood pressure, unless there is clinical evidence of bleeding, it is not necessary to obtain vital signs every 2 hours. Children need stimulation that is appropriate for their developmental level except when acutely ill.

The nurse assesses a client to be experiencing muscle cramps, numbness, and tingling of the extremities, and twitching of the facial muscle and eyelid when the facial nerve is tapped. THe nurse reports this assessment as consistent with which of the following? A. Hypokalemia B. Hypernatremia C. Hypermagnesemia D. Hypocalcemia

D. Hypocalcemia

A client with pancreatitis has been receiving potassium supplementation for four days since being admitted with a serum potassium of 3.0 mEq/L. Today the potassium level is 3.1 mEq/L. Which of the following laboratory values should the nurse check before notifying the physician of the client's failure to respond to treatment? A. Sodium B. Phosphorus C. Calcium D. Magnesium

D. Magnesium

A client is receiving intravenous potassium supplementation in addition to maintenance fluids. The urine output has been 120 ml every 8 hours for the past 16 hours and the next dose is due. Before administering the next potassium dose, which of the following is the priority nursing action? A. Encourage the client to increase fluid intake B. Administer the dose as ordered C. Draw a potassium level and administer the dose if the level is low or normal D. Notify the physician of the urine output and hold the dose

D. Notify the physician of the urine output and hold the dose

The client is admitted with a serum sodium level of 110 mEq/L. Which nursing intervention should be implemented? A. Encourage fluids orally. B. Administer 10% saline solution IVPB. C. Administer antidiuretic hormone intranasally. D. Place on seizure precautions.

D. Place on seizure precautions.

A nursing student needs to administer potassium chloride intravenously as prescribed to a client with hypokalemia. The nursing instructor determines that the student is unprepared for this procedure if the student states that which of the following is part of the plan for preparation and administration of the potassium? A. Obtaining a controlled IV infusion pump B. Monitoring urine output during administration C. Diluting in appropriate amount of normal saline D. Preparing the medication for bolus administration

D. Preparing the medication for bolus administration

A nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L. The nurse reports the serum sodium level to the physician and the physician prescribes dietary instructions based on the sodium level. Which food item does the nurse instruct the client to avoid? A. Peas B. Cauliflower C. Low-fat yogurt D. Processed oat cereals

D. Processed oat cereals

A client who suffers from an anxiety disorder is very upset, has a respiratory rate of 32, and is complaining of lightheadedness and tingling in the fingers. ABG values are pH of 7.48, PaCO2 of 29, HCO3 of 24, and O2 is at 93% on room air. The nurse performs which of the following as a priority nursing intervention? A. Monitor intake and output B. Encourage client to increase activity C. Institute deep breathing exercises every hour D. Provide reassurance to the client and administer sedatives

D. Provide reassurance to the client and administer sedatives

A nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.4 mEq/L. Which of the following would the nurse expect to note on the electrocardiogram as a result of the laboratory value? A. ST depression B. Inverted T wave C. Prominent U wave D. Tall peaked T waves

D. Tall peaked T waves

A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a potassium level of 5.5 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a potassium value at this level? A. The client with colitis B. The client with Cushing's syndrome C. The client who has been overusing laxatives D. The client who has sustained a traumatic burn

D. The client who has sustained a traumatic burn

After reviewing the urinalysis reports of a client with kidney dysfunction, the nurse suspects the presence of myoglobin. Which finding in the test reports supports the nurse's suspicion? A. Red-color urine B. Brown-color urine C. Amber-colored urine D. Very pale yellow urine

Red-colored urine in clients with kidney dysfunction indicates the presence of myoglobin. Brown-colored urine indicates increased bilirubin levels. Dark amber urine indicates concentrated urine. Very pale yellow urine indicates dilute urine.

What hormones are secreted by the hypothalamus? (Select all that apply) A. Growth Hormone B. Follicle stimulating hormone C. Prolactin inhibiting hormone D. Corticotrophin-releasing hormone E. Melanocyte-stimulating hormone

The hormones that are secreted by the hypothalamus include prolactin-inhibiting hormone and corticotropin-releasing hormone. Growth hormone, follicle-stimulating hormone, and melanocyte-stimulating hormone are hormones secreted by the anterior pituitary gland.

The nurse explains that with the exposure to an antigen, the initiator of the inflammatory response is the presence of histamine, which is released by the: A. monocytes. B. neutrophils. C. basophils. D. eosinophils.

basophils

A client's blood pressure (BP) is 145/90. According to the guidelines for determining hypertension, the nurse realizes that the client's BP is at which stage? a. Normal b. Prehypertension c. Stage 1 hypertension d. Stage 2 hypertension

c

A nurse who is giving a statin(Lipitor) realizes the importance of monitoring for which serious adverse reaction? a. Pharyngitis b. Rash/pruritus c. Rhabdomyolysis d. Agranulocytosis

c

sickle cell anemia

a genetic disorder that causes abnormal hemoglobin, resulting in some red blood cells assuming an abnormal sickle shape

Schizophrenia

a psychological disorder characterized by delusions, hallucinations, disorganized speech, and/or diminished, inappropriate emotional expression

Hypokalemia is almost universal complication of loss of gastric hydrochloric acid. Metabolic alkalosis results. Other electrolytes may be affected, but not to the degree of potassium homeostasis is altered. The nurse should observe for a Trousseau sign in the client with which of the following electrolyte abnormalities? a. Hypokalemia b. Hyponatremia c. Hypochloremia d. Hypocalcemia

d. Hypocalcemia

An older, sedentary adult may not respond to emotional or physical stress as well as a younger individual because of: a. Left ventricular atrophy b. Irregular heartbeats c. Peripheral vascular occlusion d. Pacemaker placement

a. In older adults who are less active and do not exercise the heart muscle, atrophy can result. Disuse or deconditioning can lead to abnormal changes in the myocardium of the older adult. As a result, under sudden emotional or physical stress, the left ventricle is less able to respond to the increased demands on the myocardial muscle. Decreased cardiac output, cardiac hypertrophy, and heart failure are examples of the chronic conditions that may develop in response to inactivity, rather than in response to the aging process. Irregular heartbeats are generally not associated with an older sedentary adult's lifestyle. Peripheral vascular occlusion or pacemaker placement should not affect response to stress.

The nurse should understand that which of the following treatments for Second Degree Type II AV Block would be appropriate? (Select all that apply) a. Temporary pacemaker insertion b. Close monitoring without intervention c. Atropine to increase heart rate if symptomatic d. Coronary stent placement to improve blood flow to myocardium e. An implantable defibrillator surgically implanted

a. Temporary pacemaker insertion c. Atropine to increase heart rate if symptomatic d. Coronary stent placement to improve blood flow to myocardium Rationale: Rationale: a,c, and d are correct. Temporary pacing may be needed and atropine will temporarily improve heart rate cardiac output until the pacemaker can be inserted. b. is incorrect because Type II has a tendency to develop complete heart block where adequate cardiac output is not maintained and arrest is likely. Type I can be monitored and minimal treatment is needed unless unstable hemodynamics are present. e. is incorrect because a defibrillator is not called for since it is the ventricle that is trying to maintain the cardiac output from the decreased conduction between the atria and the ventricles. An implanted pacemaker may be needed permanently.

You are the charge nurse on the telemetry unit and are responsible for making client assignments. Which client would be appropriate to assign to the float RN from the medical-surgical unit? a. The 64-year-old admitted for weakness who has a first-degree heart block with a heart rate of 58 beats/min b. The 71-year-old admitted for heart failure who is short of breath and has a heart rate of 120 to 130 beats/min c. The 88-year-old admitted with an elevated troponin level who is hypotensive with a heart rate of 96 beats/min d. The 92-year-old admitted with chest pain who has premature ventricular complexes and a heart rate of 102 beats/min

a. The 64-year-old admitted for weakness who has a first-degree heart block with a heart rate of 58 beats/min Rationale: This client has a stable, asymptomatic dysrhythmia, which usually requires no treatment; this client can be managed by a nurse with less cardiac dysrhythmia training.

When planning care for a client receiving treatment for cardiac dysrhythmias, an appropriate client outcome would be: a. The client will avoid use of caffeine during therapy. b. The client will maintain heart rate below 60 beats per minute. c. The client will limit fluid intake to 1000 ml/day. d. The client will limit cigarettes to 15/day.

a. The client will avoid use of caffeine during therapy. Causes of dysrhythmias include electrolyte imbalance, hyperthyroidism, anxiety, caffeine ingestion, and tobacco use. The client should be taught to avoid caffeine and tobacco.

Output recorded on an I/O sheet would be all of these: Urine Diarrhea Vomit Gastric suction Wound drainage Health promotion activities in the area of fluid and electrolyte imbalance focus primarily on: a. client teaching b. dietary intake c. medication d. physician involvement in care

a. client teaching

Many factors are intially controlled for the IV insertion procedure. This nurse understands this begins with: a. hand washing b. checking sterility of supplies c. 6 med rights d. checking IV order

a. hand washing

Hypersensitivity

an exaggerated response by the immune system to a particular substance

iron deficiency anemia

anemia caused by inadequate iron intake

A client has developed uncontrolled atrial fibrillation with a ventricular rate of 150 beats/min. What manifestation should the nurse observe for when performing the client's focused assessment? a. Flat neck veins b. Nausea and vomiting c. Hypotension and dizziness d. Clubbed fingertips and headache

d. Hypotension and dizziness

One of the most common electrolyte imbalances is: Hypokalemia The client most at risk for fluid volume defecit (FVD) is: a. Elder adult b. Adult c. Child d. Infant

d. Infant

A nurse who is auscultating a 56-year-old client's apical heart rate before administering digoxin (Lanoxin) notes that the heart rate is 52 beats/min. The nurse should make which interpretation about this information? a. Normal, because of the client's age b. Abnormal, requiring further assessment c. Normal, as a result of the effects of digoxin d. Normal, because this is the reason the client is receiving digoxin

b. Abnormal, requiring further assessment

The nurse is caring for a client with unstable angina whose cardiac monitor shows ventricular tachycardia. Which action is appropriate to implement first? a. Defibrillate the client at 200 J. b. Check the client for a pulse. c. Cardiovert the client at 50 J. d. Give the client IV lidocaine.

b. Check the client for a pulse. Rationale: The nurse needs to assess the client to determine stability before proceeding with further interventions. If the client has a pulse and is relatively stable, elective cardioversion or antidysrhythmic medications may be prescribed.

Which of the following is an expected outcome when a client is receiving an IV administration of furosemide? a. Increased blood pressure b. Increased urine output c. Decreased pain d. Decreased premature ventricular contractions

b. Furosemide is a loop diuretic that acts to increase urine output. Furosemide does not increase blood pressure, decrease pain, or decrease arrhythmias

One reason older adults experience fluid and electrolyte imbalance and acid-base imbalances, is they: a. Eat poor quality foods b. Have a decreased thirst sensation c. have more stress response d. have an overly active thirst response

b. Have a decreased thirst sensation

Furosemide inhibits reabsorption of sodium, water, and K leading to diuresis. ** The most common electrolyte disturbance associated with furosemde admin is hypokalemia Nurse inserts a nasogastric tube, and it immediately drains 1000 mL of fluid. Which of the follwoing electrolyte level is of greatest concern at this time? a. Na b. K c. Cl d. CO2

b. K

A client with a diagnosis of cardiac dysrhythmias and a history of type I diabetes mellitus is placed on propranolol therapy. The client asks the nurse if the drug will affect insulin needs. The best response by the nurse would be that: a. The drug will have no effect on insulin needs. b. The drug might cause hypoglycemia. c. The drug could cause hyperglycemia. d. The client should ask the physician this question.

b. The drug might cause hypoglycemia. There is increased incidence of hypoglycemia with type I diabetes mellitus, because propranolol can inhibit glycogenolysis.

Nurse would be most concerned about which lab values obtained fro ma client receiving furosemide (Lasix) therapy? a. BUN 20 b. K 3.4 c. Creatinine 1.1 d. K 3.2

d. K = 3.2

A client taking spironolactone (Aldactone) [potassium-sparing diuretic] has been taught about the therapy. Which menu selection indicates that the client understands teaching related to this medication? a. Apricots b. Bananas c. Fish d. Strawberries

c. Spironolactone is a potassium-sparing diuretic that could potentially cause hyperkalemia. Fish is an appropriate dietary choice, because it is low in potassium. The other foods are high in potassium.

When a patient has long-term atrial fibrillation, the nurse would expect to include which drug in the plan of care to minimize the greatest risk that is commonly associated with atrial fibrillation? a. Beta blockers b. Digitalis c. Anticoagulants d. Antiarrhythmics

c. Anticoagulants Rationale: c. is correct because it reflects the greatest risk or complication of thrombi or emboli that occurs with long-term atrial fibrillation. Coumadin is often given prophylactically to prevent stroke, clots, or emboli from developing when hospitalizing a patient with long-term atrial fibrillation.

A 58-year-old female with a family history of CAD is being seen for her annual physical exam. Fasting lab test results include: Total cholesterol 198; LDL cholesterol 120; HDL cholesterol 58; Triglycerides 148; Blood sugar 102; and C-reactive protein (CRP) 4.2. The health care provider informs the client that she will be started on a statin medication and aspirin. The client asks the nurse why she needs to take these medications. Which is the best response by the nurse? a. "The labs indicate severe hyperlipidemia and the medications will lower your LDL, along with a low-fat diet." b. "The triglycerides are elevated and will not return to normal without these medications." c. "The CRP is elevated indicating inflammation seen in cardiovascular disease, which can be lowered by the medications ordered." d. "The medications are not indicated since your lab values are all normal."

c. CRP is a marker of inflammation and is elevated in the presence of cardiovascular disease. The high sensitivity CRP (hs-CRP) is the blood test for greater accuracy in measuring the CRP to evaluate cardiovascular risk. The family history, post-menopausal age, LDL above optimum levels and elevated CRP place the client at risk of CAD. Statin medications can decrease LDL, whereas statins and aspirin can reduce CRP and decrease the risk of MI and stroke.

The nurse explains that medication being given to a client with a severe inflammatory response mimics a hormone secreted by the adrenal cortex. This hormone is: A. cortisol. B. aldosterone. C. histamine. D. testosterone.

cortisol

Captopril (Capoten) has been ordered for a client. The nurse teaches the client that ACE inhibitors have which common side effects? a. Nausea and vomiting b. Dizziness and headaches c. Upset stomach d. Constant, irritating cough

d

The nurse is assessing clients at a health fair. Which client is at greatest risk for coronary artery disease? a. a 32-year-old female with mitral valve prolapse who quit smoking 10 years ago. b. a 43-year-old male with a family history of CAD and cholesterol level of 158 c. A 56-year-old male with an HDL of 60 who takes atorvastatin (Lipitor) d. A 65-year-old female who is obese with an LDL of 188

d. The woman who is 65-years-old, over weight and has an elevated LDL is at greatest risk. Total cholesterol >200, LDL >100, HDL <40 in men, HDL <50 in women, men 45-years and older, women 55-years and older, smoking and obesity increase the risk of CAD. Atorvastatin is a medication to reduce LDL and decrease risk of CAD. The combination of postmenopausal, obesity and high LDL cholesterol places this client at greatest risk.

Hypocalcemia causes excitability of skeletal, cardiac, and smooth muscle tissues. Evidence of this is seen in the Trousseau sign, a carpopedal spasm. The WBC count of a client is 18,000. the nurse attributes this value to which of the following health problems of this client? a. arthritis b. alcoholism c. viral infection d. wound dehisience

d. wound dehisience

coronary artery disease

disease of the arteries surrounding the heart

Thyroid disease

disorders resulting from defects of the thyroid gland, can be genetic or acquired, results in either an increase or decrease in metabolism, controlled by drugs or surgery

chronic renal failure

gradual and progressive loss of kidney function

Increased metabolism at the inflammation site causes what?

heat

nosocomial infection

hospital acquired infection

fluid volume excess

hypervolemia: water intoxication d/t excessive Na intake, IVF,CRF, CHF, SIADH, • S/s: ^HR, ^BP, distended neck veins, dysrthymias, ^RR, altered LOC, ^UO, pitting edema, diarrhea, • Rx: diuretics, restrict fluid/Na, monitor I&O, monitor daily weight

fluid volume deficit

hypovolemia, dehydration, diarrhea, DI. • S/s: ^HR, hypotension, dysrhythmias, ^RR, dyspnea, lethargic, weakness, decreased UO, tenting, constipation • Rx: IVF, O2

A patient with an open abdominal wound has a complete blood cell (CBC) count and differential, which indicate an increase in white blood cells (WBCs) and a shift to the left. The nurse anticipates that the next action will be to a. obtain wound cultures. b. start antibiotic therapy. c. redress the wound with wet-to-dry dressings. d. continue to monitor the wound for purulent drainage.

obtain wound culture

cerebral palsy

paralysis caused by damage to the area of the brain responsible for movement

Thermoregulation

the maintenance of body temperature within a range that enables cells to function efficiently.

spinal cord injury

the type of paralysis is determined by the level of the vertebra closest to the injury

HIV/AIDS

the virus that causes AIDS, spread through bodily fluids rather than casual contact or airborne

A 76-year-old patient has an open surgical wound on the abdomen that contains a creamy exudate and small areas of deep pink granulation tissue. The nurse documents the wound as a a. red wound. b. yellow wound. c. full-thickness wound. d. stage III pressure wound.

yellow wound