CHRONIC FINAL

Glaucoma

increased intraocular pressure

What puts people at a higher risk for macular degeneration?

Smoking

Antagonist of Heparin

protamine sulfate

A patient is being discharged after surgery to correct a detached retina. Which symptoms will the nurse teach the patient to report immediately to the provider? Select all that apply.

- Pain in the eye - Fever of 102 - Purulent drainage in the post op eye Purulent: Consisting of, containing, or discharging pus.

military bereavement

- starts with a knock on the door - dignified transfer to Dover Air Force Base - buried in full dress uniform

Rapid Acting Insulin Peak

1 hour

Magnesium Levels

1.3-2.1

Intermediate Insulin Onset

2 hours

What pressure is Glaucoma?

22 to 32 mmHg

Long Acting Insulin Duration

24 hours

Potassium Levels

3.5-5

Short Acting Insulin Onset

30 minutes

esophagus usually has pH of

6 to 8

What does Phosphorus deal with?

ATP function

Location of Arterial Ulcers

Tips of toes Top of feet Pale, necrotic, black

Nursing Interventions for Gastritis

Treat H. pylori with Bismuth, Amoxicillin, and Flagyl b12 supplements

The nurse is providing dietary instructions to a patient who is immobile and experiencing frequent episodes of constipation. The patient complains that the constipation is uncomfortable. The nurse should tell the patient which food item would be most helpful to include in the diet?

Whole Grain Bread *Patient needs to include high fiber food in their diet.The only choice is whole grains. Cabbage is a gas forming food, could increase discomfort.

Edema with venous disease?

YES

What is a cataract?

a lens opacity that distorts the image * Lens will enlarge causing increased IOP resulting in glaucoma

Dysphagia & Odynophagia:

difficulty or painful swallowing

Drug Therapy for GERD: Antacids:

elevate pH and deactive pepsin

Regurgitation

food entering throat without nausea

Best "prevention" of glaucoma is?

getting eye examinations done frequently based on your age

Hypomagnesemia Symptoms

increased DTR, hypertension, seizures, tetany, confusion, depression

Hyperphosphatemia Symptoms

increased DTR, tetany/twitching, paresthesia, weak bones

Which electrolyte is essential for enzyme and neurochemical activities?

magnesium

Dyspnea near death tx:

morphine sulfate

Hypocalcemia Symptoms

muscle spasms, tetany (involuntary contraction), paresthesia (numbness), trousseau sign (BP cuff inflated causes finger twitching/palmar flexion), Chvostek's sign (tap cheek, face twitches), osteoporosis

Mary is admitted in the hospital due to having lower than normal potassium level. Her medical history reveals vomiting and diarrhea prior to hospitalization. Which foods should the nurse instruct the client to increase in her diet upon discharge?

orange juice and bananas.

What are some signs/symptoms of DKA?

polyuria, polydipsia, polyphagia

Wet AMD

sudden growth of new vessels in macular region that are fragile and leak blood/fluid which damages the macula by interfering with the blood supply

Hypersalivation:

water brash in response to reflux

Nursing Diagnosis for GERD

○ Impaired Nutrition: Less than body requirements ○ Acute Pain r/t irritation of esophagus ○ Risk for Aspiration r/t reflux of gastric contents

The nurse is caring for a terminally ill toddler. When interacting with the toddler's parents, the nurse should implement which interventions? Select all that apply. 1.Retain ritualism. 2.Avoid significant changes in lifestyle. 3.Maintain sensitivity toward the parents. 4.Encourage the parents to be near the child. 5.Encourage as normal an environment as possible. 6.Discourage the parents from verbalizing their feelings.

1, 2, 3, 4, 5 Once infants and toddlers have established trust with a parent, separation from the parent, even if temporary, is profound. Prolonged separation during the first several years is thought to be more significant in terms of future physical, social, and emotional growth than at any subsequent age. The parents of a terminally ill toddler should be assisted in verbalizing and dealing with their feelings and encouraged to remain as near to the child as possible. It is also important to maintain as normal an environment as possible to retain ritualism.

The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum sodium level to the health care provider (HCP) and the HCP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume? Select all that apply. 1.Peas 2.Nuts 3.Cheese 4.Cauliflower 5.Processed oat cereals

1, 2, 4 The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A serum sodium level of 150 mEq/L (150 mmol/L) indicates hypernatremia. On the basis of this finding, the nurse would instruct the client to avoid foods high in sodium. Peas, nuts, and cauliflower are good food sources of phosphorus and are not high in sodium (unless they are canned or salted). Peas are also a good source of magnesium. Processed foods such as cheese and processed oat cereals are high in sodium content.

The nurse recognizes that which interventions are likely to facilitate effective communication between a dying client and family? Select all that apply. 1.The nurse encourages the client and family to identify and discuss feelings openly. 2.The nurse assists the client and family in carrying out spiritually meaningful practices. 3.The nurse removes autonomy from the client to alleviate any unnecessary stress for the client. 4.The nurse makes decisions for the client and family to relieve them of unnecessary demands. 5.The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger.

1, 2, 5 Maintaining effective and open communication among family members affected by death and grief is of the greatest importance. Option 1 describes encouraging discussion of feelings and is likely to enhance communication. Option 2 is also an effective intervention because spiritual practices give meaning to life and have an impact on how people react to crisis. Option 5 is also an effective technique because the client and family need to know that someone will be there who is supportive and nonjudgmental. The remaining options describe the nurse removing autonomy and decision making from the client and family, who are already experiencing feelings of loss of control in that they cannot change the process of dying. These are ineffective interventions that could impair communication further.

Which interventions should the nurse take for a deceased client whose eyes will be donated? Select all that apply. 1.Close the client's eyes. 2.Elevate the head of the bed. 3.Place a warm compress on the eyes. 4.Place a dry sterile dressing over the eyes. 5.Place wet saline gauze pads and a cool pack on the eyes.

1, 2, 5 When a cornea donor dies, the eyes are closed, the head of the bed is elevated to prevent edema, and gauze pads wet with saline are placed over the eyes with a cool pack or small ice pack. Antibiotic eyedrops may also be prescribed. A warm compress will promote edema. Placing dry sterile dressings over the eyes serves no useful purpose. Within 2 to 4 hours the eyes are enucleated. The cornea is usually transplanted within 24 to 48 hours.

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply. 1.U waves 2.Absent P waves 3.Inverted T waves 4.Depressed ST segment 5.Widened QRS complex

1, 3, 4 The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level lower than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Potassium deficit is an electrolyte imbalance that can be potentially life-threatening. Electrocardiographic changes include shallow, flat, or inverted T waves; ST segment depression; and prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular rhythms. A widened QRS complex may be noted in hyperkalemia and in hypermagnesemia. Focus on the subject, the ECG patterns that may be noted with a client with a potassium level of 2.5 mEq/L (2.5 mmol/L). From the information in the question, you need to determine that the client is experiencing severe hypokalemia. From this point, you must know the electrocardiographic changes that are expected when severe hypokalemia exists.

Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)? 1.The client who is taking diuretics 2.The client with hyperaldosteronism 3.The client with Cushing's syndrome 4.The client who is taking corticosteroids

1, The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A serum sodium level of 130 mEq/L (130 mmol/L) indicates hyponatremia. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with hyperaldosteronism or Cushing's syndrome are at risk for hypernatremia. Also, recall that when a client takes a diuretic, the client loses fluid and electrolytes.

The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? 1.Weight loss and poor skin turgor 2.Lung congestion and increased heart rate 3.Decreased hematocrit and increased urine output 4.Increased respirations and increased blood pressure

1. A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Assessment findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased central venous pressure (CVP) (normal CVP is between 4 and 11 cm H2O), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. Lung congestion, increased urinary output, and increased blood pressure are all associated with fluid volume excess.

The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit? 1.A client with an ileostomy 2.A client with heart failure 3.A client on long-term corticosteroid therapy 4.A client receiving frequent wound irrigations

1. A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with heart failure or on long-term corticosteroid therapy or a client receiving frequent wound irrigations is most at risk for fluid volume excess.

A terminally ill client asks the nurse about hospice care and the nurse educates the client about the hospice program. Which statement by the client indicates that teaching has been effective? 1."Clients have a prognosis of 6 months or less to live." 2."Clients have a prognosis of 10 months or less to live." 3."Clients have a prognosis of 12 months or less to live." 4."Clients have a prognosis of 18 months or less to live."

1. For admission to hospice care, the client must desire the services and the client to be admitted has a prognosis of 6 months or less to live. In hospice care, care is provided when curative treatment such as chemotherapy has been stopped. Care is provided in 60- and 90-day periods with an opportunity to continue if eligibility criteria are met. Ongoing care is provided by registered nurses, social workers, chaplains, and volunteers.Therefore, the lengths of times in the remaining options are incorrect.

The nurse is caring for a terminally ill child who is receiving palliative care. When explaining the purpose of palliative care to the child's caregiver, the nurse recognizes the need for additional instruction when the caregiver makes which statement? 1."Palliative care interventions hasten death." 2."Palliative care promotes optimal functioning." 3."Palliative care will provide pain management." 4."Palliative care will provide symptom management."

1. Palliative care interventions do not serve to hasten death; rather, they provide pain and symptom management, attention to issues faced by the child and family with regard to death and dying, and promotion of optimal functioning and quality of life.

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? 1.Twitching 2.Hypoactive bowel sounds 3.Negative Trousseau's sign 4.Hypoactive deep tendon reflexes

1. The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea. Note that the three incorrect options are comparable or alike in that they reflect a hypoactivity. The option that is different is the correct option.

The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL (0.45 mmol/L). Which condition most likely caused this serum phosphorus level? 1.Malnutrition 2.Renal insufficiency 3.Hypoparathyroidism 4.Tumor lysis syndrome

1. The normal serum phosphorus (phosphate) level is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L). The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide-based or magnesium-based antacids. Renal insufficiency, hypoparathyroidism, and tumor lysis syndrome are causative factors of hyperphosphatemia.

The nurse caring for a terminally ill client has developed a close relationship with the client's family. Which interventions should the nurse include in dealing with the family during this difficult time? Select all that apply. 1.Making decisions for the family 2.Encouraging family discussion of feelings 3.Accepting the family's expressions of anger 4.Preserving the family's sense of self-direction and control 5.Maintaining open communication among family members 6.Facilitating the use of spiritual practices identified by the family

2, 3, 4, 5, 6 Maintaining effective and open communication among family members affected by death and grief is of utmost importance. The nurse needs to maintain and enhance communication as well as preserve the family's sense of self-direction and control. The incorrect option removes autonomy and decision-making from the family at a time when they are already experiencing feelings of loss of control. This is an ineffective intervention that could impair communication. Encouraging family discussion of feelings and maintaining open communication among family members are likely to enhance communication. Spiritual practices give meaning to life and have an impact on how people react to crisis, so this option should be included. Accepting the family's expression of anger and preserving the family's sense of self-direction and control are effective techniques, so that the family knows there is someone there who is supportive and nonjudgmental.

The nurse monitors a terminally ill client for which physical signs of approaching death? Select all that apply. 1.Increased appetite 2.Loss of consciousness 3.Loss of bowel control 4.Loss of bladder control 5.Decreased blood pressure 6.Decreased tactile sensation

2, 3, 4, 5, 6 Physical signs of approaching death include decreased appetite and thirst, decreased blood pressure, loss of consciousness, loss of bowel and bladder control, and decreased tactile sensation.

The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply. 1.Peas 2.Raisins 3.Potatoes 4.Cantaloupe 5.Cauliflower 6.Strawberries

2, 3, 4, 6 The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Common food sources of potassium include avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, and tomatoes. Peas and cauliflower are high in magnesium.

The nurse is monitoring ongoing care for a potential organ donor who has been diagnosed with brain death. Which finding indicates to the nurse that the standard for ongoing care has been maintained? 1.PaO2 70 mm Hg 2.Urine output 100 mL/hr 3.Heart rate 52 beats/min 4.Blood pressure 90/48 mm Hg

2. Adequate perfusion must be maintained to all vital organs in order for the client to remain viable as an organ donor. Guidelines may be used to maintain organ viability, but adequate perfusion is necessary. The correct option is the only one that indicates adequate perfusion. The incorrect options identify lower than normal values, thus adequate perfusion would not be maintained.

The nurse is caring for a client who is terminally ill. When assessing the client, the nurse recognizes which as the most common distress symptom near the end of life? 1.Pain 2.Anxiety 3.Depression 4.Withdrawal

2. Anxiety is the most common distress symptom near the end of life. Anxiety is an uneasy feeling whose cause is not easily identified. Pain, depression, and withdrawal may occur but are not the most common distress symptom.

The community health nurse is providing an educational session to a group of community members regarding the issue of organ donation. A member of the group asks the nurse, "How old does someone have to be to provide consent for organ donation?" Which response should the nurse make? 1."Written consent is never required to become a donor." 2."A donor must be 18 years of age or older to provide consent." 3."A person can sign papers to become a donor at 16 years of age." 4."The family is responsible for decision making about organ donation at the time of death."

2. Any person 18 years of age or older may become an organ donor by written consent. In the absence of appropriate documentation, a family member or legal guardian may authorize donation of the decedent's organs. Therefore, the statements in the remaining options are incorrect.

The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply. 1.ST depression 2.Prominent U wave 3.Tall peaked T waves 4.Prolonged ST segment 5.Widened QRS complexes

3, 5 The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level greater than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Electrocardiographic changes associated with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves. ST depression and a prominent U wave occurs in hypokalemia. A prolonged ST segment occurs in hypocalcemia.

The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply. 1.Discourage reminiscing. 2.Make the decisions for the family. 3.Encourage expression of feelings, concerns, and fears. 4.Explain everything that is happening to all family members. 5.Touch and hold the client's or family member's hand if appropriate. 6.Be honest and let the client and family know they will not be abandoned by the nurse.

3, 5, 6 The nurse must determine whether there is a spokesperson for the family and how much the client and family want to know. The nurse needs to allow the family and client the opportunity for informed choices and assist with the decision-making process if asked. The nurse should encourage expression of feelings, concerns, and fears and reminiscing. The nurse needs to be honest and let the client and family know they will not be abandoned. The nurse should touch and hold the client's or family member's hand, if appropriate.

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? 1.Weight loss and dry skin 2.Flat neck and hand veins and decreased urinary output 3.An increase in blood pressure and increased respirations 4.Weakness and decreased central venous pressure (CVP)

3. A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit.

A client brought to the emergency department is dead on arrival (DOA). The family of the client tells the health care provider (HCP) that the client had terminal cancer. The HCP examines the client and asks the nurse to contact the medical examiner regarding an autopsy. Family members of the client tell the nurse that they do not want an autopsy performed. Which response to the family is appropriate? 1."The decision is made by the medical examiner." 2."An autopsy is mandatory for any client who is DOA." 3."I will contact the medical examiner regarding your request." 4."It is required by federal law. Why don't we talk about it, and why don't you tell me why you don't want the autopsy done?"

3. An autopsy is required by state law in certain circumstances, including the sudden death of a client and a death that occurs under suspicious circumstances. A client may have provided oral or written instructions regarding an autopsy after death. If an autopsy is not required by law, these oral or written requests will be granted. If no oral or written instructions were provided, state law determines who has the authority to consent for an autopsy. Most often, the decision rests with the surviving relative or next of kin.

A client with terminal cancer arrives at the emergency department dead on arrival (DOA). After an autopsy is prescribed, the client's family requests that no autopsy be performed. Which response to the family is most appropriate? 1."The decision is made by the medical examiner." 2."An autopsy is mandatory for any client who is DOA." 3."I will contact the medical examiner regarding your request." 4."It is required by federal law. Tell me why you don't want the autopsy done."

3. An autopsy is required by state law in certain circumstances, including the sudden death of a client and a death that occurs under suspicious circumstances. A client may have provided oral or written instructions regarding an autopsy after death. If an autopsy is not required by law, these oral or written requests will be granted. If no oral or written instructions were provided, state law determines who has the authority to consent for an autopsy. Most often, the decision rests with the surviving relative or next of kin.

The hospice nurse visits a client who is dying of ovarian cancer. During the visit, the client says, "If I can just live long enough to celebrate my daughter's sweet-16 birthday party, I'll be ready to die." The nurse notes that the client is experiencing which phase of coping? 1.Anger 2.Denial 3.Bargaining 4.Depression

3. Denial, bargaining, anger, depression, and acceptance are recognized stages that a client facing a life-threatening illness experiences. Bargaining identifies a behavior in which the individual is willing to do anything to avoid loss or change the prognosis or fate. Anger also may be a first response to upsetting news, and the predominant theme is "Why me?" or blaming others. Denial is expressed as shock and disbelief and may be the first response to hearing bad news. Depression may be manifested by hopelessness, weeping openly, or remaining quiet or withdrawn.

The nurse is reading a health care provider's (HCP's) progress notes in the client's record and reads that the HCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse makes a notation that insensible fluid loss occurs through which type of excretion? 1.Urinary output 2.Wound drainage 3.Integumentary output 4.The gastrointestinal tract

3. Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs. Sensible losses are those of which the person is aware, such as through urination, wound drainage, and gastrointestinal tract losses.

The nurse is caring for a client with 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 a client with hyponatremia? 1.Muscle twitches 2.Decreased urinary output 3.Hyperactive bowel sounds 4.Increased specific gravity of the urine

3. The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L (135 mmol/L). Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted.

The nurse is caring for a client with terminal cancer who is close to death. On reviewing the plan of care, the nurse determines that which intervention is the priority? 1.Keep the client well sedated so that the client is totally unaware of what is happening. 2.Make sure the family has privacy and is kept informed of what is happening at all times. 3.Maintain the client's dignity and self-esteem, and make the client as comfortable as possible. 4.Carry out the health care provider's (HCP's) prescriptions so that all prescribed treatments are done on time.

3. The nurse needs to focus on the needs of the client, keep the client comfortable, and maintain the client's dignity and self-esteem. Although the nurse needs to provide adequate control of pain, it is not necessary to keep the client sedated so that the client is totally unaware of what is happening. The client should be able to interact with family members and make care decisions. Family needs are important, but the client's needs are more important. Prescribed treatment needs to be carried out, but making the client comfortable and maintaining dignity are the priority.

On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess? 1.The client taking diuretics and has tenting of the skin 2.The client with an ileostomy from a recent abdominal surgery 3.The client who requires intermittent gastrointestinal suctioning 4.The client with kidney disease and a 12-year history of diabetes mellitus

4. A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. The causes of fluid volume excess include decreased kidney function, heart failure, use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for fluid volume deficit.

The nurse is caring for a client with cancer. The client tells the nurse that a lawyer will be arriving today to prepare a living will and asks the nurse to act as one of the witnesses for the will. What is the most appropriate nursing action? 1.Agree to act as a witness. 2.Call the health care provider (HCP). 3.Ask another nurse to serve as a witness. 4.Ask the client who might be available to serve as a witness.

4. A living will addresses the withdrawal or withholding of life-sustaining interventions that unnaturally prolong life. It identifies the client who will make care decisions if the client is unable to take action. It is witnessed and signed by 2 people who are unrelated to the client. Nurses or employees of a facility in which the client is receiving care and beneficiaries of the client must not serve as a witness. There is no reason to call the HCP.

The nurse is caring for a dehydrated client who is terminally ill. When caring for this client, the nurse should take which action? 1.Force the client to eat. 2.Force the client to drink. 3.Provide the unconscious client with ice chips. 4.Use moist cloths and swabs for mouth comfort.

4. Dehydration may occur during the last days of life. Hunger and thirst are rarely experienced in the last days of life, and as the end approaches the client tends to take in less food and fluid. Nursing management includes assessing the condition of mucous membranes frequently to prevent excessive dryness, maintaining complete regular oral care, not forcing the client to eat or drink, encouraging consumption of ice chips and sips of fluids in the conscious client, and the use of moist cloths and swabs in the unconscious client to prevent aspiration.

The nurse is caring for a terminally ill adolescent client. When caring for this client the nurse should implement which intervention? 1.Comply with the client's wishes at all times. 2.Encourage the client to be dependent on hospital staff. 3.Refuse to answer questions related to impending death. 4.Encourage the client to maintain maximum self-control.

4. Interventions appropriate when caring for a terminally ill adolescent include avoiding alliances with either the parent or the child, structuring hospital admission to allow for maximum self-control and independence, and answering the adolescent's questions honestly. Complying with the client's wishes at all times is not therapeutic.

The nurse is preparing a plan of care for a client who just delivered a dead fetus. Which initial action should the nurse include in the client's plan of care to meet the emotional needs of the client and spouse? 1.Allow family members to name the infant. 2.Encourage the client to talk about the dead fetus. 3.Allow the client and the spouse to hold the infant. 4.Assess the client's and the spouse's perception of the event.

4. The initial intervention in planning to meet the emotional needs of the client and her spouse is to assess their perception of the event. Although the actions in the remaining options are likely to be components of the plan of care, the initial intervention in planning is to assess the perception of the event.

Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)? 1.The client with colitis 2.The client with Cushing's syndrome 3.The client who has been overusing laxatives 4.The client who has sustained a traumatic burn

4. The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level higher than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.

A rehabilitation nurse is teaching the client with a spastic bladder to perform intermittent catheterizations. Which client statement shows the need for further education? A. "Before I catheterize myself, I will try to urinate." B. "I can wait from 9 AM until 6 PM between catheterizations." C. "I will use the Valsalva and Credé maneuvers before trying to urinate." D. "You can teach my son to help me with the catheterizations."

B. "I can wait from 9 AM until 6 PM between catheterizations." The statement by the client that, "I can wait from 9 AM until 6 PM between catheterizations," indicates the need for further education. The client should not go beyond 8 hours between catheterizations. The time between catheterizations in this scenario is 9 hours. This concept needs to be reinforced to the client.The client with a spastic bladder must attempt to void before the catheterization is performed. The Valsalva and Credé maneuvers should be used to attempt voiding before self-catheterization in clients with spastic or flaccid bladders. If the client cannot catheterize him- or herself, a family member can be taught to do it.

Which client does the RN in the rehabilitation unit plan to assess first? A. A 45-year-old with multiple sclerosis (MS) who reports constipation B. A 56-year-old with a spinal cord injury and new-onset redness over the sacral area C. A 63-year-old who has had a myocardial infarction (MI) and is expressing anxiety about walking D. A 70-year-old with a joint replacement who needs to be medicated before exercising

B. A 56-year-old with a spinal cord injury and new-onset redness over the sacral area The RN will first assess the 56-year-old with a spinal cord injury and new-onset redness over the sacral area. Because new redness over a bony area may indicate the presence of a stage I pressure ulcer, the nurse should assess this client's skin as soon as possible and implement interventions to improve skin integrity. The MS client with constipation, the MI client with anxiety about walking and the joint replacement client all also need assessment and intervention but are not at as high a risk for acute physiologic complications.

The nurse has been effectively using digital stimulation in older adult clients with constipation problems. For which client is this practice unsafe? A. A 68-year-old with a long history of multiple sclerosis (MS) B. A 70-year-old with recently diagnosed atrial fibrillation C. A 74-year-old who is 4 months post cerebral vascular accident (CVA) with left-sided weakness D. An 84-year-old with progressive dementia and confusion

B. A 70-year-old with recently diagnosed atrial fibrillation The practice is unsafe for a 70-year-old with recently diagnosed atrial fibrillation. Digital stimulation is contraindicated in clients with cardiac disease because of the risk of initiating a vagal nerve response. Instead, another method of treatment for constipation should be used, such as diet, fluids, or laxatives.The client with MS, the client who is post-CVA, and the client with dementia and confusion are safe risks. These clients would not have a higher risk of negative effects from digital stimulation than the average person without cardiac issues.

The nurse manager for home health and hospice is scheduling daily client visits. Which client is appropriate for the nursing assistant to visit? A. Advanced cirrhosis of the liver and just called the hospice agency reporting nausea B. Aggressive brain tumor and needs daily assistance with ambulation and bathing C. Inoperable lung cancer and considering whether to have radiation and chemotherapy D. Prostate cancer and bone metastases and has new-onset leg weakness and tingling

B. Aggressive brain tumor and needs daily assistance with ambulation and bathing Assisting clients with activities of daily living such as ambulation and bathing is a common role for nursing assistants working in home health or hospice agencies.Assessing and acting upon a new symptom (nausea), helping clients make decisions, and evaluating a new-onset symptom all require more complex assessment skills and interventions, which are within the RN scope of practice.

A dying client is having difficulty swallowing oral medications. Which intervention does the nurse implement for this client? A. Asks the pharmacy to substitute intramuscular (IM) equivalents for the medications B. Asks the provider if the medications can be discontinued or substituted C. Crushes the pills, opens the sustained-release capsules, and mixes them with a spoonful of applesauce D. Does not give the medications and documents: "Unable to swallow"

B. Asks the provider if the medications can be discontinued or substituted The nurse contacts the provider to ask if the medications can be discontinued or substituted. Since the client is in the dying process, he or she may no longer require some of the medications prescribed, and other routes may be available for medications that will promote comfort.The IM route is almost never used for clients at the end of life because this method is invasive and painful, and can cause infection. Although some pills may be crushed, sustained-release capsules should not be taken apart and their contents administered directly. The client may still need the medications prescribed for comfort; withholding them could cause discomfort throughout the dying process.

The nurse is mentoring a nursing student about best practices for safe client handling. What practice does the nurse teach the student? A. "Keep the client at arm's length to maximize your leverage in moving him or her." B. "Place your feet at right angles to the client's feet to stabilize yourself." C. "Put the bed at waist level for care and hip level for movement of the client." D. "Try to keep the client positioned to your side so that you can benefit from a rotating motion when moving him or her."

C. "Put the bed at waist level for care and hip level for movement of the client." The nurse teaches the student the practice of putting the bed at waist level for care and hip level for movement of the client. Positioning the bed at the proper height keeps the student from straining or injuring the back.The client is kept as close to the body of the person transferring as possible. A wide base of support should be maintained from a position in front of the client, not at right angles. The client should be positioned in front of the student to prevent the student's spine from rotating.

A dying client says to the nurse, "I am afraid to die. I did a lot of wrong things in my life." How does the nurse respond? A. "Don't worry, God will forgive you." B. "I'm sure it is nothing to worry about." C. "Tell me more about that." D. "Why? What did you do wrong?"

C. "Tell me more about that." A response such as, "Tell me more about that," acknowledges the client's spiritual pain and encourages verbalization."Don't worry, God will forgive you" assumes that the client is religious and minimizes the client's concerns, is a nontherapeutic response, and may give false reassurance. Saying that it's nothing to worry about minimizes the client's concerns and is also a nontherapeutic response. It shuts the client off from expressing his or her concerns. Asking why the client is afraid and what he or she did wrong assumes that the client did something wrong, which may not be the case. "Why" questions are never considered to be therapeutic because they place clients on defense, too often leading the client to stop communication.

A patient is prescribed a thiazide diuretic for the treatment of hypertension. When teaching the patient about the medication, which of the following will the healthcare provider include?

"Be sure to include a number of foods that are rich in potassium in your diet." What is a thiazide diuretic? Increases urine flow by acting directly on the kidneys. Ex. hydrochlorothiazide (HCTZ) and metolazone. Used specifically for older adults with mild volume overload. Action is self-limiting, so when there is no longer excess fluid, the action decreases.

cultures and death- Native Americans

Believe in Shamans, medicine men and cultural healing Family is large and may encompass the entire tribe They do not want to speak of the dead Many believe they live on in other living things

A client in the later stages of chronic kidney disease (CKD) has hyperkalemia. With CKD, what other factors besides tissue breakdown can cause high potassium levels? Select all that apply. 1.Blood transfusions 2.Metabolic alkalosis 3.Bleeding or hemorrhage 4.Decreased sodium excretion 5.Ingestion of potassium in medications 6.Failure to restrict dietary potassium

1, 3, 5, 6 With CKD, factors other than tissue breakdown that can cause hyperkalemia include blood transfusions, bleeding or hemorrhage, ingestion of potassium in medications, and failure to restrict dietary potassium. Metabolic alkalosis and decreased sodium excretion are not contributing factors.

What parameters should the nurse monitor in a patient who has developed hypoxia due to severe anemia? Select all that apply. 1 Pulse rate 2 Blood urea 3 Serum bilirubin 4 Respiratory rate 5 Skin color change

1, 4, 5

Refluxed material has a pH of

1.5 to 2

Intermediate Insulin Duration

16 hours

Which nursing action protects the patient from infection at the portal of entry? 1. Positioning an indwelling urine collection bag below the level of the patient's pelvis 2. Enclosing a urine specimen in a biohazardous transport bag 3. Wearing clean gloves when handling a patient's excretions 4. Handwashing after removal of soiled protective gloves

1. Positioning an indwelling urine collection bag below the level of the patient's pelvis

What is a normal eye pressure?

10 to 21 mmHg

Sodium Levels

135-145

Gastric Ulcers are also affected by?

Delayed gastric emptying

Which electrolyte is decreased in malabsorption?

Calcium

chronic illness

Condition or illness that has existed for more than 3 months

A nurse caring for a patient with non healing arterial lower leg ulcer. What action by the nurse is best?

Consult with the wound care nurse.

cultures and death- Hindu/Buddhist

Death involves rebirth and eventual liberation of the spirit Body is typically burned with many mourners accompanying the body

5 stages of death

Denial and Isolation Anger Bargaining Depression Acceptance and hope

What position makes arterial pain better?

Dependent position

What position makes venous pain worse?

Dependent position

cultures and death- Asian

Do not discuss dying May use herbal or family medications Male dominated #4 is avoided it symbolizes death

How can cataracts develop?

Formation occurs earlier in life with heavy sun exposure or exposure to other sources of UV light

Which insulin does not go well with alcohol?

Glyride (LONG-ACTING)

What causes gastritis?

H. pylori

Which nursing intervention decreases the risk for catheter-associated urinary tract infection? Cleansing the urinary meatus 3 to 4 times daily with antiseptic solution. Hanging the urinary drainage bag below the level of the bladder. Emptying the urinary bag daily. Irrigating the urinary catheter with sterile water

Hanging the urinary drainage bag below the level of the bladder.

Potassium deals with?

Heart/cardiac

Venous Pain

Heavy, dull, throbbing, achy

pulse with venous disease

Normal

What diet is recommended for ulcerative colitis?

Low fiber, high protein

peaceful death initiatives

Main issue is recognizing the patient's wishes Understand that pain is whatever the patient says it is Include the family and support systems Allow the patient and family to dictate their care

Arterial pain

Sharp Patient wakes up in the middle of the night

Antagonist of Coumadin/Warfarin

Vitamin K

Which of the following is not a function of the large intestine? a. Absorbing nutrients b. Absorbing water c. Secreting bicarbonate d. Eliminating waste

a. Absorbing nutrients

The nurse knows that most nutrients are absorbed in which portion of the digestive tract? a. Stomach b. Duodenum c. Ileum d. Cecum

b. Duodenum

A patient with Type 2 Diabetes is started on the medication Glyburide. Which of the following statements by the patient causes concern?

"I will consume no more than 8 oz. of alcohol per week." What is Glyburide? Glyburide lowers blood sugar by causing the pancreas to produce insulin (a natural substance that is needed to break down sugar in the body) and helping the body use insulin efficiently. This medication will only help lower blood sugar in people whose bodies produce insulin naturally.

An older patient with Peripheral Vascular Disease (PVD) is explaining the daily foot care regimen to the family practice clinic nurse. What statement by the patient may indicate a barrier to proper foot care?

"My hands shake when I try to do things requiring coordination."

A nurse is teaching a larger female patient about alcohol intake and how it affects hypertension. The patient asks if drinking two beers a night is an acceptable intake. What answer by the nurse is best?

"No, women should only have one beer a day as a general rule."

A patient has severe peripheral venous disease. What important information below will the nurse provide to the patient about how to alleviate signs and symptoms associated with the disease?

- Elevate the lower extremities about heart level frequently. - Application of compression stockings - Limit long periods of standing and sitting.

what is grief?

- natural response to loss - the emotional suffering you feel when something or someone you love is taken away

A patient reports fatigue and an inability to lie flat. During anassessment, the nurse finds the patient has an increased blood pressure and an increased pulse rate. Further assessment reveals that the patient is dizzy, unable to concentrate, and has a decreased level of consciousness. Which condition does the nurse suspect? 1 Hypoxia 2 Hypoxemia 3 Hypovolemia 4 Hyperventilation

1 Hypoxia

Intermediate Insulin Peak

8 hours

The nurse is preparing to measure the depth of a client's tunneled wound. Which of the following implements should the nurse use to measure the depth accurately?

A sterile, flexible applicator moistened with saline.

What is common with ulcerative colitis?

Bloody stool

end of life care

Ensure patients have input Ensure the patient can involve their families if they want them involved Advance care directives

Edema with Arterial disease?

No

A nurse cares for adult clients who experience urge incontinence. For which client should the nurse plan a habit training program? a. A 78-year-old female who is confused b. A 65-year-old male with diabetes mellitus c. A 52-year-old female with kidney failure d. A 47-year-old male with arthritis

a. A 78-year-old female who is confused

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

c. Can we discontinue the indwelling catheter?

Hypophosphatemia Symptoms

weak muscles and muscle pain, decreased BP, slow pulses

A student nurse asks what " essential hypertension " is. What response by the registered nurse is best? a. "It means it is caused by another disease." b. "It means it is 'essential' that it be treated." c. "It is hypertension with no specific cause." d. "It refers to severe and life-threatening hypertension."

" It is hypertension with no specific cause " Essential hypertension is the most common type of hypertension and has no specific cause such as an underlying disease process. Hypertension that is due to another disease process is called secondary hypertension. A severe, life-threatening form of hypertension is malignant hypertension.

An older client with PVD is explaining the daily foot care regimen to the family practices clinic nurse. What statement by the client may indicate a barrier to proper foot care? a. "I nearly always wear comfy sweatpants and house shoes." b. "I'm glad I get energy assistance so my house isn't so cold." c. "My daughter makes sure I have plenty of lotion for my feet." d. "My hands shake when I try to do things requiring coordination."

" My hands shake when I try to do things requiring coordination " Clients with PVD need to pay special attention to their feet. Toenails need to be kept short and cut straight across. The client whose hands shake may cause injury when trimming toenails. The nurse should refer this client to a podiatrist. Comfy sweatpants and house shoes are generally loose and not restrictive, which is important for clients with PVD. Keeping the house at a comfortable temperature makes it less likely the client will use alternative heat sources, such as heating pads, to stay warm. The client should keep the feet moist and soft with lotion.

You're assessing a patient's health history for peripheral vascular disease. What signs and symptoms reported by the patient would indicate the patient may be experiencing peripheral arterial disease? Select all that apply:

"I often wake up at night with leg pain and have to dangle my leg out of the bed to ease the pain." "It hurts to elevate my legs." "Sometimes when I'm walking my legs start to cramp and tingle to the point where I can't walk until the pain goes away."

Which statements by the patient indicate good understanding of foot care in peripheral vascular disease?

"I will keep my feet dry, especially between the toes." "Lotion is important to keep my feet smooth and soft." "Washing my feet in room-temperature water is best."

The nurse is educating a patient who must still instill multiple types of eye drops before cataract surgery. Which patient statement requires further teaching?

"If I cannot remember when to take which drops I will just use them all at once."

A patient is asking about compartment syndrome. Select all the signs and symptoms you will discuss with the patient in compartment syndrome.

- Pallor - Feeling of tingling in the extremity - Affected extremity feels cooler to the touch than the unaffected extremity. Compartment Syndrome: A condition in which increased tissue pressure in a confined anatomic space causes decreased blood flow to the area, leading to hypoxia and pain. What is Pallor? having pale appearance

During a home visit you are helping a patient with gout identify foods in their pantry they should avoid eating. Select all the foods below the patient should avoid:

- Sardines - Sweetbreads - Craft Beer Gout: A systemic disease in which urate crystals deposit in the joints and other body tissues, causing inflammation. What should the patient with gout eat? Patients with gout should limit their intake of purine-rich animal protein (e.g., organ meats, beef, lamb, pork, shellfish) and avoid alcohol (especially beer). Purine-rich vegetables do not increase the risk of gout. Consumption of vegetables and low-fat or nonfat dairy products should be encouraged.

Your patient had a total knee 2 weeks ago. He comes to the ER with severe pain at the surgical site. Which questions from the nurse are most appropriate? (Select all that apply.)

- Which position makes the pain worse or better? - Could you describe the pain in your knee? - Please rate you pain 1-10 with 10 being the worst pain possible.

coping with loss

- face your feelings - express yourself in a tangible or creative way - look after your physical health - don't let anyone tell you how to feel - be prepared for grief triggers

examples of support to help with grief

- turning to friends and family members - joining a support group - draw comfort from your faith - talk to a therapist or grief counselor

palliative care

-an approach to care for people with chronic or end-stage illness that focuses on symptom relief and psycho-social and spiritual support. -May be used along with curative treatments -can be used at any stage of illness — not just the advanced stages - more common in an institution rather than the home

hospice

-uses the same comfort-focused approach as palliative care but is limited to those with a terminal prognosis (i.e., six months or less) after attempts at cure have ceased. -All hospice is palliative care, but not all palliative care is hospice. - normally at home

A patient wants to understand the mechanism of respiration. What should the nurse explain to the patient? Select all that apply. 1 Normal breathing is quiet with minimum or no effort. 2 Ventilation is the process of air moving in and out of lungs. 3 Normal breathing is noisy and requires all the chest muscles. 4 The diaphragm is an important muscle that helps in breathing. 5 Ventilation is the process of oxygenated blood flowing in the body.

1 Normal breathing is quiet with minimum or no effort. 2 Ventilation is the process of air moving in and out of lungs. 4 The diaphragm is an important muscle that helps in breathing.

Which predisposing condition might be responsible for a patient having both reduced circulating blood volume and extracellular fluid? 1 Shock 2 Pneumonia 3 Chest trauma 4 Multiple rib fractures

1 Shock

The nurse is conducting a teaching session for a group of young adults. One of them wants to know if substance abuse affects respiratory functions. How should the nurse answer? Select all that apply. 1 The respiratory center is depressed and affects respiratory function in addicts. 2 Having alcohol and drugs causes a reduction in airflow to the lungs and affects respiration. 3 People who are addicted often have low nutritional status, which affects respiratory functions. 4 The oxygen-carrying capacity of blood is low in people who chronically abuse substances. 5 There is no relation between respiratory function and substance abuse as it affects the nervous system.

1 The respiratory center is depressed and affects respiratory function in addicts. 3 People who are addicted often have low nutritional status, which affects respiratory functions. 4 The oxygen-carrying capacity of blood is low in people who chronically abuse substances.

The nurse is updating the client's plan of care based on the new onset of hypokalemia. Which priorities of care should the nurse include? Select all that apply. 1.Ensure adequate oxygenation. 2.Provide assistance to prevent falls. 3.Monitor medication administration of diuretics. 4.Monitor for numbness and tingling around the mouth. 5.Prevent complications during potassium administration.

1, 2, 3, 5 The priorities for nursing care of a client with hypokalemia are ensuring adequate oxygenation, client safety for fall prevention and potassium administration, and monitoring for complications related to diuretic therapy and client response to therapy. Option 4 is related to hypocalcemia.

The nurse is caring for a client who is dying. The nurse recognizes that which intervention is likely to facilitate therapeutic communication between the dying client and his or her family? Select all that apply. 1.The nurse encourages the client and family to identify and discuss feelings openly. 2.The nurse assists the client and family in carrying out spiritually meaningful practices. 3.The nurse makes decisions for the client and family to relieve them of unnecessary demands. 4.The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger. 5.The nurse is supportive and nonjudgmental of the client's or family's verbalized concerns and feelings.

1, 2, 4, 5 The incorrect option describes an intervention in which the nurse removes autonomy and decision-making from the client and family, who are already experiencing feelings of loss of control in that they cannot change the process of dying. This is an ineffective intervention and could further impair communication. Maintaining effective and open communication among family members affected by death and grief is of the greatest importance. Encouraging discussion of feelings is likely to enhance communications. Spiritual practices give meaning to life and have an impact on how people react to crisis, so it is also an effective intervention. The client and family need to know that someone will be there who is supportive and nonjudgmental.

Which clients are most likely to be at risk for the development of third spacing? Select all that apply. 1.The client with cirrhosis 2.The client with liver failure 3.The client with diabetes mellitus 4.The client with a minor burn injury 5.The client with chronic kidney disease

1, 2, 5 Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. Common sites for third spacing include the abdomen, pleural cavity, peritoneal cavity, and pericardial sac. Third-space fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Risk factors for third spacing include clients with liver or kidney disease, major trauma, burns, sepsis, wound healing or major surgery, malignancy, gastrointestinal malabsorption, malnutrition, and alcoholic or older adult clients.

A client who is at risk for fluid imbalance is to be admitted to the nursing unit. In planning care for this client, the nurse is aware that which conditions cause the release of antidiuretic hormone (ADH)? Select all that apply. 1.Dehydration 2.Hypertension 3.Physiological stress 4.Decreased blood volume 5.Decreased plasma osmolarity

1, 3, 4 ADH, or vasopressin, is produced in the brain and stored in the posterior pituitary gland. Its release from the posterior pituitary gland is controlled by the hypothalamus in response to changes in blood osmolarity. Stimuli for ADH release are increased plasma osmolality; decreased blood volume; hypotension; pain; dehydration from nausea, vomiting, or diarrhea; and stress.

The nurse is caring for a client who needs a hypertonic intravenous (IV) solution. What solutions are hypertonic? Select all that apply. 1.10% dextrose in water 2.0.45% sodium chloride 3.5% dextrose in 0.9% saline 4.5% dextrose in 0.45% saline 5.5% dextrose in 0.225% saline 6.5% dextrose in lactated Ringer's solution

1, 3, 4, 6 Hypertonic fluids include 10% dextrose in water, 5% dextrose in 0.9% saline, 5% dextrose in 0.45% saline, and 5% dextrose in lactated Ringer's solution. The solutions of 0.45% sodium chloride and 5% dextrose in 0.225% saline are not hypertonic solutions.

The nurse notes that a client's total serum calcium level is 6.0 mg/dL (1.5 mmol/L). Which assessment findings should be anticipated in this client? Select all that apply. 1.Tetany 2.Constipation 3.Renal calculi 4.Hypotension 5.Prolonged QT interval 6.Positive Chvostek's sign

1, 4, 5, 6 The normal total serum calcium level is 9.0 to 10.5 mg/dL (2.25 to 2.75 mmol/L); thus, the client's results are reflective of hypocalcemia. The most common manifestations of hypocalcemia are caused by overstimulation of the nerves and muscles; therefore, tetany and presence of Chvostek's sign would be expected. Calcium is needed by the heart for contraction. When the serum calcium level is decreased, cardiac contractility is decreased and the client will experience hypotension. A low serum calcium level could also lead to severe ventricular dysrhythmias and prolonged QT and ST intervals on the electrocardiogram.

7 stages of grief

1- shock and denial 2- pain and guilt 3- anger and bargaining 4- depression, reflection, lonliness 5- the upward turn 6- reconstruction and working through 7- acceptance and hope

The nurse aspirates 40 mL of undigested formula from the client's nasogastric (NG) tube. Before administering an intermittent tube feeding, what should the nurse do with the 40 mL of gastric aspirate? 1.Pour the aspirate into the NG tube through a syringe with the plunger removed. 2.Dilute with water and inject into the NG tube by putting pressure on the plunger. 3.Discard properly and record as output on the client's intake and output (I&O) record. 4.Mix with the formula and pour into the NG tube through a syringe with the plunger removed.

1. After checking residual feeding contents, the gastric contents should be reinstilled to maintain the client's electrolyte balance. The gastric contents should be poured into the NG tube through a syringe without a plunger and not injected by pushing on the plunger. Gastric contents are not mixed with formula or diluted with water and should not be discarded.

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which cardiovascular manifestation would the nurse expect to note? 1.Hypotension 2.Increased heart rate 3.Bounding peripheral pulses 4.Shortened QT interval on electrocardiography (ECG)

1. Cardiovascular manifestations that occur with hypocalcemia include decreased heart rate, diminished peripheral pulses, and hypotension. On the ECG, the nurse would note a prolonged ST interval and a prolonged QT interval.

The nurse understands which primary (nonspecific) defense protects the body from infection? 1. Tears in the eyes 2. Alkalinity of gastric secretions 3. Bile in the gastrointestinal system 4. Moist environment of the epidermis

1. Tears in the eyes

The nurse is reviewing a client's laboratory report and notes that the total serum calcium level is 6.0 mg/dL (1.66 mmol/L). The nurse understands that which condition most likely caused this serum calcium level? 1.Prolonged bed rest 2.Renal insufficiency 3.Hyperparathyroidism 4.Excessive ingestion of vitamin D

1. The normal serum calcium level is 9.0 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A client with a serum calcium level of 6.0 mg/dL (1.66 mmol/L) is experiencing hypocalcemia. Prolonged bed rest is a cause of hypocalcemia. Although immobilization initially can cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia. End-stage renal disease, rather than renal insufficiency, is a cause of hypocalcemia. Hyperparathyroidism and excessive ingestion of vitamin D are causative factors associated with hypercalcemia.

To interrupt the transmission link in the chain of infection, the nurse should: 1. Wash the hands before and after providing care to a patient 2. Position a commode next to a patient's bed 3. Provide education about a balanced diet 4. Change a dressing when it is soiled

1. Wash the hands before and after providing care to a patient

Rapid Acting Insulin Onset

15 mins

You're caring for Carin who has just had ileostomy surgery. During the first 24 hours post-op, how much drainage can you expect from the ileostomy?

1500 mL

A patient who has hypoxia is hospitalized. The nurse observes central cyanosis on the patient's tongue, soft palate, and conjunctiva. What should the nurse suspect based on this observation? 1 Atelectasis 2 Hypoxemia 3 Hypovolemia 4 Hyperventilation

2 Hypoxemia

A patient has a condition in which the lungs remove carbon dioxide faster than it is produced by cellular metabolism. Which predisposing factors contribute to this condition? Select all that apply. 1 Cyanosis 2 Infection 3 Severe anxiety 4 Acid-base imbalance 5 Multiple rib fracture

2 Infection 3 Severe anxiety 4 Acid-base imbalance

The nurse assesses a patient who is short of breath and fatigued. The nurse finds that the oxygen saturation of the blood is reduced. The lab report indicates that the patient's red blood cell count is increased. What do these findings suggest? 1 The patient has anemia. 2 The patient has chronic hypoxemia. 3 The patient has hypoventilation. 4 The patient has an acute infection.

2 The patient has chronic hypoxemia.

Short Acting Insulin Peak

2 hours

The nurse is caring for a terminally ill client. The nurse has developed a close relationship with the family of the client. Which interventions should the nurse employ? Select all that apply. 1.Making decisions for the family 2.Encouraging family discussion of feelings 3.Accepting the family's expressions of anger 4.Allowing spiritual practices identified by the family 5.Preserving the family's sense of self-direction and control

2, 3, 4, 5, Maintaining effective and open communication among family members affected by death and grief is of utmost importance. The nurse needs to maintain and enhance communication, as well as preserve the family's sense of self-direction and control. Option 2 is likely to enhance communications. Option 3 is also an effective technique, and the family needs to know that someone will be there who is supportive and nonjudgmental. Option 4 is also an effective intervention, because spiritual practices give meaning to life and have an impact on how people react to crisis. Option 5 is also therapeutic. Option 1 removes autonomy and decision making from the family at a time when they are already experiencing feelings of loss of control. This is an ineffective intervention that can impair communication.

Which nursing action protects the patient as a susceptible host in the chain of infection? 1. Wearing personal protective equipment 2. Administering childhood immunizations 3. Recapping a used needle before discarding 4. Disposing of soiled gloves in a waste container

2. Administering childhood immunizations

A client is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The care unit nurse is monitoring the client for signs of hyperkalemia. Which finding initially will be noted in the client if hyperkalemia is present? 1.Confusion 2.Muscle weakness 3.Mental status changes 4.Depressed deep tendon reflexes

2. Because potassium plays a major role in neuromuscular activity, elevation in serum potassium initially causes muscle weakness. Mental status changes and confusion are most likely to be noted in the client experiencing hypocalcemia. Depressed deep tendon reflexes are noted in the client with hypermagnesemia.

A patient is positive for Clostridium diffi cile. The nurse should institute the isolation precaution known as: 1. Droplet 2. Contact 3. Reverse 4. Airborne

2. Contact

The nurse has a prescription to hang a crystalloid intravenous solution of lactated Ringer's on a newly admitted client. The nurse notices that the client has a history of alcoholic cirrhosis. What action should the nurse take first? 1.Hang the solution. 2.Contact the health care provider (HCP). 3.Check the client's daily laboratory results. 4.Ask the client if any liver study tests have ever been done.

2. The nurse must contact the HCP before administering the solution. Fluid and electrolyte replacement solutions like lactated Ringer's are contraindicated for clients with kidney and liver disease or lactic acidosis.

Nurse John Joseph is totaling the intake and output of Elena Reyes, a client diagnosed with septicemia who is on a clear liquid diet. The client intakes 8 oz of apple juice, 850 ml of water, 2 cups of beef broth, and 900 ml of half-normal saline solution and outputs 1,500 ml of urine during the shift. How many milliliters should the nurse document as the client's intake?

2470

A registered nurse discusses physiological factors that affect oxygenation with a group of nursing students. Which statement if made by the nursing student is correct? 1 "The metabolic rate decreases normally in pregnancy, wound healing, and exercise." 2 "The physiological response to chronic hypoxia is an increase in white blood cell production." 3 "Carbon monoxide is the most common toxic inhalant; it decreases the oxygen-carrying capacity of the blood." 4 "The oxygen carrying capacity of the blood increases when there is a decline in inspired oxygen concentration."

3 "Carbon monoxide is the most common toxic inhalant; it decreases the oxygen-carrying capacity of the blood."

What condition involves collapsed alveoli that prevent the normal exchange of oxygen and carbon dioxide? 1 Asthma 2 Kyphosis 3 Atelectasis 4 Myocardial infarction

3 Atelectasis

Which statement is true regarding chest percussion? 1 Chest percussion involves slow striking of the chest wall. 2 Chest percussion is performed over a multilayer of clothing. 3 Chest percussion involves rhythmically clapping on the chest wall. 4 Chest percussion is commonly performed on patients who have osteoporosis.

3 Chest percussion involves rhythmically clapping on the chest wall.

A patient reports having shortness of breath and fatigue on brisk walking for the past 2 weeks. The patient has also experienced menorrhagia for the past 2 months. The patient's blood reports show decreased hemoglobin and an increased red blood cell count. Which condition is the patient most likely experiencing? 1 Decreased surfactant in the lungs 2 Decreased lung compliance 3 Decreased oxygenation of blood 4 Decreased fraction of inspired oxygen concentration

3 Decreased oxygenation of blood

In what position should the nurse place the patient in to examine the apical segments of the lungs? 1 Prone 2 Supine 3 Fowler's (Sitting) 4 High-Fowler's

3 Fowler's (Sitting)

Rapid Acting Insulin Duration

3 hours

The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding should the nurse expect to note? 1.Bradycardia 2.Elevated blood pressure 3.Changes in mental status 4.Bilateral crackles in the lungs

3. A client with dehydration is likely to be lethargic or complain of a headache. The client would also exhibit weight loss, sunken eyes, poor skin turgor, flat neck and peripheral veins, tachycardia, and a low blood pressure. The client who is dehydrated would not have bilateral crackles in the lungs because these are signs of fluid overload and an unrelated finding of dehydration.

A client who has been diagnosed with a terminal illness has an advance directive form, needs it to be signed, and asks the nurse to sign it as a witness. What is the nurse's best action? 1.Sign the form as requested. 2.Request the client's son to sign as a witness. 3.Ask a nonmedical client, such as a social worker, to witness the form. 4.Ask another nurse who is not assigned to the client to witness the form.

3. An advance directive is a legal document that relays a client's decisions about future medical care. When implementing a legal document, the best person to act as a witness is someone who is not connected to the client either by relation (such as the client's son), or as a caregiver or potential caregiver. In this situation the witness should not be a caregiver, medical personnel, or anyone related to the client. A nonmedical witness is the best choice.

The nurse understands that the factor that places a patient at the greatest risk for developing an infection is: 1. Implantation of a prosthetic device 2. Presence of an indwelling urinary catheter 3. Burns more than twenty percent of the body 4. Multiple puncture sites from laparoscopic surgery

3. Burns more than twenty percent of the body

The nurse is caring for a terminally ill client who is experiencing Cheyne-Stokes respirations. Which assessment finding should the nurse expect to note? 1.Continuous rapid regular breathing 2.Periods of apnea followed by bradypnea 3.Periods of apnea followed by deep rapid breathing 4.Periods of bradypnea followed by periods of tachypnea

3. Cheyne-Stokes respirations are characterized by alternating periods of apnea and deep rapid breathing. The descriptions in the remaining options are incorrect.

The nurse understands that a primary (nonspecific) defense that protects the body from infection is: 1. Antibiotic therapy 2. The high pH of the skin 3. Cilia in the respiratory tract 4. The alkaline environment of the vagina

3. Cilia in the respiratory tract

The nurse is caring for a client with a nasogastric (NG) tube who has a prescription for NG tube irrigation once every 8 hours. To maintain homeostasis, which solution should the nurse use to irrigate the NG tube? 1.Tap water 2.Sterile water 3.0.9% sodium chloride 4.0.45% sodium chloride

3. Homeostasis is maintained by irrigating with an isotonic solution, such as 0.9% sodium chloride. Tap water, sterile water, and 0.45% sodium chloride are hypotonic solutions.

A client who suffered a severe head injury has had vigorous treatment to control cerebral edema. Brain death has been determined. The nurse prepares to carry out which measure to maintain viability of the kidneys before organ donation? 1.Assessing lung sounds 2.Monitoring temperature 3.Administering intravenous (IV) fluids 4.Performing range-of-motion exercises to the extremities

3. Perfusion to the kidney is affected by blood pressure, which in turn is affected by blood vessel tone and fluid volume. Therefore, the client who was previously dehydrated with medications to control intracranial pressure is now in need of rehydration to maintain perfusion to the kidneys. The nurse should prepare to infuse IV fluids as prescribed and continue to monitor urine output. The remaining options will not maintain viability of the kidneys.

The nurse is assisting in the care of a client with pheochromocytoma who has been experiencing clinical manifestations of hypermagnesemia. When evaluating the client, the nurse should determine that the client's status is returning to normal if which is no longer exhibited? 1.Tetany 2.Tremors 3.Areflexia 4.Muscular excitability

3. Signs and symptoms of hypermagnesemia include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes (areflexia), respiratory paralysis, and loss of consciousness. Tetany, muscular excitability, and tremors are seen with hypomagnesemia.

The nurse is caring for a terminally ill client who is unresponsive to verbal stimuli. The client's spouse asks if her husband can still hear her. Which is the best response by the nurse? 1."Why do you want to know that?" 2."I don't know the answer to your question." 3."Assume that your husband can still hear you." 4."Your husband is unresponsive. He can't hear you anymore."

3. When a client is approaching death, hearing is usually the last sense to disappear. Telling the spouse that you don't know or that the husband cannot hear anymore due to unresponsiveness is incorrect. Asking the spouse why she wants to know is a nontherapeutic response.

A patient who started smoking in adolescence and continues to smoke 40 years later comes to the clinic. The nurse understands that this patient has an increased risk for being diagnosed with which disorder? 1 Alcoholism and hypertension 2 Obesity and diabetes 3 Stress-related illnesses 4 Cardiopulmonary disease and lung cancer

4 Cardiopulmonary disease and lung cancer

In which condition do the lungs remove carbon dioxide faster than it is produced by cellular metabolism? 1 Hypoxia 2 Hypoxemia 3 Hypovolemia 4 Hyperventilation

4 Hyperventilation

The nurse is caring for a client with hypocalcemia. Which patterns would the nurse watch for on the electrocardiogram as a result of the laboratory value? Select all that apply. 1.U waves 2.Widened T wave 3.Prominent U wave 4.Prolonged QT interval 5.Prolonged ST segment

4, 5 The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged QT interval and prolonged ST segment. A shortened ST segment and a widened T wave occur with hypercalcemia. ST depression and prominent U waves occur with hypokalemia.

A patient has been newly diagnosed with chronic lung disease. In discussing the lung disease with the nurse, which of the patient's statements would indicate a need for further education? 1. "I'll make sure that I rest between activities so I don't get so short of breath." 2. "I'll practice the pursed-lip breathing technique to reduce resp. rate, control the shortness of breath and improve exercise tolerance." 3. "If I have trouble breathing at night, I'll use two or three pillows to prop up." 4. "If I get short of breath, I'll turn up my oxygen level to 6 L/min.

4. "If I get short of breath, I'll turn up my oxygen level to 6 L/min.

The 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 result indicates a potassium level of 4.5 mEq/L (4.5 mmol/L) and a sodium level of 132 mEq/L (132 mmol/L). Based on these laboratory findings, the nurse should select which solution to use for the nasogastric tube irrigation? 1.Tap water 2.Sterile water 3.Distilled water 4.Sodium chloride

4. A potassium level of 4.5 mEq/L (4.5 mmol/L) is within normal range. A sodium level of 132 mEq/L (132 mmol/L) is low, indicating hyponatremia. In clients with hyponatremia, sodium chloride (normal saline) rather than water should be used for gastrointestinal irrigations because it is an isotonic solution.

A patient has been diagnosed with severe iron deficiency anemia. During physical assessment, which of the following symptoms are associated with decreased oxygenation as a result of the anemia? 1. Increased breathlessness but increased activity tolerance 2. Decreased breathlessness and decreased activity tolerance 3. Increased activity tolerance and decreased breathlessness 4. Decreased activity tolerance and increased breathlessness

4. Decreased activity tolerance and increased breathlessness

The nurse is caring for a group of hospitalized patients. What should the nurse do first to prevent infections? 1. Provide small bedside bags to dispose of used tissues 2. Encourage staff to avoid coughing near patients 3. Administer antibiotics as ordered 4. Identify patients at risk

4. Identify patients at risk

A patient is admitted with the diagnosis of severe left-sided heart failure. What adventitious lung sounds are expected on auscultation? 1. Sonorous wheezes in left lower lung 2. Rhonchi mid sternum 3. Crackles only in apex of lungs 4. Inspiratory crackles at lung bases

4. Inspiratory crackles at lung bases

The nurse is monitoring the fluid balance of a client with a burn injury. The nurse determines that the client is less than adequately hydrated if which information is noted during assessment? 1.Urine pH of 6 2.Urine that is pale yellow 3.Urine output of 40 mL/hr 4.Urine specific gravity of 1.032

4. The client who is not adequately hydrated will have an elevated urine specific gravity. Normal values for urine specific gravity range from approximately 1.005 to 1.030. Pale yellow urine is a normal finding, as is a urine output of 40 mL/hr (minimum is 30 mL/hr). A urine pH of 6 is adequate (4.6 to 8.0 normal), and this value is not used in monitoring hydration status.

The nurse is caring for a client whose magnesium level is 3.5 mEq/L (1.75 mmol/L). Which assessment finding should the nurse most likely expect to note in the client based on this magnesium level? 1.Tetany 2.Twitches 3.Positive Trousseau sign 4.Loss of deep tendon reflexes

4. The normal serum magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). A client with a magnesium level of 3.5 mEq/L (1.75 mmol/L) is experiencing hypermagnesemia. Assessment findings include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes, respiratory insufficiency, bradycardia, and hypotension. Tetany, twitches, and a positive Trousseau sign are seen in a client with hypomagnesemia.

Acute closed-angle glaucoma is what?

A MEDICAL EMERGENCY

In which newly admitted client situations does the nurse initiate a conversation about advance directives? Select all that apply. A. A client with a non-life-threatening illness B. A person who currently has advance directives C. The client with end-stage kidney disease D. The comatose client who was injured in an automobile crash E. The laboring mother expecting her first child

A, B, C, E All clients who are hospitalized need to be asked about advance directives by the nurse when they are admitted to a hospital. This is a requirement of the Patient Self-Determination Act. Many nurses feel uncomfortable discussing advance directives with "healthy" clients, but the circumstances of admission do not relieve the nurse of this responsibility. The client with preexisting advance directives still needs to be questioned; it is possible that the client's wishes have changed since the documents were established. Clients who have potentially life-threatening diseases or conditions should establish advance directives while they are able to do so.The comatose client is not considered capable of making decisions about his or her wishes concerning advance directives.

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

A, B, D

A nurse cares for clients with urinary incontinence. Which types of incontinence are correctly paired with their clinical manifestation? (Select all that apply.) a. Stress incontinence Urine loss with physical exertion b. Urge incontinence Large amount of urine with each occurrence c. Functional incontinence Urine loss results from abnormal detrusor contractions d. Overflow incontinence Constant dribbling of urine e. Reflex incontinence Leakage of urine without lower urinary tract disorder

A, B, D

The hospital nurse is assigned to establish a rehabilitation milieu on the unit. What elements does the nurse include? A. Allowing time for clients to practice self-management skills B. Encouraging clients and providing emotional support C. Keeping to a structured hospital schedule (e.g., medication administration) D. Making the inpatient unit a more homelike environment E. Carefully monitoring fluid and dietary intake F. Protecting clients from embarrassment (e.g., bowel training)

A, B, D, F As clients undergo rehabilitation, they must learn skills to function independently after they are discharged. Incorporating self-management skills in the environment is crucial. Rehabilitation nurses in hospital settings must provide an environment that encourages and supports clients who are undergoing rehabilitative efforts. The rehabilitative milieu needs to be less structured and more homelike for the client to begin to develop the skills and behaviors that will be needed after discharge. Along with the homelike environment, clients need to be protected from embarrassing situations in this milieu.Although keeping a structured schedule and monitoring fluid and dietary intake are important in the inpatient setting, they are less a matter of focus in the rehabilitation environment. They would not be a primary concern in establishment of this milieu.

A nurse teaches a female client who has stress incontinence. Which statements should the nurse include about pelvic muscle exercises? (Select all that apply.) a. When you start and stop your urine stream, you are using your pelvic muscles. b. Tighten your pelvic muscles for a slow count of 10 and then relax for a slow count of 10. c. Pelvic muscle exercises should only be performed sitting upright with your feet on the floor. d. After you have been doing these exercises for a couple days, your control of urine will improve. e. Like any other muscle in your body, you can make your pelvic muscles stronger by contracting them.

A, B, E

What roles does the rehabilitation nurse have in the functioning of the rehabilitation team? A. Coordinates holistic care B. Coordinates rehabilitation team activities C. Develops the client's fine motor skills D. Plans continuity of care for discharge E. Retrains clients with swallowing challenges

A, B, and D Providing holistic care and coordinating all activities of the rehabilitation team is a role for the rehabilitation nurse—perhaps the primary role. The rehabilitation team is diverse and multi-skilled; getting the right skills and services to the client is a primary role for the rehabilitation nurse. The rehabilitation nurse coordinates the care that the client will continue to receive after discharge; this coordination actually begins as the client is admitted to the rehabilitation unit. Fine motor skill development is the responsibility of specialized members of the rehabilitation team. The rehabilitation nurse may be the one who sees these needs and gets the physical therapist, the occupational therapist, and activity therapist involved. Working with clients who have swallowing difficulties is the responsibility of the speech therapist; this activity would not be a role for the rehabilitation nurse.

A nurse teaches a client about self-catheterization in the home setting. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. Wash your hands before and after self-catheterization. b. Use a large-lumen catheter for each catheterization. c. Use lubricant on the tip of the catheter before insertion. d. Self-catheterize at least twice a day or every 12 hours. e. Use sterile gloves and sterile technique for the procedure. f. Maintain a specific schedule for catheterization.

A, C, F

A nursing assistant asks the rehabilitation nurse for assistance in transferring a 320-pound (145 kg) client from the bed to a wheelchair. How does the nurse respond? A. "First, I want to check the physical therapy care plan." B. "OK, but let's get the mechanical lift device." C. "Sure, but we need to ask additional staff members for assistance." D. "Yes, I would be happy to help you transfer the client."

A. "First, I want to check the physical therapy care plan." The nurse indicates that they first should check the PT care plan. The physical therapist (PT) or occupational therapist (OT) is usually responsible for assessing a client's ability to transfer and for specifying the type of transfer; this plan needs to be consulted before the client is moved.The use of a mechanical lifting device by the nurse may be appropriate, depending on the physical therapy care plan, but the PT or OT should be consulted before the nurse goes ahead with this plan. Getting more staff to help may be the appropriate action for the nurse to take, depending on the physical therapy care plan. Before agreeing to help, the PT or OT care plan must be consulted.

A client in rehabilitation says, "This is too hard. My life will never be the same again!" What is the nurse's BEST response? A. "How did you handle challenges before you were injured?" B. "Should I call a family member to help?" C. "Why don't you try a relaxation exercise?" D. "You will be fine, don't worry so much."

A. "How did you handle challenges before you were injured?" The nurse's BEST response is to ask the client how challenges were handled before the injury. The nurse should assess the client's previous coping strategies and support systems so that they can be used during rehabilitation, if needed. This open-ended question allows the client to problem-solve and explore plausible ways to cope.Besides being a "closed" question requiring a "yes-or-no" response, asking if a family member should be called could provide a supportive environment for the client, but would not build coping skills. Suggesting a relaxation exercise minimizes the client's current situation, and "why" questions are not therapeutic because they place the client in a defensive mode. Also, relaxation may be an option, but is one that has to be learned. Telling the client that he or she will be fine minimizes the client's current situation. Giving reassurances is not considered a therapeutic response; it closes communication.

A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to target audience should the nurse provide this service? a. African-American churches b. Asian-American groceries c. High school sports camps d. Women's health clinics

African American churches African Americans in the United States have one of the highest rates of hypertension in the world. The nurse has the potential to reach this priority population by providing services at African-American churches. Although hypertension education and screening are important for all groups, African Americans are the priority population for this intervention.

A 44 year old patient with diabetes asks how often a visit to the eye care provider is recommended? What is the appropriate nursing response?

Annually

A patient newly diagnosed with diabetes type 2 is being discharged and asks the nurse how often is an appointment recommended with an ophthalmologist. The most appropriate answer for the nurse is?

Annually

A client has a deep vein thrombosis ( DVT ). What comfort measure does the nurse delegate to the unlicensed assistive personnel? a. Ambulate the client. b. Apply a warm moist pack. c. Massage the client's leg. d. Provide an ice pack.

Apply a warm moist pack Warm moist packs will help with the pain of a DVT. Ambulation is not a comfort measure. Massaging the client's legs is contraindicated to prevent complications such as pulmonary embolism. Ice packs are not recommended for DVT

A nurse is caring for a client on IV infusion of heparin. What action does this nurse include in the client's plan of care? a. Assess the client for bleeding. b. Monitor the daily activated partial thromboplastin time (aPTT) results. c. Stop the IV for aPTT above baseline. d. Use an IV pump for the infusion. e. Weigh the client daily on the same scale.

Assess the client for bleeding Monitor the daily activated partial thromboplastin time ( aPTT ) results Use an IV pump for the infusion Assessing for bleeding, monitoring aPTT, and using an IV pump for the infusion are all important safety measures for heparin to prevent injury from bleeding. The aPTT needs to be 1.5 to 2 times normal in order to demonstrate that the heparin is therapeutic. Weighing the client is not related.

When evaluating the hydration status of an 84 year old patient in a nursing home, the nurse observes tenting of the skin on the back of the patient's hand. What is the nurse's best action?

Assess the skin turgor on the patient's forehand.

An adult is admitted to the hospital. X-ray reveals a fractured tibia and a cast is applied. Of the following, which nursing action would be most important to check after the cast is applied?

Assessing for capillary refill.

A patient is prescribed a new medication for the treatment of hypertension. While supine, the patient's blood pressure is 112/70 mmHg and the heart rate is 80/minute. The healthcare provider assesses the patient when the patient changes to a sitting position. Which of the following indicates the patient is experiencing orthostatic hypotension?

BP 88/62, HR 100 Orthostatic hypotension - A decrease in blood pressure (20 mm Hg systolic and/or 10 mm Hg diastolic) that occurs during the first few seconds to minutes after changing from a sitting or lying position to a standing position. Also called postural hypotension. *Increases risk for falls and fractures

The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet? a. A 4-ounce steak, French fries, iceberg lettuce b. Baked chicken breast, broccoli, tomatoes c. Fried catfish, cornbread, peas d. Spaghetti with meat sauce, garlic bread

Baked chicken breast, broccoli, tomatoes The diet recommended for this client would be low in saturated fats and red meat, high in vegetables and whole grains (fiber), low in salt, and low in trans fat. The best choice is the chicken with broccoli and tomatoes. The French fries have too much fat and the iceberg lettuce has little fiber. The catfish is fried. The spaghetti dinner has too much red meat and no vegetables.

Hyponatremia Symptoms

Behavior changes, LOC, confusion, general weakness, hyperactive GI, rapid weak thready pulse (hypotensive)

Perforation (related to GI)

Board-like abdomen

The paraplegic patient is being admitted to a medical unit from home with a stage IV pressure ulcer over the right ischium. Which assessment tool should be completed on admission to the hospital?

Braden Scale: Scale used to predict the risk for a pressure ulcer to occur. Scoring system: 15-16 MILD RISK 12-14 MODERATE RISK <11 SEVERE RISK

The nurse is caring for a patient who injured his right leg at a construction site. Which signs/symptoms will the nurse assess to determine if the patient is experiencing a localized inflammatory response? Malaise, anorexia, enlarged lymph nodes Chest pain, shortness-of-breath, nausea/vomiting Dizziness, disorientation Edema, redness, swelling, pain

Edema, redness, swelling, pain

What position make arterial pain worse?

Elevation

What position makes venous pain better?

Elevation

What does Magnesium deal with?

Energy/Weakness/Fatigue

A patient is admitted with diabetic ketoacidosis. The physician orders intravenous fluids of 0.9% Normal Saline and 10 units of intravenous regular insulin IV bolus and then to start an insulin drip per protocol. The patient's labs are the following: pH 7.25, glucose 455, potassium 2.5. Which of the following is the most appropriate nursing intervention to perform next?

Hold the insulin and notify the doctor of the potassium level of 2.5 Diabetic Ketoacidosis: when your body produces high levels of blood acids called ketones. The condition develops when your body can't produce enough insulin. What are normal ranges of: - pH: blood ph 7.35-7.45 - Glucose: <140mg/dL (normal) >200mg/dL (Diabetic) between 140-199mg/dL (prediabetic) - Potassium: 3.6 to 5.2 millimoles per liter (mmol/L). A very low potassium level (less than 2.5 mmol/L

A nurse is caring for four patients. Which one would the nurse see first?

Hypertensive patient with a blood pressure of 188/92

Hyperglycemia or Hypoglycemia with Somogyi Phenomenon?

Hypoglycemia

What happens to potassium levels during DKA?

Hypokalemia (excreted in urine)

Why has there been an increase in chronic disease during the past century?

Improved medical care Improved sanitation Immunizations Increased drinking and smoking Lifestyle changes ****because of these improvements people live longer

Genevieve is diagnosed with hypomagnesemia, which nursing intervention would be appropriate?

Instituting seizure precaution to prevent injury Hypomagnesemia: is a serum magnesium (Mg2+) level below 1.8 mEq/L or 0.74 mmol/L. It is most often caused by decreased absorption of dietary magnesium or increased kidney magnesium excretion. Two major causes of hypomagnesemia are inadequate intake and the use of loop or thiazide diuretics. Table 11-11 lists additional causes of hypomagnesemia.

When assessing a patient diagnosed with osteoarthritis (OA), the nurse looks for which characteristic of his condition?

Joint crepitus What is osteoarthritis (OA)? The most common arthritis and a major cause of impaired mobility and disability. It is the progressive deterioration and loss of cartilage and bone in one or more joints. The production of synovial fluid also decreases. Noninflammatory form of arthritis characterized by the progressive deterioration and loss of cartilage in one or more joints; most common form of arthritis. Symptoms of OA? Pt complains of chronic joint pain and stiffness. Symptoms include crepitus, enlarged joints, Heberden's or Bouchard's nodes, joint effusions, and loss of function or decreased mobility. What is joint crepitus? A grating sound caused by loosened bone and cartilage. This is due to the disintegration of cartilage in OA, which causes pieces of bone and cartilage to "float" in the diseased joint.

A client is receiving an infusion of alteplase ( Activase ) for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse takes priority? a. Assess the client's neurologic status. b. Notify the Rapid Response Team. c. Prepare to administer vitamin K. d. Turn down the infusion rate.

Notify the Rapid Response Team Clients on fibrinolytic therapy are at high risk of bleeding. The sudden onset of neurologic signs may indicate the client is having a hemorrhagic stroke. The nurse does need to complete a thorough neurological examination, but should first call the Rapid Response Team based on the client's manifestations. The nurse notifies the Rapid Response Team first. Vitamin K is not the antidote for this drug. Turning down the infusion rate will not be helpful if the client is still receiving any of the drug.

You are caring for a patient who underwent surgery 48 hours ago. On physical assessment, you notice that the wound looks red and swollen. The patient's WBCs are elevated. You should: Start antibiotic ..... Notify the provider Document the findings and reassess in 2 hours Place the patient on isolation precautions

Notify the provider

Dr. Roberta Temes' "Living With An Empty Chair - a guide through grief." 3 behaviors

Numbness (mechanical functioning and social insulation) Disorganization (intensely painful feelings of loss) Reorganization (re-entry into a more 'normal' social life.)

cultures and death - African American

Often do not want hospice only 19% wanted a DNR and fewer wanted withdrawal of life support (07/10 AJCC) Family is very involved in the funeral planning and many come to see the patient

cultures and death- Hispanic

Open expressions of grief, especially the women Catholicism is the predominant religion Family presence is important

Glaucoma destroys what part of the eye?

Optic nerve

What is Chronic closed angle glaucoma?

Outflow of aqueous humor impaired due to narrowing of angle between iris and cornea

A nurse is caring for a client with deep vein thrombosis ( DVT ). What nursing assessment indicates a priority outcome has been met? a. Ambulates with assistance b. Oxygen saturation of 98% c. Pain of 2/10 after medication d. Verbalizing risk factors

Oxygen saturation of 98% A critical complication of DVT is pulmonary embolism. A normal oxygen saturation indicates that this has not occurred. The other assessments are also positive, but not the priority.

A student nurse is assessing the peripheral vascular system of an older adult. What action by the nurse would cause the faculty member to intervene?

Palpating both carotid arteries at the same time.

Hyperkalemia EKG

Peaked T wave, prolonged PR interval, widened QRS complex, flat/absent P wave

Marie Joy's lab test revealed that her serum calcium is 2.5 mEq/L. Which assessment data does the nurse document when a client diagnosed with hypocalcemia develops a carpopedal spasm after the blood-pressure cuff is inflated?

Positive Trousseau's Sign Trousseau's sign: carpopedal spasm(are frequent and involuntary muscle contractions in the hands and feet) caused by inflating the blood-pressure cuff to a level above systolic pressure for 3 minutes -> sends pt into hypoxic state which triggers sign to occur if pt has hypocalcemia. Positive Chvostek's sign: the twitching of the facial muscles in response to tapping over the area of the facial nerve. Paresthesia: an abnormal sensation of the skin (tingling, pricking, chilling, burning, numbness) with no apparent physical cause. Tetany: Continuous contractions of muscle groups; hyper-excitability of nerves and muscles. Carpopedal spasm: frequent and involuntary contractions in the hands and feet.

After obtaining an EKG on a patient, you notice that ST depression is present along with an inverted T wave and prominent U wave. What lab value would be the cause of this finding?

Potassium level of 2.2 Define normal potassium range: Blood potassium level is normally 3.6 to 5.2 millimoles per liter (mmol/L). Under 2.5 is really dangerous and low.

Rehabilitation concepts

Process of learning to live with chronic and disabling condition Goal is to return the patient to the best possible outcome, whether it is physical, mental, social, vocational or economic Encompasses all areas of health

Hypomagnesemia EKG

Prolonged QT interval

Hypocalcemia EKG

Prolonged ST interval and QT interval (slow heart rate, weak thready pulse)

quality of life definition

Quality of life is an individual's perception of their position in life in the context of the culture and value systems in which they live, and in relation to their goals, expectations, standards and concerns. World Health Organization Quality of Life, 1993

The nurse assesses a new patient and finds the patient short of breath with a respiratory rate of 32 and lying supine in bed. What is the priority nursing action? Raise the head of bed to 45 degrees or higher. Get the oxygen saturation with the pulse oximeter. Take the blood pressure and respiratory rate. Notify the health care provider.

Raise the head of bed to 45 degrees or higher.

The PCT tells the nurse that a patient with a PCA pump of IV morphine is very drowsy, cannot complete a sentence without falling asleep, their respirations are 10 per minute. What is the nurse's priority action?

Raise the head of the bed and wake the patient up. PRIORITY - first thing u do What is a PCA pump? (Patient-controlled analgesia) is an interactive method of management that allows patients to treat their pain by self administering doses of analgesics. It is used to manage all types of pain and given by multiple routes of administration, including IV, subcutaneous, epidural, and perineural. A PCA infusion device is used when PCA is delivered by invasive routes of administration and is programmed so the patient can press as button ("pendent") to self administer a set dose of analgesic (PCA dose) at a set time interval ("demand or "lockout") as needed.

A nurse is preparing a client for a femoropopliteal bypass operation. What action does the nurse delegate to the UAP? a. Administering preoperative medication b. Ensuring the consent is signed c. Marking pulses with a pen d. Raising the siderails on the bed e. Recording baseline vital signs

Raising the side rails on the bed Recording baseline vital sings The UAP can raise the siderails of the bed for client safety and take and record the vital signs. Administering medications, ensuring a consent is on the chart, and marking the pulses for later comparison should be done by the registered nurse. This is also often done by the postanesthesia care nurse and is part of the hand-off report.

Jerod is experiencing an acute episode of ulcerative colitis. Which is the priority for this patient?

Replace lost fluid and sodium. UC: beings in rectum, proceeds to cecum; 10-20 liquid/bloody stool per day; causes hemorrhaging and nutritional deficiencies; infrequent need for surgeries

A patient presents to the emergency department with a blood pressure of 180/130 mmHg, headache and confusion. Which additional finding is consistent with a diagnosis of hypertensive emergency?

Retinopathy Retinopathy: Inflammation of the retina. Also used as a general term for vision problems.

Hypokalemia EKG

ST segment depression, flat/inverted T wave, U wave

Theories of chronic illness- shifting perspectives

Shift between well and ill Taking on the Sick Role Finding meaning, hope and quality of life Accepting or denying illness

Hypernatremia Symptoms

Short attention span, confusion, muscle twitching (DTR), seizure/headache

Hypercalcemia EKG

Shortened QT interval (increased HR and BP)

A patient who has had rheumatic arthritis for several years is admitted to your unit. Upon physical examination of the patient the nurse should expect to find?

Small/limited joint involvement

A 24 year old man seeks medical attention for complaints of claudication in the arch of the foot. A nurse also notes superficial thrombophlebitis of the lower leg. The nurse would next assess the client for ______ ______.

Smoking History What is superficial thrombophlebitis? an inflammatory condition of the veins due to a blood clot just below the surface of the skin.

An ambulatory elderly woman with dementia is incontinent of urine. She has poor short-term memory and has not been seen toileting independently. What is the best nursing intervention for this patient? Recommend that she be evaluated for overactive bladder medication. Start a scheduled toileting program. Recommend that she be evaluated for an indwelling catheter. Start a bladder retraining program.

Start a scheduled toileting program.

The nurse caring for a client with small-bowel obstruction would plan to implement which nursing intervention first?

Start an IV and administer IV fluids.

Acute closed angle glaucoma

Sudden onset of PAIN, blurred vision, Pupil is fixed, dilated, NON-REACTIVE to light. IOP 50 mmHg or higher MEDICAL EMERGENCY

A nurse is collecting a wound culture. Which techniques should be used?

Swab an area of the wound bed that is clean and viable

The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning? a. Cholesterol: 126 mg/dL b. High-density lipoprotein cholesterol (HDL-C): 48 mg/dL c. Low-density lipoprotein cholesterol (LDL-C): 122 mg/dL d. Triglycerides: 198 mg/dL

Triglycerides: 198 mg/dL

what is a living will?

Type of advance directive States the type & amount of care such as DNR orders More of a medical directive Describes your preferences for end-of-life-care Written & legal Used when you cannot make decisions for your self

Skin with Venous Disease

Warm Thick, tough skin Brown colored

Pulse with Arterial Disease

Weak or absent

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

a. Do any of your family members have this problem?

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

a. Do you smoke cigarettes?

A nurse is assisting a patient in making dietary choices that promote healthy bowel elimination. Which menu option should the nurse recommend? a. Grape and walnut chicken salad sandwich on whole wheat bread b. Broccoli and cheese soup with potato bread c. Dinner salad topped with hard-boiled eggs, cheese, and fat-free dressing d. Turkey and mashed potatoes with brown gravy

a. Grape and walnut chicken salad sandwich on whole wheat bread

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

a. I will limit my total intake of fluids.

The nurse should place the patient in which position when preparing to administer an enema? a. Left Sims' position b. Fowler's c. Supine d. Semi-Fowler's

a. Left Sims' position

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

a. Use a second form of birth control while on this medication.

UNF student nurse Hannah is teaching a group of middle aged men about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention:

alcohol abuse and smoking

Primary open-angle glaucoma (POAG) is caused by what?

aqueous humor outflow being reduced, meaning that the fluid cannot leave the eye at the same rate it is being produced hence the pressure

A client receiving palliative care asks the nurse "Why is this happening to me?" What is the nurse's best response? a. "I don't know. God only knows when your time is up on this earth." b. "I'm sorry. I know that this is a difficult time for you." c. "It's going to be OK; at least you aren't leaving any family behind." d. "We'll make sure that all of your needs are met, so don't worry."

b. Open-ended statements encourage continued verbalization and show the client that the nurse is listening empathetically. The other statements are inappropriate because they make assumptions about the client.

A patient expresses concerns over having black stool. The fecal occult test is negative. Which response by the nurse is most appropriate? a. "This is probably a false negative; we should rerun the test." b. "Do you take iron supplements?" c. "You should schedule a colonoscopy as soon as possible." d. "Sometimes severe stress can alter stool color."

b. "Do you take iron supplements?"

Which patient is most at risk for increased peristalsis? a. A 5-year-old child who ignores the urge to defecate owing to embarrassment b. A 21-year-old patient with three final examinations on the same day c. A 40-year-old woman with major depressive disorder d. An 80-year-old man in an assisted-living environment

b. A 21-year-old patient with three final examinations on the same day

A nurse plans care for clients with urinary incontinence. Which client is correctly paired with the appropriate intervention? a. A 29-year-old client after a difficult vaginal delivery Habit training b. A 58-year-old postmenopausal client who is not taking estrogen therapy Electrical stimulation c. A 64-year-old female with Alzheimers-type senile dementia Bladder training d. A 77-year-old female who has difficulty ambulating Exercise therapy

b. A 58-year-old postmenopausal client who is not taking estrogen therapy Electrical stimulation

. The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of pulmonary complication? a. Antibiotics b. Frequent change of position c. Oxygen humidification d. Chest physiotherapy

b. Frequent change of position

1. A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for the development of bacterial cystitis? a. A 36-year-old female who has never been pregnant b. A 42-year-old male who is prescribed cyclophosphamide c. A 58-year-old female who is not taking estrogen replacement d. A 77-year-old male with mild congestive heart failure

c. A 58-year-old female who is not taking estrogen replacement

he nurse should question which order? a. A normal saline enema to be repeated every 4 hours until stool is produced b. A hypertonic solution enema with a patient with fluid volume excess c. A Kayexalate enema for a patient with hypokalemia d. An oil retention enema for a patient using mineral oil laxatives

c. A Kayexalate enema for a patient with hypokalemia

After teaching a client with bacterial cystitis who is prescribed phenazopyridine (Pyridium), the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? a. I will not take this drug with food or milk. b. If I think I am pregnant, I will stop the drug. c. An orange color in my urine should not alarm me. d. I will drink two glasses of cranberry juice daily.

c. An orange color in my urine should not alarm me.

A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicated that the patient needs airway suctioning? a. Coughing up sputum occasionally b. Coughing up thin, watery sputum after nebulization c. Decreased ability to clear airway through coughing d. Lung sounds clear after coughing

c. Decreased ability to clear airway through coughing

A nurse is caring for a patient who has had diarrhea for the past week. Which additional assessment finding would the nurse expect? a. Increased energy levels b. Distended abdomen c. Decreased serum bicarbonate d. Increased blood pressure

c. Decreased serum bicarbonate

A nurse is caring for an older adult patient with fecal incontinence due to cathartic use. The nurse is most concerned about which complication that has the greatest risk for severe injury? a. Rectal skin breakdown b. Contamination of existing wounds c. Falls from attempts to reach the bathroom d. Cross-contamination into the upper GI tract

c. Falls from attempts to reach the bathroom

The nurse administers a cathartic to a patient. The nurse determines that the cathartic has had a therapeutic effect when the patient a. Has a decreased level of anxiety. b. Experiences pain relief. c. Has a bowel movement. d. Passes flatulence.

c. Has a bowel movement.

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

c. I can teach you strategies to help control your incontinence.

The nurse is preparing to perform a fecal occult blood test. The nurse plans to properly perform the examination by a. Applying liberal amounts of stool to the guaiac paper. b. Testing the quality control section before collecting the specimen section. c. Reporting any abnormal findings to the provider. d. Applying sterile disposable gloves.

c. Reporting any abnormal findings to the provider.

A nurse assesses a client with bladder cancer who is recovering from a complete cystectomy with ileal conduit. Which assessment finding should alert the nurse to urgently contact the health care provider? a. The ileostomy is draining blood-tinged urine. b. There is serous sanguineous drainage present on the surgical dressing. c. The ileostomy stoma is pale and cyanotic in appearance. d. Oxygen saturations are 92% on room air.

c. The ileostomy stoma is pale and cyanotic in appearance.

A patient had an ileostomy surgically placed 2 days ago. Which diet would the nurse recommend to the patient to ease the transition of the new ostomy? a. Eggs over easy, whole wheat toast, and orange juice with pulp b. Chicken fried rice with stir fried vegetables and iced tea c. Turkey meatloaf with white rice and apple juice d. Fish sticks with macaroni and cheese and soda

c. Turkey meatloaf with white rice and apple juice

The nurse would anticipate which diagnostic examination for a patient with black tarry stools? a. Ultrasound b. Barium enema c. Upper endoscopy d. Flexible sigmoidoscopy

c. Upper endoscopy

Dry AMD

caused by gradual blockage of retinal capillaries, allowing retinal cells in macula to become ischemic & necrotic so central vision declines

The nurse is caring for a patient with Clostridium difficile. Which of the following nursing actions will have the greatest impact in preventing the spread of bacteria? a. Monthly in-services about contact precautions b. Placing all contaminated items in biohazard bags c. Mandatory cultures on all patients d. Proper hand hygiene techniques

d. Proper hand hygiene techniques

The nurse is caring for a patient who had a colostomy placed yesterday. The nurse should report which assessment finding immediately? a. Stoma is protruding from the abdomen. b. Stoma is moist. c. Stool is discharging from the stoma. d. Stoma is purple.

d. Stoma is purple.

A patient has constipation and hypernatremia. The nurse prepares to administer which type of enema? a. Oil retention b. Carminative c. Saline d. Tap water

d. Tap water

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

d. Use the Valsalva maneuver.

A nurse cares for a client who is scheduled for the surgical creation of an ileal conduit. The client states, I am anxious about having an ileal conduit. What is it like to have this drainage tube? How should the nurse respond? a. I will ask the provider to prescribe you an antianxiety medication. b. Would you like to discuss the procedure with your doctor once more? c. I think it would be nice to not have to worry about finding a bathroom. d. Would you like to speak with someone who has an ileal conduit?

d. Would you like to speak with someone who has an ileal conduit?

Nursing Interventions for Somogyi Phenomenon?

decrease insulin at night and give snack at bedtime

What is macular degeneration?

deterioration of the macula (area of central vision), causing a loss of central vision in one or both eyes and a decreased ability to distinguish colors

Electronystagmography:

determines if there is something wrong with the vestibular portion of inner ear by artificially stimulating the vestibular apparatus

An 86 year old female patient is immobile and is in the right lateral recumbent position. As the nurse, you know that the sites below are at most risk for pressure injury in this position?

ear, ankle, hip

A patient has an exacerbation of ulcerative colitis with cramping and diarrhea persisting longer than one week. The nurse should assess the patient for which complication?

hypokalemia

Location of Venous Ulcers

medial parts of lower legs & medial ankle region deep pink to red

Detached retina

often develop in eyes w/ retinas weakened by hole or tear; fluid seeps underneath weakening attachment and retina detaches so it cannot compose a clear image from incoming light and vision is blurred & dim

Rx for Acute Closed Angle Glaucoma?

osmotic diuretics (Mannitol)

how do you care for the dying?

pain control comfort measures (music, pillows, cool room) if SOB, raise head of bed let them rest stay with the pt as much as possible when no one is there

Hyperkalemia Symptoms

paresthesia (burning/pricking), bradycardia/abnormal beats, muscle twitching, increased GI motility

A patient diagnosed with ulcerative colitis is admitted to the medical unit. When assessing the patient, which of these findings would be of most concern?

rebound tenderness What is Ulcerative Colitis (UC)? Widespread inflammation that begins in the rectum and proceeds in a continuous matter toward the cecum. Periodic flare-ups. Peak incidence ages are 15-25 and 55-65. Priority problems for patients with UC: -diarrhea due to inflammation of the bowel mucosa -Acute pain or chronic noncancer pain due to inflammation and ulceration of the bowel mucosa and skin irritation. -Potential for lower GI bleeding and resulting anemia due to UC What is borborygmi? Rumbling or gurgling noise made by the movement of fluid or gas in the intestines. High pitched bowel sounds

Gastroesophageal reflux disease (GERD):

reflux causes esophageal mucosa to be irritated by the effects of gastric and duodenal contents, resulting in inflammation

sensorineuronal hearing loss:

results from exposure to loud noises, diabetes, damage to the inner ear, or Meniere's Disease

Hypokalemia Symptoms

shallow respirations, weak thready irregular pulse, altered mental status, paralytic ileus

clinical death definition

time between cessation of heartbeat and breathing and the brain stops (4-6 minutes)

brain death definition

when brain function has stopped, yet the heart and lungs are kept viable by artificial means.

death definition

when the heart and lungs cease to function

When is low residue (low fiber) diet recommended?

when the intestinal tract is narrowed by inflammation or scarring or when gastrointestinal motility is slowed inflammatory bowel disease partial obstructions of the intestinal tract gastroenteritis diarrhea

Common Nursing Diagnoses for Eye Problems

● Disturbed sensory perception r/t visual deficit ● Risk for injury r/t visual impairment ● Self care deficit r/t visual impairment ● Anticipatory grieving r/t loss of functional vision ● Acute pain r/t pathophysiologic process and/or surgical correction ● Noncompliance r/t inconvenience of lifelong meds

Drug Therapy for GERD: Proton Pump Inhibitors

● MAIN TREATMENT FOR GERD!! long acting inhibition of gastric acid secretions by inhibiting proton pump of parietal cell

A nurse is assessing a client with peripheral artery disease ( PAD ). The client states walking five blocks is possible without pain. What question asked next by the nurse will give the best information? a. "Could you walk further than that a few months ago?" b. "Do you walk mostly uphill, downhill, or on flat surfaces?" c. "Have you ever considered swimming instead of walking?" d. "How much pain medication do you take each day?"

" Could you walk further than that a few months ago? " As PAD progresses, it takes less oxygen demand to cause pain. Needing to cut down on activity to be pain free indicates the client's disease is worsening. The other questions are useful, but not as important.

A client has peripheral arterial disease ( PAD ). What statement by the client indicates misunderstanding about self-management activities? a. "I can use a heating pad on my legs if it's set on low." b. "I should not cross my legs when sitting or lying down." c. "I will go out and buy some warm, heavy socks to wear." d. "It's going to be really hard but I will stop smoking."

" I can use a heating pad on my legs if it's set on low " Clients with PAD should never use heating pads as skin sensitivity is diminished and burns can result. The other statements show good understanding of self-management.

A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best? a. "Do you have trouble affording your medications?" b. "Most people with hypertension do not have symptoms." c. "You are lucky; most people get severe morning headaches." d. "You need to take your medicine or you will get kidney failure."

" Most people with hypertension do not have symptoms " Dehydration can cause the BUN to be elevated, but the elevation in creatinine is more specific for a kidney injury. The client does not necessarily need to Most people with hypertension are asymptomatic, although a small percentage do have symptoms such as headache. The nurse should explain this to the client. Asking about paying for medications is not related because the client has already admitted nonadherence. Threatening the client with possible complications will not increase compliance. admitted. A urinalysis may or may not be ordered.

A client is taking warfarin ( Coummadin ) and asks the nurse if taking St. John's wort is acceptable. What response by the nurse is best? a. "No, it may interfere with the warfarin." b. "There isn't any information about that." c. "Why would you want to take that?" d. "Yes, it is a good supplement for you."

" No, it may interfere with the warfarin " Many foods and drugs interfere with warfarin, St. John's wort being one of them. The nurse should advise the client against taking it. The other answers are not accurate.

The nurse caring for a patient with intermittent claudication pain related to peripheral disease. Which statement made by the patient indicates understanding of proper self management?

"I will start to exercise gradually, stopping when I have pain." What is claudication pain? Pain in thigh, calf, or buttocks that occurs when walking.

The nurse is caring for a male client postoperatively following the creation of a colostomy. Which nursing problem should the nurse include in the plan of care?

Body image, disturbed

cultures and death- Judaism

Bury the person the next day No autopsy or cremation 7 day mourning period (Shiva) Families take food and provide for mourners

A patient has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best?

"Most people with hypertension do not have symptoms." What are symptoms of hypertension? When a diagnosis of hypertension is made, most people have no symptoms. However, some pts experience headaches, facial flushing (redness), dizziness, or fainting as a result of the elevated BP. (P. 722 textbook).

The patient had an elective below the knee amputation and reports pain in the part of his leg that was amputated. What is the nurse's best response?

"On a scale of 0-10, how would you rate your pain?" Define Phantom pain: pain that feels like it's coming from a body part that's no longer there.

You're working on a medical surgical floor. Select the patients that are at risk for a pressure injury.

- A 19 year old female who is quadriplegic. - A 35 year old male with a BMI of 13.6 that is incontinent of stool and has a right leg splint. - A 45 year old with Braden Scale score of 7.

Which of the following are good foot care tips for people with diabetes, that the nurse can use to educate the diabetic patient on footcare. (Select all that apply).

- Do daily foot care and inspections. - Have good blood glucose control. - Never walk around barefoot. - Have your doctor check your feet at least once a year. - Try to do some form of exercise several times per week.

Evaluation of patients for metabolic syndrome should include?

- Measurement of waist circumference - Measurement of vital signs - Height - Weight - BMI Metabolic syndrome: A collection of related health problems with insulin resistance as a main feature. Other features include obesity, low levels of physical activity, hypertension, high blood levels of cholesterol, and elevated triglyceride levels. Metabolic syndrome increases the risk for coronary heart disease. Also called syndrome X. Rationale: With metabolic syndrome there are usually no immediate physical symptoms or specific complaints. The medical problems tend to develop rather innocuously over time. Hx should include a thorough discussion of past medical conditions as well as current risk factors. With respect to lab tests, along with basic serum chemistry and complete blood count, there should be a measurement of fasting blood sugar and a lipid profile.

how to support a grieving person

- ask about their feelings - spending time just being with them - listen when they want to talk

Top 5 common chronic illnesses

1- arthritis 2- cancer 3- diabetes 4- heart disease 5- overweight/obesity

A registered nurse (RN) has instructed an unlicensed assistive personnel (UAP) to administer soapsuds enemas until clear to a client. The UAP reports that three enemas have been administered and the client is still passing brown, liquid stool. What should the RN instruct the UAP to do? 1.Administer a Fleet enema. 2.Administer an oil retention enema. 3.Wait 30 minutes and then administer another enema. 4.Stop administering the enemas until the health care provider (HCP) is notified.

4. Up to three enemas may be given when there is a prescription for enemas until clear. If more than three are necessary, the nurse should call the HCP (or act according to agency policy). Excessive enemas could cause fluid and electrolyte depletion. Options 1 and 3 are incorrect for these reasons. An oil retention enema is an enema that is used to soften dry, hard stool and would have no use in this situation.

Short Acting Insulin Duration

8 hours

Calcium Levels

9.0-10.5

What is the goal for HgA1c?

< 7

What is the blood glucose level of someone who is in DKA?

> 300 mg/dL

A dying client exhibits signs of agitation. The Foley catheter has drained 100 mL in the last 3 hours, and the client's last bowel movement was yesterday evening. What does the nurse do first? A. Administer an analgesic. B. Arrange for a consultation with a bereavement counselor. C. Assess the client for impaction. D. Change the Foley catheter to ensure adequate drainage.

A. Administer an analgesic. The first action taken by the nurse is to administer an analgesic. Agitation may be indicative of pain, which must be addressed in the dying client.Arranging for a consultation with a counselor is not the priority in this situation. The dying client's metabolism has slowed, so assessing for impaction may not be necessary since the client had a bowel movement the evening before. The Foley catheter should not be changed, but the tubing should be assessed to ensure that there are no kinks.

Which of these patients would be assessed immediately following the charge of shift report?

An older patient who is complaining of floaters in the visual field and an abrupt sensation of curtain over their eye. What are floaters associated with? Retinal detachment.

A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the UAP for deep vein thrombosis ( DVT ) prevention? a. Apply compression stockings. b. Assist with ambulation. c. Encourage coughing and deep breathing. d. Offer fluids frequently. e. Teach leg exercises.

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

The nurse is emptying an ileostomy pouch for a patient. Which assessment finding would the nurse report immediately? a. Liquid consistency of stool b. Presence of blood in the stool c. Noxious odor from the stool d. Continuous output from the stoma

b. Presence of blood in the stool

Intermittent Claudation occurs with?

Arterial Pain

A client with very dry mouth, skin and mucous membranes is diagnosed with having dehydration. Which intervention should the nurse perform when caring for a client diagnosed with fluid volume deficit?

Assessing urinary intake and output fluid volume deficit -dehydration

A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the recommended lifestyle changes. What action by the nurse is best? a. Assess the client's support system. b. Assist in finding one change the client can control. c. Determine what stressors the client faces in daily life. d. Inquire about delegating some of the client's obligations.

Assist in finding one change the client can control. All options are appropriate when assessing stress and responses to stress. However, this client feels overwhelmed by the suggested lifestyle changes. Instead of looking at all the needed changes, the nurse should assist the client in choosing one the client feels optimistic about controlling. Once the client has mastered that change, he or she can move forward with another change. Determining support systems, daily stressors, and delegation opportunities does not directly impact the client's feelings of control

A nurse assesses a client with a fungal urinary tract infection (UTI). Which assessments should the nurse complete? (Select all that apply.) a. Palpate the kidneys and bladder. b. Assess the medical history and current medical problems. c. Perform a bladder scan to assess post-void residual. d. Inquire about recent travel to foreign countries. e. Obtain a current list of medications.

B, E

A nurse teaches clients about the difference between urge incontinence and stress incontinence. Which statements should the nurse include in this education? (Select all that apply.) a. Urge incontinence involves a post-void residual volume less than 50 mL. b. Stress incontinence occurs due to weak pelvic floor muscles. c. Stress incontinence usually occurs in people with dementia. d. Urge incontinence can be managed by increasing fluid intake. e. Urge incontinence occurs due to abnormal bladder contractions.

B, E

A client who can't move his right leg or arm tells the nurse: "Life is over for me. I don't want to live if I'm going to be a burden to everyone." What is the nurse's best action? a. Report the client's concern to the physician. b. Consult with the clinical psychologist or social worker. c. Share the client's feelings with the family. d. Refer the client to the vocational counselor.

B. The client is potentially a suicide risk and requires assistance from a professional who is an expert in psychological assessment and interventions.

Sitty, a 66 year old patient underwent a colostomy for a ruptured diverticulum. She did well during the surgery and returned to your med-surg floor in stable condition. You assess her colostomy 2 days after surgery. Which finding do you report to the doctor?

Brownish-black stoma Stoma: The surgical creation of an opening; usually refers to an opening in the abdominal wall.

A patient was admitted this morning with an incomplete spinal cord injury and is placed in a halo fixator vest after surgery. Which assessment finding will the nurse report immediately to the healthcare provider?

BP of 80/40 What is an incomplete spinal cord injury? Having some motor or sensory function below the injury Halo Fixator: A static traction device used for immobilization of the cervical spine. Four pins or screws are inserted into the skull, and a metal halo ring is attached to a plastic vest or cast when the spine is stable, allowing increased patient mobility.

A client has just received a bisacodyl (Dulcolax) suppository. How soon after administration does the nurse expect results to be evident? A. 5 to 10 minutes B. 10 to 15 minutes C. 15 to 30 minutes D. 30 to 45 minutes

C. 15 to 30 minutes The nurse expects results to be evident within 15 to 30 minutes. Bisacodyl (Dulcolax) suppository agents are often used in bowel training programs. Suppositories must be placed against the bowel wall to stimulate the sacral arc and promote rectal emptying, which occurs within 15 to 30 minutes after administration.Five to 15 minutes is not enough time for a glycerin suppository to be effective; the mechanism of action requires a longer time period. Action from the suppository should occur by 30 minutes after insertion.

A Christian client is struggling with a diagnosis of cancer and says, "Why is life so unfair?" What health care team member does the nurse ask to provide support? A. Client's family B. Physician C. Hospital chaplain D. Psychiatrist

C. Hospital chaplain The nurse requests assistance from the chaplain. Chaplains are the most able to provide support and have the time and expertise to manage spiritual distress, no matter what the client's religious preference.The family is not a member of the health care team. Asking the physician to provide support is inappropriate. Asking the psychiatrist for support might make sense, but is not the best answer.

The RN is providing a list of recommended food to the family of a patient who recently had a total colectomy and colostomy. Which food item should the RN recommend including in the postoperative diet?

Chicken Noodle Soup

A nurse is caring for four clients. Which one should the nurse see first? a. Client who needs a beta blocker, and has a blood pressure of 92/58 mm Hg b. Client who had a first dose of captopril (Capoten) and needs to use the bathroom c. Hypertensive client with a blood pressure of 188/92 mm Hg d. Client who needs pain medication prior to a dressing change of a surgical wound

Client who had a first does of captopril ( Capoten ) and needs to use the bathroom Angiotensin-converting enzyme inhibitors such as captopril can cause hypotension, especially after the first dose. The nurse should see this client first to prevent falling if the client decides to get up without assistance. The two blood pressure readings are abnormal but not critical. The nurse should check on the client with higher blood pressure next to assess for problems related to the reading. The nurse can administer the beta blocker as standards state to hold it if the systolic blood pressure is below 90 mm Hg. The client who needs pain medication prior to the dressing change is not a priority over client safety and assisting the other client to the bathroom.

A newly admitted patient states that he has recently had a change in medications and reports that stools are now dry and hard to pass. This type of bowel pattern is consistent with: Abnormal defecation Constipation Fecal impaction Fecal incontinence

Constipation

A nurse is caring for a client with a nonhealing arterial lower leg ulcer. What action by the nurse is best? a. Consult with the Wound Ostomy Care Nurse. b. Give pain medication prior to dressing changes. c. Maintain sterile technique for dressing changes. d. Prepare the client for eventual amputation.

Consult with the Wound Ostomy Care Nurse A nonhealing wound needs the expertise of the Wound Ostomy Care Nurse (or Wound Ostomy Continence Nurse). Premedicating prior to painful procedures and maintaining sterile technique are helpful, but if the wound is not healing, more needs to be done. The client may need an amputation, but other options need to be tried first.

Skin with Arterial Disease

Cool Dry Flaky Thick Toenails

A patient has a severe exacerbation of ulcerative colitis. Long term medications will probably include:

Corticosteroids Glucocorticoids, such as prednisone and prednisolone, are corticosteroid therapies prescribed during exacerbations of the disease. Prednisone is typically prescribed, and the dose may be increased as acute flare-ups occur. Once clinical improvement occurs, the corticosteroids are tapered because of the adverse effects that commonly occur with long-term steroid therapy (e.g., hyperglycemia, osteoporosis, peptic ulcer disease, increased potential for infection, adrenal insufficiency). For patients with rectal inflammation, topical steroids in the form of small retention enemas or suppositories may be prescribed. Medications such as budesonide (Uceris or Entocort EC), steroids that are thought to work mostly in the bowel, produce less systemic side effects.

A dying client becomes increasingly withdrawn and begins to refuse to eat and drink. What intervention does the nurse implement? A. Brings in the client's favorite food B. Calls the family to come in right away C. Gives intravenous hydration D. Offers ice chips

D. Offers ice chips The dying client should not be forced to eat or drink, but small sips of liquids or ice chips at frequent intervals can be offered if the client is alert and able to swallow. This helps the client with problems of dehydration and "dry mouth."The dying client's metabolic needs have decreased, so the client will not want any food or drink. Calling the family is not yet necessary in this client's case. Because the dying client's metabolic needs have decreased, invasive procedures are not necessary at this point.

A client is being discharged on warfarin ( Coumadin ) therapy. What discharge instructions is the nurse required to provide? A. Dietary restrictions b. Driving restrictions c. Follow-up laboratory monitoring d. Possible drug-drug interactions e. Reason to take medication

Dietary restrictions Follow up laboratory monitoring Possible drug-drug interactions Reason to take medication The Joint Commission's Core Measures state that clients being discharged on warfarin need instruction on follow-up monitoring, dietary restrictions, drug-drug interactions, and reason for compliance. Driving is typically not restricted.

You're caring for Beth who underwent a Billroth II procedure (surgical removal of the pylorus and the duodenum) for treatment of a peptic ulcer. Which findings suggest that the patient is developing dumping syndrome, a complication associated with this procedure?

Dizziness and sweating What is a peptic ulcer? Dumping syndrome: A constellation of vasomotor symptoms that typically occur within 30 minutes after eating; believed to occur as a result of the rapid emptying of gastric contents into the small intestine, which shifts fluid into the gut and causes abdominal distention. Early manifestations include vertigo, tachycardia, syncope, sweating, pallor, and palpitations.

what not to say to families of pt

Don't say, "don't cry", "everything will be alright", "time will heal your wounds" Best thing to do is to stand there and be available, let them talk or cry

A patient is diagnosed with pneumonia. Which type of isolation precaution is most appropriate for this patient? Reverse isolation Droplet precautions Standard precautions Contact precautions

Droplet precautions

what causes the tissue injury in GERD?

Gastric Acid and Pepsin

Two hours after surgery, the nurse assess a patient who had a chest tube inserted during surgery. There is 200 mL if dark red drainage in the chest tube at this time. What is appropriate action for the nurse to preform? a. Record amount and continue to monitor drainage b. Notify physician c. Strip the chest tube starting at the chest d. Increase suctioning by 10 mmHg

a. Record amount and continue to monitor drainage

A client presents to the emergency department with a severely lacerated artery. What is the priority action for the nurse? a. Administer oxygen via non-rebreather mask. b. Ensure the client has a patent airway. c. Prepare to assist with suturing the artery. d. Start two large-bore IVs with normal saline

Ensure the client has a patent airway Airway always takes priority, followed by breathing and circulation. The nurse ensures the client has a patent airway prior to providing any other care measures.

True or False: The Somogyi effect causes the patient to experience an increase in their blood glucose during the hours of 2-3 am.

False Somogyi Effect: states that early morning hyperglycemia occurs due to a rebound effect from late-night hypoglycemia.

An 86-year-old woman is admitted to the unit with chills and a fever of 104 F. What physiological process explains why she is at risk for dyspnea? Fever increases metabolic demands, requiring increased oxygen need. Blood glucose stores are depleted and the cells do not have energy to use oxygen. Carbon dioxide production increases due to hyperventilation. Carbon dioxide production decreases due to hypoventilation.

Fever increases metabolic demands, requiring increased oxygen need.

military burial

Flag draped casket The honor guard lifts and holds the American flag taut over the casket. The seven-person firing party fires three volleys. A spent shell may be picked up and later tucked into the folded memorial flag. A bugler sounds "Taps." The honor guard ceremonially folds the American flag. The highest ranking officer presents the folded flag to the family with a brief statement of gratitude and a salute. flag is given to next of kin

A patient is admitted to a medical unit for a home-acquired pressure ulcer. The patient has Alzheimer's disease and has been incontinent of urine. The nurse inserts a Foley catheter. You will identify a link in the infection chain as: Restraints Poor hygiene Foley catheter bag Improper positioning

Foley catheter bag

A patient is admitted to the emergency department with suspected carbon monoxide poisoning. The nurse understands that the patient is at risk for decreased oxygen carrying capacity of the blood because carbon monoxide does which of the following? Stimulates hyperventilation, causing respiratory acidosis. Forms a strong bond with hemoglobin, thus preventing oxygen binding in the lungs. Stimulates hypoventilation, causing respiratory acidosis. Causes alveoli to overinflate, leading to atelectasis.

Forms a strong bond with hemoglobin, thus preventing oxygen binding in the lungs.

Which of the following types of wound drainage should alert the nurse to the possibility of infection?

Foul smelling drainage that is grayish in color.

The nurse is caring for a patient who reports slow onset of a gradual loss of vision in the center of both eyes. The patient describes loss of vision in the center of both eyes. The patient describes their vision as "foggy" and reports ongoing headaches from trying to concentrate to see. What condition does the nurse anticipate?

Glaucoma Glaucoma: A group of ocular diseases resulting in increased intraocular pressure, causing reduced blood flow to the optic nerve and retina and followed by tissue damage. Progressively destroys the optic nerve. Types include primary/chronic open angle, primary/chronic closed angle, and acute closed angle. Detached Retina: Often develops in the eyes with retinas weakened by a hole or tear. Fluid seeps underneath, weakening the attachment and the retina detaches. When it is detached, the retina cannot compose a clear image from incoming light and vision is blurred and dim. Cataract: Lens opacity that distorts the image projected onto the retina. Clouding of the lens of the eye, light that passes through the lens to the retina is scattered. The scattered light causes images to be blurred and visual acuity is reduced. Conjunctivitis: Inflammation of the conjunctiva. Viral or bacterial. May be caused by an allergy.

A nurse is counseling a patient who has hypertension and type 2 diabetes. During the initial assessment, the nurse notes that the patient has a blood pressure of 148/92 mmHg, a BMI of 28, and a blood glucose level of 161 mg.dL. Which of the following information about lifestyle changes would be most beneficial to help control this patient's state of health?

Help the patient understand how to lose weight to get her BMI less than 25. Hypertension- high blood pressure Diff BMI ranges: The least risk for malnutrition is associated with scores between 18.5 and 25. - Older adults should have a normal BMI of 23-27. - Underweight: Below 18.5 - Normal/Health: BMI of 18.5-24.9 - Overweight: BMI of 25-29.9. - Obese: BMI of 30+

The nurse is assessing a patient with emphysema. Which assessment finding requires further follow-up with the health care provider? Increased anterior-posterior diameter of chest. Accessory muscles used for breathing. Clubbing of the fingers. Hemoptysis

Hemoptysis

A 73 year old man with dementia has a venous ulcer related to chronic venous insufficiency. The nurse should provide education on which type of diet for this patient and his caregiver?

High-protein diet venous ulcers: leg ulcers caused by problems with blood flow (circulation) in your leg veins venous insufficiency Alteration of venous efficiency by thrombosis or defective valves; caused by prolonged venous hypertension, which stretches the veins and damages the valves, resulting in further venoushypertension, edema, and, eventually, venous stasis ulcers, swelling, and cellulitis.

Hyperglycemia or Hypoglycemia with Dawn Phenomenon?

Hyperglycemia

Duodenal ulcers are caused by

Hypersecretion of acid H. pylori infection

Jon has a potassium level of 6.6 mEq/L, which medication would nurse Wilma anticipate?

Kayexalate What is Kayexalate? This medication is used to treat a high level of potassium in your blood.

Factors influencing adaptation to chronic conditions (Turk, 1979)

Knowledge Coping resources Problem-solving attitude Sense of personal mastery Motivation

An unresponsive patient who has diabetes is brought to the emergency department with slow, deep respirations. Additional findings include: Blood glucose 450 mg/dL (24.9 mmol/L), Arterial pH 7.2, and urinalysis of ketones and glucose.

Lack of insulin causes increased counterregulatory hormones and fatty acid release.

The patient has a bag of insulins and asks which of the insulins has no peak but a duration of 24 hours?

Lantus Review the following meds: Humalin R- short acting insulin & covers blood sugar from meals eaten within 30 minutes Humalin N- intermediate acting insulin that is slower to act and lasts longer than regular human insulin Lantus- Prescription Lantus is a long-acting insulin used to treat adults with type 2 diabetes and pediatric patients (children 6 years and older) with type 1 diabetes for the control of high blood sugar. Do not use Lantus to treat diabetic ketoacidosis. NPH insulin- an intermediate-acting insulin NOVOLOG- immediate acting insulin

what is a durable power of attorney?

Legal document Patient appoints some one else to make their health care decisions

A patient received a right ORIF after a fall. In the immediate postoperative period, the nurse should:

Maintain the leg in an abducted position. Rationale: After an ORIF the affected leg should be kept ABducted. ADDuction may dislocate the hip. The hip should NOT be flexed more than 90 degrees for the first 2 months and even less for the first couple weeks. What is an ORIF? Open reduction and internal fixation (surgery is used to heal a broken bone)

Coping Tasks of Chronically ill Adults

Maintaining a sense of normalcy Modifying daily routine, adjusting lifestyle Obtaining knowledge and skill Maintaining positive self-concept Adjusting to altered social relationships Grieving over losses Dealing with role change Handling physical discomfort

To maintain normal elimination patterns in the hospitalized patient, you should instruct the patient to defecate 1 hour after meals because: The presence of food stimulates peristalsis. Mass colonic peristalsis occurs at this time. Irregularity helps to develop a habitual pattern. Neglecting the urge to defecate can cause diarrhea.

Mass colonic peristalsis occurs at this time.

The results of an adult patient's blood pressure screening on three occasions are: 120/80 mmHg, 130/76 mmHg, and 118/86 mmHg. How will the healthcare provider interpret this information?

Prehypertension Normal BP: Systolic less than 120, Diastolic less than 80 mmHg. Elevated BP: Systolic between 120-129, Diastolic less than 80 mmHg. HTN Stage 1: Systolic between 130-139, or Diastolic between 80-89 mmHg. HTN Stage 2: Systolic at least 140 mmHg, or Diastolic at least 90 mmHg.

A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein thrombosis. The client has lost 20 pounds since the last visit. What action by the nurse is best? a. Ask if the weight loss was intended. b. Encourage a high-protein, high-fiber diet. c. Measure for new compression stockings. d. Review a 3-day food recall diary.

Measure for new compression stockings Compression stockings must fit correctly in order to work. After losing a significant amount of weight, the client should be re-measured and new stockings ordered if needed. The other options are appropriate, but not the most important.

Gastric Ulcers

Mucosal barrier breaks down

What does Calcium deal with?

Muscle contraction

Hypercalcemia Symptoms

Muscle contraction, poor perfusion (blood clots), decreased DTR

Tim presents with an acute episode of gout. The student nurse expects the provider to prescribe:

NSAIDs and Colchicine Gout, or gouty arthritis, is a systemic disease in which urate crystals deposit in the joints and other body tissues, causing inflammation What are NSAIDs? Advil/Aspirin/Motrin (ibuprofen) and Tylenol (acetaminophen) What is Colchicine? decreasing swelling and lessening the build up of uric acid crystals that cause pain in the affected joint(s)

end of life symptoms

Nausea, vomiting and constipation decreased appatite Cool extremities, mottled as blood flow decreases Incontinence weakness, fatigue, lethargy visions

What is normal pain processing called?

Nociceptive pain Acute pain: Serves as a biological purpose in that it acts as a warning signal by activating the sympathetic nervous system and causing various physiologic responses. Neuropathic pain: Descriptive term used to refer to pain that is believed to be sustained by a set of mechanisms driven by damage to or dysfunction of the PNS and/or CNS. Neuropathic pain is sustained by abnormal processing of stimuli. Chronic pain AKA persistent pain: Often defined as pain that lasts or recurs for an indefinite period, usually for more than 3 months. The onset is gradual, and the character and quality of pain often change over time. Chronic pain serves no biologic purpose.

Long Acting Insulin Peak

None

post mortem care

Note the time of death MD, resident or supervisor may pronounce the patient Clean the body, close their eyes and mouth, put dentures in, arrange them on a pillow, with sheet draped Remove all tubes, unless a coroner's case, unexpected death or within 24 hours Allow the family to return and take all belongings Once family leaves, wrap the body, tag them and call security to transport them to the morgue

What test is performed to assess for cancer in the Gi tract?

Oncofetal antigens

Drug Therapy for Glaucoma

Prostaglandin agonists: reduce IOP by dilating blood vessels in trabecular mesh, which collects and drains aqueous humor at a faster rate Adrenergic agonists and beta-adrenergic blockers: reduce IOP by limiting production of aqueous humor and by dilating pupil, which improves flow of fluid to absorption site Cholinergic agonists: reduce IOP by limiting production of aqueous humor and making more room between iris and lens, which improves fluid outflow Carbonic anhydrase inhibitors: directly and strongly inhibit production of aqueous humor *watch for potassium depletion with this drug

Anne returned from hand surgery, her hand and arm must remain elevated above her heart after surgery. She asks the nurse why? The nurse responds by saying:

Reduce postoperative swelling

Which electrolyte would the nurse identify as the major electrolyte responsible for determining the concentration of the extracellular fluid?

Sodium What is the role of Potassium? K+ is the chief cation in intracellular fluid; depolarization and generation of action potentials, as well as regulation protein synthesis and glucose use and storage. What is the role of Chloride? Cl- maintains fluid balance inside and outside the cells, proper blood volume, bloodpressure, and pH of your body fluid. What is the role of Phosphate? PO3- is needed for activating vitamins and enzymes, forming adenosine triphosphate, and assisting in cell growth and metabolism; can be found in bones; food sources include meats, fish, dairy, and nuts.

Why are some patients more independent than others?

Some illnesses are less debilitating Some are controlled by medications Some have the resources to self-manage (financial & emotional)

Define the Stages of pressure ulcers:

Stage 1: INTACT skin with non-blanchable redness of localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguineous Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a category/stage 3 pressure ulcer varies by anatomical location Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. May include undermining and tunneling. Category/stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis likely to occur. Exposed bone/muscle is visible or directly palpable Deep tissue injury: Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Unstageable: Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, or black) in the wound bed.

The nurse is assessing an older bedridden patient who is admitted for a pressure ulcer. The nurse determines that the ulcer extends into the subcutaneous tissue. At which stage should the nurse document this finding?

Stage 3

The nurse is calculating a client's fluid intake for a 24-hour period. The client is on hemodialysis and urinates about 100 mL a day. The client is on a fluid restriction of 750 mL per day. The client drank 4 oz of tea and 4 oz of orange juice for breakfast, 4 oz of water at 1200 and at 1700 when taking his medications, and 4 oz of iced tea at lunch and supper. At 0800 and again at 1400, the client received his intravenous antibiotics in 50 mL of normal saline. How many mL of fluid does the client have left to drink for the day? Fill in the blank.

The hemodialysis client has severe renal insufficiency and requires fluid restriction. Clients receiving hemodialysis are limited to a fluid intake resulting in a gain of no more than 0.45 kg (1 lb) per day on the days between dialysis and a daily intake of 500 to 750 mL plus the volume lost in urine. The client consumed a total of 24 oz of fluid (8 oz at breakfast, 8 oz with medications, and 4 oz at lunch and dinner). This equals 720 mL (1 oz = 30 mL). The client also received a total of 100 mL of intravenous fluid (50 mL at 0800 and 50 mL at 1400). The total fluid intake is 820 mL. The client voids approximately 100 mL of urine a day so add that to the prescribed daily intake (750 plus 100 equals 850 allowable daily fluid intake). So, if the client drank 820 mL and is allowed 850 mL, subtract 820 from 850. The client may drink 30 mL more fluid this day.

The graduate nurse and her preceptor are establishing priorities for their morning assessments. Which client should they assess first?

The newly admitted client with acute abdominal pain.

Your educating a group of nursing students about the different stages of a pressure injury. Which statement is correct about a stage 3 pressure injury?

The skin will not be intact and there will be full loss of skin tissue that can extend to the subcutaneous tissue.

functional independence measure

a rating scale for all patients of all ages and it is used internationally. helps with uniform measurement and data on disability and rehabilitation outcomes. The FIM measures patient's independent functioning in 18 ADLs: 13 motor items covering self-care, sphincter control, transfers, and locomotion; 5 cognition items covering communication, and social cognition

A nurse is educating a patient on how to irrigate an ostomy bag. Which statement by the patient indicates the need for further instruction? a. "I can use a fleet enema to save money because it contains the same irrigation solution." b. "Sitting on the toilet lets the irrigation sleeve eliminate into the bowl." c. "I should never attempt to reach into my stoma to remove fecal material." d. "Using warm tap water will reduce cramping and discomfort during the procedure."

a. "I can use a fleet enema to save money because it contains the same irrigation solution."

The nurse is assessing a patient 2 hours after a colonoscopy. Based on the procedure done, what focused assessment will the nurse include? a. Bowel sounds b. Presence of flatulence c. Bowel movements d. Nausea

a. Bowel sounds

A nurse is performing an assessment on a patient who has not had a bowel movement in 3 days. The nurse would expect which other assessment finding? a. Hypoactive bowel sounds b. Jaundice in sclera c. Decreased skin turgor d. Soft tender abdomen

a. Hypoactive bowel sounds

Hypermagnesemia Symptoms

bradycardia and decreased BP hypotension, possible cardiac arrest, lethargy, diaphoresis

The nurse provides knows that a bowel elimination schedule would be most beneficial in the plan of care for which patient? a. A 40-year-old patient with an ileostomy b. A 25-year-old patient with Crohn's disease c. A 30-year-old patient with C. difficile d. A 70-year-old patient with stool incontinence

d. A 70-year-old patient with stool incontinence

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for bladder cancer? a. A 25-year-old female with a history of sexually transmitted diseases b. A 42-year-old male who has worked in a lumber yard for 10 years c. A 55-year-old female who has had numerous episodes of bacterial cystitis d. An 86-year-old male with a 50pack-year cigarette smoking history

d. An 86-year-old male with a 50pack-year cigarette smoking history

The nurse is reviewing the results of the patient's diagnostic testing. Of the following results, the finding that falls within the expected normal limits is: a. Palpable, elevated hardened area around tuberculosis skin testing site b. Sputum for culture and sensitivity identifies mycobacterium tuberculosis c. Presence of acid-fast bacilli in sputum d. Arterial Oxygen tension (PaO2) of 95 mmHg

d. Arterial Oxygen tension (PaO2) of 95 mmHg

A guaiac test has been ordered. The nurse knows that this is a test for a. Bright red blood. b. Dark black blood. c. Blood that contains mucus. d. Blood that cannot be seen.

d. Blood that cannot be seen.

A nurse teaches a client with functional urinary incontinence. Which statement should the nurse include in this clients teaching? a. You must clean around your catheter daily with soap and water. b. Wash the vaginal weights with a 10% bleach solution after each use. c. Operations to repair your bladder are available, and you can consider these. d. Buy slacks with elastic waistbands that are easy to pull down.

d. Buy slacks with elastic waistbands that are easy to pull down.

Fecal impactions occur in which portion of the colon? a. Ascending b. Descending c. Transverse d. Rectum

d. Rectum

Drug Therapy for GERD: Histamine receptor antagonists:

decrease acid and help promote healing of esophagus

Nurse's Role in the Rehab Team

○ Advocates for the patient and family ○ Creates a therapeutic rehabilitation milieu ○ Provides and coordinates whole-person patient care in a variety of health care settings, including the home ○ Collaborates with the rehabilitation team to establish expected patient outcomes to develop a plan of care ○ Coordinates rehabilitation team activities to ensure implementation of the plan of care ○ Acts as a resource to the rehabilitation team who has specialized knowledge and clinical skills needed to care for patient with chronic and disabling health problems ○ Communicates effectively with all members of the rehabilitation team, including the patient and family ○ Plans continuity of care when the patient is discharged from the health care facility ○ Evaluates the effectiveness of the interprofessional plan of care for the patient and family

Interventions for GERD

○ Diet therapy ■ Chocolate, fat, mints, smoking, and alcohol decrease LES pressure ■ Spicy foods irritate the esophagus ■ Carbonated drinks increase gastric pressure

Nursing Care for Patients Having GI Procedures: EGD patients

○ Given versed and fentanyl for pain ○ May be given cetacaine for gag reflex ○ Gag reflex may not return for 1 to 2 hours after so NPO until then

A nurse who is skilled in complementary and alternative medicine (CAM) therapies works on a cancer unit with clients who are terminally ill. For which client symptom does the nurse use these therapies? A. Constipation B. Cool extremities C. Increased pain D. Memory loss

C. Increased pain CAM therapies can help relieve pain and agitation, minimizing the need for increased opioids. CAM therapies are not typically used for constipation or to deal with cool extremities. Memory loss is not a symptom that would receive priority in the dying client.

Following a fall, a 62-year-old client is admitted to the rehabilitation unit with a broken collarbone and a full leg brace. Which transfer technique is indicated for this client? A. Bear-hug technique B. Cane-assisted transfer C. Mechanical lift D. Slide board

C. Mechanical lift A mechanical lift is the transfer technique indicated for this client. Mechanical lifts use slings to lift, transfer, move, and reposition immobile clients. Because the client is older and has a broken collarbone and is unable to use both arms to independently transfer safely, a mechanical lift is the best method for moving this client.

A client with a traumatic brain injury is admitted to the rehabilitation unit. Which rehabilitation team member does the nurse assign to develop the plan to improve the client's ability to bathe and dress independently? A. Activity therapist B. Cognitive therapist C. Occupational therapist D. Physical therapist

C. Occupational therapist Improving the client's ability to bathe and dress independently is part of the job of the occupational therapist. Occupational therapists work with clients to develop skills used for self-care, such as hygiene and dressing.The activity therapist will assist the client with other aspects of rehabilitation such as diversional activities, games, etc. The cognitive therapist will assist the client with other aspects of rehabilitation such as learning, remembering, etc. The physical therapist will assist the client with other aspects of rehabilitation such as mobility, that is, walking, balancing, etc.

An older client with advanced dementia and severe osteoarthritis is unresponsive, but grimaces and moans when repositioned. What intervention is the most appropriate for the nurse to implement for this client? a. Administer acetaminophen 650 mg by mouth PRN. b. Start an intravenous with 5%D/W solution. c. Provide range of motion once a shift. d. Obtain an order for transdermal fentanyl.

D. The client is likely experiencing severe pain and needs to be managed with a strong analgesic rather than a mild one like acetaminophen. The purpose of palliative care is to promote comfort

An 82-year-old client with medication-controlled hypertension has altered bladder and bowel patterns as a result of an uninhibited bowel and bladder. Bowel training has been unsuccessful despite consistent toileting and dietary modification. Why is bisacodyl (Dulcolax) prescribed for this client? A. For its action as an effective bladder antispasmodic B. To promote bladder emptying C. To enhance the action of prescribed antihypertensive medications D. To effectively reestablish defecation patterns E. To promote rectal emptying

D and E Bisacodyl (Dulcolax) and glycerin are agents commonly prescribed by health care providers as suppositories in bowel training programs. Suppositories must be placed against the bowel wall to stimulate the reflex arc. They help reestablish defecation patterns and promote rectal emptying. Bisacodyl is not an antispasmodic for the bladder and will not promote effective emptying of the bladder; it is a laxative. It will not potentiate the action of the client's antihypertensive medications; it will act on the lower gastrointestinal tract.

Which statements by the client indicate good understanding of foot care in the peripheral vascular disease? a. "A good abrasive pumice stone will keep my feet soft." b. "I'll always wear shoes if I can buy cheap flip-flops." c. "I will keep my feet dry, especially between the toes." d. "Lotion is important to keep my feet smooth and soft." e. "Washing my feet in room-temperature water is best."

" I will keep my feet dry, especially between the toes " " Lotion is important to keep my feet smooth and soft " " Washing my feet in room temperature water is best " Good foot care includes appropriate hygiene and injury prevention. Keeping the feet dry; wearing good, comfortable shoes; using lotion; washing the feet in room-temperature water; and cutting the nails straight across are all important measures. Abrasive material such as pumice stones should not be used. Cheap flip-flops may not fit well and won't offer much protection against injury.

A nurse is teaching a larger female client about alcohol intake and how it affects hypertension. The client asks if drinking two beers a night is an acceptable intake. What answer by the nurse is best? a. "No, women should only have one beer a day as a general rule." b. "No, you should not drink any alcohol with hypertension." c. "Yes, since you are larger, you can have more alcohol." d. "Yes, two beers per day is an acceptable amount of alcohol."

" No, women should only have one beer a day as a general rule " Alcohol intake should be limited to two drinks a day for men and one drink a day for women. A "drink" is classified as one beer, 1.5 ounces of hard liquor, or 5 ounces of wine. Limited alcohol intake is acceptable with hypertension. The woman's size does not matter.

The patient is prescribed 30 units of regular insulin and 70 units of insulin isophane suspension (NPH insulin) subcutaneously every morning. The nurse should provide which instruction to the patient for insulin administration?

"Draw up the regular insulin into the syringe first, following by the cloudy NPH insulin"

A patient has peripheral arterial disease (PAD). What statement by the patient indicates misunderstanding about self- management activities?

"I can use a heating pad on my legs if it's set on low."

A patient is prescribed ibuprofen 800 mg every 4 hours for the treatment of rheumatoid arthritis (RA). Which of these clinical manifestations should the healthcare provider anticipate observing if the patient is developing an adverse effect from the medication? (Choose all answers that apply).

- Positive fecal occult blood test - Patient report of epigastric pain - Increased blood urea nitrogen (BUN) Rheumatoid Arthritis (RA): A chronic, progressive, systemic, inflammatory autoimmune disease process that primarily affects the synovial joints; one of the most common connective tissue diseases and the most destructive to the joints. What are symptoms of RA? Early: Joint inflammation, generalized weakness, fatigue, anorexia, weight loss, persistent low-grade fever, and joints that are reddened, warm, stiff, swollen, and tender or painful. Late: Progressively inflamed joints that are very painful. Morning stiffness, joints feel soft and look puffy, spindle-like fingers. What is a normal BUN? 10-20 mg/dL (slightly higher in older adults).

Your patient has severe peripheral venous disease. During the head-to-toe nursing assessment, you would expect to find what skin characteristics of the lower extremities? Select all that apply:

- Thick - Tough - Brown pigmented

Issues with chronic illness

-Education of RN's about elderly and chronic illness (Only 12% of RN's are from ethically diverse groups, while 33% of ill are from these groups) -Financial issues -Cultural values

The nurse is caring for a client with heart failure (HF). Which signs and symptoms could indicate fluid overload? Select all that apply. 1.Bounding pulse 2.Difficulty breathing 3.Increased urine output 4.Presence of dependent edema 5.Neck vein distention in the upright position

1, 2, 4, 5 Care of a client with HF and fluid overload includes monitoring for bounding pulses, difficulty breathing, neck vein distention in the upright position, and dependent edema. Increased urine output is not associated with HF and fluid overload.

The nurse is creating a plan of care for a client with hypokalemia. Which interventions should be included in the plan of care? Select all that apply. 1.Ensure adequate fluid intake. 2.Implement safety measures to prevent falls. 3.Encourage low-fiber foods to prevent diarrhea. 4.Instruct the client about foods that contain potassium. 5.Encourage the client to obtain assistance to ambulate.

1, 2, 4, 5 Clients with hypokalemia will need instruction on potassium-rich foods, and all clients should maintain adequate hydration, Safety is also a priority because hypokalemia may cause muscle weakness, resulting in falls and injury. Hypokalemia is associated with constipation, not diarrhea, owing to decreased peristalsis.

The nurse is caring for a client with a diagnosis of severe dehydration. The client has been receiving intravenous (IV) fluids and nasogastric (NG) tube feedings. The nurse monitors fluid balance using which as the best indicator? 1.Daily weight 2.Urinary output 3.IV fluid intake 4.NG tube intake

1. Daily weight is the best indicator of fluid balance. Options 2, 3, and 4 are related to intake or output but are incomplete indicators of fluid balance.

The nurse is caring for a client in the early stages of disseminated intravascular coagulation (DIC). At this stage, what medication would the nurse expect to be prescribed? 1.Heparin 2.Platelets 3.Antibiotic 4.Clotting factors

1. During the early phase of DIC, anticoagulants (especially heparin) are given to limit clotting and prevent the rapid consumption of circulating clotting factors and platelets. Antibiotics are given when sepsis is suspected in an attempt to prevent DIC from occurring.

The nurse is reviewing laboratory results for a client with chronic kidney disease before a hemodialysis treatment. The serum electrolyte levels are sodium 142 mEq/L (142 mmol/L), chloride 103 mEq/L (103 mmol/L), potassium 5.2 mEq/L (5.2 mmol/L), and bicarbonate 23 mEq/L (23 mmol/L). What action should the nurse take? 1.Take no action. 2.Order a stat hemodialysis treatment. 3.Page the health care provider (HCP) with the results. 4.Recheck the labs because these values are all abnormal.

1. No action is needed because all of the blood levels are normal for a hemodialysis client before a treatment. The normal adult ranges of serum electrolyte levels are sodium 135 to 145 mEq/L (135 to 145 mmol/L), chloride 98 to 106 mEq/L (98 to 106 mmol/L), bicarbonate (venous) 21 to 28 mEq/L (21 to 28 mmol/L), and potassium 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Although the potassium level is elevated, the normal range for potassium for a client with chronic kidney disease receiving hemodialysis is 4 to 6.5 mEq/L (4 to 6.5 mmol/L).

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

b. What medications are you taking?

The nurse must collect the following specimens. Which specimen collection does not require the use of surgical aseptic technique? 1. Stool for ova and parasites 2. Specimen for a throat culture 3. Urine from a retention catheter 4. Exudate from a wound for culture and sensitivity

1. Stool for ova and parasites

The mother of 6-year-old twins says to the nurse, "My mother-in-law doesn't think our children should come to the funeral service for their grandfather. What do you advise?" The nurse should respond by making which statement? 1."What do you and your husband believe is the right thing for your children?" 2."By all means have them attend. Not to do so would promote postmortem grief." 3."It's a difficult decision, but given their young age, perhaps omitting the wake and just including the funeral would be best." 4."I agree with your mother-in-law. Your mother-in-law is upset enough as it is. Tell your children that their grandfather is in heaven."

1. The most appropriate therapeutic response is the one that encourages open expression of feelings and empowers the grieving relative. Values, beliefs, and practices differ depending on the client's ethnic and spiritual backgrounds, and the nurse should not push a decision based on the nurse's own belief system. Options 2, 3, and 4 are nontherapeutic. Option 2 provides incorrect information related to postmortem grieving. Options 3 and 4 offer the nurse's opinion and impose the nurse's own beliefs.

The nurse caring for a client with heart failure is notified by the hospital laboratory that the client's serum magnesium level is 1.0 mEq/L (0.5 mmol/L). Which would be the most appropriate nursing action for this client? 1.Monitor the client for dysrhythmias. 2.Encourage increased intake of phosphate antacids. 3.Discontinue any magnesium-containing medications. 4.Encourage intake of foods such as ground beef, eggs, or chicken breast.

1. The normal serum magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). Cardiac monitoring is indicated because this client is at risk for ventricular dysrhythmias. Phosphate use should be limited in the presence of hypomagnesemia because it worsens the condition. It is not necessary to discontinue magnesium products. Ground beef, eggs, and chicken breast are low in magnesium.

During an assessment of a newly admitted client, the nurse notes that the client's heart rate is 110 beats/minute, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, paste-like coating. The client's spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client has which condition? 1.Dehydration 2.Hypokalemia 3.Fluid overload 4.Hypernatremia

1. When a client is dehydrated, the heart rate increases in an attempt to maintain blood pressure. Blood pressure reflects orthostatic changes caused by the reduced blood volume, and when the client stands, he may experience dizziness because of insufficient blood flow to the brain. Alterations in mental status also may occur. The oral mucous membranes, usually moist, are dry and may be covered with a thick, pasty coating. These findings are not manifestations of the conditions noted in the other options.

The spouse of a terminally ill client steps out of his room in tears. The spouse tells the nurse, "I don't know what I'm going to do when he's gone!" What is the nurse's best response? 1."This must be very hard for you." 2."Don't worry, things will be fine." 3."I know. It will get easier with time." 4."You need to be strong for him! Don't cry."

1. When a family member or caregiver is expressing the pain of loss, the nurse should not minimize that person's feelings. It is important to avoid general or trite assurances. Simply listening to the spouse and acknowledging how difficult this situation is, as in responding "This must be very hard for you," is the best example of therapeutic communication. Responses that belittle or minimize the family member's feelings or those that place the client's feelings on hold are not therapeutic.

The nurse is caring for a dying client who adheres to Judaism. The nurse demonstrates cultural sensitivity when caring for this client by taking which action? 1.Encouraging a rabbi to sit with the client 2.Encouraging the client to have time alone 3.Asking the family if they would like an autopsy done 4.Encouraging the family to agree to removal of life support

1. When caring for a client who adheres to Judaism, end-of-life care includes recognizing that prolongation of life is important (a client on life support must remain so until death). A dying client should not be left alone (a rabbi's presence is desired), and autopsy and cremation are forbidden.

Which abnormality change in the fingertips iscaused by chronic hypoxemia? 1 Edema 2 Clubbing 3 Distention 4 Splinter hemorrhages

2 Clubbing

A patient with chronic obstructive pulmonary disease (COPD) is on oxygen therapy. The arterial blood gas analysis after some time reveals that the carbon dioxide levels are high. The patient's condition improves when the amount of oxygen administered (fraction of inspired oxygen) is reduced. Which is the most probable reason for high levels of carbon dioxide in the patient? 1 Hypoxia 2 Hypoventilation 3 Hyperventilation 4 Respiratory alkalosis

2 Hypoventilation

Long Acting Insulin Onset

2 hours

The nurse is caring for a terminally ill client who is experiencing delirium. When caring for this client, the nurse should take which action? 1.Provide a dark room. 2.Provide a well-lighted room. 3.Reorient the client every 8 hours. 4.Withhold benzodiazepines and sedatives.

2. Delirium may occur during the last days of life. Nursing management of a terminally ill client experiencing delirium includes providing a room that is quiet, well lighted, and familiar to reduce the effects of delirium; reorienting the dying client to client, place, and time with each encounter; and administering prescribed benzodiazepines and sedatives as needed.

A client treated for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client states a need to perform which action? 1.Increase fluid intake. 2.Resume full activity level. 3.Stay in a cool environment when possible. 4.Monitor voiding for adequacy of urine output.

2. Discharge instructions for the client hospitalized with hyperthermia include the prevention of heat-related disorders, increased fluid intake for 24 hours, self-monitoring of voiding, and the importance of staying in a cool environment and resting.

While the nurse is caring for a client with severe cardiac disease, the client states, "If anything should happen to me, please make sure that the doctors do not try to push on my chest and revive me." Which nursing action is appropriate? 1.Tell the client that the family must agree with this decision. 2.Notify the health care provider (HCP) of the client's request. 3.Consult with the ethics committee to assist the client and family. 4.Plan a nursing staff conference to discuss the client's statement.

2. External cardiac massage is a type of treatment that a client can refuse. The most appropriate nursing action is to notify the HCP because a written do not resuscitate (DNR) prescription from the HCP must be present on the client's record. The DNR prescription must be reviewed or renewed on a regular basis per agency policy. Telling the client that the family must agree with the decision and consulting with the ethics committee are incorrect and violate the client's rights. A nursing staff conference may be appropriate but only after the HCP is contacted and notified of the client's request.

The nurse is assisting in the care of a group of clients on the nursing unit. When considering the effects of each medical diagnosis, the nurse determines that which client has the least risk for developing third spacing of fluid? 1.Client with a major burn 2.Client with an ischemic stroke 3.Client with Laënnec's cirrhosis 4.Client with chronic kidney disease

2. Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. This fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Common sites for third spacing include the pleural and peritoneal cavities and pericardial sac. Risk factors include older adults and those with liver or kidney disease, major trauma, burns, sepsis, major surgery, malignancy, gastrointestinal malabsorption, and malnutrition. The client who has suffered a stroke is not at risk for third spacing.

The nurse is concerned about a patient's ability to withstand exposure to pathogens. What blood component should the nurse monitor? 1. Platelets 2. Neutrophils 3. Hemoglobin 4. Erythrocytes

2. Neutrophils

A school nurse is teaching an athletic coach how to prevent dehydration in athletes during football practice. Which action by the coach during football practice would indicate that further teaching is needed? 1.Weighs athletes before, during, and after football practice 2.Asks the athletes to take a salt tablet before football practice 3.Schedules fluid breaks every 30 minutes throughout practice 4.Tells the athletes to drink 16 oz (475 mL) of fluid per pound lost during practice

2. Salt tablets should not be taken because they can contribute to dehydration. Frequent fluid breaks should be taken to prevent dehydration. Early detection of decreased body weight alerts the athlete to drink fluids before becoming dehydrated. To prevent dehydration, 16 oz (475 mL) of fluid should be consumed for every pound lost.

The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving intravenous (IV) fluids. Which assessment finding would indicate to the nurse that the dehydration remains unresolved? 1.An oral temperature of 98.8°F (37.1°C) 2.A urine specific gravity of 1.043 3.A urine output that is pale yellow 4.A blood pressure of 120/80 mm Hg

2. The client who is dehydrated will have a urine specific gravity greater than 1.030. Normal values for urine specific gravity are 1.005 to 1.030. A temperature of 98.8°F (37.1°C) is only 0.2 point above the normal temperature and would not be as specific an indicator of hydration status as the urine specific gravity. Pale yellow urine is a normal finding. A blood pressure of 120/80 mm Hg is within normal range.

Which nursing intervention is most effective in promoting normal defecation for a patient who has muscle weakness in the legs that prevents ambulation? a. Elevate the head of the bed 45 degrees 60 minutes after breakfast. b. Use a mobility device to place the patient on a bedside commode. c. Give the patient a pillow to brace against the abdomen while bearing down. d. Administer a soap suds enema every 2 hours.

b. Use a mobility device to place the patient on a bedside commode.

The nurse is obtaining the intershift report for a group of assigned clients. Which assigned client should the nurse monitor closely for signs of hyperkalemia? 1.A client with ulcerative colitis 2.A client with Cushing's syndrome 3.A client admitted 6 hours ago with a 40% burn injury 4.A client who has a history of long-term laxative abuse

3. Hyperkalemia is likely to occur in clients who experience cellular shifting of potassium caused by early massive cell destruction, such as in trauma or burns. Other clients at risk for hyperkalemia are those with sepsis or metabolic or respiratory acidosis (with the exception of diabetic acidosis). Clients with Cushing's syndrome or ulcerative colitis or those using laxatives excessively are at risk for hypokalemia.

The nurse is caring for a terminally ill client who is experiencing dyspnea. When caring for this client, the nurse should place the client in which position? 1.Prone 2.Supine 3.Lateral 4.Trendelenburg's

3. Dyspnea may occur during the last days of life. Nursing management of a terminally ill client experiencing dyspnea includes elevating the head and/or positioning the client on the side (lateral) to improve chest expansion. The positions noted in the remaining options will increase the dyspnea.

During morning rounds the nurse comes into the room of a client who is unresponsive and near death. Two unlicensed assistive personnel (UAPs) are bathing the client, and their conversation centers on their plans for a weekend party. How should the nurse best intervene? 1.Say nothing, but check the client's vital signs and level of consciousness. 2.Tell the UAPs, "You need to be focusing on the client right now, not your party." 3.Remind the UAPs, "Remember that Mr. Smith can hear everything you are saying!" 4.Speak to the client and touch his hand, saying, "Hello, Mr. Smith, we will be finished with your bath shortly."

3. Even though clients who are near death are often not responsive, it is thought that the sense of hearing remains intact until death occurs. Therefore, conversation in the presence of the client must occur as if the client can hear. It is not wrong to remind the UAPs to alter their conversation while in the client's room, but it would be better to remind them out of the client's earshot. The correct answer has the nurse modeling the correct behavior to the UAPs.

During an assessment of skin turgor in an older client, the nurse discovers that skin tenting occurs when the skin is pinched on the client's forearm. What should the nurse do next? 1.Document this assessment finding. 2.Call another nurse to verify this finding. 3.Check skin turgor over the client's sternum. 4.Call the health care provider (HCP) to obtain a prescription for fluid replacement.

3. In an older adult, skin turgor should be checked by pinching the skin over the sternum or even the forehead, instead of the back of the hand or forearm. As a client gets older, the skin loses elasticity and can tent over the hands and arms, even when the client is adequately hydrated. Therefore, the next nursing action would be to obtain additional assessment data.

The nurse is caring for a group of clients on the clinical nursing unit. Which client should the nurse plan to monitor for signs of fluid volume deficit? 1.Client in heart failure 2.Client in acute kidney injury 3.Client with diabetes insipidus 4.Client with controlled hypertension

3. The client with an ileostomy is at risk for fluid volume deficit caused by increased gastrointestinal tract losses. Other causes of fluid volume deficit include vomiting, diarrhea, conditions that cause increased respiratory rate or urine output such as diabetes insipidus, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. Clients who have heart failure or kidney disease are at risk for fluid volume excess. Hypertension may be associated with fluid volume excess.

The nurse is reviewing the laboratory results for a client who is receiving magnesium sulfate by intravenous infusion. The nurse notes that the magnesium level is 5 mEq/L (2.5 mmol/L). On the basis of this laboratory result, the nurse should expect to note which in the client? 1.Tremors 2.Hyperactive reflexes 3.Respiratory depression 4.No specific signs or symptoms because this value is a normal level

3. The normal magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). Neurological depression occurs in hypermagnesemia and is manifested by drowsiness, sedation, lethargy, respiratory depression, muscle weakness, and areflexia.

The nurse who is caring for a client with severe malnutrition reviews the laboratory results and notes that the client has a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which electrocardiographic change should the nurse expect to observe based on the client's magnesium level? 1.Prominent U waves 2.Prolonged PR interval 3.Depressed ST segment 4.Widened QRS complexes

3. The normal serum magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). A magnesium level of 1.0 mEq/L (0.5 mmol/L) indicates hypomagnesemia. In hypomagnesemia, tall T waves and a depressed ST segment would be observed. Options 2 and 4 would be noted in a client experiencing hypermagnesemia. Prominent U waves occur with hypokalemia.

The nurse is monitoring a client who is attached to a cardiac monitor and notes the presence of prominent U waves. The nurse assesses the client and checks his or her most recent electrolyte results. The nurse expects to note which electrolyte value? 1.Sodium 135 mEq/L (135 mmol/L) 2.Sodium 140 mEq/L (140 mmol/L) 3.Potassium 3.0 mEq/L (3.0 mmol/L) 4.Potassium 5.0 mEq/L (5.0 mmol/L)

3. The normal sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level lower than 3.5 mEq/L (3.5 mmol/L) is indicative of hypokalemia. In hypokalemia, the electrocardiographic (ECG) changes that occur include inverted T waves, ST segment depression, heart block, and prominent U waves.

The nurse is supervising the postmortem care of a client. Which action by the unlicensed assistive personnel (UAP) performing the care is appropriate? 1.Keeps the client's body in a flat, supine position 2.Closes the client's eyes by taping the eyelids shut 3.Elevates the head of the bed 30 degrees as soon as possible after death 4.Removes the client's dentures and places them in a denture cup with the client's name on the lid

3. The nurse may delegate postmortem care to UAPs, but the nurse must supervise the postmortem care. The care given must protect the client's body from damage or disfigurement. Elevating the head of bed immediately after the client's death can help reduce facial discoloring from livor mortis. Using tape may damage the delicate eyelid tissues; dentures should be placed inside the client's mouth during postmortem care to maintain facial structure.

A client brought to the emergency department is dead on arrival (DOA). The health care provider (HCP) examines the client and asks the nurse to contact the medical examiner regarding an autopsy. The spouse of the client tells the nurse that she does not want an autopsy performed. Which response should the nurse make? 1."We won't have one done if you don't want one." 2."There is not much choice here. If they want to do it you need to let them." 3."Let's talk about why you don't want one done. This can help medical science and research." 4."Let me contact your husband's HCP and you can discuss your concerns with him. I will stay with you when you do this."

4. An autopsy is required by state law in certain circumstances, including the sudden death of a client and a death that occurs under suspicious circumstances. The client may have provided oral or written instructions regarding an autopsy following death. If an autopsy is not required by law, these oral or written requests will be granted. If no oral or written instructions were provided, state law determines who has the authority to consent for an autopsy. Most often, the decision rests with the surviving relative or next of kin. The correct option addresses the client's (the spouse) feelings and addresses the issue. In addition, the nurse acts as an advocate and is compassionate in telling the client that he or she will stay with the spouse when she speaks to the HCP.

The nurse is caring for a client who has a medical diagnosis of end-stage chronic obstructive pulmonary disease (COPD). The client is in severe respiratory distress and tells the nurse, "Put me on the machine." The client's family says, "No, we are not going to do this again." The client has a do not resuscitate (DNR) prescription. What is the nurse's priority action? 1.Prepare the client for intubation and mechanical ventilation. 2.Talk to the family about the client's right to change his mind. 3.Administer an antianxiety medication to the client to ease his breathing. 4.Notify the health care provider (HCP) that the client is rescinding the DNR prescription.

4. COPD cannot be cured. End-of-life issues are important for clients and families to understand; however, the client always has the right to rescind the decision as long as he or she is mentally competent. The nurse needs the HCP to reverse the DNR prescription on the chart. The HCP also needs to be informed about the conflict between the client and his family. Option 1 is incorrect because the decision to take this action is determined by the HCP. Option 2 is incorrect because the HCP should handle this. The action identified in option 3 can help but could alter the client's mental capacity to make decisions. Some states offer DNR Comfort Care and DNR Comfort Care Arrest protocols. Protocols in these instances list specific actions that health care providers will take when providing cardiopulmonary resuscitation.

The hospice nurse is visiting a client in the client's home. The client has had several episodes of dyspnea, and there is a prescription for morphine elixir. The client's wife states, "I don't understand why he needs morphine. He tells me he's not in pain." What should the nurse include in the explanation of the purpose of the morphine? 1.It reduces the secretions in the bronchi. 2.It causes dilation of the bronchial smooth muscles. 3.It relieves pain, which helps to reduce the dyspnea. 4.It helps to reduce anxiety and oxygen consumption.

4. Dyspnea is a terrifying and yet common symptom in clients who are near death. The use of opioids is considered standard treatment for dyspnea in clients who are near death. It helps to reduce dyspnea by reducing anxiety, thus reducing the consumption of oxygen and altering the client's perception of dyspnea. Morphine does not reduce secretions or cause dilation of smooth muscles in the bronchi. Although morphine does relieve pain, this client is not experiencing any pain.

The nurse is administering a dose of triamterene to an assigned client. What is the most significant adverse effect of this medication for which the client should be monitored? 1.Edema 2.Bradycardia 3.Hypertension 4.Hyperkalemia

4. Hyperkalemia is the most significant adverse effect of triamterene, especially when it is used alone. Edema, bradycardia, and hypertension are not adverse effects of this medication. Triamterene is a potassium-retaining diuretic, so the nurse needs to monitor the client for hyperkalemia. Triamterene should never be used in conjunction with another potassium-retaining diuretic or with potassium supplements or salt substitutes. In addition, caution is needed if the medication is combined with an angiotensin-converting enzyme (ACE) inhibitor, angiotensin receptor blocker, or direct renin inhibitor. Common side effects include nausea, vomiting, leg cramps, and dizziness.

The nurse is caring for a Hindu client who has just died. The nurse demonstrates cultural awareness when providing postmortem care by taking which action? 1.Washing the body after death 2.Removing sacred threads from the body 3.Prohibiting family members from viewing the body 4.Instructing the unlicensed assistive personnel (UAP) to not wash the body

4. When caring for a Hindu client, end-of-life care includes rituals such as tying a thread around the neck or wrist of the dying client and sprinkling the client with special water. After death, the sacred threads are not removed and the body is not washed. It is culturally acceptable for the family members to view the body.

For which hospitalized patient does the nurse recommend the ongoing use of a urinary catheter? 35-year-old woman who was admitted with a splenic laceration and femur fracture (closed-repair completed)following a car accident. 58-year-old man who has established paraplegia and is admitted for pneumonia. 61-year-old woman who is admitted following a fall at home and has new-onset dysrhythmia. 74-year-old man who has lung cancer with brain metastasis and is being transitioned to hospice for end-of-life care

74-year-old man who has lung cancer with brain metastasis and is being transitioned to hospice for end-of-life care

A nurse is caring for a client who weighs 22o pounds and is started on enoxaparin ( Lovenox ). How much enoxaparin does the nurse anticipate administering?

90 mg 90 mg The dose of enoxaparin is 1 mg/kg body weight, not to exceed 90 mg. This client weighs 220 pounds (110 kg), and so will get the maximal dose

Somogyi Phenomenon

A rebound phenomenon that occurs in clients with type 1 diabetes mellitus. Normal or elevated blood glucose levels are present at bedtime; hypoglycemia occurs at about 2 to 3 am. Counterregulatory hormones, produced to prevent further hypoglycemia, result in hyperglycemia (evident in the prebreakfast blood glucose level). Treatment includes decreasing the evening (predinner or bedtime) dose of intermediate acting insulin or increasing the bedtime snack.

A patient with tented skin turgor, dry mucous membranes and decreased urinary output is under nurse Mark's care. Which nursing intervention should be included in the care plan of Mark for his patient?

Administering IV and oral fluids.

A patient tells the healthcare provider, "I stopped taking my medication because it kept me up at night with a dry cough." When reviewing the patient's medical record, which of these antihypertensive medications will the healthcare provider identify as the likely cause of this patient's report?

Angiotensin-converting enzyme (ACE) inhibitor What is an ACE inhibitor? Acts by relaxing veins and arteries to lower BP. Prevents the production of angiotensin II, which usually narrows blood vessels. May cause dry cough, hyperkalemia, fatigue, dizziness, etc. What is a calcium channel blocker? Disrupt the movement of calcium through calcium channels. Used to treat hypertension. May cause constipation, dizziness, fatigue, heart palpitations, flushing, etc. What is a Loop diuretic? The most effective drug in treating fluid volume overload. May cause dehydration. What are Beta Blockers (BB)? Used to reduce BP by temporarily stopping or reducing the body's natural "fight-or-flight responses." Side effects include cold feet and hands, fatigue, nausea, weakness, dizziness, and dry mouth, skin, and eyes, etc.

A client had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding by the nurse indicates a priority outcome for this client has been met? a. Pain rated as 2/10 after medication b. Distal pulse on affected extremity 2+/4+ c. Remains on bedrest as directed d. Verbalizes understanding of procedure

Distal pulse on affected extremity 2+/4+ Assessing circulation distal to the puncture site is a critical nursing action. A pulse of 2+/4+ indicates good perfusion. Pain control, remaining on bedrest as directed after the procedure, and understanding are all important, but do not take priority over perfusion.

What nonpharmacologic comfort measures should the nurse include in the plan for a client with severe varicose veins? a. Administering mild analgesics for pain b. Applying elastic compression stockings c. Elevating the legs when sitting or lying d. Reminding the client to do leg exercises e. Teaching the client about surgical options

Applying elastic compression stockings Elevating the legs when sitting or lying Reminding the client to do leg exercises ANS: B, C, D The three E's of care for varicose veins include elastic compression hose, exercise, and elevation. Mild analgesics are not a nonpharmacologic measure. Teaching about surgical options is not a comfort measure

A client had a femoropopliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection? a. Appropriate hand hygiene before giving care b. Assessing the client's temperature every 4 hours c. Clean technique when changing dressings d. Monitoring the client's daily white blood cell count

Appropriate hand hygiene before giving care Hand hygiene is the best way to prevent infections in hospitalized clients. Dressing changes should be done with sterile technique. Assessing vital signs and white blood cell count will not prevent infection.

The nurse is working with a client who takes atorvastatin ( Lipitor ). The client's recent laboratory results include a blood urea nitrogen ( BUN ) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best? a. Ask if the client eats grapefruit. b. Assess the client for dehydration. c. Facilitate admission to the hospital. d. Obtain a random urinalysis.

Ask if the client eats grapefruit There is a drug-food interaction between statins and grapefruit that can lead to acute kidney failure. This client has elevated renal laboratory results, indicating some degree of kidney involvement. The nurse should assess if the client eats grapefruit or drinks grapefruit juice.

A nurse is caring for a client with a nonhealing arterial ulcer. The physician has informed the client about possibly needing to amputate the client's leg. The client is cry and upset. What actions by the nurse are best? a. Ask the client to describe his or her current emotions. b. Assess the client for support systems and family. c. Offer to stay with the client if he or she desires. d. Relate how smoking contributed to this situation. e. Tell the client that many people have amputations.

Ask the client to describe his or her current emotions Assess the client for support system and family Offer to stay with the client if he or she desires When a client is upset, the nurse should offer self by remaining with the client if desired. Other helpful measures include determining what and whom the client has for support systems and asking the client to describe what he or she is feeling. Telling the client how smoking has led to this situation will only upset the client further and will damage the therapeutic relationship. Telling the client that many people have amputations belittles the client's feelings.

A client is 4 hours postoperative after a femoropopliteal bypass. The client reports throbbing leg pain on the affected side, rated as a 7/10. What action by the nurse takes priority? a. Administer pain medication as ordered. b. Assess distal pulses and skin color. c. Document the findings in the client's chart. d. Notify the surgeon immediately.

Assess distal pulses and skin color

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

b. Try to consciously hold your urine until the scheduled toileting time.

A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the client's blood pressure at 82/40 mmHg. What actions by the nurse are most important? a. Administer pain medication. b. Assess distal pulses every 10 minutes. c. Have the client sign a surgical consent. d. Notify the Rapid Response Team. e. Take vital signs every 10 minutes

Assess distal pulses ever 10 minutes Notify the Rapid Response Team Take vital signs every 10 minutes This client may have a ruptured/rupturing aneurysm. The nurse should notify the Rapid Response team and perform frequent client assessments. Giving pain medication will lower the client's blood pressure even further. The nurse cannot have the client sign a consent until the physician has explained the procedure.

The nurse is assessing a client on admission to the hospital. The client's leg appears as shown below: What action by the nurse is best? a. Assess the client's ankle-brachial index. b. Elevate the client's leg above the heart. c. Obtain an ice pack to provide comfort. d. Prepare to teach about heparin sodium.

Assess the client's ankle-brachial index This client has dependent rubor, a classic finding in peripheral arterial disease. The nurse should measure the client's ankle-brachial index. Elevating the leg above the heart will further impede arterial blood flow. Ice will cause vasoconstriction, also impeding circulation and perhaps causing tissue injury. Heparin sodium is not the drug of choice for this condition.

A client with a history of heart failure and hypertension is in the clinic for a follow up visit. The client is on Lisinopril ( Prinvil ) and warfarin ( Coumadin ). The client reports new onset cough. What action by the nurse is most appropriate? a. Assess the client's lung sounds and oxygenation. b. Instruct the client on another antihypertensive. c. Obtain a set of vital signs and document them. d. Remind the client that cough is a side effect of Prinivil.

Assess the client's lung sounds and oxygenation ANS: A This client could be having an exacerbation of heart failure or be experiencing a side effect of lisinopril (and other angiotensin-converting enzyme inhibitors). The nurse should assess the client's lung sounds and other signs of oxygenation first. The client may or may not need to switch antihypertensive medications. Vital signs and documentation are important, but the nurse should assess the respiratory system first. If the cough turns out to be a side effect, reminding the client is appropriate, but then more action needs to be taken.

A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin ( Comadin ). The client is adamant about refusing the drug because " it's dangerous ". What action by the nurse is best? aa. Assess the reason behind the client's fear. b. Remind the client about laboratory monitoring. c. Tell the client drugs are safer today than before. d. Warn the client about consequences of noncompliance.

Assess the reason behind the client's fear

The nurse working in the emergency department knows that which factors are commonly related to aneurysm formation? a. Atherosclerosis b. Down syndrome c. Frequent heartburn d. History of hypertension e. History of smoking

Atherosclerosis History of hypertension History of smoking Atherosclerosis, hypertension, hyperlipidemia, and smoking are the most common related factors. Down syndrome and heartburn have no relation to aneurysm formation.

A nurse is pouching an ostomy on a patient with an ileostomy. Which action by the nurse is most appropriate? a. Changing the skin barrier portion of the ostomy pouch daily b. Selecting a pouch that is able to hold excess output to reduce the frequency of pouch emptying c. Thoroughly scrubbing the skin around the stoma to remove excess stool and adhesive d. Measuring the correct size for the barrier device while leaving a 1/8-inch space around the stoma

b. Selecting a pouch that is able to hold excess output to reduce the frequency of pouch emptying

A paraplegic client with injury to the sixth thoracic vertebra has urinary incontinence that is assessed as "sudden and gushing." When catheterized after being incontinent, urine remains in the client's bladder. Which bladder training technique does the nurse recommend for this client? A. Providing a high-fiber diet B. Scheduling intermittent catheterizations C. Taking an antispasmodic medication as prescribed D. Using the Valsalva and Credé maneuvers

B. Scheduling intermittent catheterizations The bladder training technique recommended by the nurse is to schedule intermittent catheterizations. Intermittent catheterization may be used for disorders that involve a flaccid or spastic bladder. A high-fiber diet is used for bowel, not bladder, training. Antispasmodics may be used for mild overactive bladder, but they would not be an effective choice for the client with residual urine in the bladder. Valsalva and Credé maneuvers are best used for the client with a flaccid bladder.

What does Sodium deal with?

Confusion

Fecal fat is increased with?

Crohn's disease and malabsorption

Which statement by a client with complete paraplegia indicates a need for the nurse to provide further teaching about bowel retraining? a. "I'll eat high-fiber foods each day to help prevent constipation." b. "I'll drink at least 8 to 10 glasses of water every day." c. "I'll do my daily bowel training routine after I eat breakfast." d. "I'll use a suppository to help empty my rectum."

D. The client who has complete paraplegia typically has a flaccid bowel indicating loss of sacral reflexes to stimulate bowel elimination. Suppositories work to provide a stimulus to trigger bowel contraction and stool evacuation in clients with a spastic bowel. Therefore, using this strategy would not be successful for this client. Hydration, high dietary fiber, and a regular toileting routine are important interventions to promote bowel elimination for clients with paraplegia.

An 82-year-old client is being discharged after successful bladder and bowel training. Before going home, the client asks what foods can be eaten to prevent constipation. What is the BEST response by the nurse? A. "Continue on a soft diet." B. "Decrease your fluid intake." C. "Eat at least 2 slices of whole wheat bread daily." D. "Increase your fiber intake with fruits, vegetables, beans, and unsalted nuts."

D. "Increase your fiber intake with fruits, vegetables, beans, and unsalted nuts." The nurse's BEST advice is to tell the client to eat more fruit, vegetables, beans, and unsalted nuts. For clients at risk for constipation, encourage fluids and plenty of fiber in the diet, such as whole grains, celery, fruits, and nuts.The client does not need a soft diet. The client should increase, rather than decrease, fluid intake to promote renal and bowel health. Eating two slices of whole wheat bread would be helpful, but is only a start in meeting the dietary needs of the client for preventing constipation.

While performing a skin assessment on a patient who is immobile, you note a purplish-black area on the patient's left heel. The skin is intact. On palpation, the site feels heavy and spongy. You suspect this maybe?

Deep-tissue injury: Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Which physiological change can cause a paralytic ileus? a. Chronic cathartic abuse b. Surgery for Crohn's disease and anesthesia c. Suppression of hydrochloric acid from medication d. Fecal impaction

b. Surgery for Crohn's disease and anesthesia

Dawn Phenomenon

Early morning glucose elevation produced by the release of growth hormone, which decreases peripheral uptake of glucose resulting in elevated morning glucose levels. Admin of insulin at a later time in day will coordinate insulin peak with the hormone release.

Your patient reports experiencing dull and achy sensations in the lower extremities. You note that the lower extremities have edema and brownish pigmentation. Pulses are present bilaterally and the extremities feel warm to the touch. To help alleviate the patient's symptoms, the nurse with position the lower extremities in the _____.

Elevated Position above heart level. Dependent position: simply means put the legs dangling because when you dangle legs you decrease the return of blood and reduce pulmonary congestion. Horizontal position: A position in which the patient lies supine with feet extended. It is used in palpation, in auscultation of fetal heart, and in operative procedures. Knee-flexed position: flexed at 90° angle.

The nurse is caring for four hypertensive clients. Which drug-laboratory value combination should the nurse report immediately to the health care provider? a. Furosemide (Lasix)/potassium: 2.1 mEq/L b. Hydrochlorothiazide (Hydrodiuril)/potassium: 4.2 mEq/L c. Spironolactone (Aldactone)/potassium: 5.1 mEq/L d. Torsemide (Demadex)/sodium: 142 mEq/L

Furosemide ( Lasix )/ potassium: 2.1 mEq/L Lasix is a loop diuretic and can cause hypokalemia. A potassium level of 2.1 mEq/L is quite low and should be reported immediately. Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia. A potassium level of 5.1 mEq/L is on the high side, but it is not as critical as the low potassium with furosemide. The other two laboratory values are normal.

The nurse is caring for four hypertensive patients. Which drug-laboratory value combination would the nurse report immediately to the healthcare provider?

Furosemide (Lasix)/ Potassium: 2.1 mEq/L Furosemide: treats fluid retention (edema) and swelling caused by congestive heart failure, liver disease, kidney disease, and other medical conditions. Normal potassium range: 3.5-5.0 mEq/L

A patient has an infection and reports not checking their blood glucose or regularly taking metformin. What condition is this patient MOST at risk for?

HHS (hyperglycemic hyperosmolar syndrome) HHS Hyperglycemic hyperosmolar syndrome: high blood sugar results in high osmolarity without significant ketoacidosis. Symptoms include signs of dehydration, weakness, leg cramps, vision problems, and an altered level of consciousness. Metabolic Acidosis: When the Ph is low causing the blood to become acidic. Too much acid build up in the body with an increase of HcO3 to decrease Metabolic Alkadosis: the pH of tissue is elevated beyond the normal range (7.35-7.45). This is the result of decreased hydrogen ion concentration, leading to increased bicarbonate, or alternatively a direct result of increased bicarbonate concentrations. DKADiabetic ketoacidosis (DKA): is a serious condition that can lead to diabetic coma (passing out for a long time) or even death. When your cells don't get the glucose they need for energy, your body begins to burn fat for energy, which produces ketones.

In what type of electrolyte imbalance would the nurse observe tall, tented T waves, and a prolonged PR interval on the patient's EKG?

Hyperkalemia Hypercalcemia: A condition in which the calcium level in your blood is ABOVE normal. Too much calcium in your blood can weaken your bones, create kidney stones, and interfere with how your heart and brain work. A condition in which there are lower-than-average levels of calcium in the liquid part of the blood, or the plasma Hyperkalemia: Potassium level in your blood that's HIGHER than normal. Your blood potassium level is normally 3.6 to 5.2 millimoles per liter (mmol/L). Under 2.5 is really dangerous and low. Hypokalemia: Blood's potassium levels are too LOW. Potassium is an important electrolyte for nerve and muscle cell functioning, especially for muscle cells in the heart.

A patient diagnosed with inflammatory bowel disease experiences an obstruction in the small bowel. When assessing the patient, which of the following should the student nurse anticipate?

Hypovolemia What is inflammatory bowel disease? an umbrella term used to describe disorders that involve chronic inflammation of your digestive tract. Scaphoid abdomen: caves in Hypovolemia: decrease in the volume of blood in your body, which can be due to blood loss or loss of body fluids. Could be due to internal bleeding Passage of melena: Melena is the passage of black, tarry stools What is increased flatus- gas? this is caused by swallowing air, eating high-fibre foods, lactose intolerance or some digestive disorders

Which statement, if made by the client or family member, would indicate the need for further teaching? related to pressure injuries

If a person cannot turn himself in bed, someone should help them change position q4h.

Diet for GERD

Low fat, high fiber

ALL HOSPICE CARE IS ______________, NOT ALL PALLIATIVE CARE IS __________!!

Palliative Hospice

Your patient has severe Peripheral Arterial Disease. When the lower extremities are elevated you would expect them to appear ______ and, when they are in the dependent position you would expect them to appear _______.

Pallor; Rubor Pallor: pale appearance Rubor: red appearance

A nursing student is caring for a client with an abdominal aneurysm. What action by the student requires the registered nurse to intervene? a. Assesses the client for back pain b. Auscultates over abdominal bruit c. Measures the abdominal girth d. Palpates the abdomen in four quadrants

Palpates the abdomen in four quadrants Abdominal aneurysms should never be palpated as this increases the risk of rupture. The registered nurse should intervene when the student attempts to do this. The other actions are appropriate.

A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would cause the faculty member to intervene? a. Assessing blood pressure in both upper extremities b. Auscultating the carotid arteries for any bruits c. Classifying capillary refill of 4 seconds as normal d. Palpating both carotid arteries at the same time

Palpating both carotid arteries at the same time The student should not compress both carotid arteries at the same time to avoid brain ischemia. Blood pressure should be taken and compared in both arms. Prolonged capillary refill is considered to be greater than 5 seconds in an older adult, so classifying refill of 4 seconds as normal would not require intervention. Bruits should be auscultated.

Which intervention by the emergency room nurse is critical in caring for the patient with a fractured tibia and fibula?

Palpation of the dorsalis pedis pulses. Rationale: Monitoring neurovascular (NV) status is ESSENTIAL in early recognition of NV deterioration or compromise. Delays in recognizing NV compromise can lead to permanent deficits, loss of limb or even death. Recognition of NV deterioration is therefore CRUCIAL NV deterioration can occur late after trauma, surgery, or cast application.

A nurse wants to provide community service that helps meet the goals of Healthy People 2020 related to cardiovascular disease and stroke. What activity would best meet this goal? a. Teach high school students heart-healthy living. b. Participate in blood pressure screenings at the mall. c. Provide pamphlets on heart disease at the grocery store. d. Set up an "Ask the nurse" booth at the pet store.

Participate in blood pressure screenings at the mall

Symptoms of Gastritis?

Pernicious anemia

Joshua is receiving furosemide and Digoxin, which laboratory data would be the most important to assess in planning the care for the client?

Potassium Level What are normal levels for: Potassium- 3.50-5.00 mEq/L Magnesium- 1.60-2.60 mg/dL Calcium- 9.00-10.50 mg/dL Sodium- 135-145 mmol/L Phosphorus- 2.50-4.50 mg/dL furosemide: treat fluid retention (edema) and swelling caused by congestive heart failure, liver disease, kidney disease, and other medical conditions. digoxin: treat heart failure and heart rhythm problems.

Hypermagnesemia EKG

Prolonged PR interval, widened QRS complex,

Palliative Care Goal

SYMPTOM RELIEF and PSYCHO-SOCIAL SUPPORT ● GOAL is to minimize or eliminate suffering and support the best possible quality of life for patients and family

guidelines for hospice

Say life expectancy < 6 months, however, you can go off of the benefit and pick it back up if you live longer No longer a terminal diagnosis Weight loss > 10% in the past 6 months Failure to thrive Albumin < 2.5 gm/dl Cholesterol <156 mg/dl Resting tachycardia > 100/min Increasing need for medical care and ADL support No dialysis or transplant, no life saving measures, but they will do medications

Which nursing intervention is most important when caring for a patient with an ileostomy? Cleansing the stoma with hot water. Inserting a deodorant tablet into the stoma bag. Selecting or cutting a pouch with an appropriate size stoma opening. Wearing sterile gloves while caring for the stoma

Selecting or cutting a pouch with an appropriate size stoma opening.

The nurse would expect the least formed stool to be present in which portion of the digestive tract? a. Ascending b. Descending c. Transverse d. Sigmoid

a. Ascending

The nurse knows that the ideal time to change an ostomy pouch is a. Before eating a meal, when the patient is comfortable. b. When the patient feels that he needs to have a bowel movement. c. When ordered in the patient's chart. d. After the patient has ambulated the length of the hallway.

a. Before eating a meal, when the patient is comfortable.

A patient with a hip fracture is having difficulty defecating into a bed pan while lying in bed. Which action by the nurse would assist the patient in having a successful bowel movement? a. Administering laxatives to the patient b. Raising the head of the bed c. Preparing to administer a barium enema d. Withholding narcotic pain medication

b. Raising the head of the bed

A patient informs the nurse that she was using laxatives three times daily to lose weight. After stopping use of the laxative, the patient had difficulty with constipation and wonders if she needs to take laxatives again. The nurse educates the patient that a. Long-term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur. b. Laxatives can cause trauma to the intestinal lining and scarring may result, leading to decreased peristalsis. c. Natural laxatives such as mineral oil are safer than chemical laxatives for relieving constipation. d. Laxatives cause the body to become malnourished, so when the patient begins eating again, the body absorbs all of the food, and no waste products are produced.

a. Long-term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur.

Which nursing action best reduces risk of excoriation to the mucosal lining of the nose from a nasogastric tube? a. Lubricating the nares with water-soluble lubricant b. Applying a small ice bag to the nose for 5 minutes every 4 hours c. Instilling Xylocaine into the nares once a shift d. Changing the tape holding the tube in place once a shift

a. Lubricating the nares with water-soluble lubricant

A nurse cares for a client admitted from a nursing home after several recent falls. What prescription should the nurse complete first? a. Obtain urine sample for culture and sensitivity. b. Administer intravenous antibiotics. c. Encourage protein intake and additional fluids. d. Consult physical therapy for gait training.

a. Obtain urine sample for culture and sensitivity.

While a cleansing enema is administered to an 80-year-old patient, the patient expresses the urge to defecate. What is the next priority nursing action? a. Positioning the patient in the dorsal recumbent position with a bed pan b. Assisting the patient to the bedside commode c. Stopping the enema cleansing and rolling the patient into right-lying Sims' position d. Inserting a rectal plug to contain the enema solution

a. Positioning the patient in the dorsal recumbent position with a bed pan

A patient is diagnosed with a bowel obstruction. The nurse chooses which type of tube for gastric decompression? a. Salem sump b. Dobhoff c. Sengstaken-Blakemore d. Small bore

a. Salem sump

A patient was admitted following a motor vechicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax. Which are the most common findings in pneumothorax? (Select All that apply) a. Sharp pleuritic pain that worsens on inspiration b. Crackles over lung bases of affected lung c. Tracheal deviation toward affected lung d. Worsening dyspnea e. Absent lung sounds to auscultation on affected side

a. Sharp pleuritic pain that worsens on inspiration d. Worsening dyspnea e. Absent lung sounds to auscultation on affected side

The nursing is caring for a patient who has labored breathing, is using accessory muscles, and is coughing of pink frothy sputum. The patient has diminished breath sounds In bilateral lung bases. What are the priority nursing assessments for the nuse to preform prior to notifying the patient's healthcare provider? (Select all that apply) a. SpO2 levels b. Amount, color, and consistency of sputum production c. Fluid status d. Change in RR and pattern e. Pain in lower leg

a. SpO2 levels b. Amount, color, and consistency of sputum production d. Change in RR and pattern

The nurse is devising a plan of care for a patient with the nursing diagnosis of Constipation related to opioid use. Which of the following outcomes would the nurse evaluate as successful for the patient to establish normal defecation? a. The patient reports eliminating a soft, formed stool. b. The patient has quit taking opioid pain medication. c. The patient's lower left quadrant is tender to the touch. d. The nurse hears bowel sounds present in all four quadrants.

a. The patient reports eliminating a soft, formed stool.

An older adult's perineal skin appears to be dry and thin with mild excoriation. When providing hygiene after a bowel movement, the nurse should a. Thoroughly scrub the skin with a wash cloth and hypoallergenic soap. b. Apply a skin protective lotion after perineal care. c. Tape an occlusive moisture barrier pad to the patient's skin. d. Massage the skin with deep kneading pressure.

b. Apply a skin protective lotion after perineal care.

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

b. Changing the clients incontinence brief when wet

The nurse has attempted to administer a tap water enema for a patient with fecal impaction with no success. What is the next priority nursing action? a. Preparing the patient for a second tap water enema b. Donning gloves for digital removal of the stool c. Positioning the patient on the left side d. Inserting a rectal tube

b. Donning gloves for digital removal of the stool

A nurse cares for a postmenopausal client who has had two episodes of bacterial urethritis in the last 6 months. The client asks, I never have urinary tract infections. Why is this happening now? How should the nurse respond? a. Your immune system becomes less effective as you age. b. Low estrogen levels can make the tissue more susceptible to infection. c. You should be more careful with your personal hygiene in this area. d. It is likely that you have an untreated sexually transmitted disease.

b. Low estrogen levels can make the tissue more susceptible to infection.

The nurse is caring for a patient who is confined to the bed. The nurse asks the patient if he needs to have a bowel movement 30 minutes after eating a meal because a. The digested food needs to make room for recently ingested food. b. Mastication triggers the digestive system to begin peristalsis. c. The smell of bowel elimination in the room would deter the patient from eating. d. More ancillary staff members are available after meal times.

b. Mastication triggers the digestive system to begin peristalsis.

A nurse reviews the laboratory findings of a client with a urinary tract infection. The laboratory report notes a shift to the left in a clients white blood cell count. Which action should the nurse take? a. Request that the laboratory perform a differential analysis on the white blood cells. b. Notify the provider and start an intravenous line for parenteral antibiotics. c. Collaborate with the unlicensed assistive personnel (UAP) to strain the clients urine for renal calculi. d. Assess the client for a potential allergic reaction and anaphylactic shock.

b. Notify the provider and start an intravenous line for parenteral antibiotics.

A nurse assesses a male client who is recovering from a urologic procedure. Which assessment finding indicates an obstruction of urine flow? a. Severe pain b. Overflow incontinence c. Hypotension d. Blood-tinged urine

b. Overflow incontinence

A nurse provides phone triage to a pregnant client. The client states, I am experiencing a burning pain when I urinate. How should the nurse respond? a. This means labor will start soon. Prepare to go to the hospital. b. You probably have a urinary tract infection. Drink more cranberry juice. c. Make an appointment with your provider to have your infection treated. d. Your pelvic wall is weakening. Pelvic muscle exercises should help.

c. Make an appointment with your provider to have your infection treated.

Drug Therapy for GERD: Prokinetic drugs

emptying and peristalsis ● metoclopramide (Reglan)

Signs/Symptoms of Detached Retina

floaters (blood and cells freed at time of tear) and flashers (vitreous traction on retina), progressive loss of vision in one area like a curtain drawn before eyes

You're caring for a patient with a sigmoid colostomy. The stool from this colostomy is ____.

formed

Glaucoma Symptoms

frequent changes in glasses without improvement, inability of eyes to adjust to darkened rooms, loss of peripheral vision, rainbow colored rings around lights (halos), persistent dull eye pain, headaches

Nursing Interventions for Dawn Phenomenon

give increased insulin at night & no bedtime snack

grief as a healing process

goes in cycles and is not a linear process

A patient is prescribed a calcium channel blocker to treat primary hypertension. When teaching the patient about the medication, which of these foods will the healthcare provider advise the patient to avoid?

grapefruit

most important factor in healing from loss?

having the support of other people

Dyspepsia:

heartburn aka substernal or retrosternal burning that moves up and down in wavelike fashion

It is halloween and a student nurse knows she needs to be ready for adults in the assisted living facility who have diabetes and eat all the candy with which of the following medications?

humalog What is humalog? a fast-acting mealtime insulin used to treat people with diabetes for the control of high blood sugar.

Conductive hearing loss:

problem conducting sound waves due to obstruction, otosclerosis, tumor, scar tissue

Lifestyle Modifications for GERD

■ DO NOT sleep on your back because that can push acid up ■ Decrease intra-abdominal pressure by avoiding constipation, straining ● Be sure to also lift things properly

After cataract surgery, be sure to educate:

■ Do not sleep on operated side for 3 to 4 weeks ■ Avoid rubbing - protect with patch ■ Do not bend below waistline ■ Avoid physical activity for 6 weeks ■ Avoid sneezing, coughing, straining, vomiting ■ Wear dark glasses ■ Family to administer eyedrops

Signs/Symptoms of Dyspepsia

■ Pain may radiate to neck, jaw, or back ■ Worsens when bends over, strains, or lies on their back ■ Occurs after meals and lasts 1 to 2 hrs ■ Helped with fluids and staying upright

Nursing Care for Patients Having GI Procedures: Colonoscopy

○ Have bowel prep prior ○ Given versed and fentanyl beforehand

Causes of GERD

○ Inappropriate relaxation of LES so sphincter tone is decreased ○ Irritation from refluxed material ○ Delayed gastric emptying, gastric volume, or intra-abdominal pressure increased Abnormal esophageal clearance

Main interventions before death

○ Meeting needs and preferences ○ Controlling symptoms of pain and distress ○ Meaningful interactions with loved ones ○ Peaceful death

Nursing Care for Patients Having GI Procedures: Upper GI and small bowel imaging patients

○ NPO 8 hours before ○ Give fluids after to pass barium

Treatment for cataract

○ Non-surgical management is reading glasses & increased lighting ○ Surgery is the ONLY "cure" for cataracts and therefore should be performed ASAP

Nursing Care for Patients Having GI Procedures: Barium enema patients

○ Only clear liquids for 12 to 24 hours prior ○ Given bowel prep like Golytely ○ Can be uncomfortable, MUST take a laxative afterwards

PAIN CONTROL for the dying patient

○ Opioids with morphine being the standard ○ High doses for comfort

causes of detached retina

○ Trauma ○ Myopic degeneration ○ Tumors ○ Hemorrhage ○ May follow sudden physical exertion in debilitated individual ○ May occur suddenly or develop over time

A paraplegic client is being discharged home from rehabilitation. What primary concerns does the nurse include in the client's discharge plan? Select all that apply. A. Assistive and adaptive devices B. Cast care C. Depression prevention D. Range-of-motion (ROM) exercises E. Wheelchair accessibility

A, C , D, E The paraplegic client will need to have the availability of numerous assistive and adaptive devices in the home setting, such as a portable toilet, a hospital bed, and a wheelchair. Providing some mechanisms for coping with depression should be part of the discharge plan. The client may not be depressed, but he or she is at risk for this complication. ROM exercises need to be part of the paraplegic client's daily routine; information about them is critical for this population. Paraplegic clients are often wheelchair bound; their homes need to be outfitted with adaptive ramps, wide doorways, etc.Cast care is not routinely included as part of the postdischarge care provided for a paraplegic client.

The nurse working on an inpatient hospice unit has received the change-of-shift report. Which client does the nurse assess first? A. A 26-year-old with metastatic breast cancer who is experiencing pain rated at 10 (0-to-10 scale) and anxiety B. A 30-year-old with AIDS-associated dementia and agitation who is asking for assistance with calling family members C. A 62-year-old with lung cancer who has cool, clammy, dusky skin, and blood pressure of 64/20 mm Hg D. A 70-year-old with cancer of the colon who has a respiratory rate of 8 with loud, wet-sounding respirations

A. A 26-year-old with metastatic breast cancer who is experiencing pain rated at 10 (0-to-10 scale) and anxiety Management of discomfort is the priority goal for hospice care, so decreasing this client's pain and anxiety should be the first action.The client with AIDS needs rapid assistance, but is the second priority for the nurse in this scenario. The client with lung cancer and the client with colon cancer are exhibiting normal signs and symptoms associated with dying.

A client with terminal lung cancer is receiving hospice care at home. Which nursing action does the RN manager ask the LPN/LVN to do? A. Clarify family members' feelings about the meaning of client behaviors and symptoms. B. Develop a plan for care after assessing the needs and feelings of both the client and the family. C. Teach the family to recognize signs of client discomfort such as restlessness or grimacing. D. Administer prescribed medications to relieve the client's pain, shortness of breath, and nausea.

A. Administer prescribed medications to relieve the client's pain, shortness of breath, and nausea. LPN/LVNs are educated to administer medications and monitor clients for therapeutic and adverse medication effects; the administration of prescribed medications to the client for pain, shortness of breath, and nausea is appropriate to delegate to the LPN/LVN.Clarifying family members' feelings, developing a plan of care, and teaching the family to recognize signs of discomfort all require broader education and are appropriate for the RN practice level.

A client has died after a long hospital stay. The family was present at the time of the client's death. Which postmortem action does the nurse implement? A. Asks the family if they wish to help wash the client B. Asks the family to leave during post-death care C. Raises the head of the bed and opens the client's eyes D. Removes dentures and any prosthetics

A. Asks the family if they wish to help wash the client The nurse may ask the family if they wish to be involved in washing the client after the client's death.The family should be allowed to grieve at the bedside of the client. The head of the bed should be flat and the client's eyes closed. The client's dentures and prosthetics should be replaced, not removed.

A hospitalized client of the Islamic (Muslim) religion is dying. What concept does the nurse share with the health care team about this client's beliefs about death? A. Death is seen as the beginning of a new and better life, with Islam as the vehicle. B. Life experiences do not affect the individual's preparation for "everlasting life." C. The timing of death is under the power of the person who is facing death. D. Plans for burial will take days, maybe even weeks, after the death.

A. Death is seen as the beginning of a new and better life, with Islam as the vehicle. The nurse shares the information that, in the Muslim faith, Islam is the vehicle that transports the person to a new and better life on the "other side." This is a fundamental belief of the religion.In Islam, life experiences do affect the person's afterlife existence. Life is meant to be a test of preparation for everlasting life in the hereafter. Muslims believe that God (Allah), rather than the person, has prescribed a time of death for everyone. Preparation for burial takes place as soon as possible after death has occurred.

A client diagnosed with lung cancer 6 months ago is now ventilator-dependent and unresponsive. The family wants to remove the ventilator and stop antibiotics and IV fluids. What does the nurse do next? A. Facilitates a meeting between the family and health care team B. Removes the interventions, per the family's wishes C. Tells the family that removing the interventions is illegal D. Waits to obtain information on the client's wishes

A. Facilitates a meeting between the family and health care team The nurse's next action would be to facilitate a meeting between the family and the health care team. Withdrawing or withholding life-sustaining therapy involves discontinuing one or more therapies that might prolong the life of a person who cannot be cured by the therapy. To do this, a meeting is required between the family and the health care team.Withdrawing life support requires more than simply following the family's wishes. Removal of life-sustaining therapy is not illegal except in cases of active euthanasia or physician-assisted euthanasia. The client most likely will not regain consciousness. The client's wishes should have been determined and documented earlier in the course of his or her disease (advance directives, living will, etc.).

The nurse performs an admission assessment for an older adult following a fractured hip repair. Which priority client assessment findings will require the nurse to collaborate with members of the interprofessional health team? (Select all that apply.) a. Mild dependent edema in both ankles when sitting b. Chest pain when ambulating with the walker c. Lack of appetite and weight loss d. Report of joint pain at 8 on a 0-10 intensity scale e. Dry and itchy skin over legs and arms

B, C, D The client's signs and symptoms require referral to and collaboration with the primary health care provider (chest pain), physical therapy (joint pain), and dietitian (lack of appetite and weight loss).

A client admitted with a non-life-threatening illness says, "I was asked to fill out an advance directive when I was admitted, but I was too stressed. What was it all about?" How does the nurse respond? A. "Advance directives are only for those individuals who are severely ill." B. "Advance directives allow a client to convey his or her wishes about health care ahead of time." C. "Most Americans have an advance directive in place; you will need to see a lawyer." D. "You should have completed the paperwork before you were admitted."

B. "Advance directives allow a client to convey his or her wishes about health care ahead of time." The nurse responds by stating that advanced directives allow a client to convey his or her wishes about health care ahead of time. This best addresses the client's comments.Most advance directives are in place before the client becomes severely ill. Many Americans do not have advance directives in place. Legal assistance is not necessary to complete them. Although completing paperwork pertaining to advance directives before admission would be ideal, any time is a good to do this.

A client with right-sided weakness is receiving antihypertensive medications. What does the RN communicate to the physical therapist (PT), who is planning to help the client walk? A. "Monitor the client for weakness and fatigue during exercise." B. "Move the client from lying to standing slowly." C. "Remind the client to use the left side to grip." D. "Use a gait belt when ambulating the client."

B. "Move the client from lying to standing slowly." The RN tells the PT to move the client from lying to standing slowly. Because the PT may not be aware of the client's medications or that antihypertensives can cause orthostatic hypotension, the nurse should discuss this with the PT before the client is ambulated.The PT will not need instruction about how to safely exercise (monitor for weakness), to use the left side to grip, or to ambulate the client, because these activities are included in the role of the PT in rehabilitation.

The daughter of a dying client says, "I don't want my father to be uncomfortable." How does the nurse respond? A. "Do you want to talk to the bereavement nurse?" B. "Your father will be closely monitored and cared for." C. "Your father will be kept sedated." D. "We will send him to hospice when the time comes."

B. "Your father will be closely monitored and cared for." The nurse responds by telling the daughter that her father will be closely monitored and cared for. This would reassure the daughter as well as providing support and comfort.The daughter's comment does not require the expertise of a bereavement nurse. Also, asking if the daughter wants to talk to a bereavement nurse is a "yes-or-no" question, it is a nontherapeutic response and may shut off the dialog. The dying client is not typically kept sedated; clients are kept comfortable with as little or as much pain medication as needed. A goal is to keep him or her alert and able to communicate. Telling the daughter that her father will be sent to hospice when the time comes does not address the daughter's concern about her father's comfort and it closes the dialog.

The medical-surgical nurse is coordinating transfer from acute care to community-based care for a client who requires rehabilitation. Which interdisciplinary team members will be the primary decision makers in this transition? A. Case managers B. Client and family C. Medical-surgical nurses D. Rehabilitation nurses

B. Client and family Client and family will be the primary decision makers in this transition. Clients in a rehabilitation setting are managed by an interdisciplinary team of health care professionals, but the client and client's family are at the center of the team and should be the primary decision makers.The case manager, the medical-surgical nurse, and the rehabilitation nurse are important members of the interdisciplinary team, but are not the most important members.

The nurse recognizes signs and symptoms of delirium in an 80-year-old client who is dying from metastatic breast cancer. What does the nurse do initially for this client? A. Requests an order for an antipsychotic medication to control these symptoms B. Collaborates with the end-of-life (EOL) care team to evaluate possible medication-induced causes C. Discontinues all medications that have central nervous system adverse effects D. Assures the client's family that this terminal delirium indicates that death is imminent

B. Collaborates with the end-of-life (EOL) care team to evaluate possible medication-induced causes The nurse would initially collaborate with the end-of-life (EOL) care team to evaluate possible medication-induced causes. Terminal delirium occurs in the last few weeks of life and its causes, including medication-induced causes, should be assessed and treated with the collaboration of the EOL care team and the client's physician.Antipsychotic medications are only used to treat psychosis symptoms of hallucinations and delusions. Medications may only need to be reduced. Discontinuation or reduction of medication would be decided by the health care provider. Reassuring the family does not address the symptoms.

An 80-year-old client is bedridden after having a cerebral vascular accident. Which nursing intervention does the nurse use to help prevent skin breakdown? A. Applying moist packs to the skin every shift B. Ensuring the client's skin remains dry and clean C. Decreasing calories consumed; avoiding weight gain D. Turning and repositioning at least every 4 hours

B. Ensuring the client's skin remains dry and clean The nurse ensures that the client's skin stays dry and clean to prevent skin breakdown. Keeping the client's skin clean and dry will ensure early detection and prevention of the problem.Moisture is contraindicated because it can cause further skin breakdown. Decreasing calories is contraindicated because nutrition is needed for good skin turgor; weight gain is likely not an issue for this client. The client should be repositioned at least every 2 hours to prevent skin breakdown.

The rehabilitation nurse in a medical-surgical setting is assessing the client's ability to perform activities of daily living (ADLs). Which test does the nurse use? A. Confusion Assessment Method (CAM) B. Functional Independence Measure C.Minimum Data Set D. Shift change assessment

B. Functional Independence Measure The nurse uses the Functional Independence Measure test that is most commonly used to assess a client's ability to perform ADLs. Functional assessment tools would be used to assess a client's abilities.The Confusion Assessment Method is used to evaluate cognition to screen for depression, confusion, and delirium. The Minimum Data Set is used in long-term care settings. Shift change in the medical-surgical setting is not the correct venue for assessing ADLs, which takes more time than this instance allows.

Following a cerebral vascular accident, a client with right-sided hemiplegia is in a rehabilitation unit. Which nursing intervention is effective in promoting the client's independence? A. Assisting the client with all of his or her activities of daily living (ADLs) B. Instructing the client step-by-step on how to put on his or her robe C. Telling the client to do the "best" that he or she can do D. Sending the client to a long-term care facility

B. Instructing the client step-by-step on how to put on his or her robe Instructing the client (step-by-step) on how to put on a garment provides direct teaching of skills. This promotes independence for the client.Assisting the client with all ADLs will not support the client's independence. Telling the client to do her or his best does not help teach new skills and may even add to the client's frustration. Sending the client to a long-term care facility will not support the client in gaining independence.

A client with terminal pancreatic cancer is near death and reports increasing shortness of breath with associated anxiety. Which hospice protocol order does the nurse implement first? A. Albuterol (Proventil) 0.5% solution per nebulizer B. Morphine sulfate (Roxanol) 5 to 10 mg sublingually as needed C. Oxygen 2 to 6 L/min per nasal cannula D. Prednisone (Deltasone) elixir 10 mg orally

B. Morphine sulfate (Roxanol) 5 to 10 mg sublingually as needed Morphine sulfate is the standard treatment for the dyspneic client who is near death.Albuterol (Proventil), oxygen, and steroids may be useful, but should be used as adjuncts to therapy with morphine.

The client is struggling with use of eating utensils. Which rehabilitation team member is brought in to help the client with this problem? A. Activity therapist B. Occupational therapist C. Psychiatrist D. Physical therapist

B. Occupational therapist The occupational therapist is brought in to help the client with the use of eating utensils. The occupational therapist works to develop the client's fine motor skills used for activities of daily living, such as those required for eating, maintaining hygiene, dressing, and driving.The recreational or activity therapist works to help the client continue or develop hobbies or interests. The physiatrist is a physician who specializes in rehabilitative medicine; this rehabilitation team member is not the best resource for this situation. The physical therapist helps the client achieve mobility (e.g., by facilitating ambulation and teaching the client to use a walker).

An 82-year-old woman is admitted to the transitional care unit for stroke rehabilitation with a history of uncontrolled hypertension, coronary artery disease, and elevated cholesterol levels. Her blood pressure (BP) is currently controlled with antihypertensive medications. The UAP reports that the client's systolic blood pressure drops by 20 mm Hg when the client gets out of bed. What is the likely cause of this client's change in blood pressure? A. Her stroke is worsening, becoming more acute. B. Orthostatic hypotension is exacerbated by antihypertensive medications. C. The dose of her antihypertensive medication is too high. D. The dose of her antihypertensive medication is too low.

B. Orthostatic hypotension is exacerbated by antihypertensive medications. The client is experiencing orthostatic hypotension. If the client moves from a lying to a sitting position too quickly, her BP drops. This problem is worsened by antihypertensive medications, especially in older adults.Worsening of the client's stroke would be characterized by an increase, rather than a decrease, in BP. The dosage or the type of antihypertensive medication that the client is receiving is not known in this scenario, so it is impossible to determine whether it is too high or low. However, if the dose were too low, the client's BP would be higher, not lower.

A dying client cannot swallow and is accumulating audible mucus in the upper airway (death rattles). The nursing assistant reports that these noises are upsetting to family members. What does the nurse tell the assistant to do? A. Assist the family in leaving the room so that they can compose themselves. B. Place the client in a side-lying position so secretions can drain. C. Position the client in a high-Fowler's position to minimize secretions. D. Use a Yankauer suction tip to remove secretions from the client's upper airway.

B. Place the client in a side-lying position so secretions can drain. Placing the client in a side-lying position to facilitate draining of secretions (by gravity) is the appropriate nursing care intervention. As secretions diminish, noisy respirations will decrease.Asking the family to leave at this important time is not appropriate. Placing the client in a high-Fowler's position is ineffective in helping the client who has lost the ability to swallow and increases the danger of choking and aspiration. Not only is oropharyngeal suctioning outside the scope of practice of the nursing assistant, it is also not recommended for removal of secretions, because it is not effective and may even agitate the dying client.

The nurse is reinforcing the physical therapist's teaching on gait training for a client who had a total knee replacement 6 weeks ago. Which ambulatory aid does the nurse expect the client to be using? A. Crutches B. Straight cane C. Walker with a built-in seat D. Walker with rollers

B. Straight cane A straight cane is the most likely ambulatory aid for a client who is 6 weeks postsurgery from a knee replacement. The client should be weight-bearing, with some assistance, on the affected leg.Crutches would have been used earlier in the rehabilitation process. Clients who need assistance with both weight bearing and balance would be using a walker, and specialized walkers with a seat (for resting) are especially helpful for clients who tire easily; no indication suggests that this client has those needs.

The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation? 1.Sustained tissue damage 2.Requires nasogastric suction 3.Has a history of Addison's disease 4.Uric acid level of 9.4 mg/dL (559 mmol/L)

B. The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison's disease and the client with hyperuricemia are at risk for hyperkalemia. The normal uric acid level for a female is 2.7 to 7.3 mg/dL (16 to 0.43 mmol/L) and for a male is 4.0 to 8.5 mg/dL (0.24 to 0.51 mmol/L). Hyperuricemia is a cause of hyperkalemia. Note that the subject of the question is potassium deficit. First recall the normal uric acid levels and the causes of hypokalemia to assist in eliminating option 4. For the remaining options, note that the correct option is the only one that identifies a loss of body fluid.

A rehabilitation client is being discharged home. Which nursing intervention provides the best assessment for home modification, while helping diminish the client's anxiety about the process of discharge? A. Doing discharge teaching B. Having a home visit made by the case manager C. Making a leave of absence (LOA) visit possible D. Performing a predischarge assessment

C. Making a leave of absence (LOA) visit possible The nursing intervention providing the best assessment for home modification and diminishing the client's anxiety about the discharge process is making a leave of absence (LOA) visit possible. One method of assessing the client's home is through a brief home visit, also called a leave of absence (LOA) visit, before discharge. This is a very effective method of helping the client prepare for the transition home, thus reducing any anxiety that the client may have.Discharge teaching helps with the client's adaptation to managing care at home, but does not address home modification. After discharge to home, various health care resources (e.g., physical therapy, home care nursing, vocational counseling) are available to the client with chronic illness and disability, but by this time it is often too late for home modification. Before discharge, the case manager or occupational therapist may visit the home to assess its layout and accessibility, but this would not allay the client's apprehension and anxiety.

The partner of a newly diagnosed paraplegic client says, "I don't know how I am going to manage a job, care for my partner, and take care of the family." How does the nurse respond? A. "Can you quit your job?" B. "How did you handle challenges before your partner was injured?" C. "Let's see what resources are available to help." D. "Things will get better and you will be fine."

C. "Let's see what resources are available to help." The nurse responds by suggesting helpful resources. This is the most effective response. The partner will know that support is available and can access it.The partner will know that support is available and can access it. Quitting a job is typically not an option. Also, this is a closed question that requires a "yes-or-no" answer, so it does not encourage problem solving. The partner's previous stressors most likely were not as overwhelming as this one; therefore, this response is irrelevant. Telling the client's partner that he or she will "be fine" minimizes the current situation; it is giving false reassurance and is a nontherapeutic response.

The nurse is performing a spiritual assessment on a dying client. Which question provides the most accurate data on this aspect of the client's life? A. "Do you believe in God?" B. "Tell me about the history of religion in your life." C. "What gives you purpose and meaning in your life?" D. "Where have you been attending church for the past several years?"

C. "What gives you purpose and meaning in your life?" The most accurate data about the client's spirituality would come from the question, "What gives you purpose and meaning in your life?" Spirituality arises from whatever or whoever provides the client ultimate purpose and meaning. It is not necessarily God, but it could be. It could be the client's definition of a higher power.The client may not believe in God and may find an inquiry about believing in God offensive and judgmental. Religion is considered by many people to be affiliation or membership in a faith community. Members of such a community may be supportive of the client if the client is a member, but this is not the best way to determine what the client's spirituality is. Church attendance is one way that some individuals express their religion, but it does not necessarily define a person's spirituality; asking about church could place the client on the defensive.

Which staff member does the manager of an inpatient rehabilitation unit assign as the case manager for a stroke client with physical and speech deficits? A. Physical therapist B. Recreational therapist C. Rehabilitation nurse D. Speech-language pathologist

C. Rehabilitation nurse The rehabilitation nurse coordinates the efforts of the team members and may be designated as the client's case manager.The physical therapist, the recreational therapist, and the speech-language pathologist will assist with specific aspects of the client's care, but are not responsible for coordination of care.

Which nursing intervention does the rehabilitation nurse delegate to a nursing assistant who is caring for a 70-year-old client with right-sided weakness following a stroke? A. Arrange for family members to participate in planning for discharge. B.Determine whether the client's passive range-of-motion (ROM) exercises should be increased. C. Reinforce the client's placing the right arm in the sleeve first when dressing. D. Teach the client to use an extended shoehorn when putting on shoes.

C. Reinforce the client's placing the right arm in the sleeve first when dressing. The nursing assistant is appropriate to perform the intervention of reinforcing the client's placing the right arm in the sleeve first when dressing. Reinforcement of skills that have been taught by the occupational therapist or nurse is an action that should be done by all caregivers who are involved in the client's care.Planning for discharge, assessing passive ROM exercises, and teaching the use of a shoehorn require broader education and scope of practice and should be done by a licensed staff member such as the RN.

A recently injured paraplegic client is in rehabilitation. Which client comment indicates that he or she is adapting to new self-care activities? A. "I am so tired today, I want to rest." B. "I don't want to do this today." C. "My dog can do this—why can't I do it too?" D. "This isn't working; I need to try something else."

D. "This isn't working; I need to try something else." The client's comment that he or she needs to try something else indicates an overall willingness to try on the client's part. When one method failed, the client was motivated to try something else.The comment that the client wants to rest can be indicative of depression; the client is not trying to do "more" but rather "less." Not wanting "to do this today" can be indicative of depression or denial; the client is not even making an effort to engage in self-care. Saying that "my dog can do this" exhibits extreme frustration; the client sounds angry, which should be explored to be better understood.

The family of an unconscious dying client realizes that their mother will die soon. The client's children are having a difficult time letting go. How does the nurse respond to the needs of this family? A. "Don't be upset; she wouldn't want it that way." B. "She will soon be in a better place." C. "Things will be fine, try not to worry so much." D. "This must be difficult for you."

D. "This must be difficult for you." The nurse responds by stating, "This must be difficult for you." This statement tells the family that the nurse is aware of their needs. The nurse knows that she must accept whatever the grieving person says about the situation, must remain present, be ready to listen attentively, and guide gently. In this way, the nurse can help the bereaved prepare for the necessary reminiscence and integration of the loss.The client's or family member's pain of loss should never be minimized. Trite assurances such as saying, "Don't be upset; she wouldn't want it that way" or "Things will be fine," should be avoided. Such comments can actually be barriers to demonstrating care and concern. Never try to explain a client's death or impending death in philosophic or religious terms because such statements are not helpful when the bereaved person has yet to express feelings of anguish or anger.

The nurse is coordinating interdisciplinary palliative care interventions for the dying client. Which goal is the nurse seeking to meet? A. Avoiding symptoms of client distress B. Ensuring an expedited death C. Meeting all of the client's needs D. Facilitating a peaceful death for the client

D. Facilitating a peaceful death for the client Facilitating a peaceful death for the client is one of the goals of palliative care.Symptoms of distress cannot be avoided but can be controlled. Expedited death is not a goal of palliative care. Identifying client needs is a goal of palliative care, but it is not always possible to meet all of the client's needs (e.g., to prevent death or lengthen life).

Which condition, when assessed in a dying client, requires that the nurse take action? A. Alternating apnea and rapid breathing B. Anorexia C. Cool extremities D. Moaning

D. Moaning Moaning indicates pain and requires pain medication.Alternating apnea and rapid breathing, anorexia, and cool extremities are normal assessment findings in the dying client.

A client has a priority problem of skin breakdown related to immobility and incontinence. Which nursing intervention does the rehabilitation RN delegate to a nursing assistant? A. Assessing the client's skin for areas of breakdown B. Developing a schedule for turning the client C. Planning a diet high in protein and calories D. Re-positioning the client every 2 hours

D. Re-positioning the client every 2 hours The RN delegates re-positioning the client every 2 hours to a nursing assistant. The education and scope of practice of nursing assistants include re-positioning clients.Assessment of the client's skin for integrity, planning care (developing a schedule for care), and planning for a therapeutic diet require broader education and critical thinking and should be done by RN staff members.

A client with lower motor neuron spinal cord dysfunction has not voided, and a bladder scan shows 700 mL of urine in the bladder. Using the client's bladder training plan, what action does the staff RN advise a new graduate nurse to take first with this client? A. Administer a dose of oxybutynin chloride (Ditropan). B. Insert a straight catheter to empty the bladder. C. Reassess the client's bladder volume in 2 hours. D. Remind the client to try the Valsalva maneuver.

D. Remind the client to try the Valsalva maneuver. The RN advises the new graduate nurse to first try the Valsalva maneuver. Clients with lower motor neuron problems have a flaccid bladder. Increasing pressure on the bladder with the Valsalva maneuver may help the client void. Oxybutynin chloride (Ditropan) is useful in mild cases of overactive bladder. If the Valsalva maneuver is ineffective, straight catheterization may be used to empty the bladder. Because the bladder already holds 700 mL, the nurse should not wait for 2 more hours before taking action to empty the bladder.

A hospice client has just died. Which of these postmortem nursing tasks is most appropriate to delegate to a nursing assistant? A. Assessing the client for cessation of respiratory effort and lack of pulse B. Documenting the time of death and required assessment data on the chart C. Notifying the spouse and other family members about the client's death D. Removing all IV lines or tubes according to the hospice policy

D. Removing all IV lines or tubes according to the hospice policy Preparing the body for viewing by the family (such as removing tubing and lines) and/or transfer to the morgue is an appropriate task for unlicensed assistive personnel.Assessing for signs of life, documenting about the death, and spousal and family notification all require broader education and should be done by licensed nursing staff.

A client dying of cancer is receiving high doses of opioids. In addition, which intervention is the most effective for this client? A. Classical music B. Deep muscle massage C. More pain medication D. Short, light massage

D. Short, light massage Massage has been shown to decrease pain in individuals with cancer. Light, short episodes of pressure are best. Deep or intense pressure should be avoided.Although music therapy may be effective, the type of music played should be the client's choice, and does not assume that the client wants to hear classical music. The dying client who is frail may not tolerate an extensive deep massage. The client is already receiving high doses of opioids. Complementary or alternative therapy can replace the need for increased pain medication.

A client has been hospitalized with a non-life-threatening C-spine neck injury. The interdisciplinary rehabilitation team has worked with the quadriplegic client for 4 months. Which outcome indicates that the team's efforts are effective? A. Constipation now occurs only 3 days a week. B. Mobility requires multiple assistive devices. C. Personal care is performed with help from the family. D. Skin is intact, with no evidence of skin impairment.

D. Skin is intact, with no evidence of skin impairment. The outcome that the skin is intact, with no evidence of skin impairment indicates that the team's efforts are effective. Healthy intact skin indicates good care by this client's interdisciplinary rehabilitation team.A decrease in constipation is not one of the goals of the interdisciplinary rehabilitation team. The client with a C-spine neck injury will have no mobility. Personal care activities are not part of the interdisciplinary rehabilitation program.

In a dying client's hospital room, the nurse overhears family telling the client to "calm down," and observes the client being agitated and making repetitive motions. What action does the nurse take? A. Asks the family to speak in low tones or whispers to avoid disturbing the client B. Offers to call and have a hospital chaplain come to help the client calm down C. Recommends giving the client antianxiety medications to reduce distress D. Suggests that the family tell the client that things are "all right"

D. Suggests that the family tell the client that things are "all right" The nurse suggests that the family reassure the client that things are "all right." When dying clients are agitated or performing repetitive tasks, it is often a sign that they have unfinished or unresolved issues that prevent letting go. Suggesting that family members tell the client that they will be all right and that it is OK to go can help clients relax and let go.The client needs to know that family members are present and are concerned. Having a chaplain calm the client or giving antianxiety medications will not resolve the underlying issue.

A hospice client becomes too weak to swallow. What does the nurse do initially to increase the client's comfort? A. Administers nutrition and fluids through a nasogastric tube B. Explains to the family that aspiration may be a concern C. Obtains a physician order to initiate an IV line D. Teaches the family how to provide oral care

D. Teaches the family how to provide oral care Because the oral mucosa will become dry, the initial action taken by the nurse would be to teach the family members how to moisten the lips and mouth.Although fluids can be given through a nasogastric tube and through an IV line, these are generally considered to increase discomfort by prolonging the client's suffering. Aspiration is not a concern in terminally ill clients, because fluids are not given orally to clients with decreased swallowing.