Complex Care Final Exam EAQ Review

A client with a high cholesterol level says to the nurse, "Why can't the doctor just give me a medication to eliminate all the cholesterol in my body so it isn't a problem?" Which factor related to why cholesterol is important in the human body should the nurse include in a response to the client's question? 1 Blood clotting 2 Bone formation 3 Muscle contraction 4 Cellular membranes

4. Cellular membrane structure Rationale: Cholesterol is an essential structural and functional component of most cellular membranes. The fact that it is associated with atherosclerotic plaques does not detract from its essential functions.

Which potential cause of dysrhythmia would the nurse consider when assessing a client who has sinus tachycardia? Select all that apply. A. Anxiety B. Caffeine C. Exercise D. Anemia E. Hypothermia

A. Anxiety B. Caffeine C. Exercise D. Anemia Rationale: Causes of sinus tachycardia include sympathetic, fear or pain (for example, anxiety), use of stimulant (such as caffeine), exercise, anemia, hypovolemia, heart failure, and fever. Hypothermia will cause sinus bradycardia

Which discharge instruction would the nurse give the client to decrease the risk of thromboembolic events after an abdominal hysterectomy? A. Avoid sitting for long periods of time B. Limit fluids to less than 2000 mL per day C. Have a coagulation test every 2 weeks D. Continue with hormone replacement therapyy

A. Avoid sitting for long periods of time Rationale: SITTING FOR LONG PERIODS leads to pooling of blood in the pelvic area, predisposing the client to thrombus formation. Fluids should be increased to about 2000 mL daily to decrease blood viscosity, which can lead to thrombus formation. Blood coagulation tests are not done routinely because clotting elements are not usually disturbed by a hysterectomy. Hormone replacement therapy is not considered unless the client is premenopausal and an oophorectomy has also been performed. The estrogen component in hormone replacement therapy can increase the risk of clots.

A client who had been receiving palliative care for cancer has deteriorated and now needs end-of-life care. The nurse identifies that which type of care will now be removed from the treatment plan? Select all that apply. One, some, or all responses may be correct. A. Chemotherapy B. Repositioning C. Regular oral care D. Blood transfusion E.Radiation therapy

A. Chemotherapy D. Blood transfusion E. Radiation therapy Rationale: End-of-life care comprises measures to make the client as comfortable as possible. It may include measures such as repositioning and regular oral care. Palliative care is a combination of care provided when cure is not possible for a chronic disease. Chemotherapy, radiation therapy, and blood transfusions are a part of palliative care meant to alleviate symptoms and promote well-being. These therapies may not be required in a client who is about to die and is receiving end-of-life care.

Which procedure is used to verify placement of a newly inserted central venous access device (CVAD)? A. Chest x-ray B. Flushing the line with heparin C. Withdrawing blood to ensure patency D. Chest fluoroscopy

A. Chest x-ray Rationale: The insertion of a central venous catheter (CVC) into the subclavian vein can result in a pneumothorax, which would be seen on a chest x-ray. Indications of a pneumothrorax before the chest x-ray would include shortness of breath and anxiety. If the chest x-ray is negative for pneumothorax, the CVC line may be used. The central line should not be flushed until placement is verified. Blood withdrawal is utilized once placement is verified, but is not used to verify initial placement. Fluoroscopy may be used during placement in certain settings, but not for placement verification.

A 7-year old child has a peripherally inserted central venous catheter placed into the left arm. A peripheral intravenous (IV) line is still in place, and an antibiotic is to be administered immediately. Which action would the nurse take next? A. Connect the IV antibiotic to the peripheral line. B. Administer the antibiotic through the central line placement C. Order an x-ray confirmation report on central line placement D. Document a verbal prescription on the chart stating the central line can be used.

A. Connect the IV antibiotic to the peripheral line. Rationale: The peripheral line must be used until the placement of the central venous line is confirmed with radiography or fluoroscopy; this prevents the instillation of fluid into the lung or interstitial space if the catheter is misplaced. The central line should not be used until placement is confirmed. A verbal prescription is not the best choice, because the nurse is required to confirm placement, which is done via radiography in this situation.

Which action would the nurse take when a client on a telemetry unit demonstrates a sinus rhythm with an occasional premature atrial contraction (PAC) A. Continue to monitor the client B. Activate the Rapid Response team C. Ensure that a defibrillator is available close by D. Give Lidocaine intravenously as per protocol.

A. Continue to monitor the client. Rationale: Occasional PACs are benign and will not affect cardiac output, but the nurse will continue to monitor the client for increased number of PACs or other dysrhythmias.

When assessing a client with right ventricular heart failure, the nurse would expect which finding? Select all that apply. One, some, or all responses may be correct. A. Dependent edema B. Swollen hands and fingers C. Collapsed neck veins D. Right upper quadrant discomfort E. Oliguria

A. Dependent edema B. Swollen hands and fingers D. Right upper quadrant discomfort Rationale: With right sided heart failure, signs of systemic congestion occur as the right ventricle fails; key features include dependent edema and swollen hands and fingers. Upper right quadrant discomfort is expected with right ventricular failure because of venous congestion in the systemic circulation results in hepatomegaly.

Which action would the nurse include in the plan of care for a client admitted with heart failure who has gained 20 pounds in 3 weeks? Select all that apply. One, some, or all responses may be correct. A. Diuretics B. Low-salt diet C. Daily weight checks D. Fluid restriction E. Intake and output F. Oxygen administration

A. Diuretics B. Low-salt diet C. Daily weight checks D. Fluid restriction E. Intake and output F. Oxygen administration Rationale: Interventions for a client with heart failure who has sustained a 20 pound weight gain would be focused on decreasing fluid retention. Interventions could include diuretic administration to increase fluid removal; low salt diet with fluid restriction; daily weight checks and measuring intake/output; and oxygen administration, particularly if the client has fluid in the lungs

A client presents with bilateral leg pain and cramping in the lower extremities. The client has a history of cardiovascular disease, diabetes, and varicose veins. To guide the assessment of the pain and cramping, the nurse would include which question when completing the initial assessment? A. Does walking for long periods of time increase your pain? B. Does standing without moving decrease your pain? C. Have you had your potassium levels checked recently? D. Have you had any broken bones in your lower extremities?

A. Does walking for long periods of time increase your pain? Rationale: Clients with a medical history of heart disease, hypertension, phlebitis, diabetes, or varicose veins often experience vascular-related complications. The nurse would recognize that the relationship of symptoms to exercise will clarify whether the presenting problem is vascular or musculoskeletal. Pain caused by a vascular condition tends to increase with activity. Musculoskeletal pain is not usually relieved when exercise ends.

Which assessment finding would the nurse expect when a client is diagnosed with left-sided congestive heart failure? Select all that apply. One, some, or all responses may be correct. A. Dyspnea B. Crackles C. Frequent cough D. Peripheral edema E. Jugular distention

A. Dyspnea B. Crackles C. Frequent cough Rationale: With left ventricular failure, increases in left ventricular volume and pressure lead to pulmonary congestion, causing dyspnea, lung crackles, and cough. Peripheral edema occurs when right-sided heart failure causes increases in systemic venous pressure. Jugular vein distention also occurs with right sided failure and increased systemic venous pressure

The registered nurse (RN) delegates the care of a client in the immediate postoperative period to the unlicensed assistive personnel (UAP). Which tasks are in the scope of practice of the UAP? Select all that apply. A. Feeding the client B. Ambulating the client for the first time C. Monitoring the vital signs D. Assisting the client with bathing E. Teaching leg exercises to the client

A. Feeding the client D. Assisting the client with bathing Rationale: The tasks that may be delegated to the UAP for postoperative client care include providing basic comfort and hygiene. Feeding the client is basic care provided by the UAP. Assisting the client with bathing is the basic hygiene provided by the UAP.

Which action would the nurse take initially to advocate for the client and achieve resolution when caring for a client with terminal cancer who desires to receive hospice care at home rather than pursue further treatment against the advice of both the health care provider and the immediate family? A. Help the client clarify their values prioritize actions B. Brainstorm possible alternative solutions for this issue C. Empower the client to decide to resolve the situation D. Provide support and reassurance as the client makes decisions.

A. Help the client clarify their values prioritize actions. Rationale: The nursing process as a problem-solving approach can be used by the nurse to help the client resolve value or ethically laden issues, In the first step of the process, the nurse would help the client illuminate values because values influence behaviors, feelings, and goals.

A client suffering from cancer is near the end of life. Which action(s) would be performed by the nurse to support the clients family members? Select all that apply. One, some, or all responses may be correct. A. Helping the family set up hospice B. Taking time to make sure that the family understands care options C. Staying with the client in the absence of family members D. Giving the family information about the dying process E. Making sure that the family knows what to do at the time of death

A. Helping the family set up hospice B. Taking time to make sure that the family understands care options C. Staying with the client in the absence of family members D. Giving the family information about the dying process E. Making sure that the family knows what to do at the time of death Rationale: When the client is at the last stage of life, the nurse would help the family set up hospice and other appropriate resources, including grief support. The family members should be informed about the dying process. Make sure that the family knows what to do at the time of death and understands their care options. When the client is hospitalized, stay with the client in the absence of their family members.

The nurse is instructing a community group regarding risk factors for coronary artery disease. Which risk factor cannot be modified. A. Heredity B. Hypertension C. Cigarette smoking D. Diabetes mellitus

A. Heredity Rationale: Heredity refers to genetic makeup and cannot be changed

Which topic will the nurse include when teaching a group of clients about risk factors for heart disease? Select all that apply. One, some, or all responses may be correct. A. Obseity B. Hypertension C. Diabetes insipidus D. Asian-American Ancestry E. Increased high-density lipoprotein (HDL)

A. Obesity B. Hypertension Rationale: Obesity and hypertension increase the risk for Coronary artery disease.

The nurse assess bilateral +4 peripheral edema while assessing a client with heart failure and peripheral vascular disease. Which is the pathophysiological reason for the excessive edema? A. Shift of fluid into the interstitial spaces B. Weakening of the cell wall C. Increased intravascular compliance D. Increaased intracellular fluid volume

A. Shift of fluid into the interstitial space Rationale: Edema is defined as the accumulation of fluid in the interstitial spaces. When the heart is unable to maintain adequate blood flow throughout the circulatory system, the excess fluid pressure within the blood vessels can cause shifts into the interstitial spaces.

Which priority intervention would the nurse expect to initiate for a postoperative care client with hypotension? A. Start oxygen (O2) therapy. B. Inspect the surgical incision. C. Administer intravenous (IV) fluid boluses. D. Administer vasoconstrictive agents

A. Start oxygen (O2) therapy. Rationale: Treatment of hypotension in postoperative clients should always begin with oxygen therapy to promote oxygenation of hypoperfused organs. Later on, the surgical incision should be inspected to determine if excessive bleeding is the cause of hypotension. Administration of IV fluid boluses to normalize the blood pressure and administration of vasoconstrictive agents to increase systemic vascular resistance are the ongoing treatments.

Which information would be used to determine the cause of premature atrial contractions (PAC) observed on a clients EKG? Select all that apply. One, some or all responses may be correct. A. Stress level B. Tobacco use C. Caffeine intake D. Electrolyte levels E. Home medications

A. Stress level B. Tobacco use C. Caffeine intake D. Electrolyte levels E. Home medications Rationale: There are many potential causes of PACs. Substances such as caffeine, tobacco, and alcohol; stress and fatigue; and imbalances of electrolytes can all cause PACs. Certain chronic conditions that may be treated with medications are associated with the development of PACs, such as chronic obstructive pulmonary disease, hyperthyroidism, and coronary heart diseas.

A client who had a burr hole procedure for a subdural hematoma 2 days ago now has an increased temperature of 101.3 F (38.5 C). Which conclusion would the nurse make? A. This indicates a possible infection B. The temperature was not accurate C. This is a normal assessment for a client with a subdural hematoma D. The expected reaction to cranial surgery is an elevated temperature

A. This indicates a possible infection Rationale: Any client with a temperature day 2 postoperatively could be exhibiting signs and symptoms of an infection. An increased temperature 2 days postoperatively is not normal for any client.

Which focus would the nurse associate with hospice care? a. To ease the pain from illness b. To provide curative treatment c. To assist with activities of daily living d. To adapt to the limitations due to an illness

A. to ease the pain from illness. Rationale: The focus of hospice care is palliative care to ease the pain caused by the illness.

Which client seen at a health fair will be MOST at risk for hypertension? A. 23 year old white man B. 44 year old white woman C. 50 year old Mexican-American woman D. 62 year old African American man

D. 62 year old African American man Rationale: African Americans have the highest risk for hypertension; before the age of 45, men are at higher risk than women

Which manifestation would the nurse assess for in a client with a blood pressure of 190/94 who reports minimal urinary output despite adequate fluid intake? A. Thirst B.Weight gain C. Urinary retention D. Urinary hesitancy

B. Weight gain Rationale: If urine is not being produced in the presence of an average daily intake, fluid will be retained and reflected in weight gain. One liter of fluid weighs 2.2 pounds (1kg). Excess fluid contributes to an increase in circulating blood volume, causing hypertension.

Which statement indicates that the teach has been effective after the nurse has finished teaching a 50 year old female client about symptoms of coronary artery disease in women? A. I dont need to worry about symptoms like chest pain or pressure B. I will call my health care provider about unusual fatigue C. Women have less risk of death from heart disease than men D. Bad cholesterol levels are usually higher in women than in men

B. I will call my health care provider about any unusual fatigue Rationale: Unusual fatigue is often the first symptom of coronary artery disease in women. The other statements indicate that more teaching is needed.

The nurse provides discharge teaching for a client after a laparoscopic cholecystectomy. Which statement indicates to the nurse that the client understands the instruction? A. " The bandages must be changed every day." B. " I may have mild shoulder pain for approximately 1 week." C. "The surgical sites should not be bathed for 1 week." D. " I will remain on a full liquid diet for 2 more days."

B. " I may have mild shoulder pain for approximately 1 week." Rationale: Mild shoulder pain is common up to 1 week after surgery because of diaphragmatic irritation secondary to abdominal stretching or residual carbon dioxide that was used to inflate the abdominal cavity during surgery.

Which statement indicates the client requires further teaching after the nurse teaches a client with varicose veins about prevention of venous thromboembolism (VTE)? A. "I must increase my fluid intake." B. "Elastic stockings should be work every day." C. " I will try to keep my legs lower than my heart." D." Frequent daily walks will help prevent clot formation."

B. " I will try to keep my legs lower than my heart." Rationale: To prevent VTE in clients at risk, the legs are elevated above the level of the heart as frequently as possible to promote venous return and prevent venous stasis. The other client statements indicate a good understanding of the nurse's instructions. A high fluid intake decreases blood viscosity and decreases the risk for venous stasis. Compression stockings help improve venous return, decreasing venous stasis and risk for VTE. Use of the large muscles in the legs when walking improves venous return and prevent venous stasis and VTE.

Which symptoms requires the MOST rapid action by the nurse when caring for a client with known peripheral arterial disease who calls the clinic and tells the nurse about experiencing several symptoms? A. Anxiety B. Chest Pain C. Weak pulse quality D. Cool and pale lower legs

B. Chest pain Rationale: Because atherosclerosis is a systemic disease, clients with peripheral arterial disease are likely to have coronary artery disease as well. The client's chest pain may indicate acute coronary syndrome, and the nurse should notify the health care provider or have the client activate the emergency response system immediately.

Which explanation would the nurse include when teaching a client with heart failure about the reason for low-sodium diet? A. Body weight control B. Decreased fluid retention C. Lowering blood pressure D. Prevention of hypernatremia

B. Decrease fluid retention Rationale: The purpose of a low-sodium diet for clients with heart failure is to decrease fluid retention.

How would the nurse respond to a client admitted for dehydration who has an intravenous (IV) infusion of normal saline is started at 125 mL/h and one hour later begins screaming, "I can't breathe!"? A. Discontinue the IV and notify the health care provider. B. Elevate the head of the clients bed and obtain vital signs. C. Assess the client for allergies and change the IV to an intermittent lock. D. Contact the health care provider to request a prescription for a sedative.

B. Elevate the head of the clients bed and obtain vital signs. Rationale: Verbalization indicates that the client is breathing; elevating the head of the bed facilitates breathing by decreasing pressure against the diaphragm. Vital signs reflect the current status of the client. Discontinuing the IV access line is unsafe because IV medications may need to be administered and restarting the IV will cause unnecessary discomfort and expense; more information is needed before calling the health care provider. No information is available to support requesting a prescription for a sedative; further assessment is required.

Which factor would the nurse recognize as the cause when a clients intravenous (IV) infusion infiltrates? A. Excessive height of the IV bag B. Failure to secure the catheter adequately C. Contamination during the catheter insertion D. Infusion of a chemically irritating medication

B. Failure to secure the catheter adequately Rationale: Infiltration is caused by catheter displacement, which allows fluid to leak into the tissues.

Which action will the nurse take to avoid postural hypotension when getting a postoperative client out of bed? A. Avoid giving the prescribed PRN morphine sulfate before getting the client up B. Have the client sit on the edge of the bed for a few minutes before standing up C. Withhold the prescribed calcium channel blocker until the client is already up D. Educate the client about the reasons to avoid getting up soon after surgery

B. Have the client sit on the edge of the bed for a few minutes before standing up. Rationale: Having a client sit on the edge of the bed for a few minutes will allow the neurocirculatory reflexes to adjust to the force of gravity when an upright position is assumed.

Which statement indicates that further teaching is needed after the nurse completes teaching for a client with foot pain who has peripheral arterial disease? A. I will wear my socks B. I will elevate my foot C. I will increase fluid intake D. I will drink a moderate amount of alcohol

B. I will elevate my foot Rationale: Elevating the leg decreases the flow of blood to the lower extremity because it must flow without the assistance of gravity. Wearing socks should be encouraged because it keeps the feet warm, increasing arterial dilation and perfusion. Increasing fluid intake decreases the viscosity of blood, possibly preventing thrombus formation, and should be encouraged. Clients with peripheral arterial disease can use alcohol in moderation.

Which education would the nurse teach the parent of an infant with a cardiac defect about an early sign of heart failure. A. Slowed respiration B. Increased heart rate C. Distended neck veins D. Increased urine output

B. Increased Heart rate Rationale: Increased heart rate (tachycardia) results from sympathetic stimulation in setting of heart failure; it is body's attempt to increase cardiac output and increase oxygen supply to the body's cells. The respirations will increase, not decrease, when heart failure occurs. Distended neck veins occur only in adults when heart failure has progressed to systemic congestion. Urinary output is decreased as a result of sodium and water retention.

Which priority assessment finding would the nurse expect to see when caring for a client with sinus tachycardia? Select all that apply. One, some, or all responses may be correct. A. Anxiety B. Orthopnea C. Restlessness D. Shortness of breath E. Decreased blood pressure

B. Orthopnea (Shortness of breath while laying flat) D. Shortness of breath E. Decreased blood pressure Rationale: The priority assessment findings for clients with sinus tachycardia are orthopnea, shortness of breath, and decreased blood pressure because these assessments can help in identifying the conditions of the client to start treatment. Anxiety and restlessness are observed in the client with sinus tachycardia, but they are not priorities.

Which clinical indicator would the nurse expect when an intravenous (IV) line has infiltrated? Select all that apply. One, some, or all responses may be correct. A. Heat B. Pallor C. Edema D. Decreased flow rate E. Increased blood pressure

B. Pallor C. Edema D. Decreased flow rate Rationale: The accumulation of fluid in the tissue between the surface of the skin and the blood vessels makes the skin appear pale. The accumulation of fluid in the interstitial compartment causes swelling. As the needle/ catheter is dislodged from the vein, the drip rate of the IV slows or ceases. Heat is associated with phlebitis; the accumulation of room temperature IV fluid in the tissue makes the site feel cool. Increased blood pressure is a sign of circulatory overload; when an IV infusion has infiltrated, the intravascular fluid volume does not increase.

Which cause would a nurse suspect is responsible for warmth, redness, and tenderness identified at a client's intravenous (IV) site? A. Rapid fluid delivery B. Phlebitis C. Allergic response D. Infiltration

B. Phlebitis Rationale: Phlebitis is an inflammation that can occur from prolonged IV infusion at a site, undiluted irritating medications, and other causes. It manifests as increased warmth, redness, and tenderness. Rapid infusion would not cause the site to become warm, red, and tender. A local allergic reaction is associated with hives or a pruritic rash. Infiltration causes a pale, cool insertion site because of fluid accumulation in the tissue.

Which nonpharmacological nursing intervention is effective in helping relieve postoperative pain? A. Ambulation B. Repositioning C. Pursed-lipped breathing D. Deep breathing and coughing

B. Repositioning Rationale: Acute postoperative pain always requires the use of analgesics, but nonpharmacological interventions such as repositioning the client can help relieve pain.

Which description would the nurse use to document the rhythm when a clients cardiac monitor shows a PQRST wave for each beat with a regular rhythm and a rate of 120 beats per minute? A. Atrial fibrillation B. Sinus tachycardia C. Ventricular fibrillation D. First degree atrioventricular block

B. Sinus tachycardia Rationale: The presence of a P wave before each QRS complex indicates a sinus rhythm; a heart rate greater than 100 regular beats per minute is referred to as tachycardia. Atrial fibrillation has no well-defined P waves, with an irregularly irregular pattern of ventricular beats. Ventricular fibrillation is irregular and shows no PQRST configurations. A first degree atrioventricular block pattern has a slow and regular rate with a prolonged PR interval.

When caring for a client who had abdominal intestinal surgery, which concept of postoperative management does the nurse recall? A. Rectal intubation will relieve vomiting B. Swallowing air causes gastric distention C. A preoperative enema prevents a postoperative ileus D. A clear liquid on the first postoperative day will stimulate peristalsis

B. Swallowing air causes gastric distention Rationale: When anxious, in pain, or performing deep-breathing exercises, it is common for air to be swallowed, which can cause gastric distention/

During an assessment, the client complains of tenderness when the nurse palpates the calf muscle. Which technique would be the nurses next assessment? A. To assess for any reduced hair growth B. To assess for swelling, warmth, and muscle firmness C. To assess for any history of ulcer formation around the calf muscle D. To assess for venous distension in the posterolateral part of ankle

B. To assess for swelling, warmth, and muscle firmness Rationale: Tenderness at the site of calf muscle may indicate PHLEBITIS. Other symptoms of phlebitis include swelling, warmth, and muscle firmness at the site. Reduced hair growth or a history of recurring ulcers may indicate circulatory insufficiency. Venous distension in the anterior of medial part of the thigh indicates varicosities.

Which topic would the nurse include in teaching for a client with a new diagnosis of hypertension? Select all that apply. One, some, or all responses may be correct. A. Reason for daily low-dose aspirin use B. Use of a home blood pressure monitor C. Adverse effects of tobacco on blood pressure D. Avoidance of any alcohol consumption E. Benefits of moderate daily exercise

B. Use of a home blood pressure monitor C. Adverse effects of tobacco on blood pressure F. Benefits of moderate daily exercise Rationale: Lifestyle management of blood pressure includes monitoring blood pressure at home frequently using a home blood pressure monitor, avoiding tobacco products, and a physically active lifestyle that includes moderate daily exercise. Daily aspirin is not recommended for clients with known coronary artery disease or additional risk factors for cardiovascular disease. Although excessive alcohol use should be avoided, moderated alcohol consumption (2 alcoholic drinks/day for men and 1 alcoholic drink/day for women and lighter-weight ,men) is acceptable for clients with hypertension.

The nurse reviews the medical record of a client who is eligible to receive hospice care. Which are the criteria for a client to receive this type of care? Select all that apply. One, some, or all responses may be correct. A. When the death of the client is imminent B. When the expected death of the client is within 6 months C. When the client seeks no aggressive disease management D. When a family member has signed an informed consent form E. When the client has been issued a "do not resuscitate" order

B. When the expected death of the client is within 6 months C. When the client seeks no aggressive disease management E. When the client has been issued a "do not resuscitate" order Rationale: Clients who do not seek aggressive disease management and are expected to die in a span of 6 months are eligible for HOSPICE CARE. The client may require hospice care when he or she has signed a "do not resuscitate" order.

When a previously healthy 24- year old client tells the nurse "I sometimes feel my heart racing or skipping beats", which question would the nurse ask? A. "Do you eat foods that are high in salt or fat?" B. " Do you have any family history of heart attacks?" C. " How much caffeine do you consume each day?" D. "How many glasses of water do you drink per day?"

C. "How much caffeine do you consume each day?" Rationale: Caffeine is a commonly used stimulant that causes the heart to become irritable; it can result in tachycardia and premature atrial contractions. In a young and healthy, individual, it is the most likely cause of palpitations or skipped beats.

Which clinical condition is the result of changes in the integrity of arterial walls and small blood vessels? A. Contusion B. Thrombosis C. Atherosclerosis D. Tourniquet effect

C. Atherosclerosis Rationale: In atherosclerosis, there may be changes in the integrity of the walls of the arteries and smaller blood vessels. Direct manipulation of vessels or localized edema that impairs blood flow will lead to a contusion. Blood clotting that causes mechanical obstruction to blood flow indicates thrombosis. The tourniquet effect may be caused by the application of constricting devices, which may lead to impaired blood flow to areas below the site of constriction.

Which assessment is the priority when a client with heart failure reports a 9-pound (4-kilogram) weight gain in the past 2 weeks? A. Palpate the abdomen B. Check for ankle edema C. Auscultate breath sounds D. Ask about dietary salt intake

C. Auscultate breath sounds Rationale: The clients history of heart failure and recent weight gain suggest fluid retention. The nurse would assess lung sounds first because hypoxemia may result from severe pulmonary congestion and rapid administration of treatment such as oxygen and diuretics may be needed.

A client decides to have hospice care rather than an extensive surgical procedure. What ethical principle does the client's behavior illustrate? A. Justice B. Veracity C. Autonomy D. Beneficence

C. Autonomy Rationale: The client is exhibiting the freedom to make a personal decision, and this reflects the concept of autonomy.

Which response would the nurse give when a client with syncope from a vagal response ask why it is important to avoid bearing down during a bowel movement? A. Straining can decrease blood flow to your brain because it is filling hemorrhoids B. Trouble moving your bowels is stressing your heart and may lead to a heart attack C. Bearing down stimulates a nerve response that decreases your heart rate and blood pressure D. Difficulty with a bowel movement means you are dehydrated, which causes low blood pressure

C. Bearing down stimulates a nerve response that decreases your heart rate and blood pressure Rationale: Bearing down stimulates a vagal nerve response that results in a decrease in heart rate and blood pressure leading to syncope (loss of consciousness).

Client Breathing pattern Beats per minute 1 Regular and abnormally slow. 11 2 Regular but abnormally rapid 25 3 Irregular, alternating apnea and hyperventilation 12 4 Abnormally shallow for two breaths followed by apnea. 30 A. Client 1 B. Client 2 C. Client 3 D. Client 4

C. Client 3 Rationale: In Cheyne-stokes respiration, a clients breathing pattern is characterized by progressively deeper and faster breathing, that is hyperventilation followed by apnea. Client 3 exhibits this type of respiration. Client 1's breathing pattern indicates bradypnea, whereas client 2 exhibits tachypnea. Client 4 is exhibiting Biot respirations

The nurse is caring for a client who has developed dysphagia and is unable to swallow. The client is receiving around the clock opioid pain medications for cancer pain, and hospice has recently begun to care for the client. Which is the BEST nursing intervention in preparing for the client's discharge? A. Contact the clients health care provider to ask to substitute a liquid form of medications for the pill form B. Teach the client and family members to crush the pills and administer them with applesauce C. Contact the clients health care provider to discuss use of transdermal medications for pain contorl. D. Teach the client and family members about addiction that may occur as a result of regular opioid use.

C. Contact the clients health care provider to discuss use of transdermal medications for pain control

Which action would the nurse take when observing that a post surgical client has a urine output of 800 mL total in the first 24 hours after surgery? A. Notify the provider B. Increase oral fluid intake C. Document the normal finding D. Begin an intravenous infusion of normal saline

C. Document the normal finding Rational: Urine output of 800 mL is normal postoperative output since it is more than 30mL/hour. The nurse would document the normal finding and continue to monitor urine output in the postoperative period. It is necessary to increase oral or intravenous fluid intake or notify the provider unless urine output does not increase.

Which action will the nurse take first when a client's gravity flow intravenous (IV) rate is too slow? A. Reposition the client's arm. B. Adjust the flow clamp to deliver the correct rate. C. Evaluate the appearance of the catheter insertion site. D. Determine the amount of fluid that should have been absorbed.

C. Evaluate the appearance of the catheter insertion site. Rationale: If infiltration or phlebitis is responsible for the decreased flow rate, the IV catheter must be removed and restarted in a new site. Repositioning the client's arm will do nothing if the catheter is not in a vein; this is not the priority. If the catheter is not in a vein, adjusting the flow clamp will be unsafe because fluid will enter interstitial tissues. Although determining the amount of fluid that should have been absorbed eventually will be done, this intervention will not resolve the cause of the problem; this is not the priority.

The nurse is preparing to insert an intravenous (IV) catheter in a thin, emaciated client who is scheduled to begin intravenous fluid therapy. Which interventions would the nurse follow to provide high-quality care? Select all that apply. One, some, or all responses may be correct. A. Insert an 18-gauge IV catheter B. Change the IV line every 7 days C. Flush the IV line with normal saline D. Insert the IV catheter in the client's femur E. Stop the insertion procedure when there is a break in technique

C. Flush the IV line with normal saline E. Stop the insertion procedure when there is a break in technique Rationale: The nurse would flush the IV line with normal saline to maintain patency. The nurse would stop the insertion procedure when there is a break in technique. This intervention helps prevent catheter-related bloodstream infections and provides high quality care to the client.

Which assessment after administration of diltiazem to a client with supraventricular tachycardia (SVT) and a heart rate of 170 beats/minute indicates that the medication was effective? A. Increased urine output B. Blood pressure of 90/60 mm Hg C. Heart rate of 98 beats/minute D. No longer complaining of heart palpations

C. Heart rate of 98 beats/minutes Rationale: Diltiazem hydrocholrides purpose is to slow down the heart rate. SVT has a heart rate of 150 to 250 beats/minute. A heart of 98 beat/minute indicates that the diltiazem hydrochloride is having the desired effect.

Which information would the nurse include when teaching a client about dietary guidelines to reduce heart disease risk? A. Eat small, frequent meals. B. Decrease the amount of proteins. C. Increase complex carbohydrates. D.. Avoid monounsaturated fats.

C. Increase complex carbohydrates Rational: The fiber component of complex carbohydrates help bind and eliminate dietary cholesterol and fosters growth of intestinal mircoorganisms to break down bile salts and release the cholesterol component for excretion. It is what the client eats, not the amount of each meal that is important. Proteins need not be decreased in a heart healthy diet. Although no more than 25% to 35%e of daily calories should be from fats, monosaturated fats are considered heart healthy.

The nurse is assisting with the end-of-life care of a client. Which activity is performed when the nurse views family as context. A. Assess the resources available to the family B. Meet the client's family comfort and nutritional needs C. Meet the client's comfort, hygiene, and nutritional needs D. Determine the family's need for rest and their stage of coping

C. Meet the client's comfort, hygiene, and nutritional needs Rationale: When viewing family as context, the nurse mainly focuses on the client's comfort, hygiene, and nutritional needs. Family as context means focusing on the health and development of a client. When viewing family as a system, the nurse mainly focuses on assessing the resources available to the family. Family as a system includes both family as context and family as a client. When viewing family as a client, the client's family comfort and nutritional needs are focused on, and the nurse determines the family needs for rest and their stage of coping.

Which statements made by a terminally ill client address primary goals regarding end-of-life (EOL) nursing care? Select all that apply. One, some, or all responses may be correct. A. I want my children and my grandchildren to carry my casket. B. I've repaid all my funeral costs so there's no burden on my family C. My living will states that I want no heroic measures to prolong life D. Pain is a concern, so I've discussed that thoroughly with my doctor E. I've made arrangements to spend my final days in my own home

C. My living will states that I want no heroic measures to prolong life D. Pain is a concern, so I've discussed that thoroughly with my doctor E. I've made arrangements to spend my final days in my own home Rationale: The goals for EOL care are to (1) provide comfort and supportive care during the dying process. (2) Improve the quality of the clients remaining life, (3) help ensure a dignified death, and (4) provide emotional support to the family. A living will outlines the type of care that an individual desires when dying. Pain control is often a major area of concern. The client clearly states a desire to die at home. Actual funeral and financial arrangements are not considered topics related to EOL nursing care.

Which response by the nurse is best when a client with intermittent claudication has been instructed to stop smoking and says "I don't understand why this is necessary?" A. Tobacco smoking causes many health problems B. Nicotine use is a risk factor for heart and lung disease C. Nicotine makes blood vessels smaller and will worsen pain D. Smoking is prohibited for both clients and staff members in the hospital.

C. Nicotine makes blood vessels smaller and will worsen pain Rationale: The response that nicotine decreases blood vessel size and will worsen the client's pain is truthful and addresses the specifics of the reason this client should avoid smoking.

Which clinical manifestation would the nurse expect to identify when performing an admission history and physical for a client with chronic peripheral arterial disease? A. Edema of the feet and ankles B. Reddened and painful areas on the calves C. Pain when exercising and thickening of the toenails D. Ulcers around the ankles and reports of a dull ache in the legs

C. Pain when exercising and thickening of the toenails Rationale: Inadequate oxygenation of tissues of the affected limb causes intermittent claudication ( indicated by pain when exercising) and thickened toenails. Edema of the feet and ankles occurs with venous, not arterial, insufficiency in which the veins are unable to return blood adequately from the affected legs to the heart; also, dependent edema may be associated with decreased cardio output related to heart failure. Reddened and painful areas on the calves are adaptations related to thrombophelbitis, a venous rather than arterial problem. Ulcers around the ankles and reports of dull ache in the legs occur with venous, not arterial, insufficiency in which the veins are unable to return blood adequately from the affected legs to the heart; also these changes may also be associated with decreased cardiac output related to heart failure

Which client would benefit from the administration of prophylactic antibiotics? Select all that apply. One, some , or all responses may be correct. A. Chickenpox infection B. Fever of unknown origin C. Preoperative hip replacement D. Congenital bicuspid aortic valve E. Current chemotherapy treatment

C. Preoperative hip replacement D. Congenital bicuspid aortic valve E. Current chemotherapy treatment Rationale: Prophylactic antibiotics are indicated in the preoperative hip replacement client because this decreases the occurrence of infection postoperatively. Prophylactic antibiotics are indicated for the client with congenital bicuspid aortic valve disease because this decreases the risk of endocarditis with an invasive procedure. Prophylactic antibioitics are indicated for the current chemotherapy treatment client because this decreases the risk of infection due to neutropenia.

Which interventions would the nurse perform while caring for an actively dying client? Select all that apply. A. Admit the client in hospice B. Perform aggressive laboratory test C. Provide client and family reassurance D. Keep the client undisturbed for long periods of time E. Offer symptom management to the client.

C. Provide client and family reassurance E. Offer symptom management to the client. Rationale: The nurse would provide comfort care in an actively dying client. In comfort care, the nurse would reassure the client and family to reduce their emotional anxiety. The nurse would perform symptom management to improve the clients quality of life. The client should not be admitted into hospice care if the client is actively dying. A client is admitted to hospice care if death is expected within 6 months. The client may not require aggressive laboratory tests when death is imminent. The client should be repositioned as needed for comfort.

Which action would the nurse take first when a clients blood pressure decreases to 90/70 mm Hg and their heart rate decreases to 50 beats per minute during nasotracheal suctioning? A. Administer intravenous fluids to the client B. Report to the primary health care provider C. Stop suctioning procedure immediately D. Administer 100% oxygen manually to the client

C. Stop suctioning procedure immediately. Rationale: Nasotracheal suctioning can result in vagal stimulation and bronchospasm. Vagal stimulation can result in hypotension, bradycardia, heart block, ventricular tachycardia, or other dysrhythmias and require immediate intervention. A blood pressure of 90/70 mm Hg and heart of 50 breaths per minute indicate hypotension and bradycardia so the nurse would immediately stop the suctioning procedure.

Which collaborative intervention will the nurse anticipate to treat the dysrhythmia when a client has supraventricular tachycardia that has persisted despite treatment with vagal maneuvers and medications? A. Defibrillation B. Pacemaker placement C. Synchronized cardioversion D. Cardiac resynchronization therapy

C. Synchronized cardioversion Rationale: Synchronized cardioversion is the application of a shock that is times to land on the R wave to depolarize the myocardium and allow the normal cardiac pacemaker in the sinoartrial node to take over normal cardiac stimulation.

Which action would be used to decrease risk of postoperative respiratory complications in an older client with decreased vital capacity? A. Give prescribed intravenous antibiotic B. Administer oxygen per nonrebreather mask. C. Teach the client coughing and deep breathing exercises D. Keep the client on the mechanical ventilation for several days

C. Teach the client coughing and deep-breathing exercises. Rationale: OLDER ADULTS have a decrease in vital capacity and are at an increased risk for complications from both anesthesia and surgery. Teaching coughing and deep-breathing exercises may help in preventing common postoperative complications such as atelectasis and pneumonia.

Which information regarding palliative care as opposed to hospice care would the nurse provide during a home visit to a client with heart failure who asks about this option? A. To receive palliative care, a provider must certify that you have 6 months less to live. B. The goal of palliative care is to humanize the end-of-life experience, allowing you to die with dignity. C. The focus of palliative care is to enhance you and your family's quality of life despite your heart failure D. By making the choice to begin palliative care, you must no longer pursue life-extending or curative medical treatment

C. The focus of palliative care is to enhance you and your family's quality of life despite your heart failure. Rationale: Palliative care is specialized medical care for clients and families that focuses on quality of life.

How will the nurse respond to a client who expresses concern about air in the piggyback tubing after the nurse piggybacks an intravenous antibiotic solution into a primary IV line using gravity flow tubing? A. Air in the tubing, even if it got into the vein, will not be fatal unless it is a large amount. B. The antibiotic and now the air are flowing into the primary IV bag, not into the venous system directly C. The solution from the large IV bag begins to flow when the solution from the smaller bag ceases to flow. D. The clamps on the tubing leading from both bags will be closed for a few minutes to prevent air from entering the vein.

C. The solution from the large IV bag begins to flow when the solution from the smaller bag ceases to flow. Rationale: The secondary bag, containing the medication, is hung higher than the level of fluid in the primary IV so that gravity forces it to empty first. The primary IV will begin to flow as soon as the secondary bag is finished. Air in the secondary line will not enter teh vein.

When taking the health history for a client admitted with heart failure, which assessment finding will the nurse expect the client to report? A. Losing weight over the past week B. Tingling in the upper extremities C. Using several pillows at night to sleep D. Wheezing when exposed to dust or pollen

C. Using several pillows at night to sleep Rationale: Heart failure causes pulmonary congestion, leading to orthopnea and the need to elevate the head and chest with pillows when lying down. Clients with worsening heart failure will report recent weight gain because of fluid retention. Tingling in the arms is not a clinical manifestation of heart failure or poor cardiac output. Wheezing in response to dust or pollen is typical of asthma, not heart failure.

Based upon the provided data, which client would the nurse suspect of having hypertension? Client Cardiac Output Peripheral resistance Hematocrit A Decreased Normal Decreased B Increased Increased Increased C Decreased Normal Normal D Normal Increased Normal Client A Client B Client C Client d

Client B Rationale: The blood pressure (BP) in a client rises when the clients cardiac output, peripheral resistance, and hematocrit are increased. Because all of these parameters are increased in Client B, then that client is suspected of having hypertension. The BP falls when cardiac output is decreased. So, clients A and C may be at risk of hypotension. Client D's cardiac output may not be at risk of hypertension.

The nurse is assessing four clients. Which client is at the highest medical risk of coronary heart disease and hypertension? Client. Height Weight (kg) A. 180. 70 B 185 95 C 152 56 D 145 67 Client A Client B Client C Client D

Client D Rationale: A body mass index (BMI) higher than 30 is considered obesity and puts the client at a higher medical risk of coronary heart disease, some cancers, and hypertension. Client D (who is 145 cm tall and weighs 67 kg) has a BMI of 31.9, which indicates obesity. This can lead to coronary artery disease and hypertension. Client A has a BMI of 21.6, which indicates a normal weight. Client B has a BMI of 27.77, which indicates that the client is overweight but not obese. Client C, with a BMI of 24.24, is considered as having a normal weight.

Which nursing intervention would be the safety priority when administering medication through a clients implanted port? A. Use barrel syringes to flush any central line. B. Use 20 mL of sterile saline to flush the port before medication administration and 2.5 mL of heparin 100 units/mL after. C. Use 10 mL of sterile saline to flush the port before and after medication administration. D. Assess patency and adequate noncoring needle placement before medication administration .

D. Assess patency and adequate noncoring needle placement before medication administration. Rationale: When administering medication through implanted ports, the nurse would withhold the medication until patency and adequate noncoring needle placement of the port are established. In case of a peripherally inserted central catheter (PICC), the nurse would use barrel syringes to flush any central line.

Nursing actions after a client has had general anesthesia are directed at preventing which postoperative respiratory complication? A. Pleural effusion B. Empyema C. Pneumothorax D. Atelectasis

D. Atelectasis Rationale: Atelectasis occurs after general anesthesia because of decreased respiratory depth and resulting collapse of alveoli. Pleural effusion is not a typical postoperative problem. Empyema would not be expected after surgery. Pneumothorax is not a common postoperative diagnosis.

Which client would be at an increased risk for coronary artery disease (CAD)? A. Client with total cholesterol 175 mg/dL and LDL cholesterol 80 mg/dL B. Client with total cholesterol 190 mg/dL and HDL cholesterol 40 mg/dL C. Client with total cholesterol 200 mg/dL and HDL cholesterol 45 mg/dL D. Client with total cholesterol 250 mg/dL and LDL cholesterol 120 mg/dL

D. Client with total cholesterol 250 mg/dL and LDL cholesterol 120 mg/dL Rationale: Major risk factors for CAD include elevated serum lipid levels. A total cholesterol greater than 200 mg/dL, LDL cholesterol greater than 130 mg/dL , and HDL cholesterol less than 40 mg/dL increase a clients risk for CAD. Therefore, the client with a total cholesterol of 250 mg/dL is at an increased risk for CAD.

The nurse is caring for several postoperative clients who have had abdominal surgery. Which independent nursing intervention can help prevent the development of thrombophelbitis? A. Encouraging adequate fluids B. Massaging the client's legs gently C. Applying sequential compression devices D. Helping the client perform in-bed exercises

D. Helping the client perform in-bed exercises Rationale: Inactivity causes venous stasis, hypercoagulability, and external pressure against the veins, all of which lead to thrombus formation; early ambulation or exercise of the lower extremities reduces the occurrence of this complication. Although encouraging adequate fluids may help, it is not an independent nursing intervention.

Which statement by a client is consistent with a diagnosis of heart failure? A. I see spots before my eyes B. I am tired at the end of the day C. I feel bloated when I eat a large meal D. I have trouble breathing when I climb a flight of stairs

D. I have trouble breathing when I climb a flight of stairs Rationale: Dyspnea on exertion occurs with heart failure because of the hearts inability to meet the oxygen needs of the body. Seeing spots before one's eyes is not a symptom associated with heart failure. Fatigue at the end of the day is common for many people, whereas fatigue that occurs all day is a symptom of heart failure. Feeling bloated after eating a large meal is not associated with heart failure, although feeling bloated constantly might be associated with fluid retention caused by heart failure

Which explanation would the nurse give regarding purpose of early ambulation to a client who had surgery the previous day? A. Promote healing of the incision B. Decrease the incidence of urinary tract infections C. Allow nursing staff to change the bedding D. Keep blood from pooling in the legs to prevent clots

D. Keep blood from pooling in the legs to prevent clots Rationale: The muscular action during ambulation facilitates the return of venous blood to the heart; this reduces venous stasis and minimizes the risk of postoperative thrombophelbitis.

Which rhythm is the client experiencing when the cardiac monitor shows sudden burst of a regular heart rhythm with a rate of 220 beats/minute, normal QRS duration, and P waves that are diffuclt to see? A. Sinus Tachycardia B. Atrial fibrillation C. Ventricular tachycardia (VT) D. Paroxysmal supraventricular tachycardia (PSVT)

D. Paroxysmal supraventricular tachycardia (PSVT) Rationale: PSVT occurs above the ventricles, and has an abrupt onset and cessation. Sinus tachycardia results when the sinoatrial node fires faster than 100 beats/minute. Onset is gradual rather than abrupt. PR interval is 0.12 to 0.20 seconds. P and QRS waves are consistent in shape. Atrial fibrillation is irregular and does not start and stop suddenly. VT occurs at a rate greater than 100 beats/minute, but the rate is usually around 150 beats/minute and may be up to 250 beats/minute. Depolarization of the ventricles is abnormal and produces a widened QRS complex.

Which information would the nurse include when teaching a client how to do postoperative breathing exercises? Select all that apply. One, some, or all responses may be correct. A. Take short, frequent breaths B. Exhale with the mouth open wide C. Perform the exercise twice a day D. Place a hand on the abdomen while feeling it rise E. Hold the breath for several seconds at the height of inspiration

D. Place a hand on the abdomen while feeling it rise. E. Hold the breath for several seconds at the height of inspiration. Rationale: ABDOMINAL BREATHING improves lung expansion because it makes the contraction of the diaphragm more efficient. Placing the hand on the abdomen to watch it rise provides feedback, ensuring that abdominal rather than intercostal breathing is accomplished. Holding the breath for several seconds at the height of inspiration allows several additional seconds for oxygen and carbon dioxide to exchange in the alveoli. Breathing exercises should be performed at least every 2 hours during the day.

Which part of the electrocardiogram (ECG) represents depolarization of the ventricles? A. P wave B. T wave C. PR interval D. QRS interval

D. QRS interval Rationale: Atrial and ventricular depolarization and repolarization are represented on the ECG as a series of waves: the P wave followed the QRS complex and the T wave. The QRS represents ventricular depolarization. The P wave occurs with depolarization of the atria. The T wave represents ventricular repolarization. The PR interval represents depolarization of the atria and of the atrioventricular node.

Which consideration is the nurses concern when responding to the request of a hospice client who has severe pain and asks for another dose of oxycodone? A. Prevent addiction B. Determine why the medication is needed C. Provide alternative comfort measures D. Reduce the clients pain

D. Reduce the clients pain Rationale: Hospice clients with severe pain need increasing levels of analgesics and should be maintained at a pain free level, even if addiction occurs.

After consistently obtaining a blood pressure of 140/76 mm Hg for a client, which stage of hypertension will the nurse document? A. Normal B. Elevated C. Stage 1 D. Stage 2

D. Stage 2 Rationale: Systolic blood pressure greater than or equal to 140 mm Hg is classified as stage 2 hypertension. Although the diastolic pressure of 76 mm Hg is normal, elevation of either the systolic or diastolic pressure results in a hypertension diagnosis. Normal blood pressure would be less than 120/80 mm Hg. Systolic pressure between 120 to 129 mm Hg and a diastolic pressure less than 80 mm Hg would be classified as elevated blood pressure. Stage 1 hypertension would be documented for systolic pressures between 130 to 139 mm Hg or diastolic between 80 to 89 mm Hg. Hypertensive crisis would be diagnosed for systolic pressure over 180 mm Hg and/ or diastolic pressures over 120 mm Hg.

A client with paroxysmal supraventricular tachycardia reports a mild "fluttering feeling" in their chest and has a blood pressure of 110/55 mm Hg. Which potential treatment by the health care provider would the nurse question? A. Intravenous adenosine B. Intravenous metoprolol C. Carotid sinus massage D. Synchronized cardioversion

D. Synchronized cardioversion Rationale: Because the client is hemodynamically stable and experiencing only mild symptoms associated with the tachycardia, synchronized cardioversion is not indicated at this time. Rapid injection of adenosine would slow the rate or possibly convert the rhythm to sinus rhythm. Intravenous injection of betal blockers such as metoprolol may slow the rate. Carotid sinus massage or having the client perform a Valsalva maneuver may used to slow the rate or convert the rhythm.

When the clinic nurse is teaching a group of clients with heart failure (HF) about dietary interventions to prevent fluid overload, which topic will be included? A. Fluid intake restrictions B. Low- calorie diet for weight loss C. Avoidance of high-fat, high-cholesterol foods D. Use of fresh or frozen vegetables instead of canned ones

D. Use of fresh or frozen vegetables instead of canned ones Rational: The key principle to teach HF clients is the importance of DECREASING SODIUM IN THEIR DIET and which foods contain sodium. If sodium is decreased, water retention will decrease also. Fresh or frozen vegetables have less sodium than canned ones. Most heart failure clients do not need to restrict fluid intake. A low-calorie diet is needed for overweight clients but does not improve volume status. Avoidance of high-fat and high-cholesterol foods is important to prevent coronary artery disease but will not prevent fluid overload.

Which PRIORITY nursing intervention would the nurse include in the plan of care for an older adult who sustained a right hip fracture? A. Oxygen therapy B. Cardiac monitoring C. Nutrition supplements D. Venous thromboembolism (VTE) prevention

D. Venous thromboembolism (VTE) prevention Rationale: After hip surgery, DEVELOPMENT OF A VTE, commonly occurs. Nursing must implement preventive intervention, this a component of core measures. Oxygen therapy, cardiac monitoring, and nutritional supplements may be necessary in some clients with hip fractures, but not in all.

Which response would the nurse give to a client whose total cholesterol level is found to be 210 mg/dL (5.5 mmol/L) at a screening session at a health fair and ask the nurse what to do in light of this result? A. Your cholesterol is high, and you may need medication B. This is within the acceptable range. and no action is required C. Your level is low; you should eat more food that contain cholesterol D. Your cholesterol is elevated slightly. A diet low in saturated fats should be followed

D. Your cholesterol is elevated slightly. A diet low in saturated fats should be followed. Rationale: A level more than 200 mg/dL (5 mmol/L) is considered elevated. The clients total cholesterol is mildly elevated and the initial intervention would be making changes in the diet and activity level. The clients cholesterol is not elevated enough to require medication as an initial intervention. The clients cholesterol is elevated and action is advised to lower total cholesterol level and cardiac risk. A low level is less than 140 mg/dL (2.0 mmol/L). Medical attention should be sought because low cholesterol levels are associated with hyperthyroidism, malabsorption syndrome, malnutrition, and myeloproliferative disease

Which nursing intervention would be the priority for a client in hospice care with symptoms of dyspnea? A. Administer benzodiazepines B. Apply wet cloths on the clients face C. Encourage imagery and deep breathing D. Provide prescribed oxygen by nasal cannula

d. Provide prescribed oxygen by nasal cannula Rationale: A client in the end stage of life usually experiences symptoms of dyspnea. Providing prescribed oxygen by nasal cannula is the priority nursing care, because it relieves symptoms of dyspnea and provides comfort.