Complex test 1

D

Which intervention provides safety during cardioversion? Setting the defibrillator at 220 joules Setting the defibrillator to the synchronized mode Applying oxygen Obtaining informed consent

<200

Normal cholesterol

>45

Normal hdl

1.8-2.6

Normal magnesium

Significant bradycardia with pauses

Adenosine could cause

Aortic stenosis

Can lead to right sided heart failure. You will also see a fib with this

A

For a client with an 8-cm abdominal aortic aneurysm, which assessment data must be addressed immediately? Blood pressure (BP) 192/102 mm Hg Report of constipation Anxiety Heart rate 52 beats/min

Permanent pacemaker

Heart blocks need

C

Into which environment of care would the nurse anticipate sending a client who is experiencing complications from COVID-19? Medical home Community health care Inpatient care Rehabilitation care

Creatinine

Monitor which lab when administering drugs to older adults

Skin tears

Older adults on chronic steroid therapy can get what easily

Falls

Older women are at higher risk for?

Thoracic Rupture

Sudden excruciating back or chest pain

SA node

The hearts primary pacemaker

Potential for fractures

The priority problem for patients with osteoporosis or osteopenia is

Presbycusis

age related hearing loss

Sinus bradycardia

Atropine is given to patients who are in

Sinus bradycardia

Excessive vagal response can cause

C diff

Long term antibiotic use can cause

Rupture

Maintain BP at normal levels to decrease risk of

headache

Nitroglycerin and morphine can cause

0.12-0.20

Normal PR interval

B

The nurse is caring for a client who is being treated for hypertensive crisis. Which prescribed medication would the nurse question? Enalapril Dopamine Labetalol Sodium nitroprusside

D

The nurse is caring for a patient with atrial fibrillation (AF). In addition to an antidysrhythmic, what medication does the nurse anticipate administering? Magnesium sulfate Atropine Dobutamine Heparin

B

The nurse is caring for an older adult client who has been under the care of a psychiatrist for 10 years. What is the most commonly occurring mental health disorder in the older adult population? Dementia Depression Bipolar disorder Delirium

A

The nurse is teaching a client with peripheral arterial disease. What teaching will the nurse include? "Walk to the point of leg pain, then rest, resuming when pain stops." "Inspect your legs daily for brownish discoloration around the ankles." "Apply a heating pad to the legs if they feel cold." "Elevate your legs above heart level to prevent swelling."

Afib

Warfarin and beta blockers are used to treat

100+

What age range is elite old

75-84

What age range is middle old

B

Which assessment by a new nurse requires the charge nurse to intervene? Assessing pedal pulses by Doppler Simultaneously palpating bilateral carotids Measuring blood pressure in both arms Measuring capillary refill in the fingertips

C

Which nursing element reflects systems thinking at the global level of practice? Facility health policy Quality improvement initiative Determinants of health Interprofessional practice

Primary depression

lack of neurotransmitters norepinephrine and serotonin in the brain

Sinus arrythmia

Digoxin and morphine could cause

Idioventricular Rhythm

Do not give lidocaine with

Metformin

Hold which medication if patient is getting a CT

2-3 weeks

How long does it take SSRIs to work

Temporary pacemaker

If atropine does not fix the bradycardia what's next

Chew three baby aspirins

If patient does not have nitro at home what can they do

0.04-0.10

Normal QRS duration

About 10 years

Pacemakers have a life span of

C, D, E

The nurse administers amiodarone to a client with ventricular tachycardia. Which monitoring by the nurse is necessary with this drug? (Select all that apply.) Select all that apply. Urine output Respiratory rate Heart rate Heart rhythm QT interval

A, B, C

The nurse caring for a client with heart failure who is taking digoxin. What assessment data requires that nurse notify the health care provider? (Select all that apply.) Select all that apply. Anorexia Blurred vision Fatigue Heart rate 110/beats/min Serum digoxin level of 1.5 ng/mL (1.92 nmol/L)

B

The nurse is caring for a client with dark-colored toe ulcers and blood pressure (BP) of 190/100 mm Hg. Which nursing action does the nurse delegate to the LPN/LVN? Obtain a request from the primary health care provider for a dietary consult. Administer a clonidine patch for hypertension. Develop a plan for discharge, and assess home care needs. Assess leg ulcers for signs of infection.

B

The nurse is teaching a client about the use of crutches following a foot fracture. When adjusting the crutches to ensure a correct fit, what action will the nurse take? Ensure that each crutch fits firmly into the client's armpit. Be sure that the top of each crutch is well padded. Use the crutch on the affected side only. Check to see how many steps the client can take with the crutches.

Osteomyelitis

Very painful condition that could cause sepsis

65-74

What age range is young old

Vagal maneuver

What can be tried to treat tachydysrhythmias

Hyperkalemia

What could cause a t wave to be elevated

Sleep disorders Problems with eating or feeding Incontinence Confusion Evidence of falls Skin breakdown

What does spices stand for

C

What does the nurse recognize is the fastest growing technology being used for informatics? Drug information libraries Medication bar code administration Telehealth and telenursing Electronic health record

ANS: A All attributes are important in nursing, however; the nurse's willingness to think critically is predicted by caring behaviors, self-reflection, and insight.

What factor best predicts a nurse's willingness to employ critical thinking? a. Caring b. Knowledge c. Presence d. Skills

Systemic hypertension.

What is the cause of heart failure in most cases

1000-1500

What should a geriatric patients calcium intake be

A, B, C

Which assessment data cause the nurse to suspect that a client who had a myocardial infarction (MI) is developing cardiogenic shock? (Select all that apply.) Select all that apply. Cool, diaphoretic skin Crackles in the lung fields Anxiety and restlessness Respiratory rate of 12 breaths/min Temperature of 100.4° F (38.0° C) Bradycardia

E, F

Which nursing action reflects Assessing, per the AAPIE model of Assessing, Analyzing, Planning, Implementing, and Evaluating? (Select all that apply.) Select all that apply. Administers IV furosemide 40 mg as prescribed. Sets a goal for client to resume normal activities within 4 weeks following surgery. Compares temperature at 0600 with temperature taken at 1200. Contacts health care provider after obtaining blood pressure of 200/100. Collects information about how client sustained an injury. Notes pressure injury of 2 inches by 1 inch on sacrum.

B

Which nursing action reflects systems thinking? Giving report to the next shift including client status Developing a quality improvement initiative for respiratory assessment Documenting the client's lung sounds each shift Reviewing best practice for respiratory assessment

maze procedure

surgical procedure to treat atrial fibrillation in which a new conduction pathway is created that eliminates the rapid firing of ectopic pacemaker sites in the atria

transcutaneous pacing

•For emergency pacing needs •Noninvasive •Bridge until transvenous pacer can be inserted •Use lowest current that will "capture" •Patient may need analgesia/sedation

D

A middle-age female client has osteoporosis and is at risk for developing vertebral fractures. She asks the nurse about exercises to help minimize this risk. Which exercise will the nurse recommend? Cycling Running Walking Yoga

ANS: D Abdominal aneurysms should never be palpated as this increases the risk of rupture. The nurse mentoring the new nurse would intervene when the new nurse attempts to do this. The other actions are appropriate.

A new nurse is caring for a client with an abdominal aneurysm. What action by the new nurse requires the nurse's mentor 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.

B

A new nurse is caring for four clients. Which client is at risk for secondary hypertension? The client who is physically inactive. The client with kidney disease. The client with depression. The client who eats a high-sodium diet.

ANS: B All actions are appropriate for the professional nurse. However, ensuring client safety is the priority. Health care errors have been widely reported for 25 years, many of which result in client injury, death, and increased health care costs. There are several national and international organizations that have either recommended or mandated safety initiatives. Every nurse has the responsibility to guard the client's safety. The other actions are important for quality nursing, but they are not as vital as providing safety. Not making medication errors does provide safety, but is too narrow in scope to be the best answer.

A new nurse is working with a preceptor on a medical-surgical unit. The preceptor advises the new nurse that which is the priority when working as a professional nurse? a. Attending to holistic client needs b. Ensuring client safety c. Not making medication errors d. Providing client-focused care

ANS: B The preceptor would try to reassure the nurse that implementing QI measures is not out of line for a newly licensed nurse. Simply stating that all nurses are required to participate does not help the nurse understand how that is possible and is dismissive. Identifying indicators of quality is not an easy, quick process and would not be the best place to suggest a new nurse to start. Asking to be assigned to the QI committee does not give the nurse information about how to implement QI in daily practice.

A newly graduated nurse in the hospital states that because of being so new, participation in quality improvement (QI) projects is not wise. What response by the precepting nurse is best? a. "All staff nurses are required to participate in quality improvement here." b. "Even being new, you can implement activities designed to improve care." c. "It's easy to identify what indicators would be used to measure quality." d. "You should ask to be assigned to the research and quality committee."

ANS: C Clients usually respond to adenosine with a short period of asystole, bradycardia with long pauses, nausea, or vomiting. Adenosine has no impact on intraocular pressure nor does it cause increased heart rate or hypertensive crisis.

A nurse administers prescribed adenosine to a client. Which response would the nurse assess for as the expected therapeutic response? a. Decreased intraocular pressure b. Increased heart rate c. Short period of asystole d. Hypertensive crisis

ANS: A Assessment of respiratory and oxygenation status is the most important nursing intervention for the prevention of complications. Monitoring electrolytes, administering diuretics, and asking about current medications are important but do not take precedence over assessing respiratory status.

A nurse admits a client who is experiencing an exacerbation of heart failure. What action would the nurse take first? a. Assess the client's respiratory status. b. Draw blood to assess the client's serum electrolytes. c. Administer intravenous furosemide. d. Ask the client about current medications.

ANS: D These findings are suspicious for abuse. Health care providers are mandatory reporters for suspected abuse. The nurse would notify social work, case management, or whomever is designated in facility policies. That person can then assess the situation further. If the police need to be notified, that is the person who will notify them. Adult Protective Services is notified in the community setting.

A nurse admits an older adult from a home environment. The client lives with an adult son and daughter-in-law. The client has urine burns on the skin, no dentures, and several pressure injuries. What action by the nurse is most appropriate? a. Ask the family how these problems occurred. b. Call the police department and file a report. c. Notify Adult Protective Services. d. Report the findings as per agency policy.

ANS: C, D, E, F Malnutrition in the older population is multifactorial and has several potential adverse outcomes. Appropriate actions by the nurse include assessing the client's risk for skin breakdown with the Braden Scale, requesting a consultation with a dietitian, suggesting a high-protein meal supplement, and assessing the client's dentures or own teeth. There is no evidence that the client is being abused or needs a feeding tube at this time.

A nurse admits an older adult to the hospital who lives at home with family. The nurse assesses that the client is malnourished. What actions by the nurse are best? (Select all that apply.) a. Contact Adult Protective Services or hospital social work. b. Request the primary health care provider prescribes tube feedings. c. Perform and document results of a Braden Scale assessment. d. Request a dietary consultation from the health care provider. e. Suggest a high-protein oral supplement between meals. f. Assess the client's own teeth or the dentures for proper fit.

ANS: B Many members of the LGBTQ community have faced discrimination from health care providers and may be reluctant to seek health care. The nurse would never make assumptions about the needs of members of this population. Rather, respectful questions are appropriate. If approached with sensitivity, the client with any health care need is more likely to answer honestly.

A nurse asks a more seasoned colleague to explain best practices when communicating with a person from the lesbian, gay, bisexual, transgender, and questioning/queer (LGBTQ) community. What answer by the faculty is most accurate? a. Avoid embarrassing the client by asking questions. b. Don't make assumptions about his or her health needs. c. Most LGBTQ people do not want to share information. d. No differences exist in communicating with this population.

ANS: B Clinical judgment is the observable outcome of critical thinking and decision making. It can be, but most often is not, clouded by erroneous hypotheses. Recognizing, understanding, and synthesizing interactions and interdependencies in a set of components designed for a specific purpose is systems thinking. Critical thinking is not the highest level of nursing judgment.

A nurse asks the charge nurse to explain the difference between critical thinking and clinical judgment. What statement by the charge nurse is best? a. "Clinical judgment is often clouded by erroneous hypotheses." b. "Clinical judgment is the observable outcome of critical thinking." c. "Critical thinking requires synthesizing interactions within a situation." d. "Critical thinking is the highest level of nursing judgment."

ANS: B Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Left-sided heart failure symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty breathing all could be results of left-sided heart failure.

A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right-sided heart failure? a. "I sleep with four pillows at night." b. "My shoes fit really tight lately." c. "I wake up coughing every night." d. "I have trouble catching my breath."

ANS: D The vasodilating effects of nitrates frequently cause clients to have headaches during the initial period of therapy. The nurse would inform the client about this side effect and offer a mild analgesic, such as acetaminophen. The client's headache is not related to hypoxia or dehydration; therefore, applying oxygen and drinking water would not help. The client needs to take the medication as prescribed to prevent angina; the medication would not be held.

A nurse assesses a client after administering the first dose of a nitrate. The client reports a headache. What action would the nurse take? a. Initiate oxygen therapy. b. Hold the next dose. c. Instruct the client to drink water. d. Administer PRN acetaminophen.

ANS: C Clients with left-sided heart failure report weakness or fatigue while performing normal activities of daily living, as well as difficulty breathing, or "catching their breath." This occurs as fluid moves into the alveoli. Nocturia is often seen with right-sided heart failure. Thirst and blurred vision are not related to heart failure.

A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure? a. "I have been drinking more water than usual." b. "I am awakened by the need to urinate at night." c. "I must stop halfway up the stairs to catch my breath." d. "I have experienced blurred vision on several occasions."

ANS: B Clients with a history of heart failure generally have negative findings, such as shortness of breath and fatigue. The nurse needs to determine whether the client's activity is the same or worse, or whether the client identifies a decrease in activity level. Trouble breathing, chest pain, breathlessness at night, and peripheral edema are symptoms of heart failure, but do not provide data that can determine the extent of the client's heart failure.

A nurse assesses a client who has a history of heart failure. Which question would the nurse ask to assess the extent of the client's heart failure? a. "Do you have trouble breathing or chest pain?" b. "Are you still able to walk upstairs without fatigue?" c. "Do you awake with breathlessness during the night?" d. "Do you have new-onset heaviness in your legs?"

ANS: B Atrial fibrillation is a clinical manifestation of mitral valve regurgitation and stenosis. Preventricular contractions and bradycardia are not associated with valvular problems. These are usually identified in clients with electrolyte imbalances, myocardial infarction, and sinus node problems. Sinus tachycardia is a manifestation of aortic regurgitation due to a decrease in cardiac output.

A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia would the nurse assess? a. Preventricular contractions b. Atrial fibrillation c. Symptomatic bradycardia d. Sinus tachycardia

ANS: A, B, C, F Clinical findings of heart transplant rejection include shortness of breath, fatigue, fluid gain, abdominal bloating, new-onset bradycardia, hypotension, atrial fibrillation or flutter, decreased activity tolerance, and decreased ejection fraction.

A nurse assesses a client who is recovering from a heart transplant. Which assessment findings would alert the nurse to the possibility of heart transplant rejection? (Select all that apply.) a. Shortness of breath b. Abdominal bloating c. New-onset bradycardia d. Increased ejection fraction e. Hypertension f. Fatigue

ANS: B Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in mentation, speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance.

A nurse assesses a client with atrial fibrillation. Which manifestation would alert the nurse to the possibility of a serious complication from this condition? a. Sinus tachycardia b. Speech alterations c. Fatigue d. Dyspnea with activity

ANS: B Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs increases. The other signs and symptoms do not relate to the progression of mitral valve stenosis.

A nurse assesses a client with mitral valve stenosis. What clinical sign or symptom would alert the nurse to the possibility that the client's stenosis has progressed? a. Oxygen saturation of 92% b. Dyspnea on exertion c. Muted systolic murmur d. Upper extremity weakness

ANS: B The client with pericarditis may present with a pericardial friction rub at the left lower sternal border. This sound is the result of friction from inflamed pericardial layers when they rub together. The other assessments are not related.

A nurse assesses a client with pericarditis. Which assessment finding would the nurse expect to find? a. Heart rate that speeds up and slows down. b. Friction rub at the left lower sternal border. c. Presence of a regular gallop rhythm. d. Coarse crackles in bilateral lung bases.

ANS: A Chest pain, possibly angina, indicates that tachycardia may be increasing the client's myocardial workload and oxygen demand to such an extent that normal oxygen delivery cannot keep pace. This results in myocardial hypoxia and pain. Increased urinary output and mild orthostatic hypotension are not life-threatening conditions and therefore do not require immediate intervention. The P wave touching the T wave indicates significant tachycardia and would be assessed to determine the underlying rhythm and cause; this is an important assessment but is not as critical as chest pain, which indicates cardiac cell death.

A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse? a. Midsternal chest pain b. Increased urine output c. Mild orthostatic hypotension d. P wave touching the T wave

ANS: D Normal rhythm shows one P wave preceding each QRS complex, indicating that all depolarization is initiated at the sinoatrial node. QRS complexes without a P wave indicate a different source of initiation of depolarization. This finding on an electrocardiograph tracing is not an indication of hyperkalemia, ventricular tachycardia, or disconnection of leads.

A nurse assesses a client's electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How would the nurse interpret this observation? a. The client has hyperkalemia causing irregular QRS complexes. b. Ventricular tachycardia is overriding the normal atrial rhythm. c. The client's chest leads are not making sufficient contact with the skin. d. Ventricular and atrial depolarizations are initiated from different sites.

ANS: A The client is at high risk for a fat embolism syndrome and pulmonary embolus. Although these complications are life-threatening emergencies, the nurse would administer oxygen first and then notify the primary health care provider. Oxygen administration can reduce the risk for cerebral damage from hypoxia. Pain medication most likely would not cause the client to be restless.

A nurse assesses an older adult who was admitted 2 days ago with a fractured hip. The nurse notes that the client is confused and restless with an oxygen saturation of 88%. Which action would the nurse take first? a. Administer oxygen via nasal cannula. b. Re-position to a semi-Fowler position. c. Increase the intravenous flow rate. d. Assess response to pain medication.

ANS: C The client on raloxifene needs to be assessed first because of the potential for deep vein thrombosis, which is an adverse effect of raloxifene. The client with flank pain may have had a kidney stone but is not acutely ill now. The client who cannot remember taking the last dose of ibandronate can be seen last. The client on risedronate may need to change medications.

A nurse assesses clients in an osteoporosis clinic. Which client would the nurse assess first? a. Client taking calcium with vitamin D who reports flank pain 2 weeks ago. b. Client taking ibandronate who cannot remember when the last dose was. c. Client taking raloxifene who reports unilateral calf swelling. d. Client taking risedronate who reports occasional dyspepsia.

ANS: A Causes of left ventricular failure include mitral or aortic valve disease, coronary artery disease, and hypertension. Pulmonary hypertension and chronic cigarette smoking are risk factors for right ventricular failure. A cerebral vascular accident does not increase the risk of heart failure.

A nurse assesses clients on a cardiac unit. Which client would the nurse identify as being at greatest risk for the development of left-sided heart failure? a. A 36-year-old woman with aortic stenosis b. A 42-year-old man with pulmonary hypertension c. A 59-year-old woman who smokes cigarettes daily d. A 70-year-old man who had a cerebral vascular accident

ANS: A, B, D Acute pericarditis is most commonly associated with acute exacerbations of systemic connective tissue disease, including SLE; with Dressler syndrome, or inflammation of the cardiac sac after cardiac surgery or a myocardial infarction; and with infective organisms, including bacterial, viral, and fungal infections. Abdominal and reproductive surgeries and pressure injuries do not increase clients' risk for acute pericarditis.

A nurse assesses clients on a cardiac unit. Which clients would the nurse identify as at greatest risk for the development of acute pericarditis? (Select all that apply.) a. A 36-year-old woman with systemic lupus erythematosus (SLE) b. A 42-year-old man recovering from coronary artery bypass graft surgery c. A 59-year-old woman recovering from a hysterectomy d. An 80-year-old man with a bacterial infection of the respiratory tract e. An 88-year-old woman with a stage III sacral ulcer

ANS: B For safety during cardioversion, the nurse would turn off any oxygen therapy to prevent fire. The other interventions are not appropriate for a cardioversion. The client would be placed in a supine position.

A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. What action would the nurse take prior to the cardioversion? a. Administer intravenous adenosine. b. Turn off oxygen therapy. c. Ensure that a tongue blade is available. d. Position the client on the left side.

ANS: A Skeletal traction pins or screws are surgically inserted into the bone to aid in bone alignment. As a last resort, traction can be used to relieve pain, decrease muscle spasm, and prevent or correct deformity and tissue damage. These are not primary purposes of skeletal traction.

A nurse cares for a client placed in skeletal traction. The client asks, "What is the primary purpose of this type of traction?" How would the nurse respond? a. "Skeletal traction will assist in realigning your fractured bone." b. "This treatment will prevent future complications and back pain." c. "Traction decreases muscle spasms that occur with a fracture." d. "This type of traction minimizes damage as a result of fracture treatment."

ANS: B Synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate easily and initiate the formation of blood clots. The other responses are inaccurate.

A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, "Why will I need to take anticoagulants for the rest of my life?" What is the best response by the nurse? a. "The prosthetic valve places you at greater risk for a heart attack." b. "Blood clots form more easily in artificial replacement valves." c. "The vein taken from your leg reduces circulation in the leg." d. "The surgery left a lot of small clots in your heart and lungs."

ANS: D Often the surrounding soft tissues may be swollen considerably when the cast is initially applied. After the swelling has resolved, if the cast is loose enough to permit two or more fingers between the cast and the client's skin, the cast needs to be replaced. Elevating the arm will not solve the problem, and the client's muscles should not atrophy while in a cast for 6 weeks or less. An elastic bandage will not prevent slippage of the cast.

A nurse cares for a client who had a wrist cast applied 3 days ago. The client states, "The cast is loose enough to slide off." How would the nurse respond? a. "Keep your arm above the level of your heart." b. "As your muscles atrophy, the cast is expected to loosen." c. "I will wrap a bandage around the cast to prevent it from slipping." d. "You need a new cast now that the swelling is decreased."

ANS: B Bearing down strenuously during a bowel movement is one type of Valsalva maneuver, which stimulates the vagus nerve and results in slowing of the heart rate. Such a response is not desirable in a person who has bradycardia. The other instructions are not appropriate for this condition.

A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification would the nurse suggest to avoid further slowing of the heart rate? a. "Make certain that your bath water is warm." b. "Avoid straining while having a bowel movement." c. "Limit your intake of caffeinated drinks to one a day." d. "Avoid strenuous exercise such as running."

ANS: B The client with numbness and/or tingling of the extremity may be displaying the first signs of acute compartment syndrome. This is an acute problem that requires immediate intervention because of possible decreased circulation. Moderate pain and swelling is an expected assessment after a fracture. These findings can be treated with comfort measures. Being cold can be treated with additional blankets or by increasing the temperature of the room.

A nurse cares for a client with a recently fractured tibia. Which assessment would alert the nurse to take immediate action? a. Pain of 4 on a scale of 0-10 b. Numbness in the extremity c. Swollen extremity at the injury site d. Feeling cold while lying in bed

ANS: B In temporary pacing, the wires are threaded onto the epicardial surface of the heart and exit through the chest wall. The pacemaker spike would be followed immediately by a QRS complex. Pacing spikes seen without subsequent QRS complexes imply loss of capture. If there is no capture, then there is no ventricular depolarization and contraction. The nurse would assess for cardiac output via vital signs and level of consciousness. The other interventions would not determine if the client is tolerating the loss of capture.

A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the client's electrocardiogram. What action would the nurse take next? a. Administer intravenous diltiazem. b. Assess vital signs and level of consciousness. c. Administer sublingual nitroglycerin. d. Assess capillary refill and temperature.

ANS: C Clients who have atrial fibrillation are at risk for decreased cardiac output and fatigue when completing activities of daily living. The nurse would schedule periods of exercise and rest during the day to decrease fatigue. The other interventions will not assist the client with performing self-care activities and there is no indication for oxygen.

A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What intervention would the nurse implement to address this client's concerns? a. Administer oxygen therapy at 2 L per nasal cannula. b. Provide the client with a sleeping pill to stimulate rest. c. Schedule periods of exercise and rest during the day. d. Ask assistive personnel (AP) to help bathe the client.

: A, C, E Elevated heart rates in a healthy client initially cause blood pressure and cardiac output to increase. However, in a client who has congestive heart failure or a client with long-term tachycardia, ventricular filling time, cardiac output, and blood pressure eventually decrease. As cardiac output and blood pressure decrease, urine output will fall.

A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations would the nurse assess? (Select all that apply.) a. Decrease in cardiac output b. Increase in cardiac output c. Decrease in blood pressure d. Increase in blood pressure e. Decrease in urine output f. Increase in urine output

ANS: D The client is verbalizing a real concern or fear about negative outcomes of the surgery. This anxiety itself can have a negative effect on the outcome of the surgery because of sympathetic stimulation. The best action is to allow the client to verbalize the concern and work toward a positive outcome without making the client feel as though the concerns are not valid. The client needs to feel that he or she has some control over the future. The nurse personally provides care to address the client's concerns instead of immediately calling for the chaplain or psychiatrist. The nurse would not jump to conclusions and suggest taking the client off the transplant list, which is the best treatment option.

A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, "I know a transplant is my last chance, but I don't want to become a vegetable." How would the nurse respond? a. "Would you like to speak with a priest or chaplain?" b. "I will arrange for a psychiatrist to speak with you." c. "Do you want to come off the transplant list?" d. "Would you like information about advance directives?"

ANS: A The client with infective endocarditis does not pose any specific threat of transmitting the causative organism. Standard Precautions would be used. Bleeding Precautions, reverse isolation, or Contact Precautions are not necessary.

A nurse cares for a client with infective endocarditis. Which infection control precautions would the nurse use? a. Standard Precautions b. Bleeding Precautions c. Reverse isolation d. Contact isolation

ANS: A Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2 lb (1 kg). Weight changes are the most reliable indicator of fluid loss or gain. The other responses do not address the importance of monitoring fluid retention or loss.

A nurse cares for a client with right-sided heart failure. The client asks, "Why do I need to weigh myself every day?" How would the nurse respond? a. "Weight is the best indication that you are gaining or losing fluid." b. "Daily weights will help us make sure that you're eating properly." c. "The hospital requires that all clients be weighed daily." d. "You need to lose weight to decrease the incidence of heart failure."

ANS: A Depression can occur in clients with heart failure, especially older adults. Having the client talk about his or her feelings will help the nurse focus on the actual problem. Open-ended statements allow the client to respond safely and honestly. The other options minimize the client's concerns and do not allow the nurse to obtain more information to provide client-centered care.

A nurse cares for an older adult client with heart failure. The client states, "I don't know what to do. I don't want to be a burden to my daughter, but I can't do it alone. Maybe I should die." What is the best response by the nurse? a. "I can stay if you would you like to talk more about this." b. "You are lucky to have such a devoted daughter." c. "It is normal to feel as though you are a burden." d. "Would you like to meet with the chaplain?"

ANS: C Older adults need 35 to 50 g of fiber a day. White rice is low in fiber. Foods high in fiber include barley, beans, and whole-wheat products.

A nurse caring for an older adult has provided education on high-fiber foods. Which menu selection by the client demonstrates a need for further review? a. Barley soup b. Black beans c. White rice d. Whole-wheat bread

ANS: B In this situation, each facility will have a policy designed for assessing competence. The nurse would bring these concerns to an interprofessional care team meeting. There may be physiologic reasons for the client to be temporarily too confused or incompetent to give consent. If an acute condition is ruled out, the staff would follow the legal procedure and policies in their facility and state for determining competence. The key is to bring the concerns forward. Calling Adult Protective Services is not appropriate at this time. Signing the consent would wait until competence is determined unless it is an emergency, in which case the next of kin can sign if there are grave doubts as to the client's ability to provide consent. Simply not allowing the client to sign does not address the problem.

A nurse caring for an older client in the hospital is concerned the client is not competent to give consent for upcoming surgery. What action by the nurse is best? a. Call Adult Protective Services. b. Discuss concerns with the health care team. c. Do not allow the client to sign the consent. d. Have the client's family sign the consent.

ANS: C Poorly fitting dentures and other dental problems are often manifested by a preference for soft foods and constipation from the lack of fiber. The nurse would perform an oral assessment to determine if these problems exist. The other assessments are important, but will not yield information specific to the client's food preferences as they relate to constipation.

A nurse caring for an older client on a medical-surgical unit notices the client reports frequent constipation and only wants to eat softer foods such as rice, bread, and puddings. What assessment would the nurse perform first? a. Auscultate bowel sounds. b. Check skin turgor. c. Perform an oral assessment. d. Weigh the client.

ANS: A, C, D The AP should reposition the client every 2 hours to improve oxygenation and prevent atelectasis. The AP can also accurately record intake and output, and use the same scale to weigh the client each morning before breakfast. APs are not qualified to teach clients or assess the need for and provide oxygen therapy.

A nurse collaborates with assistive personnel (AP) to provide care for a client with congestive heart failure. Which instructions would the nurse provide to the AP when delegating care for this client? (Select all that apply.) a. "Reposition the client every 2 hours." b. "Teach the client to perform deep-breathing exercises." c. "Accurately record intake and output." d. "Use the same scale to weigh the client each morning." e. "Place the client on oxygen if the client becomes short of breath."

C. It's a tricyclic

A nurse conducts an assessment of an older adult's medications, including both prescription and over-the-counter drugs. Which drug would the nurse identify as being potentially inappropriate for older adults? A. Vitamin D B. Losartan C. Nortriptyline D. Hydrochlorothiazide (HCTZ)

ANS: A, B, E, F A hematocrit of 32.8% is low (should be 42.6%), indicating a dilutional ratio of red blood cells to fluid. A serum sodium of 130 mEq/L (130 mmol/L) is low because of hemodilution. Microalbuminuria and proteinuria are present, indicating a decrease in renal filtration. These are early warning signs of decreased compliance of the heart. The potassium level is normal and the serum creatinine level is normal.

A nurse evaluates laboratory results for a client with heart failure. Which results would the nurse expect? (Select all that apply.) a. Hematocrit: 32.8% b. Serum sodium: 130 mEq/L (130 mmol/L) c. Serum potassium: 4.0 mEq/L (4.0 mmol/L) d. Serum creatinine: 1.0 mg/dL (88.4 mcmol/L) e. Proteinuria f. Microalbuminuria

ANS: B Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol, atropine, and lidocaine are not appropriate for preventing this complication.

A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication would the nurse expect to find on this client's medication administration record to prevent a common complication of this condition? a. Sotalol b. Warfarin c. Atropine d. Lidocaine

B

A nurse gives report about a client whose pain in uncontrolled and suggests that the client receive continuous analgesic administration rather than PRN analgesics. Which step of the SBAR hand-off report is the nurse using? S R B A

ANS: A, B, E Left-sided heart failure occurs with a decrease in contractility of the heart or an increase in afterload. Most of the signs will be noted in the respiratory system. These include crackles, confusion (due to decreased oxygenation), and cough. Right ventricular failure is associated with pulmonary hypertension, edema, and jugular venous distention.

A nurse is assessing a client with left-sided heart failure. For which clinical manifestations would the nurse assess? (Select all that apply.) a. Pulmonary crackles b. Confusion c. Pulmonary hypertension d. Dependent edema e. Cough that worsens at night f. Jugular venous distention

ANS: A As PAD progresses, it takes less oxygen demand to cause pain. Needing to cut down on activity to be pain free indicates that the client's disease is worsening. The other questions are useful, but not as important.

A nurse is assessing a client with peripheral artery disease (PAD). The client states that 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?"

ANS: A, B, D, E Dietary components that affect the development of osteoporosis include alcohol, caffeine, high phosphorus intake, carbonated beverages, and vitamin D. Tobacco is also a contributing lifestyle factor. Fat intake does not contribute to osteoporosis.

A nurse is assessing a community group for dietary factors that contribute to osteoporosis. In addition to inquiring about calcium, the nurse also assesses for which other dietary components? (Select all that apply.) a. Alcohol b. Caffeine c. Fat d. Carbonated beverages e. Vitamin D

ANS: C Compression stockings must fit correctly in order to work. After losing a significant amount of weight, the client would be remeasured and new stockings ordered if needed. The other options are appropriate, but not the most important.

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 lb (9.09 Kg) 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

ANS: B Atrial fibrillation occurs commonly in clients with cardiac disease. Other risk factors include hypertension (HTN), previous ischemic stroke, transient ischemic attack (TIA) or other thromboembolic event, diabetes mellitus, heart failure, obesity, hyperthyroidism, chronic kidney disease, excessive alcohol use, and mitral valve disease. The other conditions do not place these clients at higher risk for atrial fibrillation.

A nurse is assessing clients on a medical-surgical unit. Which client would the nurse identify as being at greatest risk for atrial fibrillation? a. A 45-year-old who takes an aspirin daily. b. A 50-year-old who is post coronary artery bypass graft surgery. c. A 78-year-old who had a carotid endarterectomy. d. An 80-year-old with chronic obstructive pulmonary disease.

ANS: A Friendship and support enhance coping. The quality of the relationship is what is most important, however. People who have close, intimate, stable relationships with others in whom they confide are more likely to cope with crisis. The person who is "coping well on my own" may actually need resources to help with this transition. Having children visit is important but not as important as intimate, long-term friendships. "Friends at the senior center" may refer to good acquaintances and not real friends.

A nurse is assessing coping in older women in a support group for recent widows. Which statement by a participant best indicates potential for successful coping? a. "I have had the same best friend for decades." b. "I think I am coping very well on my own." c. "My kids come to see me every weekend." d. "Oh, I have lots of friends at the senior center."

ANS: D The nurse would not compress both carotid arteries at the same time to avoid brain ischemia. Blood pressure would be taken and compared in both arms. Prolonged capillary filling 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 would be auscultated.

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

ANS: B SBAR is a recommended form of communication, and the acronym stands for Situation, Background, Assessment, and Recommendation. Appropriate background information includes allergies to medications the on-call health care provider might order. Situation describes what is happening right now that must be communicated; the client's surgery 2 days ago would be considered background. Assessment would include an analysis of the client's problem; none of the options has assessment information. Asking for a different pain medication is a recommendation. Recommendation is a statement of what is needed or what outcome is desired.

A nurse is calling the on-call health care provider about a client who had a hysterectomy 2 days ago and has pain that is unrelieved by the prescribed opioid pain medication. Which statement comprises the background portion of the SBAR format for communication? a. "I would like you to order a different pain medication." b. "This client has allergies to morphine and codeine." c. "Dr. Smith doesn't like nonsteroidal anti-inflammatory meds." d. "This client had a vaginal hysterectomy 2 days ago."

ANS: A, B, D 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 2.5 times normal in order to demonstrate that the heparin is therapeutic. Weighing the client is not related.

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

ANS: C The client is experiencing phantom limb pain, which usually manifests as intense burning, crushing, or cramping. IV infusions of calcitonin during the week after amputation can reduce phantom limb pain. Opioid analgesics such as morphine are not as effective for phantom limb pain as they are for residual limb pain. Oral acetaminophen and ibuprofen are not used in treating phantom limb pain.

A nurse is caring for a client recovering from an above-the-knee amputation of the right leg. The client reports pain in the right foot. Which prescribed medication would the nurse most likely administer? a. Intravenous morphine b. Oral acetaminophen c. Intravenous calcitonin d. Oral ibuprofen

ANS: A Clients are often in denial after a coronary event. The client who seems to be in denial but is compliant with treatment may be using a healthy form of coping that allows time to process the event and start to use problem-focused coping. The nurse would not discourage this type of denial and coping, but rather continue providing education in a positive manner. Emphasizing complications may make the client defensive and more anxious. Telling the client that denial is normal is placing too much attention on the process. Forcing the client to verbalize understanding of the illness is also potentially threatening to the client

A nurse is caring for a client who had a myocardial infarction. The nurse is confused because the client states that nothing is wrong and yet listens attentively while the nurse provides education on lifestyle changes and healthy menu choices. What response by the charge nurse is best? a. "Continue to educate the client on possible healthy changes." b. "Emphasize complications that can occur with noncompliance." c. "Tell the client that denial is normal and will soon go away." d. "You need to make sure the client understands this illness."

ANS: A, C, E The nurse can delegate assisting the client to get up in the chair or commode (if the nurse has evaluated the client as being stable), applying TEDs or sequential compression devices, and taking/recording vital signs. The spirometer would be used every hour the day after surgery. Assessing pain using a 0-10 scale is a nursing assessment, although if the client reports pain, the AP would inform the nurse so a more detailed assessment is done

A nurse is caring for a client who had coronary artery bypass grafting 2 days ago. What actions does the nurse delegate to the assistive personnel (AP)? (Select all that apply.) a. Assist the client to the chair for meals and to the commode. b. Encourage the client to use the spirometer every 4 hours. c. Ensure that the client wears TED hose or sequential compression devices. d. Have the client rate pain on a 0-10 scale and report to the nurse. e. Take and record a full set of vital signs per hospital protocol.

ANS: A Allowing the family to remain at the bedside can help calm the client with familiar voices (and faces if the client wakes up). A fan might be helpful but may also spread germs through air movement or may agitate the client further. The TV would not be kept on all the time to allow for rest. Speaking loudly may agitate the client more.

A nurse is caring for a client who is intubated and has an intra-aortic balloon pump. The client is restless and agitated. What action would the nurse perform first for comfort? a. Allow family members to remain at the bedside. b. Ask the family if the client would like a fan in the room. c. Keep the television tuned to the client's favorite channel. d. Speak loudly to the client in case of hearing problems.

ANS: D The nurse would ask the client to rate the pain on a scale of 0-10 and describe how the pain feels. Although phantom limb pain is common, the nurse would not minimize the pain that the client is experiencing by stating that it does not exist or will eventually go away. Although imagery may help, the nurse must assess the client's pain before determining the best action.

A nurse is caring for a client who is recovering from an above-the-knee amputation and reports pain in the limb that was removed. How would the nurse respond? a. "The pain you are feeling does not actually exist." b. "This type of pain is common and will eventually go away." c. "Would you like to learn how to use imagery to minimize your pain?" d. "How would you describe the pain that you are feeling?"

ANS: A, C, E Management of obstructive HCM includes administering negative inotropic agents such as beta-adrenergic blocking agents (carvedilol) and calcium antagonists (verapamil). Vasodilators, diuretics, nitrates, and cardiac glycosides are contraindicated in patients with obstructive HCM. Strenuous exercise is also prohibited. Echocardiography, radionuclide imaging, and angiocardiography during cardiac catheterization are performed to diagnose and differentiate cardiomyopathies. The CardioMEMSTM device is used with clients who have heart failure.

A nurse is caring for a client who was admitted with hypertrophic cardiomyopathy (HCM). What interprofessional care does the nurse anticipate providing? (Select all that apply.) a. Administering beta blockers b. Administering high-dose furosemide c. Preparing for a cardiac catheterization d. Loading the client on digitalis e. Instructing the client to avoid strenuous exercise f. Teaching the client how to use the CardioMEMSTM

ANS: A A nonhealing wound needs the expertise of the wound care 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.

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 care nurse. b. Give pain medication prior to dressing changes. c. Maintain sterile technique for dressing changes. d. Prepare the client for eventual amputation.

ANS: A, B, C When a client is upset, the nurse would 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. It is too early to send an amputee to visit the client as the decision to amputate has not yet been made.

A nurse is caring for a client with a nonhealing arterial ulcer. The primary health care provider has informed the client about possibly needing to amputate the client's leg. The client is crying and upset. What actions by the nurse are best? (Select all that apply.) 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. f. Arrange for an amputee to come visit the client.

ANS: D Pain from acute pericarditis may worsen when the client lays supine. The nurse would position the client in a comfortable position, which usually is upright and leaning slightly forward. An ice pack and neck rub will not relieve this pain. Dimming the lights will also not help the pain.

A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to the left side of the neck. Which nonpharmacologic comfort measure would the nurse implement? a. Apply an ice pack to the client's chest. b. Provide a neck rub, especially on the left side. c. Allow the client to lie in bed with the lights down. d. Sit the client up with a pillow to lean forward on.

ANS: A A client's medical alert bracelet or any other jewelry would be removed from the fractured arm before the affected extremity swells. Immobilization, positioning, and dressing should occur after the bracelet is removed.

A nurse is caring for a client with diabetes mellitus who has fractured her arm. Which action would the nurse take first? a. Remove the medical alert bracelet from the fractured arm. b. Immobilize the arm by splinting the fractured site. c. Place the client in a supine position with a warm blanket. d. Cover any open areas with a sterile dressing.

ANS: A The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating before they suffer either respiratory or cardiac arrest. Since the client has manifested a significant change, the nurse would call the RRT. Changes in blood pressure, mental status, heart rate, temperature, oxygen saturation, and last 2 hours' urine output are particularly significant and are part of the Modified Early Warning System guide. Documentation is vital, but the nurse must do more than document. The primary health care provider would be notified, but this is not more important than calling the RRT. The client's blood pressure would be reassessed frequently, but the priority is getting the rapid care to the client.

A nurse is caring for a postoperative client on the surgical unit. The client's blood pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action would the nurse take first? a. Call the Rapid Response Team. b. Document and continue to monitor. c. Notify the primary health care provider. d. Repeat the blood pressure in 15 minutes.

ANS: C The client feels like less of a person following the amputation. The nurse would help the client to identify coping mechanisms that have worked in the past and current support systems to assist with coping. The nurse would not ignore the client's feelings by focusing on vital signs. The nurse would not try to make the client feel guilty by alluding to family members. The nurse would not refer to the patient as being "disabled" as this labels the client and may fuel poor body image.

A nurse is caring for an older client who is recovering from a leg amputation surgery. The client states, "I don't want to live with only one leg. I should have died during the surgery." What is the nurse's best response? a. "Your vital signs are good, and you are doing just fine right now." b. "Your children are waiting outside. Do you want them to grow up without a father?" c. "This is a big change for you. What support system do you have to help you cope?" d. "You will be able to do some of the same things as before you became disabled."

ANS: B The post-angioplasty client with tongue swelling and anxiety is exhibiting signs and symptoms of an allergic reaction (perhaps to the contrast medium) that could progress to anaphylaxis. The nurse would assess this client first. The client with a heart rate of 102 beats/min may have increased oxygen demands but is just over the normal limit for heart rate. The two post coronary artery bypass clients are stable.

A nurse is caring for four client s. Which client would the nurse assess first? a. Client with an acute myocardial infarction, pulse 102 beats/min b. Client who is 1 hour post-angioplasty, and has tongue swelling and anxiety c. Client who is post coronary artery bypass, with chest tube drained 100 mL/hr d. Client who is post coronary artery bypass, with potassium 4.2 mEq/L (4.2 mmol/L)

ANS: C This client is the priority because the assessment findings indicate a critical lack of perfusion. A high white blood cell count is an expected finding for the client with osteoporosis. The client requesting pain medication should be seen second. The client who just returned from a CT scan is stable and needs no specific postprocedure care

A nurse is caring for four clients. After the hand-off report, which client would the nurse see first? a. Client with osteoporosis and a white blood cell count of 27,000/mm3 (27 × 109/L) b. Client with osteoporosis and a bone fracture who requests pain medication c. Post-microvascular bone transfer client whose distal leg is cool and pale d. Client with suspected bone tumor who just returned from having a spinal CT

ANS: B Angiotensin-converting enzyme inhibitors such as captopril can cause hypotension, especially after the first dose. The nurse would 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 would 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 to 100 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 nurse is caring for four clients. Which one would the nurse see first? a. Client who needs a beta blocker, and has a blood pressure of 98/58 mm Hg. b. Client who had a first dose of captopril 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.

ANS: D Deep vein thrombosis (DVT) as a complication with bone fractures occurs more often when fractures are sustained in the lower extremities and the client has additional risk factors for thrombus formation. Other risk factors include obesity, smoking, oral contraceptives, previous thrombus events, advanced age, venous stasis, and heart disease. The other clients do not have additional risk factors for DVT.

A nurse is caring for several clients with fractures. Which client would the nurse identify as being at the highest risk for developing deep vein thrombosis? a. An 18-year-old male athlete with a fractured clavicle b. A 36-year-old female with type 2 diabetes and fractured ribs c. A 55-year-old female prescribed ibuprofen for osteoarthritis d. A 74-year-old male who smokes and has a fractured pelvis

ANS: B A systems thinking approach to care reinforces the nurse's role in safety and quality improvement while expanding clinical judgment to include the patient's place within the greater health care system in the context of care decisions. Root-cause analyses would be a small portion of systems thinking. It does give the nurse a big-picture view, but this answer is vague. The nurse may or may not ever join management.

A nurse is confused on why systems thinking is important since working on the unit involves caring for a few specific clients. What explanation by the nurse manager is best? a. "It's a good way to conduct root-cause analysis." b. "It is important for quality improvement and safety." c. "Systems thinking helps you see the bigger picture." d. "You may enter management 1 day and need to know this."

ANS: B Hypotension after coronary artery bypass graft surgery can be dangerous because it can lead to collapse of the graft. The charge nurse would see this client first. The client who became dizzy earlier would be seen next. The client on the nitroglycerin drip is stable. The client going home can wait until the other clients are cared for.

A nurse is in charge of the coronary intensive care unit. Which client would the nurse see first? a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours b. Client who is 1-day post coronary artery bypass graft, with blood pressure 88/64 mm Hg c. Client who is 1-day post percutaneous coronary intervention, going home this morning d. Client who is 2-day post coronary artery bypass graft, who became dizzy this morning while walking

ANS: A, B, C, D, F Collaborating with the interprofessional team involves planning, implementing, and evaluating client care as a team with all other involved disciplines included. Simply showing other caregivers the nursing care plan is not actively involving them or collaborating with them.

A nurse is interested in making interprofessional work a high priority. Which actions by the nurse best demonstrate this skill? (Select all that apply.) a. Consults with other disciplines on client care. b. Coordinates discharge planning for home safety. c. Participates in comprehensive client rounding. d. Routinely asks other disciplines about client progress. e. Shows the nursing care plans to other disciplines. f. Delegate tasks to unlicensed personnel appropriately.

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

ANS: A Each action could be important for the client or family to perform. However, encouraging the client to be active in his or her health care as a safety partner is the most critical. The other actions are very limited in scope and do not provide the broad protection that being active and involved does.

A nurse is orienting a new client and family to the medical-surgical unit. What information does the nurse provide to best help the client promote his or her own safety? a. Encourage the client and family to be active partners. b. Have the client monitor hand hygiene in caregivers. c. Offer the family the opportunity to stay with the client. d. Tell the client to always wear his or her armband.

ANS: D,E The AP can raise the side rails of the bed for client safety and take and record the vital signs. Administering medications, ensuring that a consent is on the chart, and marking the pulses for later comparison would be done by the registered nurse. This is also often done by the postanesthesia care nurse and is part of the hand-off report.

A nurse is preparing a client for a femoropopliteal bypass operation. What actions does the nurse delegate to the assistive personnel (AP)? (Select all that apply.) a. Administering preoperative medication b. Ensuring that the consent is signed c. Marking pulses with a pen d. Raising the side rails on the bed e. Recording baseline vital signs

ANS: B Clients who have had heart transplants must take immunosuppressant therapy for the rest of their lives. The nurse would teach this client to avoid crowds and sick people to reduce the risk of becoming ill him- or herself. These medications do not place clients at risk for bleeding, orthostatic hypotension, or changes in heart rate. Orthostatic hypotension from the denervated heart is generally only a problem in the immediate postoperative period.

A nurse is providing discharge teaching to a client recovering from a heart transplant. Which statement would the nurse include? a. "Use a soft-bristled toothbrush and avoid flossing." b. "Avoid large crowds and people who are sick." c. "Change positions slowly to avoid hypotension." d. "Check your heart rate before taking the medication."

ANS: C, D, E Lifestyle changes can be made to decrease the occurrence of osteoporosis and include strengthening and weight-bearing exercises and getting the recommended amounts of both calcium and vitamin D. Tobacco should be totally avoided. Women should not have more than one drink per day.

A nurse is providing education to a community women's group about lifestyle changes helpful in preventing osteoporosis. What topics does the nurse cover? (Select all that apply.) a. Cut down on tobacco product use. b. Limit alcohol to two drinks a day. c. Strengthening exercises are important. d. Take recommended calcium and vitamin D. e. Walk for 30 minutes at least three times a week.

ANS: A, C, D, E Normal right atrial pressure is 0 to 8 mm Hg; high readings can indicate right ventricular failure; low readings often signify hypovolemia. Normal pulmonary artery pressure ranges from 15 to 30 mm Hg systolic to 3 to 12 mm Hg diastolic. Pulmonary artery occlusion pressure ranges from 5 to 12 mm Hg; high values may indicate left ventricular failure, hypervolemia, mitral regurgitation, or intracardiac shunting. A decreased PAOP is seen with hypovolemia or afterload reduction.

A nurse is studying hemodynamic monitoring. Which measurements are correctly matched with the physiologic cause? (Select all that apply.) a. Right atrial pressure 12 mm Hg: right ventricular failure b. Right atrial pressure 4 mm Hg: hypovolemia c. Pulmonary artery pressure 20/10 mm Hg: normal finding d. Pulmonary artery occlusion pressure 20 mm Hg: mitral regurgitation e. Pulmonary artery occlusion pressure 2 mm Hg: afterload reduction

ANS: C Client Magnet status is awarded by The Joint Commission (TJC) and certifies that nurses can demonstrate how best current evidence guides their practice. New technology doesn't necessarily mean that the hospital is safe. Affiliation with a health profession school has several advantages, but safety is most important.

A nurse is talking with a co-worker who is moving to a new state and needs to find new employment there. What advice by the nurse is best? a. Ask the hospitals there about standard nurse-client ratios. b. Choose the hospital that has the newest technology. c. Find a hospital that has achieved Magnet status. d. Work in a facility affiliated with a medical or nursing school.

ANS: A, B, D A client who has premature beats or ectopic rhythms would be taught to stop smoking, manage stress, take medications as prescribed, and report adverse effects of medications. Clients with premature beats are not at risk for vasovagal attacks or potassium imbalances. While exercise is beneficial, aerobic exercise is not specifically linked to this client's educational needs.

A nurse is teaching a client who has premature ectopic beats. Which education would the nurse include in this client's teaching? (Select all that apply.) a. Smoking cessation b. Stress reduction and management c. Avoiding vagal stimulation d. Adverse effects of medications e. Foods high in potassium f. Types of aerobic exercise

ANS: A Angiotensin-converting enzyme (ACE) inhibitors such as enalapril inhibit the excretion of potassium. Hyperkalemia can be a life-threatening side effect, and clients should be taught to limit potassium intake. Salt substitutes are composed of potassium chloride. ACE inhibitors do not need to be taken with food and have no impact on the client's pulse rate. Aspirin is often prescribed in conjunction with ACE inhibitors and is not contraindicated.

A nurse is teaching a client with heart failure who has been prescribed enalapril. Which statement would the nurse include in this client's teaching? a. "Avoid using salt substitutes." b. "Take your medication with food." c. "Avoid using aspirin-containing products." d. "Check your pulse daily."

ANS: A 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.

A nurse is teaching a 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."

ANS: A There is a drug-food interaction between clopidogrel and grapefruit that can lead to acute kidney failure. This client has elevated renal laboratory results, indicating some degree of kidney involvement. The nurse would assess if the client eats grapefruit or drinks grapefruit juice. 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 be admitted. A urinalysis may or may not be ordered.

A nurse is working with a client who takes clopidogrel. 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.

ANS: C Older adults often lose their sense of thirst. Plus older adults have less body water than younger people. Since they should drink 1 to 2 L of water a day, the best remedy is to have the older adult drink something each hour or two, whether or not he or she is thirsty. Cutting "some" sodium from the diet will not address this issue and is vague. Although dehydration can cause incontinence from the irritation of concentrated urine, this information will not help prevent the problem of dehydration. Instructing the client to take a diuretic in the morning rather than in the evening also will not directly address this issue.

A nurse is working with an older client admitted with mild dehydration. What teaching does the nurse provide to best address this issue? a. "Cut some sodium out of your diet." b. "Dehydration can cause incontinence." c. "Have something to drink every 1 to 2 hours." d. "Take your diuretic in the morning."

ANS: B, C, D, E Hypertension, obesity, smoking, and excessive stress are all modifiable risk factors for coronary artery disease. Age and gender are not nonmodifiable risk factors.

A nurse learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select all that apply.) a. Age b. Hypertension c. Obesity d. Smoking e. Stress f. Gender

ANS: C The old old is the fastest growing subset of the older population. This is the group comprising those 85 to 99 years of age. The young old are between 65 and 74 years of age; the middle old are between 75 and 84 years of age; and the elite old are over 100 years of age.

A nurse learns that the fastest growing subset of the older population is which group? a. Elite old b. Middle old c. Old old d. Young old

ANS: A, C, E SPICES stands for sleep disorders, problems with eating or feeding, incontinence, confusion, and evidence of falls.

A nurse manager institutes the Fulmer SPICES Framework as part of the routine assessment of older adults in the hospital. The nursing staff assesses for which factors? (Select all that apply.) a. Confusion b. Evidence of abuse c. Incontinence d. Problems with behavior e. Sleep disorders

ANS: A, B, C, E The SBAR method of communication has been identified as an excellent method of communication between health care professionals. It is a formalized structure consisting of Situation, Background, Assessment, and Recommendation/Request. Using a formalized mechanism for communication helps ensure successful hand-off and fewer client errors. When establishing this new format for report, the most helpful actions by the manager would be to provide initial education on the process, develop a template with suggested topics under each heading, attend rounds to coach and mentor, and encourage staff to ask questions to clarify information. Basing raises on compliance would not be the most helpful method because raises are often determined only once a year and are based on multiple criteria.

A nurse manager wants to improve hand-off communication among the staff. What actions by the manager would best help achieve this goal? (Select all that apply.) a. Attend hand-off rounds to coach and mentor. b. Create a template of suggested topics to include in report. c. Encourage staff to ask questions during hand-off. d. Give raises based on compliance with reporting. e. Provide education on the SBAR method of communication

ANS: A, B, D, E The IOM report lists five broad core competencies that all health care providers should practice. These include collaborating with the interprofessional team, implementing evidence-based practice, providing patient-focused care, using informatics in client care, and using quality improvement in client care. Systems thinking is required for quality improvement but is not a specified part of the IOM report.

A nurse manager wishes to ensure that the nurses on the unit are practicing at their highest levels of competency. Which areas would the manager assess to determine if the nursing staff demonstrate competency according to the Institute of Medicine (IOM) report Health Professions Education: A Bridge to Quality? (Select all that apply.) a. Collaborating with an interprofessional team b. Implementing evidence-based care c. Providing family-focused care d. Routinely using informatics in practice e. Using quality improvement in client care f. Formalizing systems thinking when implementing care

C

A nurse participates as part of a quality improvement (QI) team to develop a plan to "reduce deep vein thrombosis on a surgical unit." What part of the PICO(T) question does this statement represent? P C O I

ANS: D To decrease the risk for infection in a client with skeletal traction or external fixation, the nurse would provide routine pin care and assess for signs and symptoms of infection at the pin sites every shift

A nurse plans care for a client who has an external fixator on the lower leg. Which intervention would the nurse include in the plan of care to decrease the client's risk for infection? a. Washing the frame of the fixator once a day b. Releasing fixator tension for 30 minutes twice a day c. Avoiding moving the extremity by holding the fixator d. Scheduling for pin care to be provided every shift

ANS: B Clients with a below-the-knee amputation should complete range-of-motion exercises to prevent flexion contractions and prepare for a prosthesis. A pillow may be used under the limb as support. Clients recovering from this type of amputation are at low risk for infection and should not be prescribed prophylactic antibiotics. The client should be encouraged to re-position, move, and exercise frequently, and therefore should not be restricted to bedrest.

A nurse plans care for a client who is recovering from a below-the-knee amputation of the left leg. Which intervention would the nurse include in this client's plan of care? a. Place pillows between the client's knees. b. Encourage range-of-motion exercises. c. Administer prophylactic antibiotics. d. Implement strict bedrest in a supine position

ANS: A, B, D Postoperative care for a client who has ORIF of the hip includes elevating the client's heels off the bed and re-positioning every 2 hours to prevent pressure and skin breakdown. It also includes ambulating the client on the first postoperative day, and using pillows or an abduction pillow to prevent subluxation of the hip. The nurse would teach the client to use the patient-controlled analgesia pump, but the nurse would never push the button for the client.

A nurse plans care for a client who is recovering from open reduction and internal fixation (ORIF) surgery for a right hip fracture. Which interventions would the nurse include in this client's plan of care? (Select all that apply.) a. Elevate heels off the bed with a pillow. b. Ambulate the client on the first postoperative day. c. Push the client's patient-controlled analgesia button. d. Re-position the client every 2 hours. e. Use pillows to encourage subluxation of the hip.

ANS: C The nurse would discuss the client's feelings and concerns related to the surgery. The nurse would not provide false hope or simply call the chaplain. The nurse would address support systems after addressing the client's current issue.

A nurse prepares a client for coronary artery bypass graft surgery. The client states, "I am afraid I might die." What is the nurse's best response? a. "This is a routine surgery and the risk of death is very low." b. "Would you like to speak with a chaplain prior to surgery?" c. "Tell me more about your concerns about the surgery." d. "What support systems do you have to assist you?"

ANS: D To avoid injury, the rescuer commands that all personnel clear contact with the client or the bed and ensures their compliance before delivery of the shock. Defibrillation is done in asynchronous mode. Equipment would not be tested before a client is defibrillated because this is an emergency procedure; equipment would be checked on a routine basis. Defibrillation takes priority over any medications.

A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which intervention is appropriate for the nurse to perform prior to defibrillating this client? a. Make sure that the defibrillator is set to the synchronous mode. b. Administer 1 mg of intravenous epinephrine. c. Test the equipment by delivering a smaller shock at 100 J. d. Ensure that everyone is clear of contact with the client and the bed.

ANS: B, C, D, F National quality measures aim to decrease heart failure readmission by proper preparation for discharge. These measures include :(1) beta blocker prescribed for left ventricular dysfunction at discharge, (2) postdischarge follow-up appointment scheduled within 7 days of discharge with documentation of location, date, and time. (3) care transition record transmitted to next level of care within 7 days of discharge. (4) documentation of discussion of advance directives/advance care planning with a health care provider, (5) documentation of execution of advance directives within the medical record, and (6) postdischarge evaluation of patient for symptom assessment and treatment adherence within 72 hours of discharge (this can occur by phone, scheduled office visit, or home visit)

A nurse prepares to discharge a client who has heart failure. Based on national quality measures, what actions would the nurse complete prior to discharging this client? (Select all that apply.) a. Teach the client about energy conservation techniques. b. Ensure that the client is prescribed a beta blocker. c. Document a discussion about advanced directives. d. Confirm that a postdischarge nurse visit has been scheduled. e. Consult a social worker for additional resources. f. Care transition record transmitted to next level of care within 7 days of discharge.

ANS: A, B, D To ensure safety upon discharge, the nurse would assess for structural barriers to functional ability, such as stairs. The nurse would also assess the client's available social support, which may include family, friends, and home health services. The client's beliefs about and ability to adhere to medication and treatments, including daily weights, would also be reviewed. The other questions do not specifically address the client's safety upon discharge.

A nurse prepares to discharge a client who has heart failure. Which questions would the nurse ask to ensure this client's safety prior to discharging home? (Select all that apply.) a. "Are your bedroom and bathroom on the first floor?" b. "What social support do you have at home?" c. "Will you be able to afford your oxygen therapy?" d. "What spiritual beliefs may impact your recovery?" e. "Are you able to accurately weigh yourself at home?"

ANS: A The home health nurse needs to know current medications the client is taking to ensure assessment, evaluation, and further education related to these medications. The other information might be used to plan care, but not as the priority

A nurse prepares to discharge a client with a cardiac dysrhythmia who is prescribed home health care services. Which priority information would be communicated to the home health nurse upon discharge? a. Medication orders for home b. Immunization history c. Religious beliefs d. Nutrition preferences

ANS: A, B, D, E The pain from an MI is often accompanied by shortness of breath and fear or anxiety. It lasts longer than 15 minutes and is not relieved by nitroglycerin. It occurs without a known cause such as exertion or stress.

A nurse studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways? (Select all that apply.) a. Accompanied by shortness of breath b. Feelings of fear or anxiety c. Lasts less than 15 minutes d. No relief from taking nitroglycerin e. Pain occurs without known cause f. Can be precipitated by exertion or stress

ANS: A To ensure the best signal transmission, the skin would be clean and hairs clipped. Electrodes would be placed on the anterior chest, and no additional gel is needed. Oxygen has no impact on electrocardiographic monitoring

A nurse supervises an assistive personnel (AP) applying electrocardiographic monitoring. Which statement would the nurse provide to the AP related to this procedure? a. "Clean the skin and clip hairs if needed." b. "Add gel to the electrodes prior to applying them." c. "Place the electrodes on the posterior chest." d. "Turn off oxygen prior to monitoring the client."

ANS: A, D, E A client with a new prosthetic should be taught that the prosthetic device is custom made for the client, taking into account the level of amputation, lifestyle (including exercise preferences), and occupation. In collaboration with a prosthetist, the client should be taught proper techniques for cleansing the sockets and inserts, wearing the correct liners, and assessing shoe wear. Follow-up care and appointments are important for ongoing assessment.

A nurse teaches a client about prosthesis care after amputation. Which statements would the nurse include in the health teaching? (Select all that apply.) a. "The device has been custom made specifically for you." b. "Your prosthetic is good for work but not for exercising." c. "A prosthetist will clean your inserts for you each month." d. "Make sure that you wear the correct liners with your prosthetic." e. "I have scheduled a follow-up appointment for you."

ANS: A PACs usually have no hemodynamic consequences. For a client experiencing infrequent PACs, the nurse would explore possible lifestyle causes, such as excessive caffeine intake and stress. Lying on the side will not prevent or resolve PACs. Oxygen is not necessary. Although medications may be needed to control symptomatic dysrhythmias, for infrequent PACs, the client first would try lifestyle changes to control them.

A nurse teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. Which statement would the nurse include in this client's teaching? a. "Minimize or abstain from caffeine." b. "Lie on your side until the attack subsides." c. "Use your oxygen when you experience PACs." d. "Take amiodarone daily to prevent PACs."

ANS: D Clients with heart failure are instructed to weigh themselves daily to detect worsening heart failure early, and thus avoid complications. Other signs of worsening heart failure include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia. Fluid overload increases symptoms of heart failure. The client would be taught to eat a heart-healthy diet, balance intake and output to prevent dehydration and overload, and take medications as prescribed. The most important discharge teaching is daily weights as this provides the best data related to fluid retention.

A nurse teaches a client who has a history of heart failure. Which statement would the nurse include in this client's discharge teaching? a. "Avoid drinking more than 3 quarts (3 L) of liquids each day." b. "Eat six small meals daily instead of three larger meals." c. "When you feel short of breath, take an additional diuretic." d. "Weigh yourself daily while wearing the same amount of clothing."

ANS: A, B, E Health promotion activities to prevent carpal tunnel syndrome include assessing the ergonomics of the equipment being used, taking breaks to stretch fingers and wrists during working hours, and adjusting chair height to allow for good posture. The client should be allowed to participate in activities that require repetitive actions as long as precautions are taken to promote health. Pain medications are not part of health promotion activities.

A nurse teaches a client who is at risk for carpal tunnel syndrome. Which health promotion activities would the nurse include in the health teaching? (Select all that apply.) a. "Frequently assesses the ergonomics of the equipment being used." b. "Take breaks to stretch fingers and wrists during working hours." c. "Do not participate in activities that require repetitive actions." d. "Take ibuprofen to decrease pain and swelling in wrists." e. "Adjust chair height to allow for good posture."

ANS: D Gastrointestinal absorption of digoxin is erratic. Many medications, especially antacids, interfere with its absorption. Clients are taught to hold their digoxin for bradycardia; a heart rate of 80 beats/min is too high for this cutoff. Potassium and aspirin have no impact on digoxin absorption.

A nurse teaches a client who is prescribed digoxin therapy. Which statement would the nurse include in this client's teaching? a. "Avoid taking aspirin or aspirin-containing products." b. "Increase your intake of foods that are high in potassium." c. "Hold this medication if your pulse rate is below 80 beats/min." d. "Do not take this medication within 1 hour of taking an antacid."

ANS: A, B, E External fixation is a system in which pins or wires are inserted through the skin and bone and then connected to a ridged external frame. With external fixation, blood loss is less than with internal fixation, but the risk for infection is much higher. The device allows early ambulation and exercise, maintains alignment, stabilizes the fracture site, and promotes healing. The device does not increase blood supply to the tissues. The nurse would assess for distal circulation, movement, and sensation, which can be disturbed by fracture injuries and treatments.

A nurse teaches a client with a fractured tibia about external fixation. Which advantages of external fixation for the immobilization of fractures would the nurse share with the client? (Select all that apply.) a. It leads to minimal blood loss. b. It allows for early ambulation. c. It decreases the risk of infection. d. It increases blood supply to tissues. e. It promotes healing.

ANS: A, B, E The client would not submerge in water until the site has healed; after the incision is healed, the client may take showers or baths without concern for the pacemaker. The client would be instructed to report changes in heart rate or rhythm, such as rates lower than the pacemaker setting or greater than 100 beats/min. The client would be advised of restrictions on physical activity for 8 weeks to allow the pacemaker to settle in place. The client would never apply pressure over the generator and would avoid tight clothing. The client would never have MRI because, whether turned on or off, the pacemaker contains metal. The client would be advised to inform all health care providers that he or she has a pacemaker.

A nurse teaches a client with a new permanent pacemaker. Which instructions would the nurse include in this client's teaching? (Select all that apply.) a. "Until your incision is healed, do not submerge your pacemaker. Only take showers." b. "Report any pulse rates lower than your pacemaker settings." c. "If you feel weak, apply pressure over your generator." d. "Have your pacemaker turned off before having magnetic resonance imaging (MRI)." e. "Do not lift your left arm above the level of your shoulder for 8 weeks."

ANS: B A client who has heart failure would be taught to conserve energy and given an exercise plan. The client should begin walking 200-400 feet a day at home three times a week. The client should not walk until becoming short of breath because he or she may not make it back home. The lifting restriction is specifically for clients after valve replacements. Protein does help build strength, but this direction is not specific to heart failure.

A nurse teaches a client with heart failure about energy conservation. Which statement would the nurse include in this client's teaching? a. "Walk until you become short of breath, and then walk back home." b. "Begin walking 200 feet a day three times a week." c. "Do not lift heavy weights for 6 months." d. "Eat plenty of protein to build your strength."

ANS: D Traction weights should be freely hanging at all times. They should not be lifted manually or allowed to rest on the floor. The client should remain in traction during hygiene activities. The nurse would assess the client's skin and provide pin and wound care for a patient who is in traction; this would not be delegated to the AP.

A nurse teaches assistive personnel (AP) about providing hygiene for a client in traction. Which statement would the nurse include as part of the teaching about this client's care? a. "Remove the traction when re-positioning the client." b. "Assess the client's skin when performing a bed bath." c. "Provide pin care by using alcohol wipes to clean the sites." d. "Ensure that the weights remain freely hanging at all times."

ANS: B An important goal of HP2020 is to increase the proportion of adults who have had their blood pressure measured within the preceding 2 years and can state whether their blood pressure was normal or high. Participating in blood pressure screening in a public spot will best help meet that goal. The other options are all appropriate but do not specifically help meet a goal.

A nurse wants to provide community service that helps meet the goals of Healthy People 2020 (HP2020) related to cardiovascular disease and stroke. What activity would best meet this goal? a. Teach high school students heart-healthy living. b. Participate in blood pressure screenings at the mall. c. Provide pamphlets on heart disease at the grocery store. d. Set up an "Ask the nurse" booth at the pet store.

ANS: B All options are good choices for an altruistic nurse wishing to influence health outcomes; however, being involved in policy creation and health care reform is an activity specifically recognized to improve health outcomes. This action will also affect a wider population than the more local options.

A nurse wishes to participate in an activity that will influence health outcomes. What action by the nurse best meets this objective? a. Creating a transportation system for health care appointments b. Lobbying with a national organization for health care policy c. Organizing a food pantry in an impoverished community d. Running for election to the county public health board

ANS: A Showing respect for the client and family's preferences and needs is essential to ensure a holistic or "whole-person" approach to care. By assessing the effect of the client's culture on health care, this nurse is practicing client-focused care. Providing for basic needs does not demonstrate this competence. Simply telling the client about all upcoming tests is not providing empowering education. Orienting the client and family to the room is an important safety measure, but not directly related to demonstrating client-centered care

A nurse wishes to provide client-centered care in all interactions. Which action by the nurse best demonstrates this concept? a. Assesses for cultural influences affecting health care. b. Ensures that all the client's basic needs are met. c. Tells the client and family about all upcoming tests. d. Thoroughly orients the client and family to the room.

ANS: A, B, C, E, F The multiple avenues providing community-based care include hospice, "minute" or retail clinics, mobile screening and diagnostic services, telehealth, private medical practices, outpatient services, freestanding points of care, home health care, long-term ambulatory care, public health, and free clinics. Inpatient services in a hospital are not considered primary care sites.

A nurse wishes to work in a community-based practice setting. Which areas would this nurse explore for employment? (Select all that apply.) a. Hospice facility b. "Minute clinic" c. Mobile mammography unit d. Small community hospital e. Telehealth f. Home health care

ANS: B The medical home concept came into being to decrease the fragmentation of care. On a daily basis, this nurse would expect to coordinate with the interprofessional care team. Advocating with insurance companies would not be a daily function. Monthly team meetings may or may not be needed. Out of network referrals would not be needed as the interprofessional team strives to provide comprehensive care.

A nurse working in a medical home would do which of the following as part of the job? a. Advocate with insurance companies. b. Coordinate interprofessional care. c. Hold monthly team meetings. d. Provide out-of-network specialty referrals.

ANS: B, C, D Frailty is a syndrome consisting of unintentional weight loss, slowed physical activity and exhaustion, and weakness. Weight gain and dementia are not part of this syndrome. Frequent illness could occur due to frailty, but is also not part of the syndrome.

A nurse working in an Acute Care of the Elderly unit learns that frailty in the older population includes which components? (Select all that apply.) a. Dementia b. Exhaustion c. Slowed physical activity d. Weakness e. Weight gain f. Frequent illness

ANS: C Supervision is one of the five rights of delegation and includes directing, evaluating, and following up on delegated tasks. The nurse would either have asked the AP about the vital signs or instructed the AP to report them right away. An experienced AP would know how to take vital signs and the nurse would not have to assess this at this point. Double-checking the work defeats the purpose of delegation. Vital signs are within the scope of practice for a AP and are permissible to delegate. The only appropriate answer is that the nurse did not provide adequate instruction to the AP.

A nurse working on a cardiac unit delegated taking vital signs to an experienced assistive personnel (AP). Four hours later, the nurse notes that the client's blood pressure taken by the AP was much higher than previous readings, and the client's mental status has changed. What action by the nurse would most likely have prevented this negative outcome? a. Determining if the AP knew how to take blood pressure b. Double-checking the AP by taking another blood pressure c. Providing more appropriate supervision of the AP d. Taking the blood pressure instead of delegating the task

ANS: A, B, E, F Common adverse medication effects include constipation/impaction, dehydration, anorexia, and weakness. Mania and incontinence are not among the common adverse effects, although urinary retention is.

A nurse working with older adults assesses them for common potential adverse medication effects. For what does the nurse assess? (Select all that apply.) a. Constipation b. Dehydration c. Mania d. Urinary incontinence e. Weakness f. Anorexia

ANS: A All activities would be beneficial for the older population in the community. However, failure in performing one's own activities of daily living and participating in society has direct effects on morale and life satisfaction. Those who lose the ability to function independently often feel worthless and empty. An exercise program designed to maintain and/or improve physical functioning would best address this need.

A nurse working with older adults in the community plans programming to improve morale and emotional health in this population. What activity would best meet this goal? a. Exercise program to improve physical function b. Financial planning seminar series for older adults c. Social events such as dances and group dinners d. Workshop on prevention from becoming an abuse victim

B,c,d

A rock climber has sustained an open fracture of the right tibia after a 20-foot (6 m) fall 2 days ago. The nurse plans to assess the client for which potential complications? (Select all that apply.) Select all that apply. Urinary tract infection (UTI) Acute compartment syndrome (ACS) Fat embolism syndrome (FES) Osteomyelitis Heart failure

ANS: C A heart rate of 40 beats/min or less could have hemodynamic consequences. The client is at risk for inadequate cerebral perfusion. The nurse would assess for level of consciousness, dizziness, confusion, syncope, chest pain, shortness of breath. Although the other assessments would be completed, the nurse would assess the client's neurologic status next.

A telemetry nurse assesses a client who has a heart rate of 35 beats/min on the cardiac monitor. Which assessment would the nurse complete next? a. Pulmonary auscultation b. Pulse strength and amplitude c. Level of consciousness d. Mobility and gait stability

ANS: A, B, D Assessment is the first step of the nursing process and would be completed prior to intervening. Asking about transportation to get food, dentures, and normal food patterns would be part of an appropriate assessment for the client. There is no information in the question about the older adult needing to lose weight, so encouraging him or her to continue the current exercise regimen is premature and may not be appropriate. Teaching about proper nutrition is a good idea, but teaching needs to be tailored to the client's needs, which the nurse does not yet know

A visiting nurse is in the home of an older adult and notes a 7-lb weight loss since last month's visit. What actions would the nurse perform first? (Select all that apply.) a. Assess the client's ability to drive or transportation alternatives. b. Determine if the client has dentures that fit appropriately. c. Encourage the client to continue the current exercise plan. d. Have the client complete a 3-day diet recall diary. e. Teach the client about proper nutrition in the older population.

A

A young female client whose mother and grandmother have osteoporosis asks whether she needs to take steps to prevent this disease in herself. What will the nurse tell this client? "Now is the time to begin building strong bones." "Your risk isn't present until age 50; we can talk about it then." "You do not have to worry about symptoms at your age." "You should begin to take steps to prevent disease at age 30."

ANS: A, B, C, D According to the WHO, primary care involves three main areas: empowered people and communities, primary care and essential public functions, and multisectoral policy and action. Primary care focuses on both prevention and management of chronic disease.

According to the WHO, what does primary care involve? (Select all that apply.) a. Empowered people and communities b. Essential public functions c. Multisectoral policy and action d. Primary care e. Priority consideration of chronic diseases f. Elimination of chronic diseases

DVT, PE, or embolic stroke

Afib could cause

ANS: B Hypotension is a side effect of ACE inhibitors such as captopril. Clients with a fluid volume deficit should have their volume replaced or start at a lower dose of the drug to minimize this effect. The nurse would instruct the client to seek assistance before arising from bed to prevent injury from postural hypotension. ACE inhibitors do not need to be taken with food. Collaboration with assistive personnel to provide hygiene is not a priority. The client would be encouraged to complete activities of daily living as independently as possible. The nurse would monitor for hyperkalemia, not hypokalemia, especially if the client has renal insufficiency secondary to heart failure.

After administering the first dose of captopril to a client with heart failure, the nurse implements interventions to decrease complications. Which intervention is most important for the nurse to implement? a. Provide food to decrease nausea and aid in absorption. b. Instruct the client to ask for assistance when rising from bed. c. Collaborate with assistive personnel to bathe the client. d. Monitor potassium levels and check for symptoms of hypokalemia.

C

After receiving change-of-shift report about these four clients, which client would the nurse assess first? A 79 year old admitted for possible rejection of a heart transplant who has sinus tachycardia, heart rate 104 beats/min. A 55 year old admitted with pulmonary edema who received furosemide and whose current O2 saturation is 94%. A 46 year old with aortic stenosis who takes digoxin and has new-onset frequent premature ventricular contractions. A 68 year old with pericarditis who is reporting sharp chest pain with inspiration.

D

After receiving change-of-shift report in the coronary care unit, which client will the nurse assess first? The client who had a percutaneous coronary angioplasty who has a dose of heparin scheduled. A client who has first-degree heart block, rate 68 beats/min, after having an inferior myocardial infarction. The client who had bradycardia after a myocardial infarction and now has a paced heart rate of 64 beats/min. The client with acute coronary syndrome who has a 3-lb (1.4-kg) weight gain and dyspnea.

ANS: B The client being discharged with an ICD is instructed to avoid strong sources of electromagnetic fields, such as devices emitting microwaves (not microwave ovens); transformers; radio, television, and radar transmitters; large electrical generators; metal detectors, including handheld security devices at airports; antitheft devices; arc welding equipment; and sources of 60-cycle (Hz) interference. Also avoid leaning directly over the alternator of a running motor of a car or boat. Clients would avoid tight clothing, which could cause irritation over the ICD generator. The client would be encouraged to exercise but would not engage in strenuous activities that cause the heart rate to meet or exceed the ICD cutoff point because the ICD can discharge inappropriately. The client would continue all prescribed medications.

After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the client's understanding. Which statement by the client indicates correct understanding of the teaching? a. "I would wear a snug-fitting shirt over the ICD." b. "I will avoid sources of strong electromagnetic fields." c. "I would participate in a strenuous exercise program." d. "Now I can discontinue my antidysrhythmic medication."

ANS: B Clients who have defective or repaired valves are at high risk for endocarditis. The client who has had valve surgery should avoid dental procedures for 6 months because of the risk for endocarditis. When undergoing a mitral valve replacement surgery, the client needs to be placed on anticoagulant therapy to prevent vegetation forming on the new valve. Clients on anticoagulant therapy would be instructed on bleeding precautions, including using an electric razor. If the client is prescribed warfarin, the client should avoid foods high in vitamin K. Clients recovering from open-heart valve replacements should not carry anything heavy for 6 months while the chest incision and muscle heal.

After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the client's understanding. Which client statement indicates a need for additional teaching? a. "I'll be able to carry heavy loads after 6 months of rest." b. "I will have my teeth cleaned by my dentist in 2 weeks." c. "I must avoid eating foods high in vitamin K, like spinach." d. "I must use an electric razor instead of a straight razor to shave."

ANS: C Because the new heart is denervated, the baroreceptor and other mechanisms that compensate for blood pressure drops caused by position changes do not function. This allows orthostatic hypotension to persist in the postoperative period. The other options are false statements and do not correctly address the client's question

After teaching a client who is recovering from a heart transplant to change positions slowly, the client asks, "Why is this important?" How would the nurse respond? a. "Rapid position changes can create shear and friction forces, which can tear out your internal vascular sutures." b. "Your new vascular connections are more sensitive to position changes, leading to increased intravascular pressure and dizziness." c. "Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes." d. "While your heart is recovering, blood flow is diverted away from the brain, increasing the risk for stroke when you stand up."

ANS: A Before discharge, a client who has a vertebroplasty would be taught to avoid driving or operating machinery for the first 24 hours. The client should monitor the puncture site for signs of infection. Usual activities can resume slowly, including walking and slowly increasing activity over the next few days. The client should keep the dressing dry and remove it the next day.

After teaching a client who is recovering from a vertebroplasty, the nurse assesses the patient's understanding. Which statement by the client indicates a need for additional teaching? a. "I can drive myself home after the procedure." b. "I will monitor the puncture site for signs of infection." c. "I can start walking tomorrow and increase my activity slowly." d. "I will remove the dressing the day after discharge."

ANS: D The client with a healing fracture needs supplements of vitamins B and C and a high-protein, high-calorie diet. Milk for calcium supplementation and vitamin C supplementation is appropriate. Meat would increase protein in the diet that is necessary for bone healing. Fish, a sandwich, and vegetable lasagna would provide less protein.

After teaching a client with a fractured humerus, the nurse assesses the client's understanding. Which dietary choice demonstrates that the client correctly understands the nutrition needed to assist in healing the fracture? a. Baked fish with orange juice and a vitamin D supplement b. Bacon, lettuce, and tomato sandwich with a vitamin B supplement c. Vegetable lasagna with a green salad and a vitamin A supplement d. Roast beef with low-fat milk and a vitamin C supplement

ANS: A, D, E Nutritional therapy for a client with CHF is focused on decreasing sodium and water retention to decrease the workload of the heart. The client would be taught to read nutritional labels on all food items, omit table salt and foods high in sodium (e.g., ham and canned foods), and limit water intake to a normal 2 L/day. Salt substitutes typically contain potassium, so although they are not strictly banned, clients would have to have their renal function and serum potassium monitored while using them. It would be safer to avoid them.

After teaching a client with congestive heart failure (CHF), the nurse assesses the client's understanding. Which client statements indicate a correct understanding of the teaching related to nutritional intake? (Select all that apply.) a. "I'll read the nutritional labels on food items for salt content." b. "I will drink at least 3 L of water each day." c. "Using salt in moderation will reduce the workload of my heart." d. "I will eat oatmeal for breakfast instead of ham and eggs." e. "Substituting fresh vegetables for canned ones will lower my salt intake." f. "Salt substitutes are a good way to cut down on sodium in my diet."

B

An LPN/LVN is scheduled to work on the stepdown cardiac unit. Which client will the charge nurse assign to the LPN/LVN? A 69 year old who had a stent placed 2 hours ago in the left anterior descending artery and who has bursts of ventricular tachycardia. A 66 year old who has a prescription for a nitroglycerin patch and is scheduled for discharge to a long-term care later today. A 60 year old who was admitted today for pacemaker insertion because of third-degree heart block and who is now reporting chest pain. A 62 year old who underwent open-heart surgery 4 days ago for mitral valve replacement and who has a temperature of 100.8° F (38.2° C).

Beneficence

An ethical principle in which one is capable of making informed decisions about one's care

veracity

An ethical principle related to fidelity in which the nurse is obligated to tell the truth to the best of her knowledge

A

An older adult client admitted to a nursing home for rehabilitation asks the nurse if the client's care will be covered by Medicare. What response by the nurse is correct? "Medicare A should cover 100% of your rehabilitation skilled care for a limited period of time." "Medicare D should pay for the total costs of drugs you take while you are here." "Medicare G should pay 80% of your lab and x-rays while you are here." "Medicare B should pay 100% of your rehabilitation therapy sessions while you are here."

A

An older adult client admitted to the hospital for heart failure has a history of a fractured hip due to a previous fall. The client is taking hydrocodone-acetaminophen as needed for pain secondary to an extensive dental procedure. Which risk factor puts this client at greatest risk for a fall? History of a fall Age Opioid use Diagnosis

A

An older adult client has had an open reduction and internal fixation of a fractured right hip. Which intervention does the nurse implement for this client? Keep the client's heels off the bed at all times. Reposition the client every 3 to 4 hours. Avoid the use of antiembolism stockings. Administer pain medication before deep-breathing exercises.

D

An older adult client is being relocated from a home setting to a long-term care facility. Which nursing intervention best minimizes the effects of relocation stress syndrome? Providing the client with limited decision making to avoid stressful situations Explaining all procedures and routines to the client's family at the time of relocation Keeping the room clear of personal belongings to reduce the risk of falling Reorienting the client frequently to his or her new location

ANS: A Although this older adult is independent and ambulatory, being hospitalized can create confusion. Getting up in a dark, unfamiliar environment can contribute to falls. Keeping the light on in the bathroom will help reduce the likelihood of falling. The client does not need a commode or a toileting schedule. Side rails used to keep the client in bed are considered restraints and would not be used in that fashion.

An older adult client is in the hospital. The client is ambulatory and independent. What intervention by the nurse would be most helpful in preventing falls in this client? a. Keep the light on in the bathroom at night. b. Order a bedside commode for the client. c. Put the client on a toileting schedule. d. Use side rails to keep the client in bed.

ANS: C Color-coded stickers are a fast, easy-to-remember system. One color is for morning meds, one for evening meds, and the third color is for nighttime meds. Arranging medications by time in a drawer might be helpful if the person doesn't accidentally put them back in the wrong spot. Easy-open tops are not related. Writing a list might be helpful, but not if it gets misplaced. With stickers on the medication bottles themselves, the reminder is always with the medication.

An older adult client takes medication three times a day and becomes confused about which medication should be taken at which time. The client refuses to use a pill sorter with slots for different times, saying "Those are for old people." What action by the nurse would be most helpful? a. Arrange medications by time in a drawer. b. Encourage the client to use easy-open tops. c. Put color-coded stickers on the bottle caps. d. Write a list of when to take each medication.

A

An older adult client who has osteoporosis is discharged from the hospital. What does the nurse include in health teaching related to the client's home safety? "Keep walkways free of clutter." "Keep light low to prevent glare." "Walk slowly on wet floor areas after mopping." "Use area rugs on tile floors."

A

An older adult client who lives with her daughter is admitted to the hospital. During the admission assessment, the nurse notes strong body odor, several large pressure injuries, and limb contractures. What would the nurse do first? Contact the hospital social worker. Ask the daughter about the ulcers and contractures. Notify the primary health care provider. Give the client a bath.

D

An older adult client whose spouse died the previous year says to the nurse, "Life is not fun anymore." How does the nurse respond? "Why don't you go on a vacation? A change of scenery will do you good." "Are you getting enough sleep? That makes me feel better!" "How are you feeling about the death of your spouse after this length of time?" "Tell me about your support network, such as friends or family."

B

An older adult client with end-stage lung cancer and metastasis to the brain has been admitted to the hospital. After trying all options to provide a safe environment, the nursing staff has to apply restraints. Which nursing intervention is required for this client? Using chemical sedation instead of restraints Releasing the restraints at least every 2 hours Checking the restraints every 1 to 2 hours Using the most restrictive devices to prevent falls

ANS: B Medication side effects and adverse effects are common in the older population. Something as simple as a new antibiotic can cause confusion and memory loss. The nurse would determine if the client is taking any new medications. Assessments for orthostatic hypotension, gait abnormalities, and delirium may be important once more is known about the client's condition.

An older adult is brought to the emergency department because of sudden onset of confusion. After the client is stabilized and comfortable, what assessment by the nurse is most important? a. Assess for orthostatic hypotension. b. Determine if there are new medications. c. Evaluate the client for gait abnormalities. d. Perform a delirium screening test.

ANS: A Older clients may have dysrhythmias due to age-related changes in the cardiac conduction system. Or this client's dysrhythmias could be a consequence of the myocardial infarction. They may or may not have significant hemodynamic effects. The nurse would first assess for the effects of the dysrhythmia before proceeding further. The alarms on a cardiac monitor would never be shut off. The other two actions may or may not be needed.

An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate? a. Assess for any hemodynamic effects of the rhythm. b. Prepare to administer antidysrhythmic medication. c. Notify the primary health care provider or call the Rapid Response Team. d. Turn the alarms off on the cardiac monitor

ANS: C Establishing and maintaining relationships with others throughout life are especially important to the older person's happiness. When people retire, they may lose much of their social network, leading them to feeling depressed and lonely. This loss from a sudden change in lifestyle can easily lead to depression. The nurse would first assess the role that work played in the client's life. The other factors can be assessed as well, but this circumstance is commonly seen in the older population.

An older adult recently retired and reports "being depressed and lonely." What information would the nurse assess as a priority? a. History of previous depression b. Previous stressful events c. Role of work in the adult's life d. Usual leisure time activities

ANS: B Cyclobenzaprine (used for muscle spasms), ketorolac, and meperidine (both used for pain) are all on the Beers list of potentially inappropriate medications for use in older adults and would not be suggested. The nurse would suggest hydromorphone hydrochloride.

An older client had hip replacement surgery and the surgeon prescribed morphine sulfate for pain. The client is allergic to morphine and reports pain and muscle spasms. When the nurse calls the surgeon, which medication would he or she suggest in place of the morphine? a. Cyclobenzaprine b. Hydromorphone hydrochloride c. Ketorolac d. Meperidine

ANS: D The location of the client's pain indicates a possible fractured hip and therefore an x-ray of the hip is needed. A leg cast is not appropriate and oxygen may not be needed. Medication to make the client more comfortable would likely be needed after a diagnosis is determined.

An older client who fell at home is admitted to the emergency department and reports pain in her left groin and behind her left knee. What action would the nurse anticipate? a. Administer IV push morphine. b. Prepare for application of a leg cast. c. Begin oxygen at 6 L/min via mask. d. Obtain a left hip x-ray.

ANS: C In the presence of a heavily draining wound, the nurse would place the client on Contact Precautions. If the client has discomfort, acetaminophen can be used, but this client has not reported pain and is afebrile. The client may or may not need an amputation in the future. The wound care nurse may be consulted but not as the most appropriate action.

An older client with diabetes is admitted with a heavily draining leg wound. The client's white blood cell count is 38,000/mm3 (38 × 109/L) but the client is afebrile. Which nursing action is most appropriate at this time? a. Administer acetaminophen as needed. b. Educate the client on amputation. c. Place the client on Contact Precautions. d. Refer the client to the wound care nurse.

ANS: D 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 would 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.

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

C

As a result of work completed by a quality improvement (QI) team, a new nursing protocol for preventing catheter-associated urinary tract infections (CAUTIs) is piloted. Which step of the PDSA QI model is associated with this action? P D S A

B

At a follow-up homecare visit after repair of a fractured radial bone, an older adult client states, "I am not sleeping at all during the night." The client's partner reports that the client is sleeping all day. Which intervention does the nurse suggest? Taking additional pain medication during the day Increasing the client's daytime activities Placing a "Do not disturb" sign on the door at night Taking herbal remedies to enhance sleep

C

Bedside (point-of-care) computers are an example of informatics used in health care primarily for which purpose? Enhancing collaboration and coordination of care Offering clients access to email and the Internet Documenting interprofessional care Retrieving data for evidence-based practice

Fire

Before cardio version, turn off oxygen and remove from patient to prevent

C

Buck's (skin) traction for a fractured hip is applied to a client while a urinary tract infection is treated before surgery. What instruction will the nurse give assistive personnel (AP) for providing client care related to the traction? "Inspect the pins in the traction for signs of infection." "Remove the boot every shift to inspect the skin." "Do not allow the traction weights to rest on the ground." "Remove traction weights when turning the client.

secondary depression

Depression that is secondary to another diagnosis or reason. Such as depression secondary to loss of a loved one or secondary to a cancer diagnosis.

Side effects

Doctors will order a SSRI, before a tricyclic due to?

B

During discharge planning after admission for a myocardial infarction, the client says, "I won't be able to increase my activity level. I live in an apartment, and there is no place to walk." Which nursing response is appropriate? "You must find someplace to walk." "Where might you be able to walk?" "You are right. Focus more on your diet." "Walk around the edge of your apartment complex."

inhibit clotting

Garlic and ibuprofen can

Frailty

Geriatric syndrome in which older adults has unintentional weight loss, weakness, exhaustion, slowed physical activity

Adenosine

Given to get a normal sinus rhythm

9-10.5

Normal calcium

3.5-5

Normal potassium level

136-145

Normal sodium level

5-10

Normal wbc

ANS: D Analyzing cues lead to a list of potential hypotheses. The nurse prioritizes them, determines the desired outcomes, generates solutions, and acts. This is part of the six-step clinical judgment model.

Once the nurse has considered all possible collaborative and client problems, what action does the nurse take next? a. Act on the observed cues. b. Determine desired outcomes. c. Generate solutions. d. Prioritize the hypotheses.

Fatal dysrhythmia

People who use cocaine and illicit inhalants are at risk of

ANS: B, C, F Clients have many concerns about resuming sexual activity after an acute coronary event. Generally, once the client can walk one block or climb two flights of stairs, he or she can tolerate sex. The client should start after a period of rest and at least 11/2 hours after a heavy meal or exercise. Clients should be taught to choose a position that is comfortable for both parties and does not place undue stress on their incisions or on their hearts.

Prior to discharge, a client who had an acute myocardial infarction and coronary artery bypass graft asks the nurse about sexual activity. What information does the nurse provide? (Select all that apply.) a. "You will need to wait at least 6 weeks before intercourse.' b. "Your usual sexual activity is not likely to damage your heart." c. "Start having sex when you are most rested, like in the morning." d. "When you can climb four flights of stairs, you can tolerate sex." e. "Don't eat for three hours before engaging in sexual activity." f. "Use a comfortable position that doesn't stress your incision."

Plantar fasciitis

Severe pain in arch of foot especially when getting out of bed

B

The RN is arriving for night shift at an acute care hospital. Which client does the RN assess first? A 70 year old with a history of gout and joint pain A 72 year old admitted with postoperative delirium A 65 year old scheduled for next-day surgery A 68 year old with chronic protein-calorie malnutrition

D

The cardiac care unit charge nurse is assigning clients to the oncoming shift. Which patient is appropriate to assign to a float RN from the medical-surgical unit? A 92-year-old client admitted with chest pain who has premature ventricular complexes and a heart rate of 102 beats/min. An 88-year-old client admitted with elevated troponin level who is hypotensive with a heart rate of 96 beats/min. A 71-year-old client admitted for heart failure who is shortness of breath and has a heart rate of 120 to 130 beats/min. A 64-year-old client admitted for weakness with sinus bradycardia and heart rate 58 beats/min.

B

The client in the cardiac care unit has had a large myocardial infarction. What assessment data indicates to the nurse the onset of left ventricular failure? Expectoration of yellow sputum Crackles in the lung fields Pedal edema Urine output of 1500 mL on the preceding day

ANS: A, B, C, E Critical thinking must be based on logic, creativity, and intuition; driven by patient, family, or community needs; focused on safety and quality; guided by standards, policies, ethics, and laws; based on principles of nursing process, problem-solving, and the scientific method (requires forming opinions and making decisions based on evidence); centered on identification of the key problems, issues, and risks; and grounded in strategies that make the most of human potential. It is not dependent on using a specific theory.

The expert nurse understands that critical thinking requires which elements to be present? (Select all that apply.) a. Based on logic, creativity, and intuition b. Driven by needs c. Focused on safety and quality d. Grounded in a specific theory e. Guided by standards f. Requires forming options about evidence

A

The home health nurse visits a client with heart failure who has gained 5 lb (2.3 kg) in the past 3 days. The client states, "I feel so tired and short of breath." Which action does the nurse take first? Auscultate the client's posterior breath sounds. Notify the health care provider about the client's weight gain. Remind the client about dietary sodium restrictions. Assess the client for peripheral edema.

ANS: C The context of a situation considers and supports clinical judgment. The factors within this layer—such as environment, time pressure, availability or content of electronic health records, resources, and individual nursing knowledge—have a direct impact on clinical judgment. The other two options are too vague to provide appropriate information.

The new nurse asks the preceptor how context affects clinical judgment. What response by the preceptor is best? a. "Context considers the whole of the patient's story and circumstances." b. "It shouldn't, only nursing knowledge would affect clinical judgment." c. "Outside influences such as environment in which you provide care, influence your decisions." d. "The context of the situation provides an extra layer of complexity to consider."

ANS: C Clients who use cocaine or illicit inhalants are particularly at risk for potentially fatal dysrhythmias. The other responses do not adequately address the client's question.

The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, "Why do you want to know if I use cocaine?" What is the nurse's best response? a. "Substance abuse puts clients at risk for many health issues." b. "The hospital requires that I ask you about cocaine use." c. "Clients who use cocaine are at risk for fatal dysrhythmias." d. "We can provide services for cessation of substance abuse."

ANS: B, C, E With a pelvic fracture, internal organ damage may result in bleeding and hypovolemic shock. The nurse monitors the client's heart rate, blood pressure, urine output, skin color, and level of consciousness frequently to detect assess for shock. It is important to monitor the urine for blood to assess whether the urinary system has been damaged with the pelvic fracture. Changes in temperature and pupil reactions are not directly associated with hypovolemic shock. Temperature changes are usually associated with hypo- or hyperthermia or infectious processes. Pupillary changes occur with brain injuries, bleeds, or strokes.

The nurse assesses a client who is admitted with a pelvic fracture. Which assessments would the nurse monitor to prevent or detect a complication of this injury? (Select all that apply.) a. Temperature b. Urinary output c. Blood pressure d. Pupil reaction e. Skin color

B

The nurse discusses the importance of restricting sodium in the diet for a client with heart failure. Which client statement indicates the need for further teaching? "I won't put the salt shaker on the table anymore." "I need to avoid eating hamburgers." "I need to avoid lunchmeats but may cook my own turkey." "I must cut out bacon and canned foods."

C, D, E

The nurse in the cardiology clinic is reviewing teaching provided at the client's last appointment regarding hypertension management. Which actions by the client indicate that teaching has been effective? (Select all that apply.) Select all that apply. Reports walking the neighborhood once weekly. Reports eating fast food frequently to cut down on food costs. Weight loss of 3 lb (1.4 kg) since last seen in the clinic. Reports eating a low-sodium diet. Reports drinking one less cup of coffee daily.

A

The nurse in the coronary care unit is caring for a group of clients who have had a myocardial infarction. Which client will the nurse see first? Client with third-degree heart block on the monitor Client with dyspnea on exertion when ambulating to the bathroom Client who refuses to take heparin or nitroglycerin Client with normal sinus rhythm and PR interval of 0.28 second

B, C, D, F

The nurse is assessing a 54-year-old male client for risk of atherosclerosis. What assessment data is associated with an increase in risk? (Select all that apply.) Select all that apply. Takes acetylsalicylic acid daily. BMI is 32. History of type 2 diabetes mellitus. LDL of 160 mg/dL. The client's father has lung cancer. Current smoking history.

ANS: A,C Draining sinus tracts and foot ulcers are seen in chronic osteomyelitis. High fever, swelling, and redness are more often seen in acute osteomyelitis. Pain or tenderness can be in either case.

The nurse is assessing a client for chronic osteomyelitis. Which features distinguish this from the acute form of the disease? (Select all that apply.) a. Draining sinus tracts b. High fevers c. Presence of foot ulcers d. Swelling and redness e. Tenderness or pain

C

The nurse is assessing a client with a cardiac infection. Which nursing assessment data causes the nurse to suspect infective endocarditis instead of pericarditis or rheumatic carditis? Thickening of the endocardium Pain aggravated by breathing, coughing, and swallowing Splinter hemorrhages Friction rub auscultated at the left lower sternal border

B, D, F

The nurse is assessing a client with arterial insufficiency. What assessment data would cause the nurse to suspect an acute arterial occlusion of the right lower extremity? (Select all that apply.) Select all that apply. Tachycardia Mottling of right foot and lower leg Bounding right pedal pulses Numbness and tingling of right foot Hypertension Cold right foot

C

The nurse is assessing a client with chest pain to evaluate whether the client is experiencing angina or myocardial infarction (MI). Which assessment is indicative of an MI? Chest pain brought on by exertion or stress. Substernal chest discomfort relieved by nitroglycerin or rest Substernal chest pressure relieved only by opioids Substernal chest discomfort occurring at rest.

B, D

The nurse is assessing a client with right-sided heart failure. What assessment findings will the nurse anticipate? (Select all that apply.) Select all that apply. Oliguria Ascites Pulmonary congestion Peripheral edema Shortness of breath Third heart sound

All of them

The nurse is assessing an older adult client to identify possible factors that may negatively impact the client's nutritional status. Which risk factors would the nurse include? (Select all that apply.) Select all that apply. Loneliness or depression Inadequate financial resources Constipation Lack of transportation Tooth loss or poorly fitting dentures Decreased mobility

D

The nurse is assessing an older adult client who has severe kyphosis. What psychosocial client problem would the nurse anticipate? Dementia Bipolar disorder Psychosis Depression

D

The nurse is assessing an older adult client's alcohol use. Which client statement warrants a follow-up collection of more data? "I had three glasses of champagne at my granddaughter's wedding last month." "I am a 'teetotaler'; I never drink anything alcoholic." "I like to have a glass of wine every once in a while." "I usually drink two vodkas to help me get to sleep each night."

A

The nurse is assessing the nutritional status of an older adult client. Which statement made by the client needs to be explored further? "For protein in my diet, I like to get the fish sandwich and fries at the fast-food drive-through at least three times a week." "With less activity and exercise in my life these days, I should reduce my total calorie intake." "To keep my bowel movements regular, I try to eat some fresh fruits or vegetables each day." "Although I enjoy eating sweets and desserts, I need to balance them with healthier foods."

D

The nurse is caring a college athlete who collapsed during soccer practice. The client has been diagnosed with hypertrophic cardiomyopathy and states, "This can't be. I am in great shape. I eat right and exercise." Which nursing response is appropriate? "How does this make you feel?" "This can be caused by taking performance-enhancing drugs." "It could be worse if you weren't in good shape." "This may be caused by a genetic trait."

C

The nurse is caring for a client 36 hours after coronary artery bypass grafting. Which assessment causes the nurse to terminate an activity and return the client to bed? Incisional discomfort HR 72 beats/min and regular Respiratory rate 28 breaths/min Urinary frequency

D

The nurse is caring for a client immediately after a vertebroplasty. In what position would the nurse most likely place the client? Prone for the first 1 to 2 hours High-Fowler for the first hour Side-lying for the first 2 hours Flat supine for the first 1 to 2 hours

A, c, d, e, f

The nurse is caring for a client who is at risk for osteoporosis. What lifestyle changes might the client be able to implement to decrease this risk? (Select all that apply.) Select all that apply. Avoiding excessive alcohol consumption Increasing foods high in phosphorus Decreasing consumption of carbonated beverages Preventing a sedentary daily lifestyle Seeking a smoking cessation program, if needed Including more calcium-rich foods into the diet

A

The nurse is caring for a client who is diagnosed with osteopenia. Which T-score will the nurse expect to see for this client after a bone mineral density (BMD) test? −2 −3 0 to −1 +1.5

C

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

ANS: B, C, D, E, F All of the choices are correct except that the client should stay in a flat supine position immediately after the procedure.

The nurse is caring for a client who just had a kyphoplasty. What nursing care is needed for the client at this time? (Select all that apply.) a. Place the client in a prone position to prevent pressure on the surgical area. b. Apply an ice pack to the surgical area to help relieve pain. c. Assess the client's pain level to compare it with pain before the procedure. d. Take vital signs, including oxygen saturation, frequently. e. Monitor for complications such as bleeding or shortness of breath. f. Perform frequent neurologic assessments and report major changes.

ANS: A, C, D, E The client who experiences a sports injury should be managed using the RICE treatment plan. Rest, ice, compression, and elevation are all appropriate. Heat would increase swelling and probably pain. An x-ray would be obtained to determine if one or more fractures are present. Opioids may not be needed depending on the nature of the injury.

The nurse is caring for a client who recently sustained a sports injury to his right leg. What nursing interventions are appropriate for this client? (Select all that apply.) a. Immobilize the right leg. b. Apply heat immediately after the injury. c. Use compression to support the leg. d. Obtain an x-ray to detect possible fracture. e. Elevate the right leg to decrease swelling. f. Administer an opioid every 4 to 6 hours.

ANS: B If the drainage in the chest tube decreases significantly and dramatically, the tube may be blocked by a clot. This could lead to cardiac tamponade. The nurse would notify the primary health care provider immediately. The nurse would not independently increase the suction, reposition the chest tube, or take the tubing apart.

The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage stops suddenly. What action by the nurse is most important? a. Increase the setting on the suction. b. Notify the primary health care provider immediately. c. Reposition the chest tube. d. Take the tubing apart to assess for clots.

D

The nurse is caring for a client with peripheral arterial disease (PAD). Which symptom will the nurse anticipate? Decreased pain when legs are elevated Unilateral swelling of affected leg Pulse oximetry reading of 90% Reproducible leg pain with exercise

C

The nurse is caring for a female client who has a right wrist ganglion which is interfering with her ability to do her job as an administrative assistant. What collaborative treatment would the nurse anticipate for this client? Physical therapy Occupational therapy Removal of the ganglion Intravenous antibiotic therapy

D

The nurse is caring for a patient on a telemetry unit who has a regular heart rhythm and rate of 60 beats/min; a P wave precedes each QRS complex, and the PR interval is 0.20 second. Additional vital signs are: blood pressure 118/68 mm Hg, respiratory rate 16 breaths/min, and temperature 98.8° F (37° C). All of these medications are available on the medication record. What action will the nurse take? Administer clonidine. Administer atropine. Administer digoxin. Continue to monitor.

B

The nurse is caring for a patient with acute coronary syndrome (ACS) and atrial fibrillation who has a new prescription for metoprolol. Which data is essential for the nurse to assess prior to administration? Troponin Heart rate ST segment Myoglobin

ANS: D A regional nerve blockade can last for about 24 hours so the client has little to no pain until it wears off. The blockade is localized and therefore does not cause nausea or vomiting.

The nurse is caring for a postoperative client who have a regional nerve blockade for a surgical tibial fracture repair this morning. What assessment finding would the nurse expect? a. Client reports nausea and vomiting. b. Client reports tingling in the surgical leg. c. Client responds well to imagery. d. Client reports little to no pain.

ANS: D Rheumatoid arthritis often occurs in young female adults and can lead to osteoporosis as a common complication. Cushing disease (rather than Addison disease) and hyperthyroidism (rather than hypothyroidism) are also risk factors. Osteoarthritis is a joint disease.

The nurse is caring for a young client who has been diagnosed with osteopenia. Which risk factor in the client's history most likely contributed to the bone loss? a. Osteoarthritis b. Hypothyroidism c. Addison disease d. Rheumatoid arthritis

A, C, E

The nurse is caring for an adult client who has been prescribed quetiapine last year for bipolar disorder. For which adverse drug effects would the nurse observe? (Select all that apply.) Select all that apply. Urinary retention Hypoglycemia Restlessness Hypertension Parkinsonism

A

The nurse is caring for an older adult client diagnosed with osteomalacia. The nurse anticipates that the primary health care provider will request which supplement? Vitamin D3 Vitamin C Calcium Phosphorus

D

The nurse is caring for an older client who has a large bulky lower leg dressing with posterior splint to maintain alignment after closed reduction for an ankle fracture. Which client assessment finding would the nurse report to the primary health care provider or Rapid Response Team immediately? Affected foot slightly cooler than the other foot. Reports pain level is 4 on a 0-10 pain intensity scale. Pedal pulse on affected foot is 1+ and regular. Reports tingling and numbness in affected foot.

ANS: A Furosemide is a loop diuretic and can cause hypokalemia. A potassium level of 2.1 mEq/L is quite low and would 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 clients. Which drug-laboratory value combination would the nurse report immediately to the health care provider? a. Furosemide/potassium: 2.1 mEq/L b. Hydrochlorothiazide/potassium: 4.2 mEq/L c. Spironolactone/potassium: 5.1 mEq/L d. Torsemide/sodium: 142 mEq/L

ANS: D Clients on bisphosphonates must be able to sit upright for 30 to 60 minutes after taking them. The client who cannot tolerate sitting up is not a good candidate for this class of drug. Poor renal function also makes clients poor candidates for this drug, but the client with a creatinine of 0.8 mg/dL (61 mcmol/L) is within normal range. Diabetes and hypertension are not related unless the client also has renal disease. The client who recently fell and sustained fractures is a good candidate for this drug if the fractures are related to osteoporosis.

The nurse is caring for several clients with osteoporosis. For which client would bisphosphonates not be a good option? a. Client with diabetes who has a serum creatinine of 0.8 mg/dL (61 mcmol/L). b. Client who recently fell and has vertebral compression fractures. c. Hypertensive client who takes calcium channel blockers. d. Client with a spinal cord injury who cannot tolerate sitting up

D

The nurse is comparing the clinical judgment measurement model (CJMM) and the nursing process. Which step of the CJMM is specific to analysis? Generate solutions Take actions Recognize cues Prioritize hypothesis

B

The nurse is conducting a medication assessment on an older adult client who is being admitted to a long-term care facility for rehabilitation following a total hip arthroplasty. With Beers Criteria used as a resource, which drug poses a potential risk for this client? Acetaminophen Digoxin Celecoxib Mesalamine

D

The nurse is designing a program to make vaccines available to as many people as possible. Into which environment is the vaccine most likely to be introduced first? Medical home Inpatient care Long-term care Community Health Center

A, C, D, E

The nurse is discussing how context influences clinical judgment. What nursing considerations reflect context? (Select all that apply.) Select all that apply. Environment of care Taking a client's temperature Availability of electronic health records Time pressures within the unit Individual nursing knowledge

ANS: B 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.

The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates that 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

A

The nurse is evaluating factors that influence care for a client with diabetes. Which client statement does the nurse identify that reflects a social determinant of health? "The grocery store in my neighborhood went out of business." "The landlord of my apartment is putting in an access ramp for wheelchairs." "I work with a lot of toxic chemicals in my job." "Because I live on the bus line, I can ride over to park if I want to get fresh air."

C

The nurse is instructing a local community group about ways to reduce the risk for musculoskeletal injury. What information will the nurse include in the teaching plan? "Avoid rigorous exercise." "Avoid contact sports." "Wear helmets when riding a motorcycle." "Avoid driving in inclement weather."

A, C, D, E

The nurse is interviewing a transgender client about sexual orientation, gender identity, and health care. Which questions are appropriate as part of the interview? (Select all that apply.) Select all that apply. "Have you disclosed your gender identity and sexual orientation to your primary health care provider?" "Do you have problems being accepted because you are different?" "If you have more than one sexual partner, how are you protecting both of you from infections?" "Do you have sex with men, women, both, or neither?" "Are you in a relationship with someone who lives with you?"

ANS: D The normal capillary refill is usually 3 seconds, but for older adults, the refill usually takes up to 5 seconds due to vascular changes associated with aging.

The nurse is performing a neurovascular assessment for an older client who has an extremity fracture. How many seconds would the nurse expect for a capillary refill in it is within normal range? a. 20 seconds b. 15 seconds c. 10 seconds d. 5 seconds

ANS: C The most common assessment finding is the client's report of severe pain in the arch of the foot, especially when walking. The other findings are not typical in clients with this health problem.

The nurse is performing an assessment of a client with possible plantar fasciitis in the right foot. What assessment finding would the nurse expect in the right foot? a. Multiple toe deformities b. Numbness and paresthesias c. Severe pain in the arch of the foot d. Redness and severe swelling

B

The nurse is preparing to administer digoxin as prescribed to a client with heart failure and notes: Temperature: 99.8° F (37.7° C), Pulse: 48 beats/min and irregular, Respirations: 20 breaths/min, Potassium level: 3.2 mEq/L (3.2 mmol/L). What action will the nurse take? Hold the digoxin, and obtain a prescription for an additional dose of furosemide. Hold the digoxin, and obtain a prescription for a potassium supplement. Give the digoxin; document assessment findings in the medical record. Give the digoxin; reassess the heart rate in 30 minutes.

ANS: D To prevent a sternal wound infection, the nurse washes hands or performs hand hygiene as a priority and uses sterile technique when changing the dressing. Vital signs do not necessarily need to be assessed beforehand. A mask and gown are not needed. The nurse would gather needed supplies, but this is not the priority.

The nurse is preparing to change a client's sternal dressing. What action by the nurse is most important? a. Assess vital signs. b. Don a mask and gown. c. Gather needed supplies. d. Perform hand hygiene.

C

The nurse is preparing to give multiple prescribed medications to an older adult client. Which serum laboratory test value would the nurse review as the priority prior to medication administration? Blood urea nitrogen Hematocrit Creatinine Sodium

B, C, D, E

The nurse is preparing to teach a client that metabolic syndrome can increase the risk for myocardial infarction (MI). Which signs of metabolic syndrome will the nurse include? (Select all that apply.) Select all that apply. Elevated homocysteine levels Truncal obesity Client taking losartan Glucose intolerance Hypercholesterolemia

D

The nurse is providing care for a client who recently had a brain attack. Which member of the interprofessional health care team does the nurse identify that can help the client improve skills to perform ADLs? Assistive personnel Physical therapist Licensed social worker Occupational therapist

D

The nurse is providing discharge teaching to a client with heart failure, focusing on when to seek medical attention. Which client statement indicates understanding of the teaching? "I should expect occasional chest pain." "I will try walking for 1 hour each day." "I will report to the provider weight loss of 2 to 3 lb (0.9 to 1.4 kg) in a day." "I will call the provider if I have a cough lasting 3 or more days."

ANS: A, B, D Elevated levels of lipids (fats) such as low-density lipoprotein cholesterol (LDL-C) and decreased levels of high-density lipoprotein cholesterol can cause chemical damage to blood vessel walls. Smoking can cause endothelial damage in addition to increasing a client's carbon monoxide levels. African American and Hispanic ethnicities carry an increased risk for atherosclerosis. Hypertension does increase atherosclerosis risk, but an elevated reading on one occasion is not classified as hypertension.

The nurse is reviewing risk factors in a client who has atherosclerosis. Which findings are most concerning? (Select all that apply.) a. Elevated low-density lipoprotein (LDL-C) b. Decreased levels of high-density lipoprotein cholesterol (HDL-C) c. Asian ethnicity d. History of smoking e. Blood pressure: 142/92 mm Hg on one occasion

A

The nurse is reviewing the laboratory test results of a client with a recently diagnosed osteosarcoma. What abnormal laboratory finding would the nurse expect for this client? Elevated alkaline phosphatase Decreased hematocrit Increased calcium Increased white blood cell count

A

The nurse is talking to a group of active senior citizens about making healthy lifestyle choices. Which suggestion is most important in promoting health and safety? "Enroll in a safe driving refresher course and avoid risky driving situations." "Continue to eat healthy foods, especially protein." "Walk 30 minutes three to five times a week." "Seek counseling for depression, because it is not a normal part of aging."

A, E, F

The nurse is teaching a class of older adults about ways to promote their cognitive health. Which collaborative interventions will be most helpful for them? (Select all that apply.) Select all that apply. Joining a peer group with a common learning goal Meditating for 30 minutes every day Allowing for increased rest and relaxation time Having solitary times to reminisce about life experiences Starting a new physical activity Learning a new skill

C

The nurse is teaching a class on clinical judgment. What teaching will the nurse include? Clinical judgment is a fixed process. Clinical judgment is not required to make an informed decision. Clinical judgment is an outcome of critical thinking. Clinical judgment happens outside the context of the scenario.

B, E, F

The nurse is teaching a class on systems thinking in nursing. What teaching will the nurse include? (Select all that apply.) Select all that apply. Systems thinking is not affected by health policy at the national level. The complexity of client care can affect systems thinking. Systems thinking shifts the focus from safety to quality in care. It is important for the nurse to place all focus on individualized client care. Systems thinking allows the nurse to assess the root of problems. Interprofessional, collaborative care is fostered when using systems thinking.

A

The nurse is teaching a client about the risk for bradydysrhythmias. What teaching will the nurse include? "Use a stool softener." "Stop smoking and avoid caffeine." "Avoid potassium-containing foods." "Take nitroglycerin for a slow heartbeat.

ANS: A The cane should be placed on the unaffected side (left for this client) and moved forward with the injured leg (right for this client) to provide support. The cane should be parallel to the stylus of the wrist and used at all times when ambulating.

The nurse is teaching a client how to use a cane after a right surgical fractured fibula repair. What health teaching would the nurse include? a. "Place the cane on your left side." b. "Move the cane and your left leg at the same time." c. "Be sure the cane is parallel to your waist." d. "Use the cane only when your right leg is painful."

C

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

A, D, F

The nurse is teaching a client with a new pacemaker. What teaching will the nurse include? (Select all that apply.) Select all that apply. Do not lean over electrical or gasoline motors. Take your pulse for 20 seconds each day and record the rate. You may bathe, taking only showers. Be sure that you remember the rate at which your pacemaker is set. Avoid the use of microwave ovens. Avoid sudden, jerky movements for 8 weeks.

A

The nurse is teaching a client with a new permanent pacemaker. Which client statement indicates a need for further teaching? "I no longer need my heart pills." "I need to take my pulse every day." "I will be able to shower again soon." "I might trigger airport security metal detectors."

C

The nurse is teaching a client with atrial fibrillation about a new prescription for warfarin. What teaching will the nurse include? "Avoid caffeinated beverages." "You would take aspirin or ibuprofen for headache." "Report bruising to your health care provider." "It is important to consume a diet high in green leafy vegetables."

A

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

B

The nurse is teaching a postmenopausal client about the need for bone health and screening. What diagnostic test would the nurse recommend? Serum Vitamin D Dual x-ray absorptiometry (DXA) Serum calcium and phosphorus Vertebral x-rays

B, C, E, F

The nurse is teaching the client dietary methods to reduce LDL levels. What teaching will the nurse include? (Select all that apply.) Select all that apply. Aim for 10% of calories from saturated fat Limit trans-fat intake. Emphasize the intake of whole grains. Avoid cooking with all oil. Nuts are a good snack food. Try to purchase skinless chicken to cook with.

ANS: A, C, D, E The phases of clinical reasoning include assessing (noticing cues), analyzing (interpreting data), planning (anticipatin g consequences and setting priorities), implementing, and evaluating. Delegating appropriately is not included in this model.

The nurse manager is conducting an annual evaluation of a staff nurse and is appraising the nurse's clinical reasoning. What nurse actions does the manager observe to help form this judgment? (Select all that apply.) a. Anticipating consequences of actions b. Delegating appropriately c. Interpreting data d. Noticing cues e. Setting priorities

A, B, C, D, E, F

The nurse provides client-centered care for an older client who was admitted from an assisted living facility. What attributes would the nurse demonstrate when providing care for this client? (Select all that apply.) Select all that apply. Physical comfort Emotional support Client respect Communication and education Care coordination Transition and continuity of care

B

The nurse receives a report that a client with a pacemaker has experienced loss of capture. What assessment data would the nurse anticipate? The heart rate is 42 beats/min, and no pacemaker spikes are seen on the rhythm strip. The patient demonstrates hiccups. Pacemaker spikes are noted, but no P wave or QRS complex follows. The pacemaker spike falls on the T wave.

All of them

The nurse recognizes that older adult clients when admitted to the hospital are at high risk for complications and even death. Which risk factors are considered "markers" that can contribute to these negative outcomes? (Select all that apply.) Select all that apply. Sleep disorders Falls Nutritional problems Confusion Incontinence

B

The nurse requests a conference with members of the interprofessional health care team regarding care for a complex client. Which Interprofessional Education Collaborative Competency does this request represent? Role-Responsibilities Interprofessional Communication Values/Ethics for Interprofessional Practice Teams and Teamwork

ANS: C, D, E Several classes of drugs can cause secondary osteoporosis, including barbiturates, corticosteroids, and loop diuretics. Antianxiety agents and antibiotics are not associated with the formation of osteoporosis.

The nurse reviews a list of drugs that can cause secondary osteoporosis.Which drugs are most commonly associated with this health problem? (Select all that apply.) a. Antianxiety agents b. Antibiotics c. Barbiturates d. Corticosteroids e. Loop diuretics

C

The nurse supports the client and family in deciding on a "Do Not Resuscitate" order. Which ethical principle that guides nursing clinical decision making is demonstrated in this situation? Legality Beneficence Self-determination Justice

C

The nurse suspects that a client may have plantar fasciitis if the client has which assessment finding? Dorsiflexion of any metatarsophalangeal (MTP) joint, with plantar flexion of the adjacent proximal interphalangeal (PIP) joint A small tumor in a digital nerve of the foot Severe pain in the arch of the foot, especially when getting out of bed Lateral deviation of the great toe; first metatarsal head becomes enlarged

ANS: C Anyone who has osteoporosis is at risk for fragility fractures even if he or she does not experience trauma like a fall. The client needs to keep active rather than stay in bed where more bone could be lost. High-calcium foods may not be helpful because bone loss is already severe. There is no indication that the client needs assistance with ADLs.

The nurse teaches assistive personnel (AP) about care of an older adult diagnosed with osteoporosis. What teaching would the nurse include? a. "Teach the client to eat high-calcium foods in the diet." b. "Assist the client with activities of daily living." c. "Osteoporosis places the client is at risk for fractures." d. "The client should stay in bed to prevent falling."

ANS: A Patient-centered care is a QSEN competency that recognizes the patient or caregiver as the source of control and full partner in providing compassionate and coordinated care based on respect for the patient's preferences, values, and needs. QSEN is a project addressing the challenge of preparing future nurses with the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the health care systems in which they work. Critical thinking is the application of purposeful, informed, and outcome-focused care. The ability to use best evidence and practice when making care-related decisions is evidence-based practice.

The nurse understands which information regarding patient-centered care? a. A competency recognizing the client as the source of control of his or her care b. A project addressing challenges in implementing patient-centered care c. Purposeful, informed, and outcome-focused care of clients or families d. The ability to use best evidence and practice when making care-related decisions

ANS: B, C, D, E EBP consists of utilizing current evidence, the client's values and preferences, and the nurse's expertise when planning care. It does not include cost-saving measures. The PDSA model is a systematic model for quality improvement, but is not a specific component of EBP.

The nurse utilizing evidence-based practice (EBP) considers which factors when planning care? (Select all that apply.) a. Cost-saving measures b. Nurse's expertise c. Client preferences d. Research findings e. Values of the client f. Plan-do-study-act model

ANS: A, D, E, F Atherosclerosis, hypertension, hyperlipidemia, hyperlipidemia, and smoking are the most commonly related factors. Down syndrome and heartburn have no relation to aneurysm formation.

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

ANS: C Milrinone, is a positive inotrope, is a medication that increases the strength of the heart's contractions. It is not a vasoconstrictor, a vasodilator, nor does it slow the heart rate.

The primary health care provider requests the nurse start an infusion of milrinone on a client. How does the nurse explain the action of this drug to the client and spouse? a. "It constricts vessels, improving blood flow." b. "It dilates vessels, which lessens the work of the heart." c. "It increases the force of the heart's contractions." d. "It slows the heart rate down for better filling."

D

The son of an older adult client states that he has noticed progressive periods of forgetfulness in his father over the past year. After noting the son's comments and assessing the client, which cognitive problem does the nurse suspect the client may have? Depression Delirium Drug adverse effects Dementia

A

To assess if a client has had a myocardial infarction (MI), which lab value will the nurse assess? Troponin Total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol Creatine kinase-MB fraction (CK-MB) and alkaline phosphatase Homocysteine and C-reactive protein

ANS: D The components of clinical reasoning include assessing, analyzing, planning, implementing, and evaluating. This nurse shows the ability to analyze by interpreting the meaning of the lab value, to plan by anticipating the consequences of the lab value, and to implement by taking action.

To demonstrate clinical reasoning skills, what action does the nurse take? a. Collaborating with co-workers to buddy up for lunch breaks b. Delegating frequent vital signs on a new postoperative patient c. Documenting a complete history and physical on an admission d. Requesting the provider order medication for a client with high potassium

ANS: A Women are more at risk of developing primary osteoporosis after menopause due to the lack of estrogen. Men have a slower loss of bone after the age of 75. Many treatments are now available for women to slow osteoporosis after menopause.

What information does the nurse teach a women's group about osteoporosis? a. "Primary osteoporosis occurs in postmenopausal women due to lack of estrogen." b. "Men actually have higher rates of the disease but are underdiagnosed." c. "There is no way to prevent or slow osteoporosis after menopause." d. "Women and men have an equal chance of getting osteoporosis."

ANS: B, C, D The three Es 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. High impact aerobics is not encouraged and is not a comfort measure.

What nonpharmacologic comfort measures would the nurse include in the plan of care for a client with severe varicose veins? (Select all that apply.) 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 f. Encouraging participation in high impact aerobic activity

Pericardial effusion.

What puts patients at risk for cardiac tamponade

Sweets and salts

What two things diminish as a person ages

B

What will the nurse recommend as the most appropriate way to decrease the risk for osteoporosis in a client who has just been determined to be at high risk for the disease? Increase nutritional intake of phosphorus. Walk for 30 minutes three times a week. Increase nutritional intake of calcium. Engage in high-impact exercise, such as running.

A

When caring for a client with an abdominal aortic aneurysm (AAA), the nurse suspects dissection of the aneurysm when the client makes which statement? "I have a headache. May I have some acetaminophen?" "I have had hoarseness for a few weeks." "I feel my heart beating in my abdominal area." "I just started to feel a pain in my belly and low back."

D

When developing a standardized plan of care for clients with a diagnosis of pneumonia, how does the nurse find the best information about providing optimal nursing care? Survey experienced RNs about which nursing actions are effective when caring for clients with pneumonia. Research the most recent articles in nursing magazines that discuss care for clients with pneumonia. Review the chart to determine what primary health care provider's prescriptions are frequently written for clients with pneumonia. Access a website that reports on randomized controlled studies on nursing care for clients with pneumonia.

ANS: A Autonomy is self-determination. The client would make decisions regarding care. When the nurse obtains a signature on the consent form, assessing if the client still has questions is vital, because without full information the client cannot practice autonomy. Giving accurate information is practicing with veracity. Keeping promises is upholding fidelity. Treating the client fairly is providing social justice.

Which action by the nurse working with a client best demonstrates respect for autonomy? a. Asks if the client has questions before signing a consent. b. Gives the client accurate information when questioned. c. Keeps the promises made to the client and family. d. Treats the client fairly compared to other clients.

C

Which assessment data indicates proper function of the sinoatrial (SA) node? The QRS complex is present. The ST segment is elevated. The PR interval is 0.24 second. A P wave precedes every QRS complex.

B, C, D

Which atypical symptoms may be present in a female client experiencing myocardial infarction (MI)? (Select all that apply.) Select all that apply. Sharp, inspiratory chest pain Dyspnea Extreme fatigue Dizziness Anorexia

B, C, D

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

C

Which client is best to assign to an LPN/LVN working on the telemetry unit? Client with pericarditis who has a paradoxical pulse and distended jugular veins. Client with heart failure who is receiving dobutamine. Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea. Client with rheumatic fever who has a new systolic murmur.

B

Which client situation reflects the health care system of managed care? A client obtains vaccinations at a local community health center that is close to home. A client receives an annual physical where the cost has been predetermined as $80. A client sees a designed family physician who coordinates all aspects of the client's care. A client with abdominal pain is admitted to a hospital for 24 hours of observation.

D

Which client who has just arrived in the emergency department does the nurse assess as emergent and in need of immediate medical evaluation? A 64 year old with chronic venous ulcers who has a temperature of 100.1° F (37.8° C). A 60 year old with venous insufficiency who has new-onset right calf pain and tenderness. A 69 year old with a 40-pack-year cigarette history who is reporting foot numbness. A 70 year old with a history of diabetes who has "tearing" back pain and is diaphoretic.

All of them

Which factor does the nurse identify that influences client outcomes? (Select all that apply.) Select all that apply. Collaboration between members of the interprofessional health care team Health policy legislation at the state and national level The culture to which the client identifies What the individual client believes about health? Technology that is available in the local community health center The application of systems thinking to care of clients

B

Which information about a client who was admitted with a pelvic fracture after being crushed by a tractor is most important for the nurse to assess to monitor for serious complications from this type of injury? Lungs for bilateral normal breath sounds Urine specimen to assess for the red blood cells Pain score and level of alertness Skin to evaluate lacerations and abrasions

A

Which intervention best assists the client with acute pulmonary edema in reducing anxiety and dyspnea? Place the client in high-Fowler position with the legs down. Reassure the client that distress can be relieved with proper intervention. Ask a family member to remain with the client. Monitor pulse oximetry and cardiac rate and rhythm.

C

Which intervention would the nurse suggest to a client who has undergone a leg amputation to help cope with loss of the limb? Talking with a psychiatrist about the amputation Engaging in diversional activities to avoid focusing on the amputation Talking with an amputee close to the client's age who has a similar amputation Drawing a picture of how the client sees him- or herself

A

Which nursing action demonstrates use of the principle of justice? A 67-year-old client with dementia is shown the same respect as his 47-year-old roommate with prostate cancer. An 82-year-old client is provided access to the hospital Patient Advocate for processing of a complaint. A 32-year-old client is prevented from falling during the initial postoperative period following her hysterectomy. The parents of a 13 year old are included in discussions about the course of their teen's treatment and care.

A

Which nursing action may be delegated to assistive personnel (AP) working on the medical unit? Obtain daily weights for several clients with class IV heart failure. Check for peripheral edema in a client with endocarditis. Monitor the pain level for a client with acute pericarditis. Determine the usual alcohol intake for a client with cardiomyopathy.

C,D

Which nursing action reflects the QSEN competency of Patient-Centered Care? (Select all that apply.) Select all that apply. Designing nursing care with a focus on keeping the client safe Participating on a committee that is evaluating the newest bar-code scanner Including the client in discussions about dietary choices Respecting the client's preference about treatment options Referring to a nursing journal to consider trends in care Using data collected over the past quarter to determine if and how nursing care should change

A

Which nursing action reflects the process of prioritize hypotheses, per the NCSBN Clinical Judgement Measurement Model (CJMM)? Determining that a new blood pressure reading of 190/100 requires intervention now Obtaining vital signs every 4 hours and noting a client's blood pressure as 130/90 Administering amlodipine 5 mg orally once daily Contacting the registered dietician nutritionist (RDN) to evaluate a client's salt intake

C

Which of these hospital staff members will the nurse manager request to coordinate the discharge of a client who will need community-based rehabilitation services after a traumatic injury? The primary health care provider assigned as the client's medical resident The physical therapist who developed the client's exercise program The nurse responsible for the client's case management The unit-based RN who has cared for the client during the hospital stay

C, D, E

Which principal nursing actions best support a focus on client safety? (Select all that apply.) Select all that apply. Respect for others Client restraints Preoperative checklists Handwashing Five rights of drug administration

A, C, D

Which risk factors are known to contribute to atrial fibrillation? (Select all that apply.) Select all that apply. Advancing age Palpitations High blood pressure Excessive alcohol use Use of beta blockers

A, D

Which risk factors are shared by male clients who have osteoporosis or osteomalcia? (Select all that apply.) Select all that apply. High alcohol intake Homelessness Low BMI A history of smoking Inadequate exposure to sunlight

ANS: C, D, E 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; cutting the nails straight across; and inspecting the feet daily are all important measures. Abrasive material such as pumice stones would not be used. Cheap flip-flops may not fit well and won't offer much protection against injury.

Which statements by the client indicate good understanding of foot care in peripheral vascular disease? (Select all that apply.) 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." f. "I will inspect my feet daily."

ANS: A The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. The other actions are not warranted.

While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. What action would the nurse take next? a. Assess for symptoms of left-sided heart failure. b. Document this as a normal finding. c. Call the primary health care provider immediately. d. Transfer the client to the intensive care unit.

D

A client admitted after using cocaine develops ventricular fibrillation. After determining unresponsiveness, which action will the nurse take next? Place an oral airway and ventilate. Start cardiopulmonary resuscitation (CPR). Establish IV access. Prepare for defibrillation.

A

A client admitted for heart failure has a priority problem of hypervolemia related to compromised regulatory mechanisms. Which nursing assessment data, obtained the day after admission, is the best indicator that the treatment has been effective? The client's weight decreases by 2.5 kg. The client has diuresis of 400 mL in 24 hours. The client's blood pressure is 122/84 mm Hg. The client has an apical pulse of 82 beats/min.

ANS: C 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.

A client 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."

D

A client begins therapy with lisinopril. What does the nurse consider at the start of therapy with this medication? The client's ability to understand medication teaching The potential for bradycardia Liver function tests The risk for hypotension

D

A client comes to the emergency department with chest discomfort. Which action does the nurse perform first? Administers oxygen therapy. Provides pain relief medication. Remains calm and stays with the client. Obtains the client's description of the chest discomfort.

ANS: C The feet are the most distal to the heart and receive less blood flow than other organs and tissues, prolonging the healing time after surgery. The other explanations are not correct

A client had a bunionectomy with osteotomy. The client asks why healing may take up to 3 months. What explanation by the nurse is best? a. "The bones in your feet are hard to operate on." b. "The surrounding bones and tissue are damaged." c. "Your feet have less blood flow, so healing is slower." d. "Your feet bear weight so they never really heal."

: A Hand hygiene is the best way to prevent infections in hospitalized clients. Dressing changes would be done with sterile technique. Assessing vital signs and white blood cell count will not prevent infection.

A client had a femoral-popliteal 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

B

A client had a fractured tibia repair several weeks ago and tells the nurse that she has persistent burning pain, ongoing edema, and muscle spasms in her affected leg. For which chronic complication is the client at risk? Chronic osteomyelitis Complex regional pain syndrome Severe osteoporosis Compartment syndrome

ANS: A Hypertension can be caused by renovascular disease. Opening up a constricted renal artery can lead to decreased blood pressure, manifested by the need for less blood pressure medication. The other findings are normal and desired, but not specifically related to hypertension caused by renal disease.

A client had a percutaneous angioplasty for renovascular hypertension 3 months ago. What assessment finding by the nurse indicates that an important outcome for this client has been met? a. Client is able to decrease blood pressure medications. b. Insertion site has healed without redness or tenderness. c. Most recent lab data show BUN: 19 mg/dL and creatinine 1.1 mg/dL. d. Verbalizes understanding of postprocedure lifestyle changes.

ANS: C Poor peripheral pulses and cool skin may be signs of impending cardiogenic shock and would be reported immediately. A blood pressure drop of 20 mm Hg may not be worrisome. An oxygen saturation of 94% is just slightly below normal. A urine output of 1.2 mL/kg/hr for 4 hours is normal.

A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred? a. Blood pressure that is 20 mm Hg below baseline b. Oxygen saturation of 94% on room air c. Poor peripheral pulses and cool skin d. Urine output of 1.2 mL/kg/hr for 4 hours

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

ANS: A Pain medication should be given to control metastatic bone pain. Elevation and heat may or may not be helpful. Protective precautions are not needed for this client.

A client has a metastatic bone tumor in the left leg. What action by the nurse is appropriate? a. Administer pain medication as prescribed. b. Elevate the extremity and apply moist heat. c. Teach the client about amputation care. d. Place the client on protective precautions.

ANS: A Fear of falling can limit participation in activity. The nurse would first assess if the client has this fear and then offer suggestions for dealing with it. The client may or may not need extra calcium, other exercises, or weight lifting.

A client has been advised to perform weight-bearing exercises to help slow bone loss, but has not followed this advice. What response by the nurse is appropriate at this time? a. Ask the client about fear of falling. b. Instruct the client to increase calcium. c. Suggest other exercises the client can do. d. Tell the client to try weight lifting.

ANS: A, B, D The AP can apply compression stockings, assist with ambulation, and offer fluids frequently to help prevent DVT. The AP can also encourage the client to do pulmonary exercises, but these do not decrease the risk of DVT. Teaching is a nursing function.

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

ANS: A The first step is to assess the reason behind the client's fear, which may be related to the experience of someone the client knows who took warfarin or misinformation. If the nurse cannot address the specific rationale, teaching will likely be unsuccessful. Laboratory monitoring once every few weeks may not make the client perceive the drug to be safe. General statements like "drugs are safer today" do not address the root cause of the problem. Warning the client about possible consequences of not taking the drug is not therapeutic and is likely to lead to an adversarial relationship.

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

ANS: B Most people with hypertension are asymptomatic, although a small percentage do have symptoms such as headache. The nurse would explain this to the client. Asking about paying for medications utilizes closed-ended questioning and is not therapeutic. Threatening the client with possible complications will not increase compliance.

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."

ANS: B Denosumab is given by subcutaneous injection twice a year. The client does not need to drink 8 ounces (240 mL) of water with this medication as it is not taken orally. The client does not need to remain upright for 30 to 60 minutes after taking this medication, nor does the client need to take the drug on an empty stomach.

A client has been prescribed denosumab. What health teaching about this drug is most appropriate for the nurse to include? a. "Drink at least 8 ounces (240 mL) of water with it." b. "Make appointments to come get your injection." c. "Sit upright for 30 to 60 minutes after taking it." d. "Take the drug on an empty stomach."

ANS: B If the balloon remains inflated, it can cause pulmonary infarction or rupture. The nurse would ensure that the balloon remains deflated between PAOP readings. Documenting PAOP readings and assessing trends are important nursing actions related to hemodynamic monitoring, but are not specifically related to safety. The client does not have to be NPO while undergoing hemodynamic monitoring. Positioning is not related to safety with hemodynamic monitoring.

A client has hemodynamic monitoring after a myocardial infarction. What safety precaution does the nurse implement for this client? a. Document pulmonary artery occlusion pressure (PAOP) readings and assess their trends. b. Ensure that the balloon does not remain wedged. c. Keep the client on strict NPO status. d. Maintain the client in a semi-Fowler position.

ANS: B 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 would 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 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.

ANS: B A major complication related to intra-arterial blood pressure monitoring is hemorrhage from the insertion site. Since these vital signs are out of the normal range, are a change, and are consistent with blood loss, the nurse would assess the client for any bleeding associated with the arterial line. The nurse would document the findings after a full assessment. The client may or may not need pain medication and rest; the nurse first needs to rule out any emergent bleeding.

A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes that the client's heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate? a. Allow the client to rest quietly. b. Assess the client for bleeding. c. Document the findings in the chart. d. Medicate the client for pain.

A

A client has just returned from coronary artery bypass graft surgery. Which assessment data requires immediate nursing action? Chest tube drainage 175 mL last hour Temperature 98.2° F (36.8° C) Incisional pain 6 on a scale of 0-10 Serum potassium 3.9 mEq/L (3.9 mmol/L)

ANS: A 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 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."

ANS: B Best practice recommendations for acute MI require that aspirin is administered when a client with MI presents to the emergency department or when an MI occurs in the hospital. A rapid ECG (within 10 minutes) is vital for best outcomes. The Rapid Response Team is not needed if an emergency department provider is available. Thrombolytics may or may not be needed depending on the type of myocardial infarction the client has.

A client has presented to the emergency department with an acute myocardial infarction (MI). What action by the nurse is best for optimal client outcomes? a. Obtain an electrocardiogram (ECG) within 20 minutes. b. Give the client a nonenteric coated aspirin. c. Notify the Rapid Response Team immediately. d. Prepare to administer thrombolytics within 30 minutes.

ANS: D The client in class III heart failure would benefit from a positive inotrope such as dobutamine. Clients in class I typically respond well to diuretics and nitrates so this client would already be on these medications. Clopidogrel is a platelet inhibitor that will be prescribed for anyone having acute coronary syndrome for at least 12 months.

A client has progressed to Killip class III heart failure after a myocardial infarction. What does the nurse anticipate the client's care to include? a. Diuretics b. Nitrates c. Clopidogrel d. Dobutamine

C

A client has sustained a rotator cuff tear while playing baseball. The nurse anticipates that the client will receive which immediate conservative treatment? Surgical repair of the rotator cuff Patient-controlled analgesia with morphine Activity limitations for the affected arm Prescribed exercises of the affected arm

C

A client has undergone an elective below-the-knee amputation of the right leg as a result of severe peripheral vascular disease. In postoperative care teaching, the nurse would instruct the client to notify the primary health care provider immediately if which change occurs? Absence of erythema and tenderness at the surgical site Ability to flex and extend the right knee Large amount of serosanguineous or bloody drainage Mild to moderate pain controlled with prescribed analgesics

ANS: C Airway always is the priority. The other actions are important in this situation as well, but the nurse would stay with the client and ensure that the airway remains patent (especially if vomiting occurs) while another person calls the primary health care provider (or Rapid Response Team) and facilitates getting an ECG done. Aspirin will probably be administered, depending on the primary health care provider's prescription and the client's current medications.

A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority? a. Administer an aspirin. b. Call for an electrocardiogram (ECG). c. Maintain airway patency. d. Notify the provider.

C

A client in the emergency department receives moderate sedation while having a closed reduction of a fractured ankle. What is the nurse's priority assessment during this procedure? Check the client's blood pressure frequently. Monitor the client's pain level. Monitor the client's respiratory rate. Perform circulation checks before and after the procedure.

ANS: B, D, E Nonpharmacologic comfort measures can include positioning, complementary therapies, and splinting the chest incision. Medications are not nonpharmacologic. Food choices are not comfort measures.

A client is 1-day postoperative after a coronary artery bypass graft. What nonpharmacologic comfort measures does the nurse include when caring for this client? (Select all that apply.) a. Administer pain medication before ambulating. b. Assist the client into a position of comfort in bed. c. Encourage high-protein diet selections. d. Provide complementary therapies such as music. e. Remind the client to splint the incision when coughing.

ANS: B Once perfusion has been restored or improved to an extremity, clients can often feel a throbbing pain due to the increased blood flow. However, it is important to differentiate this pain from ischemia. The nurse would assess for other signs of perfusion, such as distal pulses and skin color/temperature. Administering pain medication is done once the nurse determines that the client's perfusion status is normal. Documentation needs to be thorough. Notifying the surgeon is not necessary.

A client is 4 hours postoperative after a femoral-popliteal bypass. The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse is most important? 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.

A, B, C

A client is admitted to the emergency department following a left severe ankle sprain caused by playing football with friends. What nursing actions will the nurse implement at this time? (Select all that apply.) Select all that apply. Elevate the left leg above the level of the heart. Tell the client to keep his left leg still. Apply an elastic wrap or ankle or compression brace. Administer morphine via IV push. Apply heat to promote blood flow and healing.

ANS: B As part of the primary survey, the nurse would ensure that the client does not have any life-threatening problem by assessing the ABCs first. If there are not major problems, then the nurse could attend to the injured extremity.

A client is admitted to the emergency department with a fractured femur resulting from a motor vehicle crash. What the nurse's priority action? a. Keep the client warm and comfortable. b. Assess airway, breathing, and circulation. c. Maintain the client in a supine position. d. Immobilize the injured extremity with a splint.

C

A client is admitted to the same-day surgical center PACU after a bunionectomy. After assessing the client's ABCs, what is the priority assessment for the client? Muscle strength assessment Joint assessment Neurovascular assessment Neurologic assessment

ANS: A, C, D, E Best practices state that clients being discharged on warfarin need instruction on follow-up monitoring, dietary restrictions, drug-drug interactions, using a Medic Alert bracelet or necklace, and reason for compliance. Driving is typically not restricted.

A client is being discharged on warfarin therapy. What discharge instruction is the nurse required to provide? (Select all that apply.) a. Dietary restrictions b. Driving restrictions c. Follow-up laboratory monitoring d. Possible drug-drug interactions e. Reason to take medication f. Wearing a Medic Alert bracelet

ANS: A Medication reconciliation is a formal process in which the client's actual current medications are compared to the prescribed medications at the time of admission, transfer, or discharge. This National client Safety Goal is important to reduce medication errors. The client would not have to be responsible for providers washing their hands, and even if the client does so, this is too narrow to be the most important action to prevent errors. Keeping the provider's phone number nearby and documenting everyone who enters the room also do not guarantee safety.

A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explain is the most important thing the client can do to protect against errors? a. Bring a list of all medications and what they are for. b. Keep the provider's phone number by the telephone. c. Make sure that all providers wash hands before entering the room. d. Write down the name of each caregiver who comes in the room.

ANS: A Concerns about resuming sexual activity are common after cardiac events. The nurse would gently inquire if this is the issue. While it is good that the client is sleeping well, the nurse would investigate the reason for the move. The other two responses are likely to cause the client to be defensive.

A client is in the clinic a month after having a myocardial infarction. The client reports sleeping well since moving into the guest bedroom. What response by the nurse is best? a. "Do you have any concerns about sexuality?" b. "I'm glad to hear you are sleeping well now." c. "Sleep near your spouse in case of emergency." d. "Why would you move into the guest room?"

ANS: B This client's physiologic parameters did not exceed normal during and after activity, so it is safe for the client to continue using the bathroom. There is no indication that the client needs oxygen, a commode, or a bedpan.

A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the client's O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best? a. Administer oxygen at 2 L/min. b. Allow continued bathroom privileges. c. Obtain a bedside commode. d. Suggest the client use a bedpan.

ANS: D Preoperative fear and anxiety are common prior to cardiac surgery, especially in emergent situations. The client is exhibiting anxiety, and the nurse would reassure the client that fear is common and offer to help. The other actions will not reduce the client's anxiety.

A client is in the preoperative holding area prior to an emergency coronary artery bypass graft (CABG). The client is yelling at family members and tells the doctor to "just get this over with" when asked to sign the consent form. What action by the nurse is best? a. Ask the family members to wait in the waiting area. b. Inform the client that this behavior is unacceptable. c. Stay out of the room to decrease the client's stress levels. d. Tell the client that anxiety is common and that you can help.

ANS: B Clients on fibrinolytic therapy are at high risk of bleeding. The sudden onset of neurologic signs may indicate that the client is having a hemorrhagic stroke. The nurse does need to complete a thorough neurologic examination, but would first call the Rapid Response Team based on the client's manifestations. 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.

A client is receiving an infusion of alteplase for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse is most important? 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.

ANS: C A change in neurologic status in a client receiving t-PA could indicate intracranial hemorrhage. The nurse would notify the primary health care provider immediately. A full assessment, including pupillary responses and vital signs, occurs next. The nurse may or may not need to call a neurologist.

A client is receiving an infusion of tissue plasminogen activator (tPA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best? a. Assess the client's pupillary responses. b. Request a neurologic consultation. c. Call the primary health care provider immediately. d. Take and document a full set of vital signs

D

A client is receiving unfractionated heparin (UFH) by infusion. What laboratory data will the nurse report to the primary health care provider (PCP)? Hemoglobin 12.2 g/dL (122 mmol/L) White blood cells 11,000/mm3 (11 × 109/L) Partial thromboplastin time (PTT) 60 seconds Platelets 32,000/mm3 (32 × 109/L)

D

A client is recovering from an above-the-knee amputation resulting from peripheral vascular disease. Which statement indicates that the client is coping well after the procedure? "I can't believe that this has happened to me. I can't stand to look at it." "I do not want any visitors while I'm in the hospital." "My spouse will be the only person to change my dressing." "It will take me some time to get used to this."

ANS: A Many foods and drugs interfere with warfarin, St. John's wort being one of them. The nurse would advise the client against taking it. The other answers are not accurate.

A client is taking warfarin 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."

ANS: A Dopamine should be infused through a central line to prevent extravasation and necrosis of tissue. The nurse would gather supplies for the primary health care provider to insert a central line. Monitoring vital signs is important for any client who has an acute cardiac problem, but this doesn't give the frequency of evaluation. Marking the client's pedal pulses and ensuring a weight is documented are not related to this infusion.

A client is to receive a dopamine infusion. What does the nurse do to prepare for this infusion? a. Gather central line supplies. b. Mark the client's pedal pulses. c. Monitor the client's vital signs. d. Ensure an accurate weight is charted.

ANS: C Percutaneous coronary intervention would be performed within 90 minutes of diagnosis of myocardial infarction. Therefore, the client would have a percutaneous coronary intervention performed no later than 16:30 (4:30 p.m.)

A client presents to the emergency department with an acute myocardial infarction (MI) at 15:00 (3:00 p.m.). The facility has 24-hour catheterization laboratory abilities. To improve client outcomes, by what time would the client have a percutaneous coronary intervention performed? a. 15:30 (3:30 p.m.) b. 16:00 (4:00 p.m.) c. 16:30 (4:30 p.m.) d. 17:00 (5:00 p.m.)

ANS: B After the original intracoronary clot has dissolved, large amounts of thrombin are released into the bloodstream, increasing the chance of the vessel reoccluding. The other statements are not accurate. Heparin is not a "blood thinner," although laypeople may refer to it as such.

A client received tissue plasminogen activator (tPA) after a myocardial infarction and now is on an intravenous infusion of heparin. The client's spouse asks why the client needs this medication. What response by the nurse is best? a. "The t-PA didn't dissolve the entire coronary clot." b. "The heparin keeps that artery from getting blocked again." c. "Heparin keeps the blood as thin as possible for a longer time." d. "The heparin prevents a stroke from occurring as the t-PA wears off."

A

A client sustains a fracture of one arm and the primary health care provider applies a synthetic cast to the extremity. What will the nurse teach the client to do during the first 24 hours after discharge from the emergency department? Monitor neuromuscular status for decreased circulation and sensation in the extremity. Check the fit of the cast by inserting a tongue blade between the cast and the skin. Apply a heating pad for 15 to 20 minutes four times daily to help with pain. Keep the cast covered with a soft towel to help it to dry quickly.

B

A client undergoing coronary artery bypass grafting asks why the surgeon has chosen to use the internal mammary artery for the surgery. Which nursing response is appropriate? "This way you will not need to have a leg incision." "These arteries remain open longer." "The surgeon has chosen this approach because of your age." "The surgeon prefers this approach because it is easier."

ANS: D Normal right atrial pressures are from 0 to 8 mm Hg. This pressure is at the extreme lower end, which indicates hypovolemia, so the nurse would prepare to administer a fluid bolus. The transducer would remain leveled at the phlebostatic axis. Positioning may or may not influence readings but a reading this low is definitive for volume depletion. Diuretics would be contraindicated.

A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5 mm Hg. What action by the nurse is most appropriate? a. Level the transducer at the phlebostatic axis. b. Lay the client in the supine position. c. Prepare to administer diuretics. d. Prepare to administer a fluid bolus.

ANS: B Burning pain and tingling that occurs weeks or months after a fracture or other trauma may indicate complex regional pain syndrome. Compartment syndrome tends to occur within days of the initial injury.

A client who had a fractured ankle open reduction internal fixation (ORIF) 4 weeks ago reports burning pain and tingling in the affected foot. For which potential complication would the nurse anticipate? a. Delayed bone healing b. Complex regional pain syndrome c. Peripheral neuropathy d. Compartment syndrome

A

A client who had a right elective above-the-knee amputation reports severe pain in the right lower leg and foot. What is the nurse's best action at this time? Assess the level of the client's pain. Change the subject and talk about the client's hobbies. Distract the client with stories about the nurse's family. Remind the client that the lower leg was removed.

ANS: A The client is experiencing respiratory distress which could be due to pulmonary embolus, fat embolism syndrome, or anxiety. Regardless of the cause, the nurse would place the client in a sitting position first and then perform additional assessment. Oxygen would likely be needed, especially if the client's oxygen saturation was under 95%.

A client who had a surgical fractured femur repair reports new-onset shortness of breath and increased respirations. What is the nurse's first action? a. Place the client in a high-Fowler position. b. Document the client's oxygen saturation level. c. Start oxygen therapy at 2 L/min via nasal cannula. d. Contact the primary health care provider.

ANS: B The nurse's response needs to allow further exploration of the client's feelings. Referring the client to another health professional might be appropriate at a later time but discounts the client's current feelings. Asking about marriage or a girlfriend assumes that the client is heterosexual.

A client who had a traumatic above-the-knee amputation states that he fears he will never have an intimate relationship again. What is the nurse's best response? a. "You'll be able to get a leg prosthesis soon." b. "You think you won't be able to have sex again?" c. "I will ask the social worker to talk with you." d. "Are you married now or have a girl friend?"

B

A client who has osteopenia is prescribed to begin risedonate. What health teaching would the nurse include about this drug? "Take the drug with dinner or other meal or snack every day." "Remain in an upright position for 30 minutes after taking the drug." "Be sure to follow up with lab work to monitor your liver function." "Be sure to report any new bone pain or infection."

B

A client who uses a computer for hours each day asks the nurse how to help prevent carpal tunnel syndrome (CTS). Which statement by the client indicates a need for further teaching? "I need to make sure I have an ergonomically sound computer station." "I need to exercise repetitively to strengthen my wrists." "I should stretch my fingers and wrists frequently during the day." "I may need to wear a wrist splint when my wrist gets inflamed."

ANS: A This client could be having an exacerbation of heart failure or experiencing a side effect of lisinopril (and other angiotensin-converting enzyme inhibitors). The nurse would 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 would 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 with a history of heart failure and hypertension is in the clinic for a follow-up visit. The client is on lisinopril and warfarin. 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 lisinopril.

ANS: B, D, E This client may have a ruptured/rupturing aneurysm. The nurse would 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 surgeon has explained the procedure.

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 mm Hg. What actions by the nurse are most important? (Select all that apply.) 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.

C

A client with angina has received education about acute coronary syndrome. Which client statement indicates understanding? "Because this is temporary, I don't need medications for my heart." "I need to tell my wife I've had a heart attack." "This is a warning sign and I need to change my lifestyle to prevent a heart attack." "Angina is a temporary blood flow problem that will resolve."

ANS: A The first step in the nursing process is assessment. The nurse would assess coping skills and possible support systems that will be helpful in this client's treatment. Explaining that a limb salvage procedure will extend life does not address the client's psychosocial needs. Referrals may be necessary, but the nurse should assess first. Reinforcing physical therapy is also helpful but again does not address the psychosocial needs of the client.

A client with bone cancer is hospitalized for a limb salvage procedure. How can the nurse best address the client's psychosocial needs? a. Assess the client's coping skills and support systems. b. Explain that the surgery leads to a longer life expectancy. c. Refer the client to the social worker or hospital chaplain. d. Reinforce physical therapy to aid with ambulating normally.

ANS: A, C, E The client going home with chronic osteomyelitis will need long-term antibiotic therapy—first intravenous, and then oral. The client needs education on how to properly administer IV antibiotics, care for the IV line, adhere to the regimen, and eat a healthy diet to encourage wound healing. The antibiotics are not given by IM injection. The client does not need daily follow-up.

A client with chronic osteomyelitis is being discharged from the hospital. What information is important for the nurse to teach this client and family? (Select all that apply.) a. Adherence to the antibiotic regimen b. Correct intramuscular injection technique c. Eating high-protein and high-carbohydrate foods d. Keeping daily follow-up appointments e. Proper use of the intravenous equipment

ANS: B Omega-3 fatty acids have shown benefit in reducing lipid levels, in reducing the incidence of sudden cardiac death, and for stabilizing atherosclerotic plaque. The preferred source of omega-3 acids is from fish rich in long-chain n-3 polyunsaturated fatty acids two times a week or a daily fish oil nutritional supplement (1 to 2 g/day). The other options are not accurate

A client with coronary artery disease (CAD) asks the nurse about taking fish oil supplements. What response by the nurse is best? a. "Fish oil is contraindicated with most drugs for CAD." b. "The best source is fish, but pills have benefits too." c. "There is no evidence to support fish oil use with CAD." d. "You can reverse CAD totally with diet and supplements."

D

A client with heart failure is prescribed furosemide. Which assessment data concerns the nurse with this new prescription? Serum sodium level of 135 mEq/L (135 mmol/L) Serum magnesium level of 1.9 mEq/L (0.95 mmol/L) Serum creatinine of 1.0 mg/dL (88.4 mcmol/L) Serum potassium level of 2.8 mEq/L (2.8 mmol/L)

D

A client with hypertension is started on verapamil. What teaching will the nurse provide for this client? "Consume foods high in potassium." "Monitor for muscle cramping." "Monitor for irregular pulse." "Avoid grapefruit juice."

ANS: B This client has several risk factors that place him or her at a high risk for falling. The nurse should consult social work or home health care to conduct a home safety evaluation. The other options may or may not be needed based upon the client's condition at discharge.

A client with osteoporosis is going home where the client lives alone. What action by the nurse is best? a. Refer the client to Meals on Wheels. b. Arrange a home safety evaluation. c. Ensure that the client has a walker at home. d. Help the client look into assisted living.

C

A client with peripheral arterial disease (PAD) has a percutaneous vascular intervention. What is the priority nursing assessment? Dye allergy Gag reflex Pedal pulses Ankle-brachial index

D

A client's rhythm strip shows a heart rate of 116 beats/min, one P wave occurring before each QRS complex, a PR interval measuring 0.16 second, and a QRS complex measuring 0.08 second. How does the nurse interpret this rhythm strip? Sinus rhythm with premature ventricular contractions Normal sinus rhythm Sinus bradycardia Sinus tachycardia

ANS: A, B, D, E Older adults need increased amounts of calcium; vitamins A, C, and D; and fiber. Milk and cheese have calcium; carrots have vitamin A; vitamin D supplement has vitamin D; and oranges have vitamin C. Lean ground beef is healthier than more fatty cuts, but does not contain these needed nutrients.

A home health care nurse assesses an older adult for the intake of nutrients needed in larger amounts than in younger adults. Which foods found in an older adult's kitchen might indicate an adequate intake of these nutrients? (Select all that apply.) a. 1% milk b. Carrots c. Lean ground beef d. Oranges e. Vitamin D supplements f. Cheese sticks

ANS: B As a person ages, he or she may experience a decreased sense of touch. The older adult may not be aware of where his or her foot is on the step. Combined with diminished visual acuity, this can create a fall hazard. Holding the handrail would help keep the person safer. If the client does not need an assistive device, he or she would not use a cane or walker just on stairs. Using an alternative door may be necessary but does not address making the front steps safer. A two-footed gait may not help if the client is unaware of where the foot is on the step.

A home health care nurse has conducted a home safety assessment for an older adult. There are five concrete steps leading out from the front door. Which intervention would be most helpful in keeping the older adult safe on the steps? a. Have the client use a walker or cane on the steps. b. Teach the client to hold the handrail when using the steps c. Instruct the client to use the garage door instead. d. Tell the client to use a two-footed gait on the steps.

ANS: A This older adult is mostly homebound. Exercise regimens for homebound clients include things to increase functional fitness and ability for activities of daily living. Strength and flexibility will help the client to be able to maintain independence longer. The other plans are good but will not specifically maintain the client's functional abilities.

A home health care nurse is planning an exercise program with an older adult who lives at home independently but whose mobility issues prevent much activity outside the home. Which exercise regimen would be most beneficial to this adult? a. Building strength and flexibility b. Improving exercise endurance c. Increasing aerobic capacity d. Providing personal training

ANS: C, D, E The nurses' aide or AP can assist in keeping the client's skin dry, order a special mattress on direction of the RN, and turn the client on a schedule. Assessing the skin is a nursing responsibility, although the aide would be directed to report any redness noticed. Documenting the Braden Scale results is the RN's responsibility as the RN is the one who performs that assessment.

A hospitalized older adult has been assessed at high risk for skin breakdown. Which actions does the registered nurse (RN) delegate to the assistive personnel (AP)? (Select all that apply.) a. Assess skin redness when turning. b. Document Braden Scale results. c. Keep the client's skin dry. d. Obtain a pressure-relieving mattress. e. Turn the client every 2 hours.

A

The nurse is assigned to all of these clients. Which client would the nurse assess first? The client who had percutaneous vascular intervention of the right femoral artery 30 minutes ago. The client admitted with hypertensive crisis who has a nitroprusside drip and blood pressure of 149/80 mm Hg. The client with peripheral vascular disease who has a left leg ulcer draining purulent yellow fluid. The client who had a right femoral-popliteal bypass 3 days ago and has ongoing edema of the foot.

B, C, D, G

The nurse is caring for a client immediately following a cardioversion. What nursing actions are appropriate? (Select all that apply.) Select all that apply. Allow the client to eat a meal. Ensure electrodes are in place for continued monitoring. Assess the chest for burns. Document results of procedure. Remove crash cart from the room. Provide continued sedation. Administer oxygen.

B

The nurse is caring for a client in phase 1 cardiac rehabilitation. Which activity does the nurse suggest? Planning and participating in a walking program Placing a chair in the shower for independent hygiene Consultation with social worker for disability planning The need to increase activities slowly at home

ANS: C The primary health care provider should be notified to examine the client and determine the source of the drainage. The nurse's assessment should be documented, but that is not the most important action.

The nurse is caring for a client who had a closed reduction of the left arm and notes a large wet area of drainage on the cast. What action is the most important? a. Cut off the old cast. b. Document the assessment. c. Notify the primary health care provider. d. Wrap the cast with gauze.

A

The nurse is caring for a client who had abdominal aortic aneurysm (AAA) repair. Which assessment data is most concerning to the nurse? Urine output of 20 mL over 2 hours Blood pressure of 106/58 mm Hg +3 pedal pulses Absent bowel sounds

A

The nurse is caring for a client who has an external fixator for an open fracture of the tibia and fibula. What is the nurse's priority for care related to the fixator? Inspect the pins to monitor for infection and do not remove crusts. Make sure that the wound is managed using a moist wound healing method. Keep the leg covered to keep the extremity warm to promote circulation. Keep the extremity elevated to three pillows while in bed or in a chair.

D

The nurse is caring for a client who has been treated for osteoporosis for 15 years and is starting on denosumab. What health teaching is appropriate for the nurse to include about this drug? "You will receive an IV infusion once a year by your provider." "Take the drug every morning with a glass of water." "Have a dental examination prior to beginning the drug." "See your primary health care provider for twice yearly injections."

A

The nurse is caring for a client with heart failure in a cardiac clinic. What assessment data indicates that the client has demonstrated a positive outcome related to the addition of metoprolol to the medication regimen? Client states, "I can sleep on one pillow." Current ejection fraction is 25%. Client reports feeling like her heart beats very fast at times. Records indicate five episodes of pulmonary edema last year.

C

The nurse is caring for a client with heart failure in the coronary care unit. The client is exhibiting signs of air hunger and anxiety. Which nursing intervention will the nurse perform first for this client? Monitor and document heart rate, rhythm, and pulses. Encourage alternate rest and activity periods. Position the client to alleviate dyspnea. Determine the client's physical limitations.

A, C, D

The nurse is caring for a client with heart failure. What assessment data will the nurse anticipate? (Select all that apply.) Select all that apply. Fatigue Sleeping on back without a pillow Chest discomfort or pain Tachycardia Expectorating thick, yellow sputum

A, B, E

The nurse is caring for a client with heart rate of 143 beats/min. Which assessment data will the nurse anticipate? (Select all that apply.) Select all that apply. Chest discomfort Hypotension Flushing of the skin Increased energy Palpitations

<130

normal LDL

ANS: B 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 as important.

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

ANS: B,E Signs of a thoracic aortic aneurysm include shortness of breath, hoarseness, and difficulty swallowing. Pain is often rated as a 10 on a 10-point scale. Bowel habits are not related.

A client presents to the emergency department with a thoracic aortic aneurysm. Which findings are most consistent with this condition? (Select all that apply.) a. Abdominal tenderness b. Difficulty swallowing c. Changes in bowel habits d. Shortness of breath e. Hoarseness

ANS: B A T-score from a bone density scan at or lower than -2.5 indicates osteoporosis. The nurse would plan to teach about medications used to treat this disease, such as the bisphosphonates. A food diary is helpful to determine if the client gets adequate calcium and vitamin D, but at this point, dietary changes will not prevent the disease. Simply scheduling another scan will not help treat the disease either

A client has a bone density score of -2.8. What intervention would the nurse anticipate based on this assessment? a. Asking the client to complete a food diary b. Planning to teach about bisphosphonates c. Scheduling another scan in 2 years d. Scheduling another scan in 6 months

D

A client is in skeletal traction for a complex femoral fracture. Which nursing intervention ensures proper care of this client? Ensure that weights are placed on the floor. Remove the traction weights only for bathing. Ensure that pins are not loose and tighten as needed. Inspect the skin at least every 8 hours.

A

A client with an open fracture of the left femur is admitted to the emergency department after a motorcycle crash. Which action is essential for the nurse to take first? Check the dorsalis pedis pulses. Administer the prescribed analgesic. Place a dressing on the affected area. Immobilize the left leg with a splint.

P wave

A fib has no clear

ANS: D The pelvis is very vascular and close to major organs. Injury to the pelvis can cause integral damage that may manifest as blood in the urine (hematuria) or stool. The nurse would also assess for signs of hemorrhage and hypovolemic shock, which include hypotension and tachycardia. Diarrhea and infection are not common complications of a pelvic fracture.

A nurse assesses a client with a pelvic fracture. Which assessment finding would the nurse identify as a complication of this injury? a. Hypertension b. Diarrhea c. Infection d. Hematuria

Synchronized cardio version

If poor perfusion is severe and persistent, the patient may require what