Exam 3

The nurse is caring for a patient with a halo vest after cervical spine injury. Which care instructions should the nurse include in the patient's discharge plan? A. Keep a wrench close or attached to the vest. B. Use the frame and vest to assist in positioning. C. Clean around the pins using betadine swab sticks. D. Loosen both sides of the vest to provide skin care.

A A halo vest is used to provide cervical spine immobilization while vertebrae heal. There should always be a wrench with the halo vest in case emergency removal of the vest is needed (e.g., performance of CPR). Cleaning around the pins is typically performed with normal saline or chlorhexidine, based on provider instructions. Only one side of the vest can be loosened for skin care and changing clothes. After that side has been reattached, the other side of the vest can be loosened.

The nurse performs discharge teaching for a 34-yr-old male patient with a thoracic spinal cord injury (T2) from a construction accident. Which statement indicates the patient understands teaching about autonomic dysreflexia? A. "I will perform self-catheterization at least 6 times per day." B. "A reflex erection may cause an unsafe drop in blood pressure." C. "If I develop a severe headache, I will lie down for 15 to 20 minutes." D. "I can avoid this problem by taking medications to prevent leg spasms."

A Autonomic dysreflexia usually is caused by a distended bladder. Performing self-catheterization 5 or 6 times a day prevents bladder distention. Signs and symptoms of autonomic dysreflexia include a severe headache, hypertension, bradycardia, flushing, piloerection (goosebumps), and nasal congestion. Patients should raise the head of the bed to 45 to 90 degrees. This action helps to relieve hypertension (systolic pressure up to 300 mm Hg) that occurs with autonomic dysreflexia.

A patient with systemic lupus erythematosus is receiving plasmapheresis to treat an acute attack. What symptoms will the nurse monitor to determine if the patient develops complications related to the procedure? A. Hypotension, paresthesias, and dizziness B. Polyuria, decreased reflexes, and lethargy C. Intense thirst, flushed skin, and weight gain D. Abdominal cramping, diarrhea, and leg weakness

A Common complications associated with plasmapheresis are hypotension and citrate toxicity. Citrate is used as an anticoagulant and may cause hypocalcemia, which may manifest as headache, paresthesias, and dizziness. Polyuria, decreased reflexes, and lethargy are symptoms of hypercalcemia. Abdominal cramping, diarrhea, and leg weakness indicate hyperkalemia. Intense thirst, flushed skin, and weight gain indicate hypernatremia with normal or increased extracellular fluid volume.

A nurse is assessing a client who has had a suspected stroke. The nurse should place the priority on which of the following findings? A. Dysphagia B. Aphasia C. Ataxia D. Hemianopsia

A Dysphagia indicates that this client is at greatest risk for aspiration due to impaired sensation and function within the oral cavity. Therefore, the nurse should place priority on this finding.

A nurse is assessing a client who had extracorporeal shock wave lithotripsy (ESWL) 6 hr ago. Which of the following findings should the nurse expect? A. Stone fragments in the urine B. Fever C. Decreased urine output D. Bruising on the lower abdomen

A ESWL is an effort to break the calculi so that the fragments pass down the ureter, into the bladder, and through the urethra during voiding. Following the procedure, the nurse should strain the client's urine to confirm the passage of stones.

What nursing intervention should be implemented for a patient with increased intracranial pressure (ICP)? A. Monitor fluid and electrolyte status carefully. B. Position the patient in a high Fowler's position. C. Administer vasoconstrictors to maintain cerebral perfusion. D. Maintain physical restraints to prevent episodes of agitation.

A Fluid and electrolyte changes can have an adverse effect on ICP and must be monitored vigilantly. The head of the patient's bed should be kept at 30 degrees in most circumstances, and physical restraints are not applied unless absolutely necessary. Vasoconstrictors are not typically used in the treatment of ICP.

The nurse teaches a 64-yr-old man with gouty arthritis about food that may be consumed on a low-purine diet. The patient's choice of which food item indicates an understanding of the instructions? A. Eggs B. Liver C. Salmon D. Chicken

A Gout is caused by an increase in uric acid production, underexcretion of uric acid by the kidneys, or increased intake of foods containing purines, which are metabolized to uric acid by the body. Liver is high in purine, and chicken and salmon are moderately high in purine.

When teaching a patient infected with HIV about transmission of the virus to others, which statement made by the patient would indicate a need for further teaching? A. "I will need to isolate any tissues I use so as not to infect my family." B. "I will notify all of my sexual partners so they can get tested for HIV." C. "Unprotected sexual contact is the most common mode of transmission." D. "I do not need to worry about spreading this virus to others by sweating at the gym."

A HIV is not spread casually. The virus cannot be transmitted through hugging, dry kissing, shaking hands, sharing eating utensils, using toilet seats, or attending school with an HIV-infected person. It is not transmitted through tears, saliva, urine, emesis, sputum, feces, or sweat.

The condition of a patient who has cirrhosis of the liver has deteriorated. Which diagnostic study would best help determine if the patient has developed liver cancer? A. MRI scanning B. Serum α-fetoprotein level C. Ventilation/perfusion scan D. Abdominal girth measurement

A Hepatic ultrasonography, CT scan, and MRI scanning are used to screen for and diagnose liver cancer. Serum α-fetoprotein level may be elevated with liver cancer or other liver problems. Ventilation/perfusion scans are used to diagnose pulmonary emboli. Abdominal girth measurement would not differentiate between cirrhosis and liver cancer.

A patient has human immunodeficiency virus (HIV) infection and the viral load is reported as undetectable. What patient teaching should be provided by the nurse related to this laboratory study result? A. The patient has the virus but the infection is well controlled. B. The syndrome has been cured, and the patient can discontinue all medications. C. The patient will be prescribed lower doses of antiretroviral medications for 2 months. D. The patient is not taking antiretrovirals and needs to be taught the benefits of therapy.

A In human immunodeficiency virus (HIV) infections, viral loads are reported as real numbers of copies/μL or as undetectable. "Undetectable" indicates that the viral load is lower than the test is able to report. "Undetectable" indicates that the patient still has the virus, but the virus is well controlled.

A 24-yr-old female patient with systemic lupus erythematosus (SLE) tells the nurse she wants to have a baby and is considering getting pregnant. Which response by the nurse is most appropriate? A. "Infertility can result from some medications used to control your disease." B. "Temporary remission of your signs and symptoms is common during pregnancy." C. "Autoantibodies transferred to the baby during pregnancy will cause heart defects." D. "The baby is at high risk for neonatal lupus erythematosus being diagnosed at birth."

A Infertility may be caused by renal involvement and the previous use of high-dose corticosteroid and chemotherapy drugs. Neonatal lupus erythematosus rarely occurs in infants born to women with SLE. Exacerbation is common after pregnancy during the postpartum period. Spontaneous abortion, stillbirth, and intrauterine growth retardation are common problems with pregnancy related to deposits of immune complexes in the placenta and because of inflammatory responses in the placental blood vessels. There is not an increased risk for heart defects.

A nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. The client is experiencing excessive stools. Which of the following findings is an adverse effect of this medication? A. Hypokalemia B. Hypercalcemia C. Gastrointestinal bleeding D. Confusion

A Lactulose works by stimulating the production of excess stools to rid the body of excess ammonia. These excessive stools can result in hypokalemia and dehydration.

Which assessment findings in a patient with a thoracic spinal cord injury (T4) would alert the nurse to possible autonomic dysreflexia? A. Headache and rising blood pressure B. Irregular respirations and shortness of breath C. Abdominal distention and absence of bowel sounds D. Decreased level of consciousness and hallucinations

A Manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic), a throbbing headache, bradycardia, and diaphoresis. Respiratory changes, decreased level of consciousness, and gastrointestinal problems are not characteristic manifestations.

Which assessment finding would the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury? A. Bradycardia B. Hypertension C. Neurogenic spasticity D. Bounding pedal pulses

A Neurogenic shock is caused by the loss of vasomotor tone after injury and is characterized by bradycardia and hypotension. Loss of sympathetic innervation causes peripheral vasodilation, venous pooling, and decreased cardiac output. Thus hypertension, neurogenic spasticity, and bounding pedal pulses are not seen in neurogenic shock.

Four patients have been newly diagnosed with connective tissue disorders. The nurse is concerned with safety issues and interstitial lung involvement for the patient with which diagnosis? A. Polymyositis B. Reactive arthritis C. Sjögren's syndrome D. Systemic lupus erythematosus (SLE)

A Polymyositis is an inflammatory disease affecting striated muscle and resulting in muscle weakness that increases the patient's risk of falls and injury. Weakened pharyngeal muscles also increase the risk for aspiration, with interstitial lung disease in up to 65% of patients. Safety concerns and interstitial lung involvement are not associated with reactive arthritis (Reiter's syndrome) or Sjögren's syndrome. Safety may be an issue later in disease progression of SLE.

The nurse is caring for a group of patients. Which patient has the highest risk for developing pancreatic cancer? A. A 72-yr-old black man who has smoked cigarettes for 50 years B. A 19-yr-old patient who has a 5-year history of uncontrolled type 1 diabetes C. A 38-yr-old Hispanic woman who is obese and has hyperinsulinemia D. A 23-yr-old man who has cystic fibrosis-related pancreatic enzyme insufficiency

A Risk factors for pancreatic cancer include chronic pancreatitis, diabetes, age, cigarette smoking, family history of pancreatic cancer, high-fat diet, and exposure to chemicals such as benzidine. Blacks have a higher incidence of pancreatic cancer than whites. The most firmly established environmental risk factor is cigarette smoking. Smokers are 2 to 3 times more likely to develop pancreatic cancer compared with nonsmokers. The risk is related to duration and number of cigarettes smoked.

A patient with type 2 diabetes and chronic hepatitis C asks the nurse if it would be acceptable to take silymarin (milk thistle) to help minimize liver damage. The nurse responds based on what knowledge? A. Milk thistle may affect liver enzymes and thus alter drug metabolism. B. Milk thistle is generally safe in recommended doses for up to 10 years. C. There is unclear scientific evidence for the use of milk thistle in treating cirrhosis. D. Milk thistle may increase serum glucose levels and is thus contraindicated in diabetes.

A Scientific evidence indicates there is no real benefit from milk thistle to protect liver cells from toxic damage in the treatment of chronic hepatitis C. Milk thistle does affect liver enzymes and thus could alter drug metabolism. Therefore, patients will need to be monitored for drug interactions. It is generally well tolerated. It may lower, not elevate, blood glucose levels.

The patient's MRI showed the presence of a brain tumor. The nurse anticipates which treatment modality? A. Surgery B. Chemotherapy C. Radiation therapy D. Biologic drug therapy

A Surgical removal is the preferred treatment for brain tumors. Chemotherapy and biologic drug therapy are limited by the blood-brain barrier, tumor cell heterogeneity, and tumor cell drug resistance. Radiation therapy may be used as a follow-up measure after surgery.

A patient has been diagnosed with human immunodeficiency virus (HIV) infection. What rationale for taking more than one antiretroviral medication should the nurse give to the patient to improve compliance? A. Viral replication will be inhibited. B. They will decrease CD4+ T-cell counts. C. It will prevent interaction with other drugs. D. More than one drug has a better chance of curing HIV.

A The major advantage of using several classes of antiretroviral drugs is that viral replication can be inhibited in several ways, making it more difficult for the virus to recover and decreasing the likelihood of drug resistance that is a major problem with monotherapy. Combination therapy also delays disease progression and decreases HIV symptoms and opportunistic diseases. HIV cannot be cured. CD4+ T-cell counts increase with therapy. There are dangerous interactions with many antiretroviral drugs and other commonly used drugs.

A patient who is infected with human immunodeficiency virus (HIV) is being taught by the nurse about health promotion activities such as good nutrition; avoiding alcohol, tobacco, drug use, and exposure to infectious agents; keeping up to date with vaccines; getting adequate rest; and stress management. What is the rationale for these interventions? A. Delaying disease progression B. Preventing disease transmission C. Helping to cure the HIV infection D. Enabling an increase in self-care activities

A These health promotion activities along with mental health counseling, support groups, and a therapeutic relationship with health care providers will promote a healthy immune system, which may delay disease progression. These measures will not cure HIV infection, prevent disease transmission, or increase self-care activities.

The nurse is assessing an older adult patient. What age-related disorder should the nurse assess for related to the increased immunologic response? A. Autoimmune response B. Cell-mediated immunity C. Hypersensitivity response D. Humoral immune response

A With aging, autoantibodies increase, which lead to autoimmune diseases (e.g., systemic lupus erythematosus, acute glomerulonephritis, rheumatoid arthritis, hypothyroidism). Cell-mediated immunity decreases with decreased thymic output of T cells and decreased activation of both T and B cells. There is a decreased or absent delayed hypersensitivity reaction. Immunoglobulin levels decrease and lead to a suppressed humoral immune response in older adults.

A healthy older adult patient requests a "flu shot" during an office visit. When assessing the patient, what other vaccinations should the nurse ask the patient about receiving? (Select all that apply.) A. Shingles B. Pneumonia C. Meningococcal D. Haemophilus influenzae type b (Hib) E. Measles, mumps, and rubella (MMR)

A, B The patient should receive the vaccines for shingles (herpes zoster), pneumococcus, and influenza. The other options do not apply to this patient. Meningococcal vaccination is recommended for adults at risk (e.g., adults with anatomic or functional asplenia or persistent complement component deficiencies). Adults born before 1957 are generally considered immune to measles and mumps. Haemophilus influenzae type b (Hib) vaccination is only considered for adults with selected conditions (e.g., sickle cell disease, leukemia, HIV infection, or for those who have anatomic or functional asplenia) if they have not been previously vaccinated.

What should the nurse teach the patients in the assisted living facility to decrease their risk for antibiotic-resistant infection? (Select all that apply.)? A. Wash hands frequently. B. Take antibiotics as prescribed. C. Take the antibiotic until it is gone. D. Take antibiotics to prevent illnesses like colds. E. Save leftover antibiotics to take if needed later.

A, B, C To decrease the risk for antibiotic-resistant infections, people should wash their hands frequently, follow the directions when taking the antibiotics, finish the antibiotic, do not request antibiotics for colds or flu, do not save leftover antibiotics, or take antibiotics to prevent an illness without them being prescribed by a health care provider.

Which conditions predispose the patient to the development of a brain abscess? (Select all that apply.) A. Endocarditis B. Ear infection C. Tooth abscess D. Skull fracture E. Sinus infection F. Scalp laceration

A, B, C, D, E (ALL except for F) Infections in close proximity to the brain can migrate into the brain. A skull fracture impairs the protection of the brain, and infection could occur. Endocarditis can release organisms in the bloodstream that mobilize to the brain. A scalp laceration does not lead to a brain abscess.

The nurse is caring for a patient admitted for evaluation and surgical removal of a brain tumor. Which complications will the nurse monitor for? (Select all that apply.) A. Seizures B. Vision loss C. Cerebral edema D. Pituitary dysfunction E. Parathyroid dysfunction F. Focal neurologic deficits

A, B, C, D, F (ALL except for E) Brain tumors can cause a wide variety of symptoms depending on location such as seizures, vision loss, and focal neurologic deficits. Tumors can put pressure on the pituitary, leading to dysfunction of the gland. As the tumor grows, clinical manifestations of increased intracranial pressure and cerebral edema appear. The parathyroid gland is not regulated by the cerebral cortex or the pituitary gland.

A patient with fibromyalgia has pain at 12 of the 18 identified tender sites, including the neck, upper back, and knees. The patient reports nonrefreshing sleep, depression, and anxiety when dealing with multiple tasks. Which treatments would be included in the plan of care? (Select all that apply.) A. Massage therapy B. Low-impact aerobic exercise C. Relaxation strategy (biofeedback) D. Antiseizure drug pregabalin (Lyrica) E. Morphine sulfate extended-release tablets F. Serotonin reuptake inhibitor (e.g., sertraline [Zoloft])

A, B, D, F Massage will improve blood flow and relaxation. Low-impact aerobic exercise will prevent muscle atrophy without increasing pain at the knees. Relaxation using biofeedback may decrease the patient's stress and anxiety. Because the treatment of fibromyalgia is symptomatic, this patient will preferably be prescribed a nonopioid pain medication, an antiseizure medication such as pregabalin to help with widespread pain, and a serotonin reuptake inhibitor for depression. Long-acting opioids such as morphine are avoided unless other medications do not relieve pain.

The nurse is caring for an older patient who has been receiving antiretroviral therapy for HIV infection for many years. The nurse is aware that complications of long-term antiretroviral use can include: (Select all that apply.) A. osteoporosis. B. insulin resistance. C. cognitive problems. D. urinary incontinence. E. cardiovascular disease.

A, B, E Patients receiving HIV antiretroviral therapy are more likely to develop other conditions include osteoporosis, insulin resistance, and cardiovascular disease.

When caring for a patient with a biliary obstruction, the nurse will anticipate administering which vitamin supplements? (Select all that apply.) A. Vitamin A B. Vitamin B C. Vitamin D D. Vitamin E E. Vitamin K

A, C, D, E (Vitamins ADEK --> biliary) Biliary obstruction prevents bile from entering the small intestine and thus prevents the absorption of fat-soluble vitamins. Vitamins A, D, E, and K are all fat-soluble and thus would need to be supplemented in a patient with biliary obstruction.

When caring for a patient with a known latex allergy, the nurse would monitor the patient closely for a cross-sensitivity to which foods? (Select all that apply.) A. Grapes B. Oranges C. Bananas D. Potatoes E. Tomatoes

A, C, D, E Because some proteins in rubber are similar to food proteins, some foods may cause an allergic reaction in people who are allergic to latex. The most common of these foods are bananas, avocados, chestnuts, kiwi fruit, tomatoes, water chestnuts, guava, hazelnuts, potatoes, peaches, grapes, and apricots.

A patient with longstanding Raynaud's phenomenon currently reports red spots on the hands, forearms, palms, face, and lips. Which additional findings would the nurse expect? (Select all that apply.) A. Calcinosis B. Weight loss C. Sclerodactyly D. Difficulty swallowing E. Weakened leg muscles F. Skin thickening below the elbow and knee

A, C, D, E This patient is at risk for scleroderma. The acronym CREST represents the manifestations. C: calcinosis, painful calcium deposits in the skin; R: Raynaud's phenomenon; E: esophageal dysfunction, difficulty swallowing; S: sclerodactyly, tightening of skin on fingers and toes; and T: telangiectasia. Weight loss and weakened leg muscles are associated with polymyositis and dermatomyositis, not scleroderma.

While on a mission trip, the nurse is caring for a patient diagnosed with tetanus. The patient has been given tetanus immune globulin (TIG). What interprofessional care is appropriate? (Select all that apply.) A. Administer penicillin. B. Administer polyvalent antitoxin. C. Control spasms with diazepam (Valium). D. Teach correct processing of canned foods. E. Provide analgesia with opioids (morphine). F. Prepare for tracheostomy for mechanical ventilation.

A, C, E, F Penicillin is administered to inhibit further growth of Clostridium tetani. Control of the spasms of tetanus is essential because laryngeal and respiratory spasms cause apnea and anoxia. Morphine can be used to manage pain. A tracheostomy is performed early so mechanical ventilation may be done to maintain respirations. Using polyvalent antitoxin and teaching the correct canning process are done for botulism.

A nurse assesses a patient with joint pain and stiffness who was diagnosed with stage III rheumatoid arthritis (RA). Which additional characteristics should the nurse expect? (Select all that apply.) A. Presence of nodules B. Consistent muscle strength C. Localized disease symptoms D. No destructive changes on x-ray E. Subluxation of joints without fibrous ankyloses F. Joint space narrowing and formation of osteophytes

A, E In stage III severe RA, extraarticular soft tissue lesions or nodules may be present along with subluxation without fibrous or bony ankylosis. Muscle strength is decreased because of extensive muscle atrophy. Manifestations are systemic rather than localized. There is x-ray evidence of cartilage and bone destruction in addition to osteoporosis. Joint space narrowing with osteophytes is consistent with osteoarthritis.

A patient waiting for a kidney transplant asks the nurse to explain the difference between a negative and positive crossmatch. Which statement by the nurse would be the most accurate response? A. "A negative crossmatch means that both the donor and recipient are Rh negative, and the transplant is safe." B. "A negative crossmatch means that no preformed antibodies are present, and the transplant would be safe." C. "A positive crossmatch means the blood type is the same between donor and recipient, and the transplant is safe." D. "A positive crossmatch means that both the donor and the recipient have antigens that are similar, and the transplant would be safe."

B A crossmatch uses serum from the recipient mixed with donor lymphocytes to test for any preformed antibodies to the potential donor organ. A positive crossmatch indicates that the recipient has cytotoxic antibodies to the donor and is an absolute contraindication to transplantation. A negative crossmatch indicates that no preformed antibodies are present, and it is safe to proceed with transplantation.

The nurse is teaching a patient with a latex allergy about preventing and treating allergic reactions. Which statement, if made by the patient, indicates a need for further teaching? A. "My dentist should be told about my latex allergy." B. "My reactions are not severe; I will not need an EpiPen."C. "I should avoid foods such as bananas, avocados, and kiwi." D. "I will use vinyl gloves for activities such as housekeeping."

B A person with latex allergies should carry an injectable epinephrine pen. The proteins in latex are like the proteins in certain foods and may cause an allergic reaction in people who are allergic to latex. Foods to avoid include banana, avocado, chestnut, kiwi, tomato, water chestnuts, guava, hazelnuts, potatoes, peaches, grapes, and apricots. Vinyl gloves are not latex and are safe to use. Individuals with latex allergies need to share this information with all health care providers and wear a medical alert bracelet.

The nurse is caring for a patient admitted with a spinal cord injury after a motor vehicle accident. The patient has a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as: A. central cord syndrome. B. spinal shock syndrome. C. anterior cord syndrome. D. Brown-Séquard syndrome.

B About 50% of people with acute spinal cord injury develop spinal shock, a temporary loss of reflexes, sensation, and motor activity. Central cord syndrome is manifested by motor and sensory loss greater in the upper extremities than the lower extremities. Anterior cord syndrome results in motor and sensory loss but not loss of reflexes. Brown-Séquard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory function.

The public health nurse is providing community education to increase the number of people who seek care after a tick bite. What priority information should the nurse provide to people at risk for tick bites? A. The best therapy for the acute illness is IV antibiotics. B. Check for an enlarging reddened area with a clear center. C. Surveillance is necessary during the summer months only. D. Antibiotics will prevent Lyme disease if taken for 10 days.

B After a tick bite, the expanding "bull's eye rash" is the most characteristic symptom that usually occurs in 3 to 30 days. Flu-like symptoms and migrating joint and muscle pain also may be present. Active lesions are treated with oral antibiotics for 2 to 3 weeks; doxycycline is effective in preventing Lyme disease when given within 3 days after the bite of a deer tick. IV therapy is used with neurologic or cardiac complications. Although ticks are most prevalent during summer months, residents of high-risk areas should check for ticks whenever they are outdoors. No vaccine is available.

When providing discharge teaching for a patient after a laparoscopic cholecystectomy, what information should the nurse include? A. Do not return to work or normal activities for 3 weeks. B. A low-fat diet may be better tolerated for several weeks. C. Bile-colored drainage will probably drain from the incision. D. Keep the bandages on and the puncture site dry until it heals.

B Although the usual diet can be resumed, a low-fat diet is usually better tolerated for several weeks after surgery. Normal activities can be gradually resumed as the patient tolerates. Bile-colored drainage or pus, redness, swelling, severe pain, and fever may all indicate infection. The bandage may be removed the day after surgery, and the patient can shower.

A nurse is reviewing the laboratory results of a client who has cirrhosis. Which of the following laboratory values should the nurse expect? A. Decreased prothrombin time B. Elevated bilirubin level C. Decreased ammonia level D. Elevated albumin level

B Bilirubin levels reflect the liver's ability to conjugate and excrete bilirubin, a byproduct of the hemolysis of red blood cells. Bilirubin levels rise with liver disease and clinically reflect the client's degree of jaundice.

The nurse is caring for a patient admitted with a subdural hematoma after a motor vehicle accident. What change in vital signs would the nurse interpret as a manifestation of increased intracranial pressure (ICP)? A. Tachypnea B. Bradycardia C. Hypotension D. Narrowing pulse pressure

B Bradycardia could indicate increased ICP. Changes in vital signs (known as Cushing's triad) occur with increased ICP. They consist of increasing systolic pressure with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations.

A patient is hospitalized for a frontal skull fracture from a blunt force head injury. Thin bloody fluid is draining from the patient's nose. What action by the nurse is most appropriate? A. Place packing in the patient's nares. B. Apply a loose gauze pad under the patient's nose. C. Place the patient in a modified Trendelenburg position. D. Ask the patient to gently blow the nose to clear the drainage.

B Cerebrospinal fluid (CSF) rhinorrhea (clear or bloody drainage from the nose) may occur with a frontal skull fracture. A loose collection pad may be placed under the nose, and if thin bloody fluid is present, the blood will coalesce, and a yellow halo will form if CSF is present. If clear drainage is present, testing for glucose would indicate the presence of CSF. Mixed blood and CSF will test positive for glucose because blood contains glucose. If CSF rhinorrhea occurs, the nurse should inform the provider immediately. The head of the bed may be raised to decrease the CSF pressure so that a tear can seal. The nurse should not place packing in the nasal cavity, and the patient should not sneeze or blow the nose.

The patient is diagnosed with vancomycin-resistant enterococci (VRE) infection in a surgical wound. What infection precautions should the nurse use to prevent transmission of the infection to others? A. Droplet precautions B. Contact precautions C. Airborne precautions D. Standard precautions

B Contact precautions are used to minimize the spread of pathogens that are acquired from direct or indirect contact. Droplet precautions are used with pathogens that are spread through the air at close contact and that affect the respiratory system or mucous membranes (e.g., influenza, pertussis). Airborne precautions are used if the organism can cause infection over long distances when suspended in the air (e.g., tuberculosis, rubeola). Standard precautions are used with all patients and included in the transmission-based precautions above.

A 66-yr-old man with type 2 diabetes and atrial fibrillation has begun taking glucosamine and chondroitin for osteoarthritis. Which question is most important for the nurse to ask? A. "Did you have any hypoglycemic reactions?" B. "Have you noticed any bruising or bleeding?" C. "Have you had any dizzy spells when standing up?" D. "Do you have any numbness or tingling in your feet?"

B Glucosamine and chondroitin are dietary supplements commonly used to treat osteoarthritis. Both may increase the risk of bleeding. Patients with atrial fibrillation routinely take an anticoagulant to reduce the risk of venous thromboembolism and stroke. Use of glucosamine and chondroitin along with an anticoagulant may precipitate excessive bleeding. Glucosamine may decrease the effectiveness of insulin or other drugs used to control blood glucose, and hyperglycemia may occur.

The nurse is teaching a group of young adults who live in a dormitory about the prevention of antibiotic-resistant infections. What should be included in the teaching plan? A. Save leftover antibiotics for future uses. B. Hand washing can prevent many infections. C. Antibiotics are indicated for preventing most colds. D. Stop taking prescribed antibiotics when symptoms improve.

B Hand washing is the single most important action to prevent infections. Antibiotics are used to treat bacterial infections, not colds and flu caused by viruses. Patients should complete the entire prescription of antibiotics to prevent the development of resistant bacteria. Antibiotics should not be taken to prevent infections unless they are given prophylactically before undergoing certain surgeries and dental work.

The nurse manager has noted a recent increase in the incidence of hospital care-associated infections (HAIs) on the unit. Which nursing action should be prioritized in the response to this trend? A. Double glove use during procedures. B. Frequent and thorough hand washing. C. Prophylactic, broad-spectrum antibiotics. D. Fitting and appropriate use of N95 masks.

B Hand washing remains the mainstay of the prevention of HAIs. Gloves, masks, and antibiotics may be appropriate in specific circumstances, but none of these replaces the central role of vigilant, thorough hand washing between patients and when moving from one task to another, even with the same patient.

A patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. Which intervention should the nurse include in the patient's plan of care? A. Immediately start enteral feeding to prevent malnutrition. B. Insert an NG and maintain NPO status to allow pancreas to rest. C. Initiate early prophylactic antibiotic therapy to prevent infection. D. Administer acetaminophen (Tylenol) every 4 hours for pain relief.

B Initial treatment with acute pancreatitis will include an NG tube if there is vomiting and being NPO to decrease pancreatic enzyme stimulation and allow the pancreas to rest and heal. Fluid will be administered to treat or prevent shock. The pain will be treated with IV morphine because of the NPO status. Enteral feedings will only be used for the patient with severe acute pancreatitis in whom oral intake is not resumed. Antibiotic therapy is only needed with acute necrotizing pancreatitis and signs of infection.

A nurse is working with a 73-yr-old patient with osteoarthritis. Which description of the disorder should be included in the teaching plan? A. Joint destruction caused by an autoimmune process B. Degeneration of articular cartilage in synovial joints C. Overproduction of synovial fluid resulting in joint destruction D. Breakdown of tissue in non-weight-bearing joints by enzymes

B OA is a degeneration of the articular cartilage in diarthrodial (synovial) joints from damage to the cartilage. The condition has also been referred to as degenerative joint disease. OA is not an autoimmune disease. There is no overproduction of synovial fluid causing destruction or breakdown of tissue by enzymes.

The nurse is admitting a patient who is scheduled for knee arthroscopy related to osteoarthritis. Which finding should the nurse expect when examining the patient's knees? A. Ulnar drift B. Pain with joint movement C. Reddened, swollen affected joints D. Stiffness that increases with movement

B Osteoarthritis is characterized predominantly by joint pain upon movement and is a classic feature of the disease. Ulnar drift occurs with rheumatoid arthritis, not osteoarthritis. Local inflammation (red, swollen joints) is unlikely with osteoarthritis. Stiffness decreases with movement.

The patient with right upper quadrant abdominal pain has an abdominal ultrasound that reveals cholelithiasis. What is the nurse's priority? A. Prevent all oral intake. B. Control abdominal pain. C. Provide enteral feedings. D. Avoid dietary cholesterol.

B Patients with cholelithiasis can have severe pain, so controlling pain is important until the problem can be treated. NPO status may be needed if the patient will have surgery but will not be used for all patients with cholelithiasis. Patients with pancreatitis may be NPO. Enteral feedings should not be needed, and avoiding dietary cholesterol is not used to treat cholelithiasis.

The patient with an autoimmune disease will be treated with plasmapheresis. What should the nurse teach the patient about this treatment? A. It will gather platelets for use later when needed. B. It will remove the IgG autoantibodies and antigen complexes from the plasma. C. It will remove the peripheral stem cells in order to cure the autoimmune disease. D. It will cause anemia because it removes whole blood and red blood cells are damaged.

B Plasmapheresis removes plasma that contains autoantibodies (usually IgG class) and antigen-antibody complexes to remove the pathologic substances in the plasma without causing anemia. Plateletpheresis removes platelets from normal individuals for use by patients with low platelet counts. Apheresis is used to collect stem cells from peripheral blood that does not cure autoimmune disease.

A nurse was accidently stuck with a needle used on a patient who is infected with human immunodeficiency virus (HIV). After reporting the incident, what care should this nurse receive first? A. Personal protective equipment B. Combination antiretroviral therapy C. Counseling to report blood exposures D. A negative evaluation by the manager

B Postexposure prophylaxis with combination antiretroviral therapy can significantly decrease the risk of infection. Personal protective equipment should be available, although it may not have stopped this needle stick. The needle stick has been reported. The negative evaluation may or may not be needed but would not occur first.

The nurse is caring for a 63-yr-old woman taking prednisone (Deltasone) for Bell's palsy. Which statement by the patient requires CORRECTION by the nurse? A. "I can take the medication with food or milk." B. "The medication should be started 1 week after paralysis." C. "I can take acetaminophen with the prescribed medications." D. "Chances of a full recovery are good if I take the medication"

B Prednisone should be started immediately. Patients have the best chance for full recovery if prednisone is initiated before complete paralysis occurs. Prednisone will be tapered over the last 2 weeks of treatment. Oral prednisone may be taken with food or milk to decrease gastrointestinal upset. Patients with Bell's palsy usually begin recovery in 2 to 3 weeks, and most patients have complete recovery in 3 to 6 months. No serious drug interactions occur between prednisone and acetaminophen.

Which statement made by the nurse is most appropriate in teaching patient interventions to minimize the effects of seasonal allergic rhinitis? A. "You will need to get rid of your pets." B. "You should sleep in an air-conditioned room." C. "You would do best to stay indoors during the winter months." D. "You will need to dust your house with a dry feather duster twice a week."

B Seasonal allergic rhinitis is most commonly caused by pollens from trees, weeds, and grasses. Airborne allergies can be controlled by sleeping in an air-conditioned room, daily damp dusting, covering the mattress and pillows with hypoallergenic covers, and wearing a mask outdoors.

The patient with diabetes mellitus has been chronically ill with a severe lung infection requiring corticosteroids and antibiotics. What condition should the nurse monitor for related to the patient's condition? A. Primary immunodeficiency B. Secondary immunodeficiency C. Major histoincompatibility D. Acute hypersensitivity reaction

B Secondary immunodeficiency is most commonly caused by immunosuppressive drugs, such as corticosteroids. It can also be caused by diabetes mellitus, severe infection, malnutrition, and chronic stress, all of which are present in this patient. The other options are not possible for this patient. Histoincompatibility occurs when the human leukocyte antigen (HLA) system of the donor is not compatible with the recipient's HLA genes. Primary immunodeficiency is rare and includes phagocytic defects, B-cell deficiency, T-cell deficiency, or a combination of B-cell and T-cell deficiency. Acute hypersensitivity reaction is an anaphylactic-type allergic reaction to an antigen.

Which nursing intervention is appropriate for a patient with Sjögren's syndrome? A. Ambulate with assistive devices. B. Use lubricating eyedrops frequently. C. Administer acetaminophen as needed. D. Apply ice or heat compresses to affected areas.

B Sjögren's syndrome is an autoimmune disorder in which lymphocytes attack moisture-producing glands. Treatment is symptomatic, including adding moisture to eyes and increasing intake of fluids, especially with meals.

The nurse teaches the staff that standard precautions should be used when providing care for which type of patient? A. Pediatric and older adult patients B. All patients regardless of diagnosis C. Patients who are immunocompromised D. Patients with a history of infectious diseases

B Standard precautions are designed for all care of all patients in hospitals and health care facilities.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). A new bag is not available when the current infusion is nearly completed. Which of the following actions should the nurse take? A. Keep the line open with 0.9% sodium chloride until the new bag arrives. B. Administer dextrose 10% in water until the new bag arrives. C. Flush the line and cap the port until the new bag arrives. D. Decrease the infusion rate until the new bag arrives.

B TPN solutions have a high concentration of dextrose. Therefore, if a TPN solution is temporarily unavailable, the nurse should administer dextrose 10% or 20% in water to avoid a precipitous drop in the client's blood glucose level.

A parent does not want their child to have any extra immunizations for diseases that no longer occur. What teaching about immunization should the nurse provide this mother? A. There is currently no need for those older vaccines. B. There is a reemergence of some of the infections, such as pertussis. C. There is no longer an immunization available for some of those diseases. D. The only way to protect your child is to have the federally required vaccines.

B Teaching the parent that some of the diseases are reemerging and the damage they can do to her child gives the mother the information to make an informed decision. The immunizations still exist and do protect individuals.

A patient has a hemoglobin level of 8.2 g/dL and hematocrit of 28% and is receiving a transfusion of packed red blood cells. The patient reports back pain, chills, and has a fever during the transfusion. What is the prioritynursing action? A. Call the provider. B. Stop the transfusion. C. Give acetaminophen for the pain and fever. D. Monitor the patient for the rest of the transfusion.

B The patient is having a transfusion reaction and the transfusion should immediately be stopped. Vital signs are taken, and medications administered to counteract the reaction. The blood should be saved for testing. The provider may be called after the transfusion is stopped. The patient should be monitored after the transfusion is discontinued until the condition is stable. After the transfusion is discontinued and the reaction is terminated, the back pain, fever, and chills will cease, and the acetaminophen will not be required.

A patient admitted with diabetes, malnutrition, osteomyelitis, and chronic alcohol use has a serum amylase level of 480 U/L and a serum lipase level of 610 U/L. Which diagnosis does the nurse expect? A. Starvation B. Pancreatitis C. Systemic sepsis D. Diabetic ketoacidosis

B The patient with chronic alcohol use could develop pancreatitis as a complication, which would increase the serum amylase (normal, 30 to 122 U/L) and serum lipase (normal, 31 to 186 U/L) levels as shown.

A 25-yr-old male patient has anterior spinal cord syndrome at T10. His history is significant for tobacco, alcohol, and marijuana use. What is the nurse's priority when planning for rehabilitation? A. Prevent urinary tract infection. B. Encourage him to share his feelings. C. Monitor the patient every 15 minutes. D. Teach him about using the gastrocolic reflex.

B To help the patient with coping and prevent self-harm, the nurse should create a therapeutic patient environment that encourages self-expression and verbalization of thoughts and feelings. The patient is at high risk for depression and self-injury because loss of function below the umbilicus is expected. He is a young adult male patient who will need a wheelchair and have impaired sexual function. Because the patient uses tobacco, alcohol, and marijuana frequently, hospitalization is likely to result in a loss of these habits and can make coping difficult. Preventing urinary tract infection and facilitating bowel evacuation with the gastrocolic reflex will be important during recovery. In rehabilitation, monitoring every 15 minutes is not needed unless the patient is on suicide precautions.

The nurse is aware of potential complications related to cirrhosis. Which interventions would be included in a safe plan of care? (Select all that apply.) A. Provide a high-protein, low-carbohydrate diet. B. Tell the patient to use soft-bristle toothbrush and electric razor. C. Teach the patient to avoid vigorous blowing of nose and coughing. D. Apply gentle pressure for the shortest possible time after venipuncture. E. Use the smallest gauge needle possible when giving injections or drawing blood. F. Teach the patient to avoid aspirin and nonsteroidal antiinflammatory (NSAIDs).

B, C, E, F Using the smallest gauge needle for injections, using a soft bristle toothbrush and an electric razor will minimize the risk of bleeding into the tissues. Avoiding straining, nose blowing, and coughing will reduce the risk of hemorrhage at these sites. The nurse should apply gentle but prolonged pressure to venipuncture sites to minimize the risk of bleeding. Aspirin and NSAIDs should not be used in patients with liver disease because they interfere with platelet aggregation, thus increasing the risk for bleeding. A low-salt, low-protein, high-carbohydrate diet may be recommended.

A patient with a spinal cord injury has a neurogenic bowel. Beyond the use of bisacodyl suppositories and digital stimulation, which measures should the nurse teach the patient and caregiver to assist with bowel evacuation? (Select all that apply.) A. Drink milk with each meal. B. Eat 20 to 30 g of fiber per day. C. Use an oral laxative every day. D. Limit intake of caffeinated beverages. E. Drink 1800 to 2800 mL of water or juice. F. Establish bowel evacuation time at bedtime.

B, D, E The patient with a spinal cord injury and neurogenic bowel should eat 20 to 30 g of fiber and drink 1800 to 2800 mL of water or juice each day. Caffeine stimulates fluid loss and can contribute to constipation, so caffeine intake should be limited. Milk also may cause constipation. Daily oral laxatives may cause diarrhea and are avoided unless needed. Bowel evacuation time usually is established 30 minutes after the first meal of the day to take advantage of the gastrocolic reflex induced by eating.

The nurse is caring for a patient admitted to the hospital with a head injury who requires frequent neurologic assessment. Which components are assessed using the Glasgow Coma Scale (GCS)? (Select all that apply.) A. Judgment B. Eye opening C. Abstract reasoning D. Best motor response E. Best verbal response F. Cranial nerve function

B, D, E The three dimensions of the GCS are eye opening, best verbal response, and best motor response. Judgment, abstract reasoning, and cranial nerve function are not components of the GCS.

The nurse is caring for a patient with acute pancreatitis resulting from gallstones. Which clinical manifestation would the nurse expect? (Select all that apply.) A. Hematochezia B. Nausea and vomiting C. Hyperactive bowel sounds D. Left upper abdominal pain E. Ascites and peripheral edema F. Temperature 99.3° F (37.4° C)

B, D, F Abdominal pain (usually in the left upper quadrant) is the predominant manifestation of acute pancreatitis. Other manifestations include nausea and vomiting, low-grade fever, leukocytosis, hypotension, tachycardia, and jaundice. Abdominal tenderness with muscle guarding is common. Bowel sounds may be decreased or absent. Ileus may occur and causes marked abdominal distention. Areas of cyanosis or greenish to yellow-brown discoloration of the abdominal wall may occur. Other areas of ecchymoses are the flanks (Grey Turner's spots or sign, a bluish flank discoloration) and the periumbilical area (Cullen's sign, a bluish periumbilical discoloration).

The nurse is providing care for a patient who has been living with human immunodeficiency virus (HIV) for several years. Which assessment finding most clearly indicates an acute exacerbation of the disease? A. A new onset of polycythemia B. Presence of mononucleosis-like symptoms C. A sharp decrease in the patient's CD4+ count D. A sudden increase in the patient's WBC count

C A decrease in CD4+ count signals an exacerbation of the severity of HIV. Polycythemia is not characteristic of the course of HIV. A patient's WBC count is very unlikely to suddenly increase, with decreases being typical. Mononucleosis-like symptoms such as malaise, headache, and fatigue are typical of early HIV infection and seroconversion.

The nurse provides discharge instructions for a patient with ascites and peripheral edema related to cirrhosis. Which patient statement indicates teaching was effective? A. "Lactulose should be taken every day to prevent constipation." B. "It is safe to take acetaminophen up to four times a day for pain." C. "Herbs and other spices should be used to season my foods instead of salt." D. "I will eat foods high in potassium while taking spironolactone (Aldactone)."

C A low-sodium diet is indicated for patients with ascites and edema related to cirrhosis. Table salt is a well-known source of sodium and should be avoided. Alternatives to salt to season foods include the use of seasonings such as garlic, parsley, onion, lemon juice, and spices. Pain medications such as acetaminophen, aspirin, and ibuprofen should be avoided because these medications may be toxic to the liver. The patient should avoid potentially hepatotoxic over-the-counter drugs (e.g., acetaminophen) because the diseased liver is unable to metabolize these drugs. Spironolactone is a potassium-sparing diuretic. Lactulose results in the acidification of feces in bowel and trapping of ammonia, causing its elimination in feces.

A nurse is assessing the recent health history of a 63-yr-old patient with osteoarthritis. Which activity pattern should the nurse recommend? A. Bed rest with bathroom privileges B. Daily high-impact aerobic exercise C. Regular exercise program of walking D. Frequent rest periods with minimal exercise

C A regular low-impact exercise, such as walking, is important in helping to maintain joint mobility in patients with osteoarthritis. A balance of rest and activity is needed. High-impact aerobic exercises would cause stress to affected joints and further damage.

A patient received penicillin V potassium intramuscular (IM) causing a systemic anaphylactic reaction. What manifestations does the nurse observe initially? A. Dyspnea B. Dilated pupils C. Itching and edema D. Wheal-and-flare reaction

C A systemic anaphylactic reaction starts with edema and itching at the site of exposure to the antigen. Shock can rapidly develop with rapid, weak pulse; hypotension; dilated pupils; dyspnea; and possible cyanosis. The wheal-and-flare reaction occurs with a localized anaphylactic reaction such as a mosquito bite.

The nurse is providing care for a patient diagnosed with Guillain-Barré syndrome. Which assessment should be the nurse's priority? A. Pain assessment B. Glasgow Coma Scale C. Respiratory assessment D. Musculoskeletal assessment

C Although all the assessments are necessary in the care of patients with Guillain-Barré syndrome, the acute risk of respiratory failure requires vigilant monitoring of the patient's respiratory function.

The nurse is monitoring the effectiveness of antiretroviral therapy (ART) for a patient with human immunodeficiency virus (HIV). What laboratory study result indicates the medications are effective? A. Increased viral load B. Decreased neutrophil count C. Increased CD4+ T-cell count D. Decreased white blood cell count

C Antiretroviral therapy is effective if the HIV viral load is decreased, and the CD4+ T-cell count is increased.

A patient with suspected bacterial meningitis just had a lumbar puncture in which cerebrospinal fluid was obtained for culture. Which medication should the nurse give first? A. Codeine B. Phenytoin C. Ceftriaxone D. Acetaminophen

C Bacterial meningitis is a medical emergency. When meningitis is suspected, antibiotic therapy (e.g., ceftriaxone) is started immediately after the collection of specimens for cultures and even before the diagnosis is confirmed. Dexamethasone may be given before or with the first dose of antibiotics. The nurse should collaborate with the health care provider to manage the headache (with codeine), fever (with acetaminophen), and seizures (with phenytoin).

The nurse is caring for a patient with bilateral knee osteoarthritis. Which measure should the nurse recommend to slow progression of the disease? A. Use a wheelchair to avoid walking as much as possible. B. Sit in chairs that cause the hips to be lower than the knees. C. Eat a well-balanced diet to maintain a healthy body weight. D. Use a walker for ambulation to relieve the pressure on the hips.

C Because maintaining an appropriate load on the joints is essential to the preservation of articular cartilage integrity, the patient should maintain an optimal overall body weight or lose weight if overweight. Walking is encouraged. The best chairs for this patient have a higher seat and armrests to facilitate sitting and rising from the chair. Relieving pressure on the hips is not important for knee disease.

The nurse teaches a patient about cholestyramine to reduce pruritus caused by gallbladder disease. Which statement indicates understanding of the instructions? A. "This medication will help me digest fats and fat-soluble vitamins." B. "I will apply the medicated lotion sparingly to the areas where I itch." C. "The medication is a powder and needs to be mixed with milk or juice." D. "I should take this medication on an empty stomach at the same time each day."

C For treatment of pruritus, cholestyramine may provide relief. This is a resin that binds bile salts in the intestine, increasing their excretion in the feces. Cholestyramine is in powder form and should be mixed with milk or juice before oral administration. Excess bile in the body can cause severe itching.

In planning long-term care for a patient after craniotomy, what must the nurse include in family and caregiver education? A. Seizures will develop within weeks or months. B. The family will be unable to cope with role reversals. C. There are often residual changes in personality and cognition. D. Referrals will be made to eliminate residual deficits from the damage.

C In long-term care planning, the nurse must include the family and caregiver when teaching about potential residual changes in personality, emotions, and cognition as these changes are most difficult for the patient and family to accept. Seizures may or may not develop. The family and patient may or may not be able to cope with role reversals. Although residual deficits will not be eliminated with referrals, they may be improved.

When reinforcing health teaching on managing osteoarthritis, which patient statement indicates additional instruction is needed? A. "I can use a cane to relieve the pressure on my back and hip." B. "I should take the Naprosyn as prescribed to help control the pain." C. "I should try to stay standing all day to keep my joints from becoming stiff." D. "A warm shower in the morning will help relieve the stiffness I have when I get up."

C Maintaining a balance between rest and activity is important to prevent overstressing joints affected by OA. Naproxen may be used for moderate to severe OA pain. Using a cane and warm shower to help relieve pain and morning stiffness are helpful.

When planning care for a patient with a cervical spinal cord injury (C5), which nursing problem has the highest priority? A. Constipation B. Difficulty coping C. Impaired breathing D. Impaired nutritional status

C Maintaining a patent airway is the most important goal for a patient with a cervical spinal cord injury. Respiratory needs are always the highest priority (ABCs).

A patient has a systemic BP of 120/60 mm Hg and an ICP of 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), how does the nurse interpret the results? A. High blood flow to the brain B. Normal intracranial pressure C. Impaired blood flow to the brain D. Adequate autoregulation of blood flow

C Normal CPP is 60 to 100 mm Hg. The CPP is calculated with mean arterial pressure (MAP) minus ICP. MAP = SBP + 2 (DBP)/ 3: 120 mm Hg + 2 (60 mm Hg)/3 = 80 mm Hg. MAP − ICP: 80 mm Hg − 24 mm Hg = 56 mm Hg CPP. The decreased CPP indicates that there is impaired cerebral blood flow and that autoregulation is impaired. Because the ICP is 24 mm Hg, treatment is required.

A pregnant woman who was tested and diagnosed with human immunodeficiency virus (HIV) infection is upset. What should the nurse teach this patient about her baby's risk of being born with HIV infection? A. "The baby will be infected with HIV." B. "Having a cesarean section will keep your baby from having HIV." C. "Treatment with antiretroviral therapy will decrease the baby's chance of HIV infection." D. "The duration and frequency of contact with the organism will determine if the baby gets HIV infection."

C On average, 25% of infants born to women with untreated HIV will be born with HIV. The risk of transmission is reduced to less than 2% if the infected pregnant woman is treated with antiretroviral therapy. Duration and frequency of contact with the HIV organism is one variable that influences whether transmission of HIV occurs. Volume, virulence, and concentration of the organism as well as host immune status are variables related to transmission via blood, semen, vaginal secretions, or breast milk.

Which intervention should the nurse perform first in the acute care of a patient with autonomic dysreflexia? A. Urinary catheterization B. Check for bowel impaction C. Elevate the head of the bed D. Administer intravenous hydralazine

C Positioning the patient upright is the first action so blood pressure will decrease. Then assessment of indwelling urinary catheter patency or immediate catheterization should be performed to relieve bladder distention. Next, the rectum should be examined for retained stool or impaction. Finally, the nurse will consider administering an intravenous antihypertensive medication if needed.

The nurse is delivering teaching to a female patient newly diagnosed with systemic lupus erythematosus (SLE). Which statement demonstrates the patient's need for further teaching about the disease? A. "I'll try my best to stay out of the sun this summer." B. "I know that I have a high chance of getting arthritis." C. "I'm hoping surgery will be an option for me in the future." D. "I understand I'm going to be vulnerable to getting infections."

C Surgery is not a key treatment modality for SLE, so this indicates a need for further teaching. SLE carries an increased risk of infection, sun damage, and arthritis.

A patient with chronic hepatitis B is being discharged with pain medication after knee surgery. Which medication order should the nurse question? A. Tramadol B. Hydromorphone (Dilaudid) C. Hydrocodone with acetaminophen D. Oxycodone with aspirin (Percodan)

C The analgesic with acetaminophen should be questioned because this patient has chronic hepatitis B and is likely to have impaired liver function. Acetaminophen is not suitable for this patient because it is converted to a toxic metabolite in the liver after absorption, increasing the risk of hepatocellular damage.

The patient with suspected pancreatic cancer is having many diagnostic studies done. Which test can be used to establish the diagnosis of pancreatic cancer and for monitoring the response to treatment? A. Spiral CT scan B. A PET/CT scan C. Cancer-associated antigen 19-9 D. Abdominal ultrasound

C The cancer-associated antigen 19-9 (CA 19-9) is the tumor marker used for the diagnosis of pancreatic cancer and monitoring the response to treatment. Although a spiral CT scan may be the initial study done and provides information on metastasis and vascular involvement, this test and the positron emission tomography (PET)/CT scan or abdominal ultrasonography does not provide additional information.

A nurse is caring for a client who is having a seizure. Which of the following interventions is the nurse's priority? A. Loosen the clothing around the client's neck. B. Check the client's pupillary response. C. Turn the client to the side. D. Move furniture away from the client.

C The greatest risk to this client is hypoxia from an impaired airway. Therefore, the priority intervention the nurse should take is to place the client in a side-lying position to prevent aspiration.

A nurse is providing preoperative teaching for a client who is scheduled for an open cholecystectomy. Which of the following actions should the nurse take? A. Teach the importance of a clear liquid diet after discharge. B. Tell the client to remove the incisional adhesive strips 3 days after discharge. C. Demonstrate ways to deep breathe and cough. D. Instruct the client to maintain bed rest for 48 hr.

C The nurse should demonstrate deep breathing and coughing exercises and explain the importance of splinting the incision to reduce the risk for respiratory complications.

A 22-yr-old woman with paraplegia after a spinal cord injury tells the home care nurse she has bowel incontinence 2 or 3 times each day. Which action should the nurse perform first? A. Insert a rectal stimulant suppository. B. Have the patient to gradually increase intake of high-fiber foods. C. Assess bowel movements for frequency, consistency, and volume. D. Teach the patient to avoid all caffeinated and carbonated beverages.

C The nurse should establish baseline bowel function and explore the patient's current knowledge of an appropriate bowel management program after spinal cord injury. To prevent constipation, caffeine intake should be limited but need not be eliminated. After stabilization, creation of a bowel program including a rectal stimulant, digital stimulation, or manual evacuation at the same time each day will regulate bowel elimination. Instruction on high-fiber foods is indicated if the patient has a knowledge deficit.

The provider orders intracranial pressure (ICP) readings every hour for a patient with a traumatic brain injury from a motor vehicle crash. The patient's ICP reading is 21 mm Hg. It is most important for the nurse to take which action? A. Document the ICP reading in the chart. B. Determine if the patient has a headache. C. Assess the patient's level of consciousness. D. Position the patient with head elevated 60 degrees.

C The patient has an increased ICP (normal ICP ranges from 5 to 15 mm Hg). The most sensitive and reliable indicator of neurologic status is level of consciousness. The Glasgow Coma Scale may be used to determine the degree of impaired consciousness.

The patient with a brain tumor is being monitored for increased intracranial pressure (ICP) with a ventriculostomy. What nursing intervention is priority? A. Administer IV mannitol as ordered. B. Ventilator use to hyperoxygenate the patient. C. Use strict aseptic technique with dressing changes. D. Be aware of changes in ICP related to cerebrospinal fluid leaks.

C The priority nursing intervention is to use strict aseptic technique with dressing changes and any handling of the insertion site to prevent the serious complication of infection. IV mannitol or hypertonic saline will be administered as ordered for increased ICP. Ventilators may be used to maintain oxygenation. CSF leaks may cause inaccurate ICP readings, or CSF may be drained to decrease ICP, but strict aseptic technique to prevent infection is the nurse's priority of care.

A patient has begun immunotherapy for the treatment of intractable environmental allergies. When administering the patient's immunotherapy, what is the nurse's priority action? A. Monitor the patient's fluid balance. B. Assess the patient's need for analgesia. C. Monitor for signs and symptoms of an adverse reaction. D. Assess the patient for changes in level of consciousness.

C When administering immunotherapy, it is imperative to closely monitor the patient for any signs of an adverse reaction. The high risk and significant consequence of an adverse reaction supersede the need to assess the patient's fluid balance. Pain and changes in level of consciousness are not likely events when administering immunotherapy.

A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurse's priority? A. Anorexia B. Abdominal pain radiating to the right shoulder C. Tachycardia D. Rebound abdominal tenderness

C When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is tachycardia. Tachycardia is a manifestation of biliary colic, which can lead to shock. The nurse should position the head of the client's bed flat and report this finding immediately to the provider.

A patient is admitted to the emergency department (ED) with fever, swollen lymph glands, sore throat, headache, malaise, joint pain, and diarrhea. What nursing actions will help identify the need for further assessment of the cause of this patient's manifestations if the nurse suspects the patient is at risk for HIV infection? (Select all that apply.) A. Assessment of lung sounds B. Reviewing living conditions C. Assessment of sexual behavior D. Assessment of drug and syringe use E. Evaluating for exposure to an ill person

C, D With these symptoms, assessing this patient's sexual behavior and possible exposure to shared drug equipment will identify if further assessment for HIV infection should be made or the manifestations are from some other illness (e.g., lung sounds and living conditions may indicate further testing for TB).

A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which of the following findings indicates that the client is experiencing increased intracranial pressure (ICP)? (Select all that apply.) A. Flat jugular veins B. A Glasgow Coma Scale score of 15 C. Sleepiness exhibited by the client D. Widening pulse pressure E. Decerebrate posturing

C, D, E Flat jugular veins is incorrect. With increased ICP, the jugular veins are typically distended. A Glasgow Coma Scale score of 15 is incorrect. A Glasgow Coma Scale score of 15 indicates neurological functioning within the expected reference range for eye opening, motor, and verbal response. Sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the client from sleep is an indication of increased ICP. Widening pulse pressure is correct. A widening pulse pressure (increase in systolic with concurrent decrease in diastolic blood pressure) is an indication of increased ICP. Decerebrate posturing is correct. Both decerebrate and decorticate posturing indicate increased ICP.

A heterosexual patient is concerned that they may contract human immunodeficiency virus (HIV) from a bisexual partner. What should the nurse include when teaching about preexposure prophylaxis? (Select all that apply.) A. Take fluconazole (Diflucan). B. Take amphotericin B (Fungizone). C. Use condoms for risk-reducing sexual relations. D. Take emtricitabine and tenofovir (Truvada) regularly. E. Have regular HIV testing for herself and her husband.

C, D, E Using male or female condoms, having regular HIV testing for the patient and partner, and taking emtricitabine and tenofovir regularly have shown to decrease the infection of heterosexual women having sex with a partner who participates in high-risk behavior. Fluconazole and amphotericin B are taken for Candida albicans, Coccidioides immitis, and Cryptococcus neoformans, which are all opportunistic diseases associated with HIV infection.

The patient with peripheral facial paresis on the left side is diagnosed with Bell's palsy. What should the nurse teach the patient about self-care? (Select all that apply.) A. Use of antiseizure medications B. Preparing for a nerve block to manage pain C. Administration of corticosteroid medications D. Surgery if conservative therapy is not effective E. Dark glasses and artificial tears to protect the eyes F. A facial sling to support the muscles and facilitate eating

C, E, F Self-care for Bell's palsy includes use of corticosteroid medications to decrease inflammation of the facial nerve (cranial nerve VII). Dark glasses and artificial tears protect the cornea from drying because of the inability to close the eyelid. The occupational therapist may fit a facial sling to support muscles and facilitate eating. Antiseizure medications, a nerve block, or surgeries are used for trigeminal neuralgia.

A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing's triad? A. Hypotension B. Tachypnea C. Nuchal rigidity D. Bradycardia

D A client who has increased intracranial pressure from a traumatic brain injury can develop bradycardia, which is one component of Cushing's triad. The other components of Cushing's triad are severe hypertension and a widened pulse pressure.

A nurse is caring for a client who has pancreatitis. The nurse should expect which of the following laboratory results to be below the expected reference range? A. Amylase B. Alkaline phosphatase C. Bilirubin D. Calcium

D A client who has pancreatitis is expected to have decreased calcium and magnesium levels due to fat necrosis.

A patient sustained a diffuse axonal injury from a traumatic brain injury. Why are IV fluids being decreased and enteral feedings started? A. Free water should be avoided. B. Sodium restrictions can be managed. C. Dehydration can be better avoided with feedings. D. Malnutrition promotes continued cerebral edema.

D A patient with diffuse axonal injury is unconscious and, with increased intracranial pressure, is in a hypermetabolic, hypercatabolic state that increases the need for energy to heal. Malnutrition promotes continued cerebral edema, and early feeding may improve outcomes when begun within 3 days after injury. Fluid and electrolytes will be monitored to maintain balance with the enteral nutrition. Excess intravenous fluid administration will also increase cerebral edema.

When planning care for a patient with cirrhosis, the nurse will give highest priority to which nursing diagnosis? A. Fluid imbalance B. Impaired tissue integrity C. Impaired nutritional status D. Ineffective breathing pattern

D Although all these nursing diagnoses are appropriate and important in the care of a patient with cirrhosis, airway and breathing are always the highest priorities.

A patient with cholelithiasis is being prepared for surgery. Which patient assessment represents a contraindication for a cholecystectomy? A. Low-grade fever of 100° F and dehydration B. Abscess in the right upper quadrant of the abdomen C. Multiple obstructions in the cystic and common bile duct D. Activated partial thromboplastin time (aPTT) of 54 seconds

D An aPTT of 54 seconds is above normal and indicates insufficient clotting ability. (Normal aPTT is 30-40 sec). If the patient had surgery, significant bleeding complications postoperatively are very likely. Fluids can be given to eliminate the dehydration. The abscess can be assessed during surgery, and the obstructions in the cystic and common bile duct would be relieved with the cholecystectomy.

Which statement by the patient who had an organ transplant would indicate that the patient understands teaching about immunosuppressive medications? A. "My drug dosages will be lower because the medications enhance each other." B. "Taking more than one medication will put me at risk for developing allergies." C. "I will be more prone to malignancies because I will be taking more than one drug." D. "The lower doses of my medications can prevent rejection and minimize the side effects."

D Because immunosuppressants work at different phases of the immune response, lower doses of each drug can be used to produce effective immunosuppression while minimizing side effects. The use of several medications is not because they enhance each other and does not increase the risk of allergies or of malignancies.

A patient was exposed to human immunodeficiency virus (HIV) 2 weeks ago through sharing needles with other substance users. What symptoms will the nurse teach the patient to report that would indicate the patient has developed an acute HIV infection? A. Cough, diarrhea, headaches, blurred vision, muscle fatigue B. Night sweats, fatigue, fever, and persistent generalized lymphadenopathy C. Oropharyngeal candidiasis or thrush, vaginal candida infection, or oral or genital herpes D. Flu-like symptoms such as fever, sore throat, swollen lymph glands, nausea, or diarrhea

D Clinical manifestations of an acute infection with HIV include flu-like symptoms between 2 to 4 weeks after exposure. Early chronic HIV infection clinical manifestations are either asymptomatic or include fatigue, headache, low-grade fever, night sweats, and persistent generalized lymphadenopathy. Intermediate chronic HIV infection clinical manifestations include candida infections, shingles, oral or genital herpes, bacterial infections, Kaposi sarcoma, or oral hairy leukoplakia. Late chronic HIV infection or acquired immunodeficiency syndrome (AIDS) includes opportunistic diseases (infections and cancer).

A patient with a history of lung cancer and hepatitis C has developed liver failure and is considering liver transplantation. After a comprehensive evaluation, which finding may be a contraindication for liver transplantation? A. History of hypothyroidism B. Stopped smoking cigarettes C. Well-controlled type 1 diabetes D. Chest x-ray shows a new lung cancer lesion

D Contraindications for liver transplant include severe extrahepatic disease, advanced hepatocellular carcinoma or other cancer, ongoing drug or alcohol use, and the inability to comprehend or comply with the rigorous posttransplant course.

The health care provider orders lactulose for a patient with hepatic encephalopathy. Which finding indicates the medication has been effective? A. Relief of constipation B. Relief of abdominal pain C. Decreased liver enzymes D. Decreased ammonia levels

D Hepatic encephalopathy is a complication of liver disease and is associated with elevated serum ammonia levels. Lactulose traps ammonia in the intestinal tract. Its laxative effect then expels the ammonia from the colon, resulting in decreased serum ammonia levels and correction of hepatic encephalopathy. An additional finding may be an improvement in level of consciousness.

The nurse is caring for a woman recently diagnosed with viral hepatitis A. Which person should the nurse refer for an immunoglobulin (IG) injection? A. A friend who delivers meals to the patient and family each week. B. A relative with a history of hepatitis A who visits the patient daily. C. A child living in the home who received the hepatitis A vaccine 3 months ago. D. A caregiver with no history of hepatitis A antibodies who lives in the same household with the patient.

D IG is recommended for persons who do not have anti-HAV antibodies and are exposed because of close contact with persons who have HAV or foodborne exposure. Persons who have received a dose of HAV vaccine more than 1 month previously or who have a history of HAV infection do not require IG.

A patient being tested for multiple allergies develops localized redness and swelling in reaction to a patch skin test. Which intervention by the nurse would have the highest priority? A. Notify the health care provider. B. Administer oral diphenhydramine. C. Apply a topical antiinflammatory cream. D. Remove the patch and extract from the skin.

D If a severe reaction to a patch skin test occurs, the nurse should immediately remove the patch and the extract from the skin. Next the nurse should apply a topical antiinflammatory cream to the site. A subcutaneous injection of epinephrine may also be necessary.

The patient with cirrhosis is being taught self-care. Which statement indicates the patient needs further teaching? A. "A scrotal support may be more comfortable when I have scrotal edema." B. "I need to take good care of my belly and ankle skin where it is swollen." C. "I can use pillows to support my head to help me breathe when I am in bed." D. "If I notice a fast heart rate or irregular beats, this is normal for cirrhosis."

D If the patient with cirrhosis develops a fast or irregular heart rate, it may be indicative of hypokalemia and should be reported to the health care provider because this is not normal for cirrhosis. Edematous tissue is subject to breakdown and needs meticulous skin care. Pillows and a semi-Fowler's or Fowler's position increase respiratory efficiency. A scrotal support may improve comfort if there is scrotal edema.

The family of a patient newly diagnosed with hepatitis A asks the nurse what they can do to prevent becoming ill. Which response by the nurse is most appropriate? A. "You will need to be tested first; then treatment can be determined." B. "The hepatitis vaccine will provide immunity from this and future exposures." C. "There is nothing you can do since the patient was infectious before admission." D. "An immunoglobulin injection will be given to prevent infection or limit symptoms."

D Immunoglobulin provides temporary (1 to 2 months) passive immunity and is effective for preventing hepatitis A if given within 2 weeks after exposure. It may not prevent infection in all persons, but it will at least modify the illness to a subclinical infection. The hepatitis vaccine is only used for preexposure prophylaxis.

The patient with an allergy to bee stings was just stung by a bee. After applying oxygen, removing the stinger, and administering epinephrine, the nurse notices the patient is hypotensive. What should be the nurse's first action?A. Administer IV diphenhydramine B. .Initiate IV nitroprusside as soon as possible. C. Anticipate tracheostomy with laryngeal edema. D. Place the patient recumbent and elevate the legs.

D In this emergency situation, the ABCs (airway, breathing, circulation) are being followed. For hypotension, the patient should be placed in a recumbent position with the legs elevated, epinephrine will continue to be administered every 2 to 5 minutes, and fluids will be administered with vasopressors. Diphenhydramine is an antihistamine used to treat allergy symptoms. Anticipating a tracheostomy may occur with ongoing patient monitoring. Nitroprusside is a vasodilator and would not be used now.

A patient is diagnosed with diabetes insipidus after transsphenoidal resection of a pituitary adenoma. What should the nurse consider as a sign of improvement? A. Serum sodium of 120 mEq/L B. Urine specific gravity of 1.001 C. Fasting blood glucose of 80 mg/dL D. Serum osmolality of 290 mOsm/kg

D Laboratory findings in diabetes insipidus include elevated serum osmolality and serum sodium and decreased urine specific gravity. Normal serum osmolality is 285 to 295 mOsm/kg, normal serum sodium is 136 to 145 mEq/L, and normal specific gravity is 1.005 to 1.030. High blood glucose levels occur with diabetes.

When teaching the patient with acute hepatitis C (HCV), which statement demonstrates understanding of the disease process? A. "I will use care when kissing my wife to prevent giving it to her." B. "I will need to take adefovir (Hepsera) to prevent chronic HCV." C. "Now that I have had HCV, I will have immunity and not get it again." D. "I will need to be monitored for chronic HCV and other liver problems."

D Many patients who acquire HCV develop chronic infection, which may lead to cirrhosis or liver cancer. HCV is not transmitted via saliva but by blood exposures such as sharing needles and high-risk sexual activity. The treatment for acute viral hepatitis focuses on resting the body and adequate nutrition for liver regeneration. Adefovir (Hepsera) is taken for severe hepatitis B (HBV) with liver failure. HCV is treated with oral direct-acting antivirals (DAAs). Immunity with HCV does not occur as it does with HAV and HBV, so the patient may be reinfected with another type of HCV.

The nurse obtains a history from a 46-yr-old woman with rheumatoid arthritis. The nurse should follow up on which patient statement? A. "I perform range of motion exercises at least twice a day." B. "I use a heating pad for 20 minutes to reduce morning stiffness." C. "I take a 20-minute nap in the afternoon even if I sleep 9 hours at night." D. "I restrict fluids to prevent edema when taking methotrexate (Rheumatrex)."

D Methotrexate can affect renal function. Patients should be well hydrated to prevent nephropathy. Heat application, range of motion, and rest are appropriate interventions to manage rheumatoid arthritis.

The nurse assesses a patient for signs of meningeal irritation. Which finding indicates nuchal rigidity is present? A. Tonic spasms of the legs B. Curling in a fetal position C. Arching of the neck and back D. Resistance to flexion of the neck

D Nuchal rigidity is a manifestation of meningitis. During assessment, the patient will resist passive flexion of the neck by the health care provider. Tonic spasms of the legs, curling in a fetal position, and arching of the neck and back are not related to meningeal irritation.

A patient learns about rehabilitation for a spinal cord tumor. Which statement by the patient reflects appropriate understanding of this process? A. "I want to be rehabilitated for my daughter's wedding in 2 weeks." B. "Rehabilitation will be more work done by me alone to try to get better." C. "I will be able to do all my normal activities after I go through rehabilitation." D. "With rehabilitation, I will be able to function at my highest level of wellness."

D Rehabilitation is an interprofessional endeavor to teach and enable the patient to function at their highest level of wellness and adjustment. Intense work will be required of all involved persons; the process will take longer than 2 weeks. With neurologic dysfunction, the patient will not be able to perform all normal activities at the same level as previously.

The nurse is providing postoperative care for a patient with human immunodeficiency virus (HIV) infection after an appendectomy. What type of precautions should the nurse observe to prevent the transmission of this disease? A. Droplet precautions B. Contact precautions C. Airborne precautions D. Standard precautions

D Standard precautions are indicated for prevention of transmission of HIV to the health care worker. HIV is not transmitted by casual contact or respiratory droplets. HIV may be transmitted through sexual intercourse with an infected partner; exposure to HIV-infected blood or blood products; and perinatal transmission during pregnancy, at delivery, or though breastfeeding.

A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take first? A. Check laboratory values for recent hemoglobin and hematocrit levels. B. Establish a peripheral IV line for possible transfusion. C. Call the laboratory to obtain a stat platelet count. D. Obtain vital signs.

D The first action the nurse should take using the nursing process is to assess the client's vital signs. A client who has portal hypertension can develop esophageal varices, which are fragile and can rupture, resulting in large amounts of blood loss and shock. Obtaining vital signs provides information about the client's condition that can contribute to decision making.

Ten days after receiving a bone marrow transplant, a patient develops a skin rash on the palms, soles of feet, jaundice, and diarrhea. What does the nurse determine these clinical manifestations are indicating? A. The patient is experiencing a type I allergic reaction. B. An atopic reaction is causing the patient's symptoms. C. The patient is experiencing rejection of the bone marrow. D. Cells in the transplanted bone marrow are attacking the host tissue.

D The patient's symptoms are characteristic of graft-versus-host-disease (GVHD) in which transplanted cells mount an immune response to the host's tissue. The target organs for the GVHD phenomenon are the skin, liver, and GI tract. GVHD is not a type I allergic response or an atopic reaction, and it differs from transplant rejection in that the graft rejects the host rather than the host rejecting the graft.

A patient was recently diagnosed with a sinus infection and prescribed a 10 day course of an antibiotic. After 3 days the patient felt back to normal and informed the nurse that he decided to stop the antibiotics and save the rest of the antibiotics in case he gets another infection. Which statement by the nurse would be correct in providing education to the patient? A. "You should keep left over antibiotics in a cool, dry place so they do not expire." B. "It is okay to save the antibiotics for next time, but you should check the expiration date." C. "If you have left over antibiotics, please return them back to the clinic so we can give them to patients who cannot afford their medication." D. "If you are prescribed antibiotics, you should complete the entire course of treatment because you may create drug resistance by stopping early."

D To decrease the risk of antibiotic resistance, patients should be educated to complete the entire course of antibiotic therapy, even if they feel better before the treatment course is finished. Patients should never share or keep left over antibiotics.

The patient developed acute gout while hospitalized for a heart attack. Because the patient takes aspirin for its antiplatelet effect, what should the nurse recommend in preventing future attacks of gout? A. Decrease fluid intake B. Drink a glass of wine daily C. Administration of probenecid D. Administration of allopurinol

D To prevent future attacks of gout, the urate-lowering drug allopurinol may be administered. Increased fluid will be encouraged to prevent precipitation of uric acid in the renal tubules. This patient will not be able to take the uricosuric drug probenecid because the patient's aspirin will inactivate its effect, resulting in urate retention. Dietary restrictions that limit alcohol and foods high in purine help minimize uric acid production.

A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? A. Insert a padded tongue blade B. Apply oxygen C. Restrain the client D. Loosen restrictive clothing

D The nurse should loosen tight, restrictive clothing to prevent injury and suffocation. Do NOT insert anything into the mouth or restrain the client in any way.

A patient with cirrhosis has increased abdominal girth from ascites. Which statements describe the pathophysiology of ascites? (Select all that apply.) A. Hepatocytes are unable to convert ammonia to urea. B. Osmoreceptors in the hypothalamus stimulate thirst. C. An enlarged spleen removes blood cells from the circulation. D. Portal hypertension causes leaking of protein and water into the peritoneal cavity. E. Aldosterone is released to stabilize intravascular volume by saving salt and water. F. Inability of the liver to synthesize albumin reducing intravascular oncotic pressure.

D, E, F Ascites related to cirrhosis is caused by decreased colloid oncotic pressure. The liver does not produce albumin that holds fluid in the vascular space, so fluid shifts into interstitial and third spaces. Portal hypertension causes back pressure in the vessels, shifting protein and fluids into the peritoneal cavity. Decreased intravascular volume stimulates the release of aldosterone, which increases sodium and fluid retention. Oral intake of fluids and removal of blood cells by the spleen do not directly contribute to ascites.

Cholecystitis actions and parameters

The nurse should plan to administer an opioid analgesic, such as morphine, for acute pain. Since the client is experiencing nausea and vomiting, the nurse should also ensure they are NPO. The client is likely experiencing cholecystitis, which typically presents with nausea, vomiting, upper abdominal pain that radiates to the right shoulder, fever, and dyspepsia. The client also has elevated liver enzymes and a WBC count, which is consistent with cholecystitis. Surgical management for cholecystitis might be indicated. The nurse should monitor the client's stool and urine color because a biliary obstruction from gallstones may cause clay-colored stools and dark urine.