Fall 18 Med Surg Exam 1

An older client with an elevated serum calcium level is receiving IV furosemide (Lasix) and an infusion of normal saline at 150 mL/hr. Which nursing action can the RN delegate to unlicensed assistive personnel (UAP)? A. Ask the client about any numbness or tingling. B. Check for bone deformities in the client's back. C. Measure the client's intake and output hourly. D. Monitor the client for shortness of breath.

C. Measuring intake and output is a commonly delegated nursing action that is within the UAP scope of practice. Numbness and tingling is part of the client assessment that needs to be completed by a licensed nurse. Bony deformities can be due to pathologic fractures; physical assessment is a complex task that cannot be delegated. An older client receiving an IV at 150 mL/hr is at risk for congestive heart failure; careful monitoring for shortness of breath is the responsibility of the RN.

An RN and LPN/LVN are caring for a group of clients on the medical-surgical unit. Which client will be the best to assign to the LPN/LVN? A. Client with Graves' disease who needs discharge teaching after a total thyroidectomy B. Client with hyperparathyroidism who is just being admitted for a parathyroidectomy C. Client with infiltrative ophthalmopathy who needs administration of high-dose prednisone (Deltasone) D. Newly diagnosed client with hypothyroidism who needs education about the use of thyroid supplements

C. Medication administration for the client with infiltrative ophthalmopathy is within the scope of practice of the LPN/LVN. Discharge teaching is a complex task that cannot be delegated to the LPN/LVN. A client being admitted for a parathyroidectomy needs preoperative teaching, which must be provided by the RN. A client who has a new diagnosis will have questions about the disease and prescribed medications; teaching is a complex task that is appropriate for the RN.

A client comes to the emergency department with a productive cough. Which symptom does the nurse look for that will require immediate attention? A. Blood in the sputum B. Mucoid sputum C. Pink, frothy sputum D. Yellow sputum

C. Pink, frothy sputum is common with pulmonary edema and requires immediate attention and intervention to prevent the client's condition from getting worse. Blood in the sputum may occur with chronic bronchitis or lung cancer; because this condition is chronic, the situation does not require immediate attention. Mucoid sputum may be related to smoking and does not require immediate attention. Although yellow sputum may indicate an infection that requires treatment, the condition is not emergent.

A client who is to undergo cardiac catheterization should be taught which essential information by the nurse? A. "Monitor the pulses in your feet when you get home." B. "Keep your affected leg straight for 2 to 6 hours." C. "Do not take your blood pressure medications on the day of the procedure." D. "Take your oral hypoglycemic with a sip of water on the morning of the procedure."

B. The client will remain in bed and the affected leg must remain straight for 2 to 6 hours after the procedure, depending on the type of vascular closure device used, to allow the arterial puncture to heal well and prevent bleeding. The nurse monitors the pulses in the affected extremity until discharge, then teaches the client to contact the health care provider immediately if pallor, pain, paresthesia, or coolness of the extremity develops. The client may take regular medications except oral hypoglycemics. Blood pressure may be elevated due to anxiety before the procedure; therefore, antihypertensive medications are taken. Oral hypoglycemics are taken with or before meals based on an anticipated rise in glucose after eating; they are not taken when the client is NPO for procedures or surgery.

What atypical symptoms might a woman who is having a myocardial infarction experience? A. Sudden, intermittent, stabbing chest pain. B. Moderate ache in the chest that is worse on inspiration. C. Indigestion, feelings of chronic fatigue, and a choking sensation. D. Pain that spreads across the chest and back and/or radiates down the arm.

C. Some patients, especially women, do not experience pain in the chest with a myocardial infarction, but instead feel discomfort or indigestion. Women often present with a "triad" of symptoms. In addition to indigestion or feeling of abdominal fullness, feelings of chronic fatigue despite adequate rest and feelings of "inability to catch one's breath" are also attributable to heart disease. The patient may also describe the sensation as aching, choking, strangling, tingling, squeezing, constricting, or viselike.

A client recovering from cardiac angiography develops slurred speech. What does the nurse do first? A. Maintains NPO (nothing by mouth) until this resolves B. Calls in another nurse for a second opinion C. Performs a complete neurologic assessment and notifies the health care provider D. Explains to the client and family that this is expected after sedation

C. Based on this assessment, the client probably is suffering a neurologic event, possibly a stroke. Neurologic changes such as visual disturbances, slurred speech, swallowing difficulties, and extremity weakness should be reported immediately for prompt intervention. Be confident in this decision; this assessment does not warrant a second opinion. Keeping the client NPO and waiting for symptoms to resolve is not appropriate. Slurred speech is not expected after sedation.

Which cranial nerve allows a person to feel a light breeze on the face? A. I (olfactory) B. III (oculomotor) C. V (trigeminal) D. VII (facial)

C. Cranial nerve V (trigeminal) is responsible for sensation from the skin of the face and scalp and the mucous membranes of the mouth and nose. Cranial nerve I (olfactory) is responsible for smell. Cranial nerve III (oculomotor) is responsible for eye movement. Cranial nerve VII (facial) is responsible for pain and temperature from the ear area, deep sensations from the face, and taste from the anterior two thirds of the tongue.

All of this information is obtained by the nurse who is admitting a client for a coronary arteriogram. Which information is most important to report to the health care provider before the procedure begins? A. The client has had intermittent substernal chest pain for 6 months. B. The client develops wheezes and dyspnea after eating crab or lobster. C. The client reports that a previous arteriogram was negative for coronary artery disease. D. The client has peripheral vascular disease, and the dorsalis pedis pulses are difficult to palpate.

B. The contrast agent injected into the coronary arteries during the arteriogram is iodine-based; the client with a shellfish allergy is likely to have an allergic reaction to the contrast and should be medicated with an antihistamine or a steroid before the procedure. The reason the client is having the procedure is to determine whether atherosclerotic plaque obstructing the coronary arteries is the underlying cause of the chest pain; the intermittent substernal chest pain does not need to be reported to the provider. The provider does not need information about the previous arteriogram at this time; it is nice to know, but does not change the current need for the procedure. The nurse will palpate the distal pulses after the procedure; they can be assessed with a Doppler device and marked in ink. Therefore, this information is not needed before the procedure is performed.

After a cardiac catheterization, the client should increase his or her fluid intake for which reason? A. NPO status will cause the client to be thirsty. B. The dye causes an osmotic diuresis. C. The dye contains a heavy sodium load. D. The pedal pulses will be more easily palpable.

B. The dye is osmotically heavy, causing increased urine output, possible decreased blood flow to the kidney, and renal impairment. Although the client may report thirst while NPO, the reason to increase fluids is related to osmotic diuresis from the contrast medium. The contrast medium is iodine-based. Although maintaining fluid volume may make pulses more obvious, this is not the reason to encourage fluids.

An RN and an LPN/LVN, both of whom have several years of experience in the intensive care unit, are caring for a group of clients. Which client is appropriate for the RN to assign to the LPN/LVN? A. A client with pulmonary edema who requires hourly monitoring of pulmonary artery wedge pressures B. A client who was admitted with peripheral vascular disease and needs assessment of the ankle-brachial index C. A client who has intermittent chest pain and requires teaching about myocardial nuclear perfusion imaging D. A client with acute coronary syndrome who has just been admitted and needs an admission assessment

B. The scope of practice of the LPN/LVN includes assessment of blood pressure in the arm and lower extremity. The scope of practice for the LPN/LVN does not include interpretation of hemodynamic monitoring results. The scope of practice of the RN includes providing client education; the LPN/LVN may reinforce that teaching. The role of the professional nurse is to perform assessment and develop the plan of care; the LPN/LVN may implement the plan.

What is the function of the turbinates? A. They decrease the weight of the skull on the neck. B. They increase the surface area of the nose for heating and filtering. C. They move inspired particles from nose to throat for removal. D. They separate two nasal passages down the middle.

B. The turbinates increase the surface area of the nose, so that more heating, filtering, and humidifying of inspired air can occur before air passes into the nasopharynx. The paranasal sinuses are air-filled cavities that decrease the weight of the skull. The cilia are responsible for moving inspired particles to the throat so they can be swallowed or expectorated. The septum is the cartilage that separates the nasal cavity into two passages.

The nurse has received report on a group of clients. Which client requires the nurse's attention first? A. Adult who is lethargic after a generalized tonic-clonic seizure B. Young adult who has experienced four tonic-clonic seizures within the past 30 minutes C. Middle-aged adult with absence seizures who is staring at a wall and does not respond to questions D. Older adult with a seizure disorder who has a temperature of 101.9° F (38.8° C)

B. The young adult client who is experiencing repeated seizures over the course of 30 minutes is in status epilepticus, which is a medical emergency and requires immediate intervention. The adult client who is lethargic and the middle-aged adult client with absence seizures do not require immediate attention; these are not medical emergencies. A fever of 101.9° F (38.8° C) is not a medical emergency and does not require immediate attention.

The nurse is caring for a client with an arterial line. How does the nurse recognize that the client is at risk for insufficient perfusion of body organs? A. Right atrial pressure is 4 mm Hg. B. Mean arterial pressure (MAP) is 58 mm Hg. C. Pulmonary artery wedge pressure (PAWP) is 7 mm Hg. D. PO2 is reported as 78 mm Hg.

B. To maintain tissue perfusion to vital organs, the MAP must be at least 60 mm Hg. A MAP of between 60 and 70 mm Hg is necessary to maintain perfusion of major body organs such as the kidneys and brain. An arterial line will not measure atrial pressure, PAWP, or oxygenation. Normal right atrial pressure is 1 to 8 mm Hg. Normal PAWP is 4 to 12 mm Hg. A normal PO2 is greater than 75 mm Hg.

Which client has pain most consistent with myocardial infarction (MI) requiring notification of the health care provider? A. Client with abdominal pain and belching B. Client with pressure in the mid-abdomen and profound diaphoresis C. Client with dyspnea on exertion (DOE) and inability to sleep flat who sleeps on four pillows D. Client with claudication and fatigue

B. Typical symptoms of MI include chest pain or pressure, ashen skin color, diaphoresis, and anxiety. Although atypical cardiac pain can be perceived in the abdomen, abdominal pain and belching are more typical of peptic ulcer. DOE and orthopnea are typical problems for clients with heart failure. Claudication (pain in the legs with exercise or at rest) is symptomatic of peripheral arterial occlusive disease.

The client returns to the medical unit after a therapeutic bronchoscopy. Which intervention does the nurse apply first? A. Assess the puncture site for drainage. B. Implement nothing-by-mouth (NPO) status. C. Monitor for signs of anaphylaxis. D. Perform aggressive chest physiotherapy.

B. Until the client has a gag reflex and is fully alert, he or she should be maintained on NPO status to prevent aspiration. No external puncture site is needed for bronchoscopy. Although the client will have received medications during the bronchoscopy, an anaphylactic reaction will occur immediately, not in a client who has returned to the medical unit. Aggressive chest physiotherapy is not indicated in a client who has had a bronchoscopy and may cause bleeding if biopsies have been obtained.

Which of these factors contribute to the risk for cardiovascular disease? (Select all that apply.) A. Consuming a diet rich in fiber B. Elevated C-reactive protein levels C. Low blood pressure D. Elevated high-density lipoprotein (HDL) cholesterol level E. Smoking

B. E. Elevation in C-reactive protein, suggestive of inflammation, is a risk factor for atherosclerosis and cardiac disease. Smoking cessation should be emphasized; smoking is a major modifiable risk factor for cardiovascular disease. A diet rich in fiber is not a risk factor for cardiovascular disease; rather, it is a desirable behavior. Hypertension, not low blood pressure, is a risk for cardiovascular disease. Elevated low-density lipoprotein cholesterol is a risk for atherosclerosis; elevated HDL cholesterol is desirable and may be cardioprotective.

The parents of a young child report that their child sometimes stares blankly into space for just a few seconds and then gets very tired. The nurse anticipates that the child will be assessed for which seizure disorder? A. Absence B. Myoclonic C. Simple partial D. Tonic

A. Absence seizures are more common in children and consist of brief (often just seconds) periods of loss of consciousness and blank staring, as though he or she is daydreaming. Myoclonic seizures are characterized by brief jerking or stiffening of the extremities, which may occur singly or in groups. Partial seizures are most often seen in adults. Tonic seizures are characterized by an abrupt increase in muscle tone, loss of consciousness, and autonomic changes lasting from 30 seconds to several minutes.

A client with asthma reports shortness of breath. What is the nurse assessing when auscultating this client's chest? A. Adventitious breath sounds B. Fremitus C. Oxygenation status D. Respiratory excursion

A. Adventitious sounds are additional breath sounds superimposed on normal sounds. They indicate pathologic changes in the lung. Fremitus is vibration and is not detected by auscultation. Oxygenation status cannot be detected specifically by auscultation. Respiratory excursion is detected by both observation of the movement of the chest and palpation as the client inhales and exhales.

The charge nurse on the medical-surgical unit is making client assignments for the shift. Which client is the most appropriate to assign to an LPN/LVN? A. Client with Cushing's syndrome who requires orthostatic vital signs assessments B. Client with diabetes mellitus who was admitted with a blood glucose of 45 mg/dL C. Client with exophthalmos who has many questions about endocrine function D. Client with possible pituitary adenoma who has just arrived on the nursing unit

A. An LPN/LVN will be familiar with Cushing's syndrome and the method for assessment of orthostatic vital signs. The client with a blood glucose of 45 mg/dL, the client with questions about endocrine function, and the client with a possible pituitary adenoma all have complex needs that require the experience and scope of practice of an RN.

Four clients are sent back to the emergency department from triage at the same time. Which client requires the nurse's immediate attention? A. Client with acute allergic reaction B. Client with dyspnea on exertion C. Client with lung cancer with cough D. Client with sinus infection and fever

A. An acute allergic reaction can lead to immediate respiratory distress; this is an emergent situation that requires the immediate attention of the nurse. Dyspnea on exertion is a condition that will need further evaluation by the nurse, but is not usually an emergency. Coughing is a frequent symptom of lung cancer; although coughing may be related to something not associated with the client's cancer, this situation is not an emergency. Sinus infections are not considered emergencies.

The RN has received report about all of these clients. Which client needs the most immediate assessment? A. Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry B. Client admitted 3 hours ago for a scheduled thoracentesis in 30 minutes C. Client with bronchogenic lung cancer who returned from bronchoscopy 3 hours ago D. Client with pleural effusion who has decreased breath sounds at the right base

A. An oxygen saturation level less than 91% indicates hypoxemia and requires immediate assessment and intervention to improve blood and tissue oxygenation. The client who is scheduled for a thoracentesis will be able to receive teaching and will have the opportunity to ask questions and have them answered before the procedure is performed, if this was not already completed. The client who had a bronchoscopy 3 hours ago and has returned to the floor does not require the most immediate attention at this moment. It would not be unusual to have diminished breath sounds at the base of the lung of the client with pleural effusion.

A client with an endocrine disorder says, "I can't, you know, satisfy my wife anymore." What is the nurse's best response? A. "Can you please tell me more?" B. "Don't worry. That is normal." C. "How does she feel?" D. "Should I make an appointment with a counselor?"

A. Asking the client to explain his concerns in an open-ended question allows the nurse to explore his feelings more thoroughly. Telling a client that something is "normal" is dismissive; this is new to the client and is a concern for him. The focus of the nurse's response needs to be on the client, not on the wife initially. Referring the client to a counselor is not an appropriate first step; this dismisses the client's concerns and does not allow him to express his frustrations at the moment.

The nurse is reviewing the history of a client who has been prescribed topiramate (Topamax) for treatment of intractable partial seizures. The nurse plans to contact the health care provider if the client has which condition? A. Bipolar disorder B. Diabetes mellitus C. Glaucoma D. Hypothyroidism

A. Cases of suicide have been associated with topiramate when it is used in larger doses of 400 mg daily, most often in clients with bipolar disorder. Topiramate is not contraindicated in clients with diabetes mellitus, glaucoma, or hypothyroidism.

Which client diagnosed with neurologic injury is typically at highest risk for depression? A. Young man with a spinal cord injury B. Older man with a spinal cord injury C. Older man with a mild stroke D. Young woman with a mild stroke

A. Clients who experience a loss of independent movement are more likely to experience depression. A young male who experiences a significant life-changing event, such as a spinal cord injury, is at a higher risk for depression. The older man with a spinal cord injury and the older man and young woman with mild strokes are at a somewhat lower risk.

Which component of a client's family history is of particular importance to the home health nurse who is assessing a new client with asthma? A. Brother is allergic to peanuts. B. Father is obese. C. Mother is diabetic. D. Sister is pregnant.

A. Clients with asthma often have a family history of allergies; it will be important to assess whether this client has any allergies that may serve as triggers for an asthma attack. Obesity, diabetes, and pregnancy are not correlated with asthma.

Which change in the cerebrospinal fluid (CSF) indicates to the nurse that a client may have bacterial meningitis? A. Cloudy, turbid CSF B. Decreased white blood cells C. Decreased protein D. Increased glucose

A. Cloudy, turbid CSF is a sign of bacterial meningitis. Clear fluid is a sign of viral meningitis. Increased white blood cells, increased protein, and decreased glucose are signs of bacterial meningitis.

The nurse understands which symptom to be a hallmark subjective sign of lung disease? A. Cough B. Dyspnea C. Chest pain D. Sputum production

A. Cough is a main sign of lung disease. Dyspnea is a subjective perception and varies among patients. A patient's feeling of dyspnea may not be consistent with the severity of the presenting problem. Sputum production may be associated with coughing and indicate an acute or chronic lung condition. Chest pain can occur with other health problems, as well as with lung problems.

The nurse auscultates popping, discontinuous sounds over the client's anterior chest. How does the nurse classify these sounds? A. Crackles B. Rhonchi C. Pleural friction rub D. Wheeze

A. Crackles are described as a popping, discontinuous sound caused by air moving into previously deflated airways. The airways have been deflated due to the presence of fluids in the lungs, and crackles should be considered to be a sign of fluid overload. Rhonchi are low-pitched, coarse snoring sounds caused by fluid or secretions in larger airways. A pleural friction rub sounds grating, loud, or scratchy as inflamed surfaces of the pleura rub together. Wheezes are frequently referred to as musical or squeaky; they may occur on inspiration or on expiration and may be heard without a stethoscope as air rushes through narrowed airways.

The nurse is teaching a client about maintaining a proper diet to prevent an endocrine disorder. Which food does the nurse suggest after the client indicates a dislike of fish? A. Iodized salt for cooking B. More red meat C. More green vegetables D. Salt substitute for cooking

A. Dietary deficiencies in iodide-containing foods may be a cause of an endocrine disorder. For clients who do not eat saltwater fish on a regular basis, teach them to use iodized salt in food preparation. The client should eat a well-balanced diet that includes less animal fat. Eating vegetables contributes to a proper diet; however, this does not prevent an endocrine disorder. Using a salt substitute does not prevent an endocrine disorder; in addition, salt substitutes may contain high levels of potassium, which may lead to electrolyte imbalances.

A client has just returned from cerebral angiography. Which symptom does the client display that causes the nurse to act immediately? A. Bleeding B. Increased temperature C. Severe headache D. Urge to void

A. If bleeding is present in the client who has had cerebral angiography, maintain manual pressure on the site and notify the health care provider immediately. Increased temperature or the urge to void are not typical complications of cerebral angiography. Severe headache is a typical complication of a lumbar puncture, but not of cerebral angiography.

In the older adult client, which respiratory change requires no further assessment by the nurse? A. Increased anteroposterior (AP) diameter B. Increased respiratory rate C. Shortness of breath D. Sputum production

A. Increased AP diameter is normal with aging. Increased respiratory rate is not a normal finding with aging and may be an indication of pain or infection; it needs to be evaluated further by the nurse. Shortness of breath is not associated with aging and needs to be evaluated further, because it may be related to infection, tumor, or cardiac issues, for example. Sputum production is not related to the aging process; although it may be chronic in nature, it should be assessed further. It is important to note the character and quantity of the sputum, as well as the duration of sputum production.

The nurse is performing a neurologic assessment on an 81-year-old client. Which physiologic change does the nurse expect to find because of the client's age? A. Decreased coordination B. Increased sleeping during the night C. Increased touch sensation D. Stability in pain perception

A. Older adults experience decreased coordination as a result of the aging process. They also experience decreased sleeping during the night, decreased touch sensation, and instability in pain perception as a result of aging.

Which client has the highest risk for cardiovascular disease? A. Man who smokes and whose father died at 49 of myocardial infarction (MI) B. Woman with abdominal obesity who exercises three times per week C. Woman with diabetes whose high-density lipoprotein (HDL) cholesterol is 75 mg/dL D. Man who is sedentary and reports four episodes of strep throat

A. Smoking is a major risk factor for MI, and family history is a stronger risk factor than hypertension, obesity, diabetes, or sudden cardiac death. Although abdominal obesity is a risk factor, exercising three times weekly is not. Diabetes is a major risk factor for MI; however, HDL cholesterol of 75 mg/dL is in the optimal range of greater than 55 mg/dL. Sedentary lifestyle is a risk factor but is not a major risk. Frequent strep infections may be associated with valvular disease rather than coronary artery disease.

Which gland releases catecholamines? A. Adrenal B. Pancreas C. Parathyroid D. Thyroid

A. The adrenal medulla releases catecholamines in response to stimulation of the sympathetic nervous system. The principal hormones of the pancreas are insulin, glucagon, and somatostatin. Parathyroid hormone is the principal hormone of the parathyroid gland. Triiodothyronine (T3), thyroxine (T4), and calcitonin are the principal hormones of the thyroid.

Which statement reflects correct cardiac physical assessment technique? A. Auscultate the aortic valve in the second intercostal space at the right sternal border. B. Evaluate for orthostatic hypotension by moving the client from a standing to a reclining position. C. Palpate the apical pulse over the third intercostal space in the midclavicular line. D. Assess for carotid bruit by auscultating over the anterior neck.

A. The aortic valve is auscultated at the second intercostal space at the right sternal border. Orthostatic hypotension is measured when a person moves from a reclining to a standing position. The apical pulse is palpated over the fifth intercostal space in the midclavicular line. A bruit is assessed by auscultating the carotid artery in the neck.

The nurse has just received report on a group of clients on the neurosurgical unit. Which client is the nurse's first priority? A. Young adult whose Glasgow Coma Scale (GCS) score has changed from 15 to 10 B. Adult whose deep tendon reflexes have become hyperactive C. Middle-aged adult who displays plantar flexion when the bottom of the foot is stroked D. Older adult who consistently demonstrates decortication when stimulated

A. The change in the young client's GCS score indicates a significant change in neurologic status that should be immediately assessed further and reported to the health care provider. The client with hyperactive reflexes, the client displaying plantar flexion when the bottom of the foot is stroked, and the client with decortication upon stimulation will need to be assessed, but the changes in their conditions do not require immediate attention.

The nurse is about to administer a contrast medium to the client undergoing diagnostic testing. Which question does the nurse first ask the client? A. "Are you taking ibuprofen daily?" B. "Are you in pain?" C. "Are you wearing any metal?" D. "Do you know what this test is for?"

A. The client should be asked about allergies to contrast agents, and conditions that may compromise kidney function should be explored. Ask the client about the use of drugs that may compromise renal perfusion, such as metformin and nonsteroidal anti-inflammatory drugs (NSAIDs). Ibuprofen is an NSAID, and daily use may place the client's renal function at risk for complications with contrast medium administration. Asking whether the client is in pain is not a priority in this situation. Asking the client whether she or he is wearing any metal is important for magnetic resonance imaging, but not for a contrast injection. The client should be asked well before this point whether he or she knows why the test is being performed.

The nurse manager for the medical-surgical unit is making staff assignments. Which client will be most appropriate to assign to a newly graduated RN who has completed a 6-week unit orientation? A. Client with chronic hypothyroidism and dementia who takes levothyroxine (Synthroid) daily B. Client with follicular thyroid cancer who has vocal hoarseness and difficulty swallowing C. Client with Graves' disease who is experiencing increasing anxiety and diaphoresis D. Client with hyperparathyroidism who has just arrived on the unit after a parathyroidectomy

A. The client with chronic hypothyroidism and dementia is the most stable of the clients described and would be most appropriate to assign to an inexperienced RN. A client with vocal hoarseness and difficulty swallowing is at higher risk for complications and requires close observation by a more experienced nurse. Increasing anxiety and diaphoresis in a client with Graves' disease can be an indication of impending thyroid storm, which is an emergency; this is not a situation to be managed by a newly graduated RN. A client who has just arrived on the unit after a parathyroidectomy requires close observation for bleeding and airway compromise and requires assessment by an experienced nurse

The home health nurse is assigned to visit all of these clients when a change in agency staffing requires that one of the clients be rescheduled for a visit on the following day. Which client would be best to reschedule? A. Client with emphysema who has been on home oxygen for a month and has SpO2 levels of 91% to 93% B. Client with history of a cough, weight loss, and night sweats who has just had a positive Mantoux test C. Client with newly diagnosed pleural effusion who needs an admission visit and an initial intake assessment D. Client with percutaneous lung biopsy yesterday who called in to report increased dyspnea

A. The client with emphysema has an appropriate SpO2 for home oxygen use. A positive Mantoux test, in addition to a history of cough, weight loss, and night sweats, is highly suspicious for tuberculosis and needs follow-up and reporting, because this becomes a public and a personal health issue. A client with a newly diagnosed pleural effusion needs a complete and thorough admission and intake assessment to ensure that he has adequate respiratory function to meet his basic oxygenation needs. Although a percutaneous lung biopsy may be an outpatient procedure, pneumothorax or hemothorax is a possible life-threatening complication of this procedure that would cause dyspnea and requires assessment in a timely manner by the home health nurse.

A client is admitted with bacterial meningitis. Which nursing intervention is the highest priority for this client? A. Assessing neurologic status at least every 2 to 4 hours B. Decreasing environmental stimuli C. Managing pain through drug and nondrug methods D. Strict monitoring of hourly intake and output

A. The most important nursing intervention for clients with meningitis is the accurate monitoring and recording of their neurologic status, vital signs, and vascular assessment. The client's neurologic status and vital signs should be assessed at least every 4 hours, or more often if clinically indicated. The priority for care is to monitor for early neurologic changes that may indicate increased intracranial pressure, such as decreased level of consciousness. Decreasing environmental stimuli is helpful for the client with bacterial meningitis, but is not the highest priority. Clients with bacterial meningitis report severe headaches requiring pain management, but this is the second-highest priority. Assessing fluid balance while preventing overload is not the highest priority.

A patient is admitted with a weight loss of 2.3 kg over 36 hours, diarrhea, nausea, and vomiting. Based on this information, the nurse should assess which cardiovascular parameter more closely? A. Preload B. Afterload C. Heart rate D. Stroke volume

A. The variables preload, afterload, and contractility influence stroke volume and preload is determined by the amount of blood returning to the heart from both the venous system (right heart) and the pulmonary system (left heart). Dehydration and over hydration directly influence preload. Blood flow from the heart into the systemic arterial circulations measured clinically as cardiac output (CO), the amount of blood pumped from the left ventricle each minute. CO is derived from the patient's heart rate and stroke volume. Stroke volume is the amount of blood ejected by the left ventricle during each contraction.

A client with a migraine is lying in a darkened room with a wet cloth on the head after receiving analgesic drugs. What does the nurse do next? A. Allow the client to remain undisturbed. B. Assess the client's vital signs. C. Remove the cloth because it can harbor microorganisms. D. Turn on the lights for a neurologic assessment.

A. At the beginning of a migraine attack, the client may be able to alleviate pain with analgesics and by lying down in a darkened room with a cool cloth on his or her forehead. If the client falls asleep, he or she should remain undisturbed until awakening. Assessing the client's vital signs will disturb the client unnecessarily. A cool cloth is helpful for the client with a migraine and does not present enough of a risk that it should be removed. Turning on the lights for a neurologic assessment is not appropriate because light can cause the migraine to worsen.

The nurse is preparing the room for the client returning from a thyroidectomy. Which items are important for the nurse to have available for this client? (Select all that apply.) A. Calcium gluconate B. Emergency tracheotomy kit C. Furosemide (Lasix) D. Hypertonic saline E. Oxygen F. Suction

A. B. E. F. Calcium gluconate should be available at the bedside to treat hypocalcemia and tetany that might occur if the parathyroid glands have been injured during the surgery. Equipment for an emergency tracheotomy must be kept at the bedside in the event that hemorrhage or edema should occlude the airway. Respiratory distress can result from swelling or damage to the laryngeal nerve leading to spasm, so it is important that the nurse work with respiratory therapy to have oxygen ready at the bedside for the client on admission. Because of the potential for increased secretions, it is important that a working suction device is present at the bedside for admission of the client from the operating room. Furosemide might be useful in the postoperative client to assist with urine output; however, this is not of added importance for this client. Hypertonic saline would not be of benefit to this client as the client is not hyponatremic.

Which laboratory findings are consistent with acute coronary syndrome (ACS)? (Select all that apply.) A. Troponin 3.2 ng/mL B. Myoglobin 234 mcg/L C. C-reactive protein 13 mg/dL D. Triglycerides 400 mg/dL E. Lipoprotein-a 18 mg/dL

A. B.. Normal troponin should be less than 0.03 ng/mL. Normal myoglobin should be less than 90 mcg/L. Normal C-reactive protein should be less than 1 mg/dL; however, this tests for risk for coronary artery disease (CAD), not ACS. Normal triglycerides should be less than 150 mg/dL; however, this tests for risk for CAD, not ACS. Normal lipoprotein-a is 18 mg/dL; however, this tests for risk for CAD, not ACS.

A client with heart failure reports a 7.6-pound weight gain in the past week. What intervention does the nurse anticipate from the health care provider? A. Dietary consult B. Sodium restriction C. Daily weight monitoring D. Restricted activity

C. A sudden weight increase of 2.2 pounds (1 kg) can result from excess fluid (1 L) in the interstitial spaces. The best indicator of fluid balance is weight. It is possible for weight gains of up to 10 to 15 pounds (4.5 to 6.8 kg, or 4 to 7 L of fluid) to occur before excess fluid accumulation (edema) is apparent. The weight change is most likely from excessive fluid, so a dietary consult, sodium restrictions, and restricted activity are not appropriate interventions.

A client who had an earlier bronchoscopy has the following vital signs: heart rate 132 beats/min, respiratory rate 26 breaths/min, and blood pressure 98/50 mm Hg. The client is anxious and his skin is cyanotic. What is the nurse's first action? A. Call the Rapid Response Team. B. Give methylene blue 1% 1 to 2 mg/kg by IV injection. C. Administer oxygen. D. Notify the health care provider immediately.

C. Administering oxygen and reassessing vital signs to observe for improvement is the first action. Administration of oxygen by itself may help relieve the client's anxiety. The Rapid Response Team should be called if the client has any symptoms of methemoglobinemia; calling a rapid response will not be the nurse's first action because abnormal vital signs can result from many causes. Methylene blue is given for treatment of methemoglobinemia; information is insufficient for the nurse to determine whether the client has this condition. The health care provider will receive an update of the client's condition; however, this is not the highest priority at this time.

Which statement best reflects correct client education for a client with a blood pressure of 136/86 mm Hg? A. This blood pressure is good because it is a normal reading. B. This blood pressure indicates that the client has hypertension or high blood pressure. C. This blood pressure increases the workload of the heart; the client should consider modifying his or her lifestyle. D. This blood pressure seems a little low; the client should be further assessed for orthostatic hypotension.

C. Although not considered hypertension because the blood pressure is not greater than 140/90 mm Hg, it is consistent with increased risk for heart disease; the client requires further education. Hypertension is defined as blood pressure greater than 140/90 mm Hg. A blood pressure that exceeds 135/85 mm Hg increases the workload of the left ventricle and oxygen consumption of the myocardium. Orthostatic hypotension is defined as blood pressure less than 90/60 mm Hg.

The nurse has just received report on a group of clients. Which client does the nurse assess first? A. Young adult who was in a car accident and has a Glasgow Coma Scale score of 13 B. Adult who had a cerebral arteriogram and has a cool, pale right leg C. Middle-aged adult who has a headache after undergoing a lumbar puncture D. Older adult who has expressive aphasia after a left-sided stroke

B. A cool, pale leg after an arteriogram could indicate clot formation at the catheter insertion site and loss of blood flow to the extremity. The client with a 13 GCS score, the client with a headache following a lumbar puncture, and the older adult with expressive aphasia should be assessed as soon as possible, but the data do not indicate any serious complications.

The nurse in a coronary care unit interprets information from hemodynamic monitoring. The client has a cardiac output of 2.4 L/min. Which action should be taken by the nurse? A. No intervention is needed; this is a normal reading. B. Collaborate with the health care provider to administer a positive inotropic agent. C. Administer a STAT dose of metoprolol (Lopressor). D. Ask the client to perform the Valsalva maneuver.

B. A positive inotropic agent will increase the force of contraction (stroke volume [SV]), thus increasing cardiac output (CO). Recall that SV × HR = CO (heart rate [HR]). Normal cardiac output is 4 to 7 L/min. The beta blocker metoprolol (Lopressor) has side effects of bradycardia and decreased contractility; cardiac output would be further reduced. The Valsalva maneuver, or bearing down, will decrease the heart rate and thus cardiac output.

Which assessment finding is of greatest concern in a client with emphysema? A. Barrel-shaped chest B. Bronchial breath sounds heard at the bases C. Hyperresonance to percussion of the chest D. Ribs lying horizontal

B. Bronchial breath sounds are not normally heard in the periphery and may indicate increased lung density, as in a tumor or an infective process such as pneumonia. The anteroposterior diameter is the same as the lateral-to-lateral or side-to-side diameter in a client with emphysema, so he will generally have a barrel-shaped chest. Air-filled cavities, such as the lung, are hyperresonant to percussion. Air trapping causes the lungs in a client with emphysema to lie in a horizontal direction.

A female client with newly diagnosed migraines is being discharged with a prescription for sumatriptan (Imitrex). Which comment by the client indicates an understanding of the nurse's discharge instructions? A. "Sumatriptan should be taken as a last resort." B. "I must report any chest pain right away." C. "Birth control is not needed while taking sumatriptan." D. "St. John's wort can also be taken to help my symptoms."

B. Chest pain must be reported immediately with the use of sumatriptan. Sumatriptan must be taken as soon as migraine symptoms appear. Remind the client to use contraception (birth control) while taking the drug because it may not be safe for women who are pregnant. Triptans should not be taken with selective serotonin reuptake inhibitors or St. John's wort, an herb used commonly for depression.

The nurse is teaching a client about the correct procedure for a 24-hour urine test for creatinine clearance. Which statement by the client indicates a need for further teaching? A. "I should keep the urine container cool in a separate refrigerator or cooler." B. "I should not eat any protein when I am collecting urine for this test." C. "I won't save the first urine sample." D. "To end the collection, I must empty my bladder, adding it to the collection."

B. Eating protein does not interfere with collection or testing of the urine sample. Because the specimen must be kept cool, it can be placed in an inexpensive cooler with ice; the client should not keep the specimen container with food or beverages. The timing of the 24-hour collection begins after the initial void. To end a 24-hour urine specimen, emptying the bladder and adding it to the collection is the proper procedure.

To best determine how well a client with diabetes mellitus is controlling blood glucose, which test does the nurse monitor? A. Fasting blood glucose B. Glycosylated hemoglobin (HbA1c) C. Oral glucose tolerance test D. Urine glucose level

B. Glycosylated hemoglobin indicates the average blood glucose over several months and is the best indicator of overall blood glucose control. Fasting blood glucose can be used to monitor glucose control, but it is not the best method (although this may be the method that clients are most familiar with). Oral glucose testing and urine glucose levels look at one period of time and are not the best methods to look at overall effectiveness of treatment.

Which statement is true about hormones and their receptor sites? A. Hormone activity is dependent only on the function of the receptor site. B. Hormones need a specific receptor site to work. C. Hormones need to be plasma-bound to activate the receptor site. D. Hormone stores are available for activation until needed.

B. In general, each receptor site type is specific for only one hormone. Hormone receptor actions work in a "lock and key" manner, in that only the correct hormone (key) can bind to and activate the receptor site (lock). Hormones travel through the blood to all body areas, but exert their actions only on target tissues. Not all hormones are plasma-bound; for example, thyroid hormones are plasma protein-bound, whereas posterior pituitary hormones are transported by axons. Only certain cells manufacture specific hormones and store the hormones in vesicles.

Which is the most effective way for a college student to minimize the risk for bacterial meningitis? A. Avoid large crowds. B. Get the meningococcal vaccine. C. Take a daily vitamin. D. Take prophylactic antibiotics.

B. Individuals ages 16 to 21 years have the highest rates of meningococcal infection and should be immunized against the virus. Adults are advised to get an initial or booster vaccine if living in a shared residence (residence hall, military barracks, group home), traveling or residing in countries in which the disease is common, or immunocompromised due to a damaged or surgically removed spleen or a serum complement deficiency. Avoiding large crowds is helpful, but is not practical for a college student. Taking a daily vitamin is helpful, but is not the best way to safeguard against bacterial meningitis. Taking prophylactic antibiotics is inappropriate because it leads to antibiotic-resistant strains of microorganisms.

A client is hospitalized for pituitary function testing. Which nursing action included in the client's plan of care will be most appropriate for the RN to delegate to the LPN/LVN? A. Assess the client for clinical manifestations of hypopituitarism. B. Inject regular insulin for the growth hormone stimulation test. C. Palpate the thyroid gland for size and firmness. D. Teach the client about the adrenocorticotropic hormone stimulation test.

B. Injection of insulin is within the LPN/LVN scope of practice. Client assessment for clinical manifestations of hypopituitarism, palpating the thyroid gland, and client education are complex skills requiring training and expertise, and are best performed by an RN.

Which statement about diagnostic cardiovascular testing is correct? A. Complications of coronary arteriography include stroke, nonlethal dysrhythmias, arterial bleeding, and thromboembolism. B. An alternative to injecting a medium into the coronary arteries is intravascular ultrasonography. C. Holter monitoring allows periodic recording of cardiac activity during an extended period of time. D. The left side of the heart is catheterized first and may be the only side examined.

B. Intravascular ultrasonography is an alternative to the medium injection method of diagnostic cardiovascular testing. Lethal, not nonlethal, dysrhythmias are a complication of diagnostic cardiovascular testing. Holter monitoring allows periodic recording of cardiac activity during short periods of time. Several parts of the heart are examined during diagnostic cardiovascular testing.

The nurse is caring for a client who is scheduled to have a brain biopsy. The nurse anticipates that the health care provider will request which test before the brain biopsy is performed? A. Lumbar puncture (LP) B. Magnetic resonance imaging (MRI) C. Skull x-ray D. Transcranial Doppler ultrasonography (TCD)

B. MRI or computed tomography is done before a brain biopsy to assist with identification and visualization of the affected area, because the procedure involves drilling a hole through the skull and inserting a hollow needle to the site of the lesion. An LP is a diagnostic test that may be indicated to obtain cerebrospinal fluid or to inject contrast medium or medications. A skull x-ray does not show the detailed visualization needed for the provider to perform a brain biopsy. TCD is used to evaluate intracranial hemodynamics.

The nurse is assessing a client for endocrine dysfunction. Which comment by the client indicates a need for further assessment? A. "I am worried about losing my job because of cutbacks." B. "I don't have any patience with my kids. I lose my temper faster." C. "I don't seem to have any stressors now." D. "My weight has been stable these past few years."

B. Many endocrine problems can change a client's behavior, personality, and psychological responses; the client stating that he or she has become short-tempered warrants further assessment. Worrying about losing a job is a normal concern but does not give any indication of a need for further assessment. The nurse will need to assess the client's claim that he or she has no stressors at present because the client's response does not provide enough information to make this determination; however, the client's statement about losing patience is the priority. Weight gain or loss may or may not be an indication of an endocrine disorder.

The nurse is teaching a client newly diagnosed with migraines about trigger control. Which statement made by the client demonstrates good understanding of the teaching plan? A. "I can still eat Chinese food." B. "I must not miss meals." C. "It is okay to drink a few wine coolers." D. "I need to use fake sugar in my coffee."

B. Missing meals is a trigger for many people suffering from migraines. The client should not skip any meals until the triggers are identified. Monosodium glutamate-containing foods, alcohol, and artificial sweeteners are triggers for many people suffering from migraines and should be eliminated until the triggers are identified.

The nurse is reviewing the medical record of a client admitted with heart failure. Which laboratory result warrants a call to the health care provider by the nurse for further instructions? A. Calcium 8.5 mEq/L B. Potassium 3.0 mEq/L C. Magnesium 2.1 mEq/L D. International normalized ratio (INR) of 1.0

B. Normal potassium is 3.5 to 5.0 mEq/L; hypokalemia may predispose to dysrhythmia, especially if the client is taking digitalis preparations. A normal calcium level is 8.5 to 10.5 mEq/L. A normal magnesium level is 1.7 to 2.4 mEq/L. INR of 1.0 reflects a normal value.

The nurse knows that under normal physiologic conditions of tissue perfusion, a patient will have what percent of oxygen dissociate from the hemoglobin molecule? A. 25% B. 50% C. 75% D. 100%

B. Oxygen dissociates with the hemoglobin molecule based on the need for oxygen to perfuse tissues. Under normal conditions, 50% of hemoglobin molecules completely dissociate their oxygen molecules when blood perfuses tissues that have an oxygen tension of 26 mmHg. This is considered a normal point at which 50% of hemoglobin are no longer saturated with oxygen.

In assessing the client's respiratory status, arterial blood gas (ABG) test results reveal pH of 7.50, PaO2 of 99 mm Hg, PaCO2 of 29 mm Hg, and HCO3- of 22 mEq/L. What action does the nurse need to take first? A. Call the health care provider. B. Encourage the client to slow his breathing rate. C. Nothing; these results are within the normal range. D. Provide oxygen support.

B. The ABGs indicate respiratory alkalosis, which is commonly caused by hyperventilation; encouraging the client to slow down his breathing rate may help the client return to normal breathing and may correct this abnormality. This situation is not an emergency condition and does not require that the health care provider be called or that oxygen be given. The client's PaO2 is within normal limits, but it is important for the nurse to assess the client and not just look at the numbers.

Which client should the charge nurse assign to a graduate RN who has completed 2 months of orientation to the coronary care unit? A. Client with a new diagnosis of heart failure who needs a pulmonary artery catheter inserted B. Client who has just arrived after a coronary arteriogram and has vital signs requested every 15 minutes C. Client with acute electrocardiographic changes who is requesting nitroglycerin for left anterior chest pain D. Client who has many questions about the electrophysiology studies (EPS) scheduled for today

B. The client returning from angiography is stable, requiring vital signs and checks of the insertion site every 15 minutes; this is within the scope of practice of a newly licensed RN. An experienced critical care nurse is needed to assist with insertion of a pulmonary artery catheter for hemodynamic monitoring. A client with electrocardiographic changes is potentially unstable; the experienced nurse will need to monitor the electrocardiogram, administer nitroglycerin, and identify additional interventions as needed. The experienced critical care nurse needs to provide extensive teaching about the invasive procedure of EPS; the newly licensed nurse just off orientation may not have the depth of knowledge to perform this teaching independently.

Which client does the neurologic unit charge nurse assign to a registered nurse who has floated from the labor/delivery unit for the shift? A. Older adult client who was just admitted with a stroke and needs an admission assessment B. Young adult client who has had a lumbar puncture and reports, "Light hurts my eyes." C. Adult client who has just returned from having a cerebral arteriogram and needs vital sign checks every 15 minutes D. Middle-aged client who has a possible brain tumor and has questions about the scheduled magnetic resonance imaging

C. An RN with experience in labor and delivery would be able to check vital signs and limbs for this client and would recognize signs of bleeding. The older adult admitted with a stroke, the young adult post lumbar puncture, and the middle-aged client with a possible brain tumor all require a nurse with more experience with neurologic diagnoses and diagnostic procedures; these clients should be assigned to a nurse with experience on the neurologic unit.

Which information is most important for the nurse to communicate to the health care provider about a client who is scheduled for cerebral angiography? A. Allergy to penicillin B. History of bacterial meningitis C. Poor skin turgor and dry mucous membranes D. The client's dose of metformin (Glucophage) held today

C. An assessment of poor skin turgor and dry mucous membranes indicates dehydration; to prevent contrast-induced nephropathy, angiography should not be done until the client is hydrated. Allergy to penicillin, history of bacterial meningitis, and withheld metformin will need to be reported, but none indicates the need to intervene before the surgery.

A client who is suffering dyspnea on exertion and congestive heart failure will likely report which symptom during the health history? A. Fatigue B. Swelling of one leg C. Slow heart rate D. Brown discoloration of lower extremities

A. Although fatigue in itself is not diagnostic of heart disease, many people with heart failure are limited by leg fatigue during exercise. Fatigue that occurs after mild activity and exertion usually indicates inadequate cardiac output (due to low stroke volume) and anaerobic metabolism in skeletal muscle. Unilateral swelling is more typical with a local finding such as deep vein thrombosis, not a systemic problem such as heart failure. Tachycardia, rather than bradycardia, develops with heart failure and decreased cardiac output. Brown discoloration of the lower extremities is indicative of long-standing venous stasis, such as occurs with varicose veins.

A client is hospitalized with a possible disorder of the adrenal cortex. Which nursing activity is best for the charge nurse to delegate to an experienced nursing assistant? A. Ask about risk factors for adrenocortical problems. B. Assess the client's response to physiologic stressors. C. Check the client's blood glucose levels every 4 hours. D. Teach the client how to do a 24-hour urine collection.

C. Blood glucose monitoring is within the nursing assistant's scope of practice if the nursing assistant has received education and evaluation in the skill. Assessing risk factors for adrenocortical problems is not part of a nursing assistant's education. Assessing the client's response to physiologic stressors requires the more complex skill set of licensed nursing staff. Teaching the proper method for a 24-hour urine collection is a multi-step process; this task should not be delegated.

A client is admitted to the surgical floor with chest pain, shortness of breath, and hypoxemia after having a knee replacement. What diagnostic test does the nurse expect to help confirm the diagnosis? A. Bronchoscopy B. Chest x-ray C. Computed tomography (CT) scan D. Thoracoscopy

C. CT scans, especially spiral or helical CT scans, with injected contrast can detect pulmonary emboli. The client has a pulmonary embolism; bronchoscopy will not help to confirm this diagnosis. A chest x-ray will rule out other causes of the symptoms but is not specific for pulmonary embolism. Thoracoscopy is not used to detect pulmonary emboli.

A 72-year-old client admitted with fatigue and dyspnea has elevated levels of all of these laboratory results. Which finding is consistent with acute coronary syndrome (ACS) and should be communicated immediately to the health care provider? A. White blood cell count B. Low-density lipoproteins C. Serum troponin I level D. C-reactive protein

C. Elevation in serum troponin levels is associated with acute myocardial injury and indicates a need for immediate interventions such as angioplasty, anticoagulant administration, or administration of fibrinolytic medications. The white blood cell count does not reflect ACS; a mild leukocytosis may occur secondary to inflammation, but this does not constitute an emergency. Although elevated lipoproteins may have contributed to development of atherosclerosis, which is the cause of ACS, the results are not emergent. C-reactive protein indicates inflammation and is increased in people at risk for atherosclerosis and ACS, but it does not indicate an acute problem.

Which negative feedback response is responsible for preventing hypoglycemia during sleep in nondiabetic clients? A. Alpha cells of the pancreas B. Beta cells of the pancreas C. Glucagon release D. Insulin release

C. Glucagon is the hormone that binds to receptors on liver cells. This causes the liver cells to convert glycogen to glucose, which keeps blood sugar levels normal during sleep. Alpha cells are responsible for synthesizing and secreting the hormone glucagon. Beta cells are responsible for synthesizing and secreting the hormone insulin. Insulin is the hormone responsible for lowering blood glucose. Insulin improves glucose uptake by the cell.

Which hormone responds to elevated serum calcium blood level by decreasing bone resorption? A. PTH B. T4 C. T3 D. Calcitonin

D.

The RN has just received change-of-shift report on the medical-surgical unit. Which client will need to be assessed first? A. Client with Hashimoto's thyroiditis and a large goiter B. Client with hypothyroidism and an apical pulse of 51 beats/min C. Client with parathyroid adenoma and flank pain due to a kidney stone D. Client who had a parathyroidectomy yesterday and has muscle twitching

D. A client who is 1 day postoperative for parathyroidectomy and has muscle twitching is showing signs of hypocalcemia and is at risk for seizures. Rapid assessment and intervention are needed. Clients with Hashimoto's thyroiditis are usually stable; this client does not need to be assessed first. Although an apical pulse of 51 is considered bradycardia, a low heart rate is a symptom of hypothyroidism. A client with a kidney stone will be uncomfortable and should be asked about pain medication as soon as possible, but this client does not need to be assessed first.

A nurse is providing discharge instructions to a client who has a new diagnosis of migraine headaches. Which of the following instructions should the nurse include? A. Use music therapy for relaxation with the onset of the headache. B. Increase physical activity when a headache is present. C. Drink beverages that contain artificial sweeteners to prevent headaches. D. Apply a cool cloth to the face during a headache.

D. A cool cloth placed over the client's eyes provides comfort and can relieve pain.

The nurse is teaching a client about the purpose of electrophysiology studies (EPS). Which statement by the nurse reflects the most correct teaching? A. "This is a noninvasive test performed to assess your heart rhythm." B. "You will receive an injection of dobutamine (Dobutrex) and will walk on a treadmill to reveal whether you have coronary artery disease." C. "This is a painless test that is done to assess the structure of your heart using sound waves." D. "This test evaluates you for potentially fatal cardiac rhythms."

D. EPS are invasive tests performed to determine whether the client has lethal dysrhythmias and conduction abnormalities. A noninvasive test to assess the heart rhythm best describes the electrocardiogram. Injection of dobutamine (Dobutrex) followed by walking on a treadmill best describes an exercise stress test. Using sound waves to assess the structure of the heart best describes echocardiography.

The nurse is instructing a client for whom a positron emission tomography (PET) scan has been requested. Which statement indicates to the nurse that the client understands the instructions? A. "It's okay to have a cup of coffee before the test." B. "Because I am diabetic, I will take my insulin just before the test." C. "I can continue to smoke cigarettes up to 4 hours before the test." D. "I will drink plenty of fluids after the test."

D. Fluid intake should be increased after the test because this helps to remove the radioisotope more quickly. Caffeine should be avoided for 24 hours before the test. The client is NPO for 4 to 12 hours before the test, and insulin is not given to diabetic clients before a PET scan. Tobacco should be withheld for 24 hours before PET.

The nurse is caring for a client with hemodynamic monitoring. Right atrial pressure is 8 mm Hg. The nurse anticipates which request by the health care provider? A. Saline infusion B. Morphine sulfate C. No treatment, continue monitoring D. Intravenous furosemide

D. Normal right atrial pressure is 0 to 5 mm Hg; thus the health care provider may prescribe furosemide, a diuretic, to reduce the fluid volume and right atrial pressure. Administering saline will increase the right atrial fluid balance and pressure. Morphine is indicated to reduce preload, measured by left ventricular end-diastolic pressure or left atrial pressure. Because this is an abnormal finding, the nurse should collaborate with the provider to decrease the right atrial pressure.

The nurse is reviewing the laboratory test results for a client admitted with a possible pituitary disorder. Which information has the most immediate implication for the client's care? A. Blood glucose 125 mg/dL B. Blood urea nitrogen (BUN) 40 mg/dL C. Serum potassium 5.2 mEq/L D. Serum sodium 110 mEq/L

D. The normal range for serum sodium is 135 to 145 mEq/L; a result of 110 mEq/L is considered hyponatremia and is extremely dangerous. The client is at risk for increased intracranial pressure, seizures, and death. The RN must act rapidly because this situation requires immediate intervention. The normal range for fasting blood glucose is 60 to 110 mg/dL; 125 mg/dL is high, but is not considered dangerous. The normal range for BUN is 7 to 20 mg/dL; 40 mg/dL is high. An elevated BUN can be an indication of kidney failure, dehydration, fever, increased protein intake, and shock, so the client should have a creatinine drawn for a more complete picture of kidney function. The normal range for serum potassium is 3.5 to 5.2 mEq/L; 5.2 mEq/L is high normal.

A client has been admitted to the hospital with chest pain radiating down the left arm. The pain has been unrelieved by rest and antacids. Which test result best confirms that the client sustained a myocardial infarction? A. C-reactive protein of 1 mg/dL B. Homocysteine level of 13 mmol/L C. Creatine kinase (CK) of 125 mg/dL D. Troponin of 5.2 ng/mL

D. The presence of elevated troponin indicates myocardial damage; normal troponin should be less than 0.03 ng/mL. A C-reactive protein level lower than 1 mg/dL is optimal for identifying inflammation and risk for heart disease. A homocysteine level lower than 12 mmol/dL is optimal, but elevation indicates risk, not myocardial damage. CK totals must be broken down into isoenzyme MB to evaluate for heart damage. Elevations in the CK total may be caused by stroke or skeletal muscle damage.

The nurse is administering the intake assessment for a newly admitted client with a history of seizures. The client suddenly begins to seize. What does the nurse do next? A. Documents the length and time of the seizure. B. Forces a tongue blade in the mouth. C. Restrains the client. D. Positions the client on the side.

D. Turning the client on the side during a generalized tonic-clonic or complex partial seizure is indicated because he or she may lose consciousness. Documenting the length and time of seizures is important, but not the first priority intervention. Forcing a tongue blade in the mouth can cause damage. Restraining the client can cause injury.

Which action does the nurse delegate to experienced unlicensed assistive personnel (UAP) working in the cardiac catheterization laboratory? A. Assess preprocedure medications the client took that day. B. Have the client sign the consent form before the procedure is performed. C. Educate the client about the need to remain on bedrest after the procedure. D. Obtain client vital signs and a resting electrocardiogram (ECG).

D. Vital signs and 12-lead ECGs can be obtained by UAP. The health care provider will explain the catheterization procedure and have the client sign the consent form. Assessments and client teaching should be done by the RN.

The nurse understands that which assessment finding is the best indicator of fluid retention? A. Tachycardia B. Weight gain C. Crackles in the lungs D. Increased blood pressure.

B. Weight gain is the best indicator of fluid retention and is commonly called edema.

The nurse understands that the expected assessment for the older adult related to the natural aging process of the respiratory system includes which finding? A. Tightening of the vocal cords. B. Decrease in the residual volume C. Decrease in the anteroposterior diameter D. Decrease in respiratory muscle strength

D. As a person ages, vocal cords become slack, changing the quality and strength of the voice; the AP diameter increases; respiratory muscle strength decreases; residual volume increases

The nurse prepares to assess a client with diabetes mellitus for sensory loss. Which equipment does the nurse use to perform this assessment? A. Glucometer B. Hammer C. Nothing; the client is asked to walk D. Cotton-tipped applicator

D. Pain sensation is assessed with any sharp or dull object, such as a cotton-tipped applicator. The client indicates whether the touch is sharp or dull. The sharp and dull ends should be interchanged at random, so that the client does not anticipate the next type of sensation. A glucometer tests blood sugar. A hammer tests tendon reflexes. Asking the client to walk tests the client's gait and equilibrium.

Which task does the nurse plan to delegate to the nursing assistant caring for a group of clients in the neurosurgical unit? A. Prepare a client who is going to radiology for a cerebral arteriogram B. Attend to the care needs of a client who has had a transcranial Doppler study C. Assist the health care provider in performing a lumbar puncture on a confused client D. Educate a client about what to expect during an electroencephalogram (EEG)

B. Transcranial Doppler studies are noninvasive and do not require any postprocedure monitoring or care; the nursing assistant can attend to this client. Preparing a client for a cerebral arteriogram and assisting the health care provider in performing a lumbar puncture require assessment and intervention that should be done by licensed nursing staff. Client teaching should be provided by licensed nursing staff.

A client has received contrast medium. Which teaching does the nurse provide to avoid any neurologic health problems after the procedure? A. "Practice memory drills this afternoon." B. "Drink at least 1000 to 1500 mL of water today." C. "Avoid sunlight." D. "Rest in bed for 24 hours."

B. Drinking an adequate amount of water helps flush the contrast out of the body. Practicing memory drills and getting bedrest are not effective precautions after the use of contrast medium. Sunlight does not affect contrast medium.

Which signs and symptoms are seen with suspected pericarditis? (Select all that apply.) A. Squeezing, vise-like chest pain B. Chest pain relieved by sitting upright C. Chest and abdominal pain relieved by antacids D. Sudden-onset chest pain relieved by anti-inflammatory agents E. Pain in the chest described as sharp or stabbing

B. D. E. The pain of pericarditis is relieved when sitting upright or forward, may appear abruptly, and is relieved by anti-inflammatory agents. The inflammatory pain of pericarditis tends to be sharp, stabbing, and related to breathing; squeezing, vise-like chest pain is characteristic of myocardial infarction. Chest and abdominal pain relieved by antacids is characteristic of peptic ulcer.

A client is admitted into the emergency department with frontal-temporal pain, preceded by a visual disturbance. The client is upset and thinks it is a stroke. What does the nurse suspect may be occurring? A. Stroke B. Tension headache C. Classic migraine D. Cluster headache

C. The client's symptoms match those of a classic migraine. Symptoms of a stroke include sudden, severe headache with unknown cause, facial drooping, sudden confusion, and sudden difficulty walking or standing. A tension headache is characterized by neck and shoulder muscle tenderness and bilateral pain at the base of the skull and in the forehead. Symptoms of a cluster headache include intense, unilateral pain occurring in the fall or spring and lasting 30 minutes to 2 hours.

The nurse is assessing a client with a neurologic condition who is reporting difficulty chewing when eating. The nurse suspects that which cranial nerve has been affected? A. Abducens B. Facial C. Trigeminal D. Trochlear

C. The trigeminal nerve affects the muscles of mastication. The abducens nerve affects eye movement via lateral rectus muscles. The facial nerve affects pain and temperature from the ear area, deep sensations in the face, and taste in the anterior two thirds of the tongue. The trochlear nerve affects eye movement via superior oblique muscles.

The nurse is educating a group of women about the differences in symptoms of myocardial infarction (MI) in men versus those in women. Which information should be included? A. Men do not tend to report chest pain. B. Men are more likely than women to die after MI. C. Men more than women tend to deny the importance of symptoms. D. Women may experience extreme fatigue and dizziness as sole symptoms.

D. Women may have atypical symptoms, including absence of chest pain. Women often present with a "triad" of symptoms. In addition to indigestion or a feeling of abdominal fullness, chronic fatigue despite adequate rest and feeling an inability to "catch the breath" (dyspnea) are also common in heart disease. The client may also describe the sensation as aching, choking, strangling, tingling, squeezing, constricting, or vise-like. Men do report chest pain. Women have higher mortality from MI than men. Because of differences in symptoms, denial may occur more often in women.

Which hormones are secreted by the thyroid gland? (SATA) A. Calcitonin B. Somatostatin C. Glucagon D. Thyroxine (T4) E. Aldosterone F. Triiodothyronine (T3)

A. D. F.

After a bronchoscopy procedure, the patient coughs up sputum which contains blood. What is the best nursing action at this time? A. Assess vital signs and respiratory status and notify the provider of the findings. B. Monitor the patient for 24 hours to see if blood continues in the sputum. C. Send the sputum to the lab for cytology for possible lung cancer. D. Reassure the patient that this is a normal response after a bronchoscopy.

A.

An older adult reports a lack of energy and not being able to do the usual daily activities without several naps during the day. Which problem may these symptoms indicate that is often seen in the older adult? A. Hypothyroidism B. Hyperparathyroidism C. Overproduction of cortisol D. Underproduction of glucagon

A.

Which hormone responds to a low serum calcium blood level by increasing bone resorption? A. PTH B. T4 C. T3 D. Calcitonin

A.

At the beginning of a shift, a nurse is assessing a client who has Cushing's disease. Which of the following findings is the priority? A. Weight gain B. Fatigue C. Fragile skin D. Joint pain

A. The greatest risk to a client who has Cushing's disease is fluid retention, which can lead to pulmonary edema, hypertension, and heart failure; therefore, this is the priority finding.

A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform first? A. keep the client in a side-lying position. B. Document the duration of the seizure. C. Reorient the client to the environment. D. Provide client hygiene.

A. The greatest risk to the client is aspiration during the postictal phase. Therefore, the priority intervention is to keep the client in a side-lying position so secretions can drain from the mouth, keeping the airway patent.

A client receiving sumatriptan (Imitrex) for migraine headaches is experiencing adverse effects after taking the drug. Which adverse effect is of greatest concern to the nurse? A. Chest tightness B. Skin flushing C. Tingling feelings D. Warm sensation

A. Triptan drugs are contraindicated in clients with coronary artery disease because they can cause arterial narrowing. Clients taking triptan drugs should report angina or chest discomfort to prevent cardiac injury associated with myocardial ischemia. Skin flushing, tingling feelings, and a warm sensation are common adverse effects with triptan medications and are not indications to avoid using this group of drugs.

A nurse is assessing a client who has a seizure disorder. The client reports he thinks he is about to have a seizure. Which of the following actions should the nurse implement? (SATA) A. Provide privacy B. Ease the client to the floor if standing. C. Move furniture away from the client. D. Loosen the client's clothing. E. Protect the client's head with padding. F. Restrain the client.

A. B. C. D. E.

A nurse is reviewing the laboratory findings of a client who has Cushing's disease. Which of the following findings should the nurse expect for the client? (SATA) A. Sodium 150 mEq/L B. Potassium 3.3 mEq/L C. Calcium 8.0 mg/dL D. Lymphocyte count 35% E. Fasting glucose 145 mg/dL

A. B. C. E.

Which statements about T3 and T4 hormones are correct? (SATA) A. The basal metabolic rate is affected. B. Hypothalamus is stimulated by cold and stress to secrete thyrotropin-releasing hormone. C. These hormones need intake of protein and iodine for production. D. Circulating hormone in the blood directly affects the production of TSH E. T3 and T4 increase oxygen use in tissues.

A. B. C. E.

A nurse is planning care for a client who has Cushing's disease. The nurse should recognize that clients who have Cushing's disease are at increased risk for which of the following?(SATA) A. Infection B. Gastric ulcer C. Renal calculi D. Bone fractures E. Dysphagia

A. B. D.

A nurse is preparing to receive a patient from the PACU who is postoperative following a thyroidectomy. The nurse should ensure that which of the following equipment is available? (SATA) A. Suction equipment B. Humidified oxygen C. Flashlight D. Tracheostomy tray E. Chest tube tray

A. B. D.

A nurse is planning care for a client who has meningitis and is at risk for increased ICP. Which of the following actions should the nurse plan to take? (SATA) A. Implement seizure precautions B. Perform neurological checks four times a day C. Administer morphine for the report of neck and generalized pain. D. Turn off room lights and television E. Monitor for impaired extraocular movements F. Encourage the client to cough frequently

A. D. E.

A patient demonstrates labored, shallow respirations and a respiratory rate of 32/min with a pulse oximetry reading of 85%. What is the priority nursing intervention? A. Notify respiratory therapy to give the patient a breathing treatment. B. Start oxygen via nasal cannula at 2 L/min C. Obtain an order for a stat ABG D. Encourage coughing and deep-breathing exercises

B.

The respiratory therapist consults with and reports to the nurse that a patient is producing frothy pink sputum. What does the nurse suspect is occurring with this patient? A. Pneumothorax B. Pulmonary edema C. Pulmonary infection D. Pulmonary infarction

B.

Which statement about age-related changes in older adults and the endocrine system is true? A. All hormone levels are elevated. B. Thyroid hormone levels decrease. C. Adrenal glands enlarge. D. The thyroid gland enlarges.

B.

Which statement about performing a physical assessment of the thyroid gland is correct? A. The thyroid gland is easily palpated in all patients. B. The patient is instructed to swallow sips of water to aid palpation. C. The anterior approach is preferred for thyroid palpation. D. The thumbs are used to palpate the thyroid lobes.

B.

Which statement by the client with a recent cardiovascular diagnosis indicates maladaptive denial? A. "I don't know how I am going to change my lifestyle." B. "I don't need to change. It hasn't killed me yet." C. "I don't think it is as bad as the doctors say." D. "I will have to change my diet and exercise more."

B. A common and normal response is denial, which is a defense mechanism that enables the client to cope with threatening circumstances. He or she may deny the current cardiovascular condition, may state that it was present but is now absent, or may be excessively cheerful. Denial becomes maladaptive when the client is noncompliant or does not adhere to the interdisciplinary plan of care. The statement about not changing because "it hasn't killed me yet" indicates maladaptive denial. Not knowing how to change indicates that the client is overwhelmed, not in denial. Not thinking it is that bad indicates denial, but not maladaptive denial. Changing diet and exercising more indicates a willingness to change.

A client recently admitted with hyperparathyroidism has a very high urine output. Of these actions, what does the nurse do next? A. Calls the health care provider B. Monitors intake and output C. Performs an immediate cardiac assessment D. Slows the rate of IV fluids

B. Diuretic and hydration therapies are used most often for reducing serum calcium levels in clients with hyperparathyroidism. Usually, a diuretic that increases kidney excretion of calcium is used together with IV saline in large volumes to promote renal calcium excretion. The health care provider does not need to be notified in this situation, given the information available in the question. Cardiac assessment is part of the nurse's routine evaluation of the client. Slowing the rate of IV fluids is contraindicated because the client will become dehydrated due to the use of diuretics to increase kidney excretion of calcium.

A client had a parathyroidectomy 18 hours ago. Which finding requires immediate attention? A. Edema at the surgical site B. Hoarseness C. Pain on moving the head D. Sore throat

B. Hoarseness or stridor is an indication of respiratory distress and requires immediate attention. Edema at the surgical site of any surgery is an expected finding. Pain when the client moves the head or attempts to lift the head off the bed is an expected finding after a parathyroidectomy. Any time a client has been intubated for surgery, a sore throat is a common occurrence in the postoperative period. This is especially true for clients who have had surgery involving the neck.

The nurse is performing a physical assessment of a patient's endocrine system. Which gland can be palpated? A. Pancreas B. Thyroid C. Adrenal glands D. Parathyroids

B. I really hope nobody missed this one.

A nurse in a provider's office is reviewing the medical record of a client who is being evaluated for Graves' disease. The nurse should identify that which of the following laboratory results is an expected finding? A. Decreased thyrotropin receptor antibodies B. Decreased TSH C. Decreased free thyroxine index D. Decreased triiodothyronine

B. In the presence of Graves' disease, low TSH is an expected finding. The pituitary gland decreases the production of TSH when thyroid hormone levels are elevated.

A client being treated for hyperthyroidism calls the home health nurse and mentions that his heart rate is slower than usual. What is the nurse's best response? A. Advise the client to go to a calming environment. B. Ask whether the client has increased cold sensitivity or weight gain. C. Instruct the client to see his health care provider immediately. D. Tell the client to check his pulse again and call back later.

B. Increased sensitivity to cold and weight gain are symptoms of hypothyroidism, indicating an overcorrection by the medication. The client must be assessed further because he may require a lower dose of medication. A calming environment will not have any effect on the client's heart rate. The client will want to notify the health care provider about the change in heart rate. If other symptoms such as chest pain, shortness of breath, or confusion accompany the slower heart rate, then the client should see the health care provider immediately. If the client was concerned enough to call because his heart rate was slower than usual, the nurse needs to stay on the phone with the client while he re-checks his pulse. This time could also be spent providing education about normal ranges for that client.

A client has been diagnosed with hypothyroidism. What medication is usually prescribed to treat this disorder? A. Atenolol (Tenormin) B. Levothyroxine sodium (Synthroid) C. Methimazole (Tapazole) D. Propylthiouracil

B. Levothyroxine is a synthetic form of thyroxine (T4) that is used to treat hypothyroidism. Atenolol is a beta blocker that is used to treat cardiovascular disease. Methimazole and propylthiouracil are used to treat hyperthyroidism.

A nurse is assessing a client who reports severe headache and a stiff neck. The nurse's assessment reveals positive Kernig's and Brudzinski's signs. Which of the following actions should the nurse perform first? A. Administer antibiotics B. Implement droplet precautions C. Initiate IV access D. Decrease bright lights

B. When using the urgent vs. non urgent approach to care, the nurse determines the priority action is to initiate droplet precautions when meningitis is suspected to prevent spread of the disease to others.

A nurse in a clinic is caring for a client who has frequent migraine headaches. The client asks about foods that can cause headaches. The nurse should recommend that the client avoid which of the following foods? A. Baked salmon B. Salted cashews C. Frozen strawberries D. Fresh asparagus

B. Nuts contain tyramine, which can trigger migraine headaches.

A nurse is providing instructions to a client who has Graves' disease and has a new prescription for propranolol. Which of the following information should the nurse include? A. An adverse effect of this mediation is jaundice. B. Take your pulse before each dose. C. The purpose of this medication is to decrease production of thyroid hormone. D. You should stop taking this medication if you have a sore throat.

B. Propranolol can cause bradycardia. The client should take his pulse before each dose. If there is a significant change, he should withhold the dose and consult the provider.

Family members of a client diagnosed with hyperthyroidism are alarmed at the client's frequent mood swings. What is the nurse's response? A. "How does that make you feel?" B. "The mood swings should diminish with treatment." C. "The medications will make the mood swings disappear completely." D. "Your family member is sick. You must be patient."

B. Telling the family that the client's mood swings should diminish over time with treatment will provide information to the family, as well as reassurance. Asking how the family feels is important; however, the response should focus on the client. Any medications or treatment may not completely remove the mood swings associated with hyperthyroidism. The family is aware that the client is sick; telling them to be patient introduces guilt and does not address the family's concerns.

A client admitted with hyperthyroidism is fidgeting with the bedcovers and talking extremely fast. What does the nurse do next? A. Calls the provider B. Encourages the client to rest C. Immediately assesses cardiac status D. Tells the client to slow down

B. The client with hyperthyroidism often has wide mood swings, irritability, decreased attention span, and manic behavior. The nurse should accept the client's behavior and provide a calm, quiet, and comfortable environment. Because the client's behavior is expected, there is no need to call the provider. Monitoring the client's cardiac status is part of the nurse's routine assessment. Telling the client to slow down is unsupportive and unrealistic.

A nurse is planning care for a client who has bacterial meningitis. Which of the following actions should the nurse include in the plan of care? (SATA) A. Monitor for bradycardia B. Provide an emesis basin at the bedside C. Administer antipyretic medication D. Perform a skin assessment E. Keep the head of the bed flat

B. C. D.

Which are the target organs of PTH in the regulation of calcium and phosphorus? (SATA) A. Stomach B. Kidney C. Bone. D. GI tract E. Thyroid gland

B. C. D.

Which statements about the thyroid gland and its hormones are correct? (SATA) A. The gland is located in the posterior neck below the cricoid cartilage. B. The gland has two lobes joined by a thin tissue called the isthmus. C. T3 and T4 are two thyroid hormones. D. Thyroid hormones increase RBC production. E. Thyroid hormone production depends on dietary intake of iodine and potassium.

B. C. D.

A nurse in a provider's office is obtaining the health history from a client who has cluster headaches. Which of the following are expected findings? (SATA) A. Pain is bilateral across the posterior occipital area B. Client experiences altered sleep-wake cycle C. Headache occurs at approximately the same time of the day D. Client describes headache pain as dull and throbbing E. Nasal congestion and drainage occur

B. C. E.

Which factors or conditions cause a decreased PETCO level due to abnormal ventilation? (SATA) A. Hyperthermia B. Hypotension C. Apnea D. Hyperventilation E. Hypothermia

B. C. E.

Which respiratory changes occur as a result of aging? (SATA) A. Increased elastic recoil B. Dilation of alveolar ducts C. Decreased ability to cough D. Alveolar surface tension increases E. Diffusion capacity decreases

B. C. E.

A nurse is reviewing the manifestations of hyperthyroidism with a client. Which of the following findings should the nurse include? (SATA) A. Anorexia B. Heat intolerance C. Constipation D. Palpitations E. Weight loss F. Bradycardia

B. D. E.

A client has been admitted with new-onset status epilepticus. Which seizure precautions does the nurse put in place? (Select all that apply.) A. Bite block at the bedside B. Intravenous access C. Continuous sedation D. Suction equipment at the bedside E. Siderails up

B. D. E. Intravenous access is needed to administer medications. Suctioning equipment should be available to suction secretions and facilitate an open airway during a seizure. Raised, padded siderails may be used to protect the client from falling out of bed during a seizure. Bite blocks or padded tongue blades should not be used because the client's jaw may clench, causing teeth to break and possibly obstructing the airway. Continuous sedation is a medical intervention and not a seizure precaution.

A patient who had a thoracentesis is now experiencing the following clinical manifestations: rapid shallow respirations, rapid heart rate, and pain on the affected side that is worse at the end of inhalation. What complication does the nurse suspect this patient has developed? A. Hemoptysis B. Lung abscess C. Pneumothorax D. Lung cancer

C.

A patient who received a bronchoscopy was NPO for several hours before the test. Now a few hours after the test, the patient is hungry and would like to eat a meal. What does the nurse do before allowing the patient to eat? A. Order a meal because the patient is now alert and oriented. B. Check pulse oximetry to be sure oxygen saturation has returned to normal. C. Check for a gag reflex before allowing the patient to eat. D. Assess for nausea from the medications given for the test

C.

A patient's pulse oximetry reading is 89%. What is the nurse's first priority action? A. Recheck the reading with a different oximeter. B. Apply supplemental oxygen and recheck the oximeter reading in 15 minutes. C. Assess the patient for respiratory distress and recheck the oximeter reading. D. Place the patient in the recovery position and monitor frequently.

C.

What is the best position for a patient to assume for a thoracentesis? A. Side-lying, affected side exposed, head slightly raised. B. Lying flat with arm on affected side across the chest. C. Sitting up, leaning forward on the overbid table. D. Prone position with arms above the head.

C.

Which action does the postanesthesia care unit (PACU) nurse perform first when caring for a client who has just arrived after a total thyroidectomy? A. Assess the wound dressing for bleeding. B. Give morphine sulfate 4 to 8 mg IV for pain. C. Monitor oxygen saturation using pulse oximetry. D. Support the head and neck with sandbags.

C. Airway assessment and management is always the first priority with every client. This is especially important for a client who has had surgery that involves potential bleeding and edema near the trachea. Assessing the wound dressing for bleeding is a high priority, although this is not the first priority. Pain control and supporting the head and neck with sandbags are important priorities, but can be addressed after airway assessment.

A client with hypothyroidism is being discharged. Which environmental change may the client experience in the home? A. Frequent home care B. Handrails in the bath C. Increased thermostat setting D. Strict infection-control measures

C. Manifestations of hypothyroidism include cold intolerance. Increased thermostat settings or additional clothing may be necessary. A client with a diagnosis of hypothyroidism can be safely managed at home with adequate discharge teaching regarding medications and instructions on when to notify the health care provider or home health nurse. In general, hypothyroidism does not cause mobility issues. Activity intolerance and fatigue may be an issue, however. A client with hypothyroidism is not immune-compromised or contagious, so no environmental changes need to be made to the home.

A client has hyperparathyroidism. Which incident witnessed by the nurse requires the nurse's intervention? A. The client eating a morning meal of cereal and fruit B. The physical therapist walking with the client in the hallway C. Unlicensed assistive personnel pulling the client up in bed by the shoulders D. Visitors talking with the client about going home

C. The client with hyperparathyroidism is at risk for pathologic fracture. All members of the health care team must move the client carefully. A lift sheet should be used to re-position the client. The client with hyperparathyroidism is not restricted from eating and should maintain a balanced diet. The client can benefit from moderate exercise and physical therapy, and is not restricted from having visitors.

The nurse is teaching a client about thyroid replacement therapy. Which statement by the client indicates a need for further teaching? A. "I should have more energy with this medication." B. "I should take it every morning." C. "If I continue to lose weight, I may need an increased dose." D. "If I gain weight and feel tired, I may need an increased dose."

C. Weight loss indicates a need for a decreased dose, not an increased dose. One of the symptoms of hypothyroidism is lack of energy; thyroid replacement therapy should help the client have more energy. The correct time to take thyroid replacement therapy is in the morning. If the client is gaining weight and continues to feel tired, that is an indication that the dose may need to be increased.

A nurse is assessing a client who is 12 hr postoperative following a thyroidectomy. The nurse should identify which of the following findings as indicative of thyroid crisis? (SATA) A. Bradycardia B. Hypothermia C. Dyspnea D. Abdominal pain E. Mental confusion

C. D. E.

A nurse is obtaining a health history from a client who is being evaluated for the cause of frequent headaches. Which of the following questions should the nurse ask to identify the findings of migraine headaches? A. Do the headaches occur at the same time each day? B. is your headache accompanied by profuse facial sweating? C. Does your headache occur on one side of your head? D. Is there a pattern of headaches among family members?

D. A familial pattern of headaches is a common finding with migraines.

The nurse is caring for several patients who had diagnostic testing for respiratory disorders. Which diagnostic test has the highest risk for the post procedure complication of pneumothorax? A. Bronchoscopy B. Laryngoscopy C. Computed tomography of lungs D. Percutaneous lung biopsy

D.

Which assessment finding is an objective sign of chronic oxygen deprivation? A. Continuous cough productive of clear sputum. B. Audible inspiratory and expiratory wheeze. C. Chest pain that increases with deep inspiration. D. Clubbing of fingernails and a barrel-shaped chest.

D.

What effect can starting a dose of levothyroxine sodium (Synthroid) too high or increasing a dose too rapidly have on a client? A. Bradycardia and decreased level of consciousness B. Decreased respiratory rate C. Hypotension and shock D. Hypertension and heart failure

D. Hypertension and heart failure are possible if the levothyroxine sodium dose is started too high or raised too rapidly, because levothyroxine would essentially put the client into a hyperthyroid state. The client would be tachycardic, not bradycardic. The client may have an increased respiratory rate. Shock may develop, but only as a late effect and as the result of "pump failure."

The nurse reviews the vital signs of a client diagnosed with Graves' disease and sees that the client's temperature is up to 99.6° F. After notifying the health care provider, what does the nurse do next? A. Administers acetaminophen B. Alerts the Rapid Response Team C. Asks any visitors to leave D. Assesses the client's cardiac status completely

D. If the client's temperature has increased by even 1°, the nurse's first action is to notify the provider. Continuous cardiac monitoring should be the next step. Administering a nonsalicylate antipyretic such as acetaminophen is appropriate, but is not a priority action for this client. Alerting the Rapid Response Team is not needed at this time. Asking visitors to leave would not be the next action, and if visitors are providing comfort to the client, this would be contraindicated.

The nurse is assessing a client with mitral stenosis who is to undergo a transesophageal echocardiogram (TEE) today. Which nursing action is essential? A. Auscultate the client's precordium for murmurs. B. Teach the client about the reason for the TEE. C. Reassure the client that the test is painless. D. Validate that the client has remained NPO.

D. Owing to the risk for aspiration, the client must be NPO before the procedure. It is anticipated that the client with mitral stenosis may have an audible murmur; auscultation is not essential at this time. Although teaching is important, the client could undergo the procedure without understanding the reason for the test. The client will have sedation during the test because it is uncomfortable.

The results of a client's lumbar puncture indicate that the client's protein level is 150 mg/dL. The nurse suspects that the client may have which condition? A. Guillain-Barré syndrome B. Meningismus C. Paraventricular tumor D. Viral infection

D. Protein levels of 50 to 200 mg/dL are indicative of a viral infection. A protein level greater than 500 mg/dL is indicative of a bacterial infection or Guillain-Barré syndrome. A protein level less than 15 mg/dL is indicative of meningismus. Protein levels of 45 to 100 mg/dL are indicative of a paraventricular tumor.

The nurse is performing a rapid neurologic assessment on a trauma client. Which assessment finding is normal? A. Decerebrate posturing B. Increased lethargy C. Minimal response to stimulation D. Constriction of pupils

D. Pupil constriction is a function of cranial nerve III. Pupils should be equal in size and round and regular in shape, and should react to light and accommodation (PERRLA). Decerebrate or decorticate posturing, as well as pinpoint or dilated and nonreactive pupils, is a late sign of mental deterioration. Minimal response to stimulation and increased lethargy are not normal findings.

The nurse has just received change-of-shift report about a group of clients on the neurosurgical unit. Which client does the nurse attend to first? A. Young adult client involved in a motor vehicle crash (MVC) who is yelling obscenities at the nursing staff B. Adult postoperative left craniotomy client whose hand grips are weaker on the right C. Middle-aged adult client who had a cerebral aneurysm clipping and is increasingly stuporous D. Older adult client who had a carotid endarterectomy and is unable to state the day of the week

C. A change in level of consciousness is an early indication that central neurologic function has declined; the neurologic status of this client should be assessed and the health care provider notified about the change in status. The other clients are not the nurse's first priority. The young adult who is post-MVC does need to be assessed, but the client's behavior does not indicate a decline in neurologic function. The postoperative left craniotomy client and the older adult do need to be assessed, but these clients' neurologic assessment indicates better function.

A client had a thoracentesis 1 day ago. He calls the home health agency and tells the nurse that he is very short of breath and anxious. What is the major concern of the nurse? A. Abscess B. Pneumonia C. Pneumothorax D. Pulmonary embolism

C. A pneumothorax would be the complication of thoracentesis that causes the greatest concern, along with these symptoms. Although it is possible that an abscess has formed, this is not the most likely diagnosis because it would not cause a great deal of shortness of breath. It is not likely that pneumonia would develop this rapidly, causing this level of symptoms. Thoracentesis is not a cause of pulmonary emboli.

The nurse is providing medication instructions for a client for whom phenytoin (Dilantin) has been ordered for treatment of epilepsy. The nurse instructs the client to avoid which beverage? A. Apple juice B. Grape juice C. Grapefruit juice D. Milk

C. Grapefruit juice can interfere with the metabolism of phenytoin. Apple juice, grape juice, and milk do not interact with phenytoin.

The RN and the LPN/LVN are working together to provide care for a client hospitalized with dyspnea who requires all of these nursing actions. Which action is best accomplished by the RN? A. Administer the purified protein derivative for tuberculosis testing. B. Assess vital signs and the puncture site after thoracentesis. C. Monitor oxygen saturation using pulse oximetry every 4 hours. D. Plan client and family teaching regarding upcoming pulmonary function testing.

D. Developing the teaching plan is the most complex of the skills listed and requires RN education and licensure. Medication administration and monitoring of vital signs and client status after procedures can be accomplished by the LPN/LVN. Monitoring of oxygen saturation by pulse oximetry can be included in the vital signs assessment.

The nurse is working in an urgent care clinic. Which client needs to be evaluated first by the nurse? A. Client who is short of breath after walking up two flights of stairs B. Client with soreness of the arm after receiving purified protein derivative (Mantoux) skin test C. Client with sore throat and fever of 102.2° F (39° C) oral D. Client who is speaking in three-word sentences and has an SpO2 of 90% by pulse oximetry

D. A client should be able to speak in sentences of more than three words, and an SpO2 of 90% indicates hypoxemia that requires intervention on the part of the nurse. Shortness of breath after walking up two flights of stairs may not be an emergency. Although not a usual finding, the arm may be sore after a skin test is performed. Sore throat and fever are symptoms of infection that require further evaluation but not emergently.

Which client does the charge nurse on the medical unit assign to an RN who has floated from the postanesthesia care unit (PACU)? A. Client with allergic rhinitis scheduled for skin testing B. Client with emphysema who needs teaching about pulmonary function testing C. Client with pancreatitis who needs a preoperative chest x-ray D. Client with pleural effusion who has had 1200 mL removed by thoracentesis

D. A nurse working in the PACU would be familiar with assessing vital signs and respiratory status after procedures such as thoracentesis. Skin testing is performed in the outpatient setting. Pulmonary function testing is not a procedure that requires PACU care. Although a client with pancreatitis is seriously ill and would require a chest x-ray before undergoing operative procedures, a nurse with a PACU monitoring skill set would not be required.

A client has returned to the postanesthesia care unit (PACU) after a bronchoscopy. Which nursing task is best for the charge nurse to delegate to the experienced nursing assistant working in the PACU? A. Assess breath sounds. B. Check gag reflex. C. Determine level of consciousness. D. Monitor blood pressure and pulse.

D. A nursing assistant working in the PACU would have experience in taking client vital signs after the client has had conscious sedation or anesthesia. Evaluating breath sounds and gag reflex and determining level of consciousness require the skill and knowledge of a higher-level provider.

A client has undergone single-photon emission computed tomography (SPECT). Which instruction does the nurse give the client? A. "Continue to use the ice pack." B. "Call me if you have any itching." C. "Keep the head of the bed flat." D. "Return to your usual activity."

D. Clients who have undergone SPECT can return to their usual activities immediately after the test. Ice packs may be used by clients who have undergone cerebral angiography. Asking clients to call if they have itching may be a typical instruction for a contact allergy, but not for this situation. The head of the bed should be kept flat for clients who have undergone a lumbar puncture.