Final Exam - Med Surg

A nurse is assessing a client who is experiencing perforation of a peptic ulcer. Which of the following manifestations should the nurse expect? a. Increased blood pressure b. Decreased heart rate c. Yellowing of the skin d. Boardlike abdomen

Correct Answer: D. Boardlike abdomen---The nurse should expect this client who is experiencing perforation of a peptic ulcer to exhibit manifestations of a board-like abdomen and severe pain in the abdomen or back that radiates to the right shoulder. Vomiting of blood and shock can occur if the perforation causes hemorrhaging.

A nurse is caring for an adolescent client who has a long hx of DM & is being admitted to the emergency department confused, flushed, & with an acetone odor on the breath. DKA is suspected. The nurse should anticipate using which of the following types of insulin to treat this client? a. NPH insulin b. Insulin glargine c. Insulin detemir d. Regular insulin

D) Regular insulin--- regular insulin is classified as a short-acting insulin. It can be given intravenously with an onset of action of less than 30 min. This is the insulin that is most appropriate in emergency situations of severe hyperglycemia or DKA

An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen? a. Arrange for a friend to administer the medication on schedule. b. Give the patient written instructions about how to take the medications. c. Teach the patient about the high risk for infecting others unless treatment is followed. d. Arrange for a daily noon meal at a community center where the drug will be administered.

D. Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients but are not likely to be as helpful for this patient.

A nurse is providing teaching to a newly licensed nurse about administering morphine via IV bolus to a client. Which of the following pieces of information should the nurse include in the teaching? a. Respiratory depression can occur 7 min after the morphine is administered. b. The morphine will peak in 10 min. c. Withhold the morphine if the client has a respiratory rate of <16/min. d. Administer the morphine over 2 min.

Respiratory depression can occur 7 min after the morphine is administered. ----Respiratory depression can occur within 7 minutes of the administration of IV bolus morphine. The nurse should monitor the client's respirations and have naloxone available to reverse the effects of the morphine.

A nurse is evaluating the injection site of a client who had a Mantoux skin test 48 hr ago. The nurse finds 10 mm of induration with slight redness. Which of the following conclusions should the nurse make? a. The client has active tuberculosis. b. The client had an exposure to tuberculosis. c. The nurse must re-evaluate the result in 24 hr. d. The test is negative for tuberculosis.

B. The client had an exposure to tuberculosis. A Mantoux test is a skin test that determines exposure to tuberculosis. The nurse should look at the test site and palpate the area to determine if the injection site is raised and feels hard to the touch (induration). Then, the nurse should record the results in millimeters to represent the size of the raised bump. Redness alone does not determine a positive result.

A nurse in a medical-surgical unit is assessing a client. The nurse should identify which of the following findings is a manifestation of a pulmonary embolism? a. Stabbing chest pain b. Calf tenderness c. Elevated temperature d. Bradycardia

A. Stabbing chest pain---- A manifestation of a pulmonary embolism is sudden chest pain that is sharp and stabbing. Other manifestations include dyspnea, coughing, hemoptysis (coughing up blood), tachypnea, tachycardia, diaphoresis, and a feeling of impending doom.

A nurse is caring for a client who is scheduled to undergo surgery to repair an open hip fracture. In which of the following positions should the nurse plan to place the client postoperatively? a. With the leg on the affected side adducted b. With the hip externally rotated on the affected side c. With the leg on the affected side abducted d. With the hip flexed to 90° on the affected side

C. With the leg on the affected side abducted---The nurse should plan to place the client with the leg abducted on the affected side postoperatively. Adduction or external rotation of the leg will cause the hip to dislocate.

Which nursing responsibilities are priorities when caring for a patient returning from a cardiac catheterization (select all that apply)? a. Monitoring vital signs and ECG b. Checking the catheter insertion site and distal pulses c. Helping the patient to ambulate to the bathroom to void d. Telling the patient that he will be sleepy from the general anesthesia e. Teaching the patient about the risks of the radioactive isotope injection

a. Monitoring vital signs and ECG b. Checking the catheter insertion site and distal pulses

A nurse is providing teaching to a client who has a new diagnosis of type 2 DM. The nurse should recognize that the clients understands the teaching when he identifies which of the following as manifestations of hypoglycemia. (Select all that apply) a. Polyuria b. Blurred vision c. Polydipsia d. Tachycardia e. Moist, clammy skin

B) blurred vision D) tachycardia E) moist, clammy skin

A nurse is assessing a client who has DM & reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (select all that apply) a. Bradycardia b. Increased neutrophils c. Increased RBCs d. Increased platelets e. Localized edema

B) increased neutrophils E) Localized edema

A nurse is assessing a client for manifestations of aplastic anemia. Which of the following findings should the nurse expect? a. Plethoric appearance of facial skin b. Glossitis and weight loss c. Jaundice with an enlarged liver d. Petechiae and ecchymosis

D. Petechiae and ecchymosis--- A client who has aplastic anemia will have manifestations of petechiae and ecchymosis. Dyspnea on exertion also can be present. In aplastic anemia, all 3 major blood components (red blood cells, white blood cells, and platelets) are reduced or absent, which is known as pancytopenia. Manifestations usually develop gradually.

A nurse is caring for a client who has femoral thrombophlebitis and a prescription for enoxaparin. Which of the following actions should the nurse take? A. Elevate the affected leg B. Place the client on bed rest C. Massage the affected leg D. Administer aspirin for discomfort

A. Elevate the affected leg--- The nurse should elevate the client's affected leg when the client is in bed to reduce inflammation.

A nurse is preparing to provide self-care teaching to a client who is 4 days postoperative following the creation of a colostomy and refuses to look at the stoma. Which of the following actions should the nurse take? a. Postpone any teaching with the client at this time b. Reinforce the preoperative information with the client c. Encourage the client to empty the colostomy bag first d. Ask the client to begin assuming responsibility for self-care of the colostomy

A. Postpone any teaching with the client at this time---The nurse should postpone any teaching with the client at this time and should encourage the client to look at and touch the stoma before continuing to teach about self-care. Refusal to look at the stoma indicates the client is in the denial stage of grief and might not be able to learn anything further at this time about self-care of the colostomy.

A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. Which of the following findings should the nurse recognize as an indication of pulmonary embolism? a. Sudden onset of dyspnea b. Tracheal deviation c. Bradycardia d. Difficulty swallowing

A. Sudden onset of dyspnea---Clinical manifestations of pulmonary embolism have a rapid onset. Dyspnea occurs due to reduced blood flow to the lungs. Incorrect Answers: B. Tracheal deviation is an indication of pneumothorax. C. Tachycardia is a clinical manifestation of pulmonary embolism. D. Difficulty swallowing is an indication of many conditions, including oral cancer.

A nurse is teaching a client who has diabetes about which dietary source should provide the greatest percentage of calories. Which of the following statements indicates the client understands the teaching? a. "Most of my calories each day should be from fats" b. "I should eat more calories from complex carbohydrates than anything else" c. "Simple sugars are needed more than other calorie sources" d. "Protein should be my main source of calories"

B) "I should eat more calories from complex carbohydrates than anything else"--- The client who has diabetes should consume the majority of calories from complex carbs, such as whole grains, fruits, and veggies

A nurse is conducting a home visit for an older adult client who has diabetes mellitus and takes regular insulin subcutaneously before each meal. The client appears disoriented and weak and has slurred speech. Which of the following conditions should the nurse consider first when responding to these manifestations? a. Dementia b. Hypoglycemia c. Infection d. Transient ischemic attack

B. Hypoglycemia---Evidence-based practice indicates the nurse should first check the client for hypoglycemia by drawing a blood glucose level. A client who has hypoglycemia can have slurred speech, disorientation, weakness, and confusion near meal time each day because regular insulin peaks in 2 to 4 hours, causing a drop in the client's blood glucose. Other manifestations of hypoglycemia include irritability, mental confusion, double vision, hunger, tachycardia, diaphoresis, and palpitations.

A nurse is providing teaching to a client who is scheduled for a sigmoid colon resection with colostomy. Which of the following statements by the client indicates a need for further teaching? a. "Because most of my colon is still intact and functioning, my stool will be formed." b. "My stoma will appear large at first, but it will shrink over the next several weeks." c. "My colostomy will begin to function in 2 to 6 days after surgery." d. "I'll have to consume a soft diet after surgery."

D. "I'll have to consume a soft diet after surgery."---The nurse should identify that this statement requires further teaching. After surgery, the client quickly returns to a regular diet, and there are no food restrictions unless the client chooses to decrease the intake of foods that increase gas or odor.

A nurse is assessing a client who is 85 years old. Which of the following findings should the nurse identify as a manifestation of myocardial infarction? a. Sudden hemoptysis b. Acute diarrhea c. Frontal headache d. Acute confusion

D. Acute confusion--- Acute confusion is a manifestation of myocardial infarction in clients age 65 or older. Other manifestations can include nausea, vomiting, dyspnea, diaphoresis, anxiety, dizziness, palpitations, and fatigue.

Which finding by the nurse will be most helpful in determining whether a 67-year-old patient with benign prostatic hyperplasia has an upper urinary tract infection (UTI)? a. Bladder distention b. Foul-smelling urine c. Suprapubic discomfort d. Costovertebral tenderness

D. Costovertebral tenderness is characteristic of pyelonephritis. Bladder distention, foul-smelling urine, and suprapubic discomfort are characteristic of lower UTI and are likely to be present if the patient also has an upper UTI.

A nurse is caring for a client with a hip fracture who has Buck's extension traction in place. Which of the following pieces of information should the nurse give the client about this type of traction? (Select all that apply.) a. "You'll have considerably less pain with the traction in place." b. "You'll have the traction in place for a week or so." c. "The traction will help decrease muscle spasms." d. "The weights act as a pulling force to keep your leg and hip still." e. "We have to make sure the weights are just barely touching the floor."

A. "You'll have considerably less pain with the traction in place." C. "The traction will help decrease muscle spasms." D. "The weights act as a pulling force to keep your leg and hip still." Pain is usually more severe without the traction. Buck's extension traction uses weights to help decrease muscle spasms. Typically, 2.3 to 5.5 kg (5 to 10 lb) of force helps stabilize the hip and leg preoperatively.

A charge nurse receives notification of the admission of a client who is coughing frequently and whose sputum is pink, frothy, and copious. The client has a history of night sweats, anorexia, and weight loss. Which of the following actions should the nurse take? (Select all that apply.) a. Assign the client to a private room with negative-pressure airflow. b. Add contact precautions to the client's plan of care. c. Wear an N95 respirator when entering the client's room. d. Ensure the client's environment provides 4 exchanges of fresh air per minute. e. Institute protective environment precautions as soon as the client arrives on the unit.

A. Assign the client to a private room with negative-pressure airflow. C. Wear an N95 respirator when entering the client's room.---This client's history and present status suggest tuberculosis, a communicable infection that mandates a private room with negative-pressure airflow. Airborne precautions will be required, including wearing an N95 respirator when entering the client's room.

A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take? a. Place the client in the Trendelenburg position b. Perform percussions directly over the client's bare skin c. Use a flattened hand to perform percussions d. Remind the client that chest percussions can cause mild pain

A. Place the client in the Trendelenburg position---- The nurse should place the client in a right-sided Trendelenburg position to promote drainage from the client's left lower lobe.

A nurse is preparing an in-service presentation about the management of myocardial infarction (MI). Death following MI is often a result of which of the following complications? a. Cardiogenic shock b. Dysrhythmias c. Heart failure d. Pulmonary edema

B. Dysrhythmias---- According to evidence-based practice, dysrhythmias (specifically ventricular fibrillation) are the most common cause of death following MI. Therefore, nurses should monitor clients' ECGs carefully for dysrhythmias and report and treat them immediately.

A nurse is providing discharge teaching to a client who is post-operative following a right mastectomy for breast cancer. The client will be discharged with 2 Jackson-Pratt drains. Which of the following pieces of information should the nurse include in the teaching? a. "Empty the drainage tubes once per day." b. "Showering is permitted before the drainage tubes are removed." c. "The drainage tubes often are removed at the same time as the stitches." d. "Do not begin exercising your arm until the provider removes the drainage tubes."

C. "The drainage tubes often are removed at the same time as the stitches."---The nurse should instruct the client that the provider will remove the drainage tubes at the same time the stitches are removed, usually within 7 to 10 days.

A nurse is caring for a client who has a fractured right hip. Which of the following types of traction should the nurse expect the client to have prior to hip arthroplasty surgery? a. Balanced skeletal traction b. Pelvic belt c. Pelvic sling d. Buck's traction

D. Buck's traction---Buck's traction is used prior to hip arthroplasty to maintain alignment and prevent muscle spasms prior to surgery. Incorrect Answers: A. Balanced skeletal traction is used to stabilize fractures of the femur or pelvis, not the hip. Skeletal traction involves the surgical insertion of pins, tongs, wires, or screws; this is sometimes used to stabilize long bone and vertebral fractures. B. A pelvic belt is used to treat back pain and does not provide traction prior to hip arthroplasty. C. A pelvic sling is used to stabilize pelvic fractures, not hip fractures.

A nurse is planning care for a client during a sickle cell crisis. Which of the following interventions should the nurse include in the client's plan of care? a. Maintain the client's knees and hips in a flexed position b. Apply cold compresses to painful joints c. Withhold opioids until the crisis is resolved d. Encourage increased fluid intake

D. Encourage increased fluid intake--- The nurse should encourage increased fluid intake to promote hydration because dehydration increases the viscosity of the blood, which can aggravate sickling and client discomfort.

A nurse is preparing a client for a bronchoscopy. Which of the following actions should the nurse take? (Select all that apply.) a. Explain that the client will receive sedation and will not remember the procedure. b. Verify that the client understands the purpose and nature of the procedure. c. Offer the client sips of clear liquids until 1 hr before the test d. Obtain a pre-procedural sputum specimen e. Instruct the client to keep his neck in a neutral position.

A. Explain that the client will receive sedation and will not remember the procedure. B. Verify that the client understands the purpose and nature of the procedure.---For a bronchoscopy, clients typically receive premedication with a benzodiazepine or an opioid to ensure sedation and amnesia. The client will have signed a consent form, so the nurse should verify that the provider explained the procedure and that the client understands it.

A nurse is caring for an older adult client who had an acute myocardial infarction (MI). When assessing this client, the nurse should identify that older adults are prone to complications of MI from poor tissue perfusion because of which of the following age-related factors? a. Peripheral vascular resistance increases. b. The sensitivity of blood pressure-adjusting baroreceptors increases. c. Blood is hyper-coagulable and clots more quickly. d. Cardiac medications are less effective.

A. Peripheral vascular resistance increases.----Older adult clients are more prone to complications from poor tissue perfusion following an acute MI because peripheral vascular resistance increases with aging. This results from calcification and loss of elasticity of the blood vessels.

A nurse is providing teaching to a client who has gout and urolithiasis. The client asks how to prevent future uric acid stones. Which of the following suggestions should the nurse provide? (Select all that apply.) a. Take allopurinol as prescribed b. Exercise several times a week c. Limit intake of foods high in purine d. Decrease daily fluid intake e. Avoid citrus juices

A. Take allopurinol as prescribed B. Exercise several times a week C. Limit intake of foods high in purine---The nurse should inform the client that allopurinol is an antigout medication that reduces uric acid, which helps prevent uric acid stone formation. Immobility is a risk factor for stone formation; therefore, the client should maintain a healthy lifestyle, including regular exercise. Purine increases the risk of uric acid stone formation; organ meats, poultry, fish, red wine, and gravy are high in purine.

A nurse is teaching a client who has diabetes mellitus about hypoglycemia. Which of the following manifestations should the nurse include? (Select all that apply.) a. Bradycardia b. Diaphoresis c. Deep, rapid respirations d. Palpitations e. Shakiness

B. Diaphoresis D. Palpitations E. Shakiness---Diaphoresis, palpitations, and shakiness are sympathetic nervous system responses to hypoglycemia.

A nurse is monitoring the electrocardiogram of a client who has hypocalcemia. Which of the following findings should the nurse expect? a. Flattened T waves b. Prolonged QT intervals c. Shortened QT intervals d. Widened QRS complexes

B. Prolonged QT intervals--- Manifestations of hypocalcemia include tingling, numbness, tetany, seizures, prolonged QT intervals, and laryngospasm. Causes include hypoparathyroidism, chronic kidney disease, and diarrhea.

A nurse is admitting a client who is scheduled to undergo a cardiac catheterization. The client says, "My coworker died last week from a heart attack." Which of the following responses should the nurse offer? a. "Your provider will not let that happen because she knows how to treat your condition." b. "Do you think the same thing might happen to you?" c. "You appear to be feeling anxious." d. "Has anyone in your family had a heart attack?"

C. "You appear to be feeling anxious."---The nurse is sharing observations that will encourage the client to be more specific about these feelings.

A nurse is caring for a client who is having a possible myocardial infarction (MI). Which of the following findings should the nurse identify as an associated manifestation of an MI? a. Headache b. Hemoptysis c. Nausea d. Diarrhea

C. Nausea---Nausea is an associated manifestation of MI. Manifestations of MI include chest pain and pain in the jaw, shoulder, or abdomen.

A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the health care provider? a. The Mantoux test had an induration of 7 mm. b. The chest-x-ray showed infiltrates in the lower lobes. c. The patient is being treated with antiretrovirals for HIV infection. d. The patient has a cough that is productive of blood-tinged mucus.

C. The patient is being treated with antiretrovirals for HIV infection. Drug interactions can occur between the antiretrovirals used to treat HIV infection and the medications used to treat TB. The other data are expected in a patient with HIV and TB.

A nurse delegates the collection of a client's temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary temperature; however, the nurse wanted an oral temperature. The nurse should identify which of the following rights of delegation should have prevented this situation from occurring? a. Right task b. Right circumstance c. Right person d. Right communication

D. Right communication--- The situation could have been avoided if the right communication was given by the nurse to the AP. The right communication entails providing clear, concise instructions regarding the task, including the objective, limits, and expectations.

A nurse is preparing a client for cardiac catheterization. Which of the following pieces of information should the nurse give the client before the procedure? (Select all that apply.) a. "You'll have to lie flat for several hours after the procedure." b. "You'll receive medication to relax you before the procedure." c. "You'll feel a cool sensation after the injection of the dye." d. "You'll have to keep your leg straight after the procedure." e. "You'll have to limit the amount of fluid you drink for the first 24 hr."

A. "You'll have to lie flat for several hours after the procedure." B. "You'll receive medication to relax you before the procedure." D. "You'll have to keep your leg straight after the procedure." Depending on the provider's prescription, the client should remain flat or with the head of the bed elevated to no more than 30° for 2 to 6 hours after the procedure. The amount of time depends on the type of closure device the provider uses. The client will receive a mild sedative for relaxation and comfort prior to the procedure. A soft knee brace can help keep the client from bending the knee after the procedure. Incorrect Answers: C. The client will feel a sensation similar to a hot flash when the dye enters the heart. E. Adequate hydration, both IV and oral, is crucial for excreting the contrast medium and reducing the risk of renal toxicity from retaining the dye.

A nurse is caring for a client who is in skeletal traction following a femur fracture. On entering, the nurse finds that the client has slid toward the foot of the bed, and the traction weight is resting on the floor. Which of the following actions should the nurse take? a. Remove the weight temporarily to reposition the client to the correct alignment in bed b. Have the client use a trapeze to pull himself up while ensuring the weight hangs freely c. Lift the rope off the pulley while the client rocks back and forth to reposition himself d. Lift the weight manually while another staff member moves the client up in bed

B. Have the client use a trapeze to pull himself up while ensuring the weight hangs freely---The nurse should ensure that traction weight is hanging freely. The client can use an overhead trapeze bar to move up in bed, or the nurse can assist the client while making sure to maintain proper alignment of the extremity.

A client who reports shortness of breath requests the nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next? a. Encourage the client to take deep breaths b. Observe the rate, depth, and character of the client's respirations c. Prepare to administer oxygen d. Give the client a back rub to promote relaxation

B. Observe the rate, depth, and character of the client's respirations--- The nurse should apply the nursing process priority-setting framework when caring for this client in order to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge needed to make an appropriate decision; therefore, the nurse should first assess the client's respiratory status.

A nurse in a clinic is providing teaching for a client who is scheduled to have a tuberculin skin test. Which of the following pieces of information should the nurse include? a. "If the test is positive, it means you have an active case of tuberculosis." b. "If the test is positive, you should have another tuberculin skin test in 3 weeks." c. "You must return to the clinic to have the test read in 2 or 3 days." d. "A nurse will use a small lancet to scratch the skin of your forearm before applying the tuberculin substance."

C. "You must return to the clinic to have the test read in 2 or 3 days."---The client should have the skin test read in 2 to 3 days. An area of induration after 48 to 72 hours indicates exposure to the tubercle bacillus. If the client does not return to have the test read within 72 hours, another tuberculin skin test is necessary.

A nurse is caring for a client who is postoperative following a total knee arthroplasty and has been prescribed a continuous passive motion (CPM) machine and PCA. The client tells the nurse, "I am in so much pain." Which of the following actions should the nurse take first? a. Remind the client to push the button for the PCA device b. Discuss activities the client may use to distract from the pain c. Ask the client to describe the characteristics of the pain d. Pause the CPM machine briefly to apply a cold pack to the client's knee

C. Ask the client to describe the characteristics of the pain--- The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the first action the nurse should take is to acquire further data by asking the client to describe the characteristics of the pain.

A nurse is assessing a client who has a fractured left femur and is in skeletal traction. Which of the following findings should the nurse report to the provider? a. Ecchymosis of the thigh b. Serous drainage at the pin site c. Chest petechiae d. Muscle spasms in the left leg

C. Chest petechiae--- The nurse should identify chest petechiae as an indication of fat embolism syndrome. Clients who have fractures of the long bones such as the femur are at increased risk of fat emboli. Fat emboli typically occur 12 to 48 hours after the injury when fat droplets from the marrow enter into the systemic circulation and are deposited in the lungs. The nurse should immediately notify the provider because the client could progress to acute respiratory failure.

A nurse is teaching a client who has pernicious anemia. The nurse should encourage the client to increase consumption of which of the following foods? a. Eggs b. Squash c. Kale d. Tofu

A. Eggs---The nurse should encourage the client to increase consumption of foods rich in vitamin B12, such as dairy products, animal protein, poultry, shellfish, and eggs.

A nurse on a medical-surgical unit is caring for a client who is at risk of experiencing seizures. Which of the following pieces of equipment must be available at the client's bedside at all times? a. Suction equipment b. Clean gloves c. Blankets d. Oxygen

A. Suction equipment---The greatest risk to a client who is having a seizure is an injury from aspirating secretions or emesis; therefore, the nurse must have suction equipment available for clearing the mouth of secretions or emesis to reduce this risk.

A nurse is caring for a client who reports recurrent flank pain, nausea, & vomiting for 24 hr. Which of the following actions is the nurse's priority? a. Monitor I&O b. Strain the urine c. Administer pain med d. Administer an antiemetic

C) Administer pain med--- using Maslow's hierarchy of needs, the nurse's priority is to meet the client's physiological need for comfort. Therefore, the first action the nurse should take is to administer pain meds to relieve the client's flank pain.

A nurse is assessing a 6-month-old infant following a cardiac catheterization. Which of the following findings should the nurse report to the provider? a. Temperature 37.5°C (99.5°F) b. Apical pulse rate 140/min c. BP 86/40 mmHg d. Respiratory rate 32/min

C. BP 86/40 mmHg---A BP of 86/40 mmHg is indicative of hypotension and bleeding in a 6-month-old infant and should be immediately reported to the provider.

A nurse is caring for a client with pneumonia who is experiencing thick oral secretions. Which of the following actions should the nurse take first? a. Provide chest physiotherapy b. Perform oropharyngeal suction c. Encourage deep-breathing and coughing d. Assist the client with ambulation

C. Encourage deep-breathing and coughing---The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach is to encourage the client to breathe deeply and cough to clear secretions from the airway.

A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first? a. Provide oxygen b. Place the client in a side-lying position c. Provide privacy d. Lower the client to the floor

D. Lower the client to the floor---The nurse should apply the safety and risk reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, if a client begins to have a seizure while sitting or standing, the nurse should first lower the client to the floor to protect the client from injury.

A nurse is assessing a client who has urolithiasis and reports pain in his thigh. This finding indicates the stone is in which of the following structures? a. Ureter b. Bladder c. Renal pelvis d. Renal tubules

A. Ureter--- When stones are in the ureters, pain radiates to the genitalia and to the thighs

A nurse is assessing a client who has deep-vein thrombosis in her left calf. Which of the following manifestations should the nurse expect to find? (Select all that apply.) a. Hardening along the blood vessel b. Absence of a peripheral pulse c. Tenderness in the calf d. Cool skin on the leg e. Increased leg circumference

A. Hardening along the blood vessel C. Tenderness in the calf E. Increased leg circumference--- Deep-vein thrombosis can cause hardening along the affected blood vessel and prominence of superficial veins, pain or tenderness in the calf, and an increase in the circumference of the leg due to swelling.

A nurse is assessing a client who has fluid volume overload from a cardiovascular disorder. Which of the following manifestations should the nurse expect? (Select all that apply.) a. Jugular vein distension b. Moist crackles c. Postural hypotension d. Increased heart rate e. Fever

A. Jugular vein distension B. Moist crackles D. Increased heart rate----The increased venous pressure due to excessive circulating blood volume results in neck vein distension. Moist crackles are an indicator of pulmonary edema that can quickly lead to death. Fluid volume excess (hypervolemia) is an expansion of fluid volume in the extracellular fluid compartment, which results in an increased heart rate and bounding pulses.

A nurse is teaching a client who has coronary artery disease about the difference between angina pectoris and myocardial infarction (MI). Which of the following manifestations should the nurse identify as indications of MI? (Select all that apply.) a. Nausea and vomiting b. Diaphoresis and dizziness c. Chest and left arm pain that subsides with rest d. Anxiety and feelings of doom e. Bounding pulse and bradypnea

A. Nausea and vomiting B. Diaphoresis and dizziness D. Anxiety and feelings of doom--- Nausea, vomiting, epigastric distress, diaphoresis (sweating), dizziness, fatigue, anxiety, and feelings of doom and fear are common manifestations of MI.

After 2 months of tuberculosis (TB) treatment with isoniazid (INH), rifampin (Rifadin), pyrazinamide (PZA), and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next? a. Teach about treatment for drug-resistant TB treatment. b. Ask the patient whether medications have been taken as directed. c. Schedule the patient for directly observed therapy three times weekly. d. Discuss with the health care provider the need for the patient to use an injectable antibiotic.

B. The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Assessment is the first step in the nursing process. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. The other options are interventions based on assumptions until an assessment has been completed.

A nurse in a provider's office is reviewing the medical records of a group of clients. Which of the following clients is at risk for iron deficiency? (Select all that apply.) a. A client who is postmenopausal b. A client who is a vegetarian c. A middle adult male client d. A client who is pregnant e. A toddler who is overweight

B. A client who is a vegetarian D. A client who is pregnant E. A toddler who is overweight---A client who is a vegetarian might require additional iron because the availability of iron in vegetable food sources is limited. During pregnancy, maternal blood volume increases, and the fetus requires additional iron. Therefore, the RDA of iron for clients who are pregnant is increased to 27 mg per day. Toddlers who are overweight may get most of their calories from milk and foods that are not considered healthy, which increases their risk for iron-deficiency anemia.

A nurse is providing discharge teaching to a client who has venous thrombosis and a prescription for warfarin. Which of the following instructions should the nurse include in the teaching? a. Take ibuprofen as needed for headaches or other minor pains b. Carry a medical alert ID card c. Report to the laboratory weekly to have blood drawn for aPTT d. Increase intake of dark green vegetables

B. Carry a medical alert ID card---A client who is taking warfarin is at increased risk for bleeding. In the case of an emergency, any medical personnel must be aware of the client's medication history.

A nurse is caring for a client who has a fractured hip and was placed in Buck's traction 4 hr ago. Which of the following actions should the nurse take? a. Inspect the client's skin underneath the boot every 12 hr b. Encourage the client to perform dorsiflexion of the affected extremity every 2 hr c. Remove the weights from the traction while repositioning the client in bed d. Loosen the ropes if the client reports muscle spasms in the affected extremity

B. Encourage the client to perform dorsiflexion of the affected extremity every 2 hr ---The nurse should encourage the client to perform dorsiflexion of the affected extremity every 2 hours to assess if the client is experiencing nerve damage. Weakness of dorsiflexion can indicate peroneal nerve damage. If this occurs, the nurse should notify the provider immediately. Incorrect Answers: A. The nurse should inspect the client's skin underneath the boot for irritation, increased swelling, and skin breakdown every 8 hours. C. The weights should never be removed without a prescription from the provider. The purpose of the weights is to decrease muscle spasms as a result of the hip fracture. D. The ropes of the traction should never be loosened. This can affect the traction and increase the client's muscle spasms.

A nurse is preparing a client who is scheduled for an intravenous pyelogram (IVP). Which of the following findings should the nurse report to the provider? a. Allergy to egg products b. Vomiting and diarrhea for the last 6 hr c. Serum potassium of 3.6 mEq/L d. Serum creatinine of 1.2 mg/dL

B. Vomiting and diarrhea for the last 6 hr--- Vomiting and diarrhea for 6 hours deplete the client's fluid volume, which results in dehydration that can cause renal failure following a procedure that uses contrast dye. Therefore, the nurse should notify the provider.

A patient with TB has been admitted to the hospital and is placed on airborne precautions and in an isolation room. What should the nurse teach the patient? (select all that apply) a. Expect routine TB testing to evaluate the infection. b. No visitors will be allowed while in airborne isolation. c. Adherence to precautions includes coughing into a paper tissue. d. Take all medications for a full length of time to prevent multidrug-resistant TB. e. Wear a standard isolation mask if leaving the airborne infection isolation room.

C, D, E

A nurse is teaching a client who has a new prescription for warfarin. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. "I'll use a safety razor to shave each day." b. "I'll be sure to eat lots of spinach." c. "I'll avoid contact sports like football." d. "I'll take ibuprofen if I get a headache."

C. "I'll avoid contact sports like football." ---The most common adverse effect of taking anticoagulants is bleeding. Therefore, the client should avoid any activities that have a high risk of causing injury, such as contact sports.

A nurse is providing discharge teaching to a client who had a sickle cell crisis. Which of the following statements indicates that the client understands the instructions? a. "I should try to drink at least 2 liters of fluid per day." b. "I can still fly out to visit my sister in Colorado for a while." c. "Physical activity is good for me, but I need to avoid overexertion." d. "I can still go skiing during the cold winter months."

C. "Physical activity is good for me, but I need to avoid overexertion."---To help prevent a recurrence of sickle cell crisis, the client should avoid overexertion from especially strenuous activities.

A nurse is planning care for a client who is postoperative and scheduled to ambulate. At which of the following times should the nurse plan to administer PO morphine to the client for peak analgesic effect during the ambulation? a. 3 to 4 hr before ambulation b. 10 to 15 min prior to ambulation c. 60 to 90 min prior to ambulation d. Immediately before ambulation

C. 60 to 90 min prior to ambulation--The peak effect of PO morphine takes 60 to 90 minutes to occur. Medicating the client 60 to 90 minutes prior to ambulation will provide the greatest analgesic effect.

A nurse is assessing a client who has a positive tuberculin skin test. Which of the following findings indicates that the client has active tuberculosis? a. Rhinitis b. Air hunger c. Night sweats d. Weight gain

C. Night sweats--- Manifestations of active tuberculosis include a fever, coughing, night sweats, anorexia, and fatigue.

A nurse is assessing a client who has pernicious anemia. Which of the following findings should the nurse expect? a. Thick, white coating on the client's tongue b. Decreased pulse rate c. Paresthesias in the hands and feet d. Joint pain in the extremities

C. Paresthesias in the hands and feet--- The nurse should identify that paresthesias (tingling sensations) in the hands and feet is an expected finding of pernicious anemia. Other manifestations include weight loss and fatigue.

A nurse is caring for a client who has receptive aphasia. Which of the following communication problems should the nurse expect when assessing the client? a. The client cannot name simple objects or formulate sentences or phrases. b. The client has difficulty articulating correctly due to muscle weakness of the mouth and tongue. c. The client is unable to understand words or sentences she hears. d. The client speaks words that substitute for those she intends to say.

C. The client is unable to understand words or sentences she hears.---Clients who cannot understand words or sentences they hear have receptive aphasia.

Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB. Which information should the occupational health nurse plan to teach the staff nurse? a. Standard four-drug therapy for TB b. Need for annual repeat TB skin testing c. Use and side effects of isoniazid (INH) d. Bacille Calmette-Gurin (BCG) vaccine

C. Use and side effects of isoniazid (INH) The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for individuals who have already had a positive skin test. BCG vaccine is not used in the United States for TB and would not be helpful for this individual, who already has a TB infection.

A nurse in the emergency department is preparing to discharge a client following a Grade II (moderate) ankle sprain. Which of the following instructions should the nurse plan to give to the client? a. Perform passive range-of-motion exercises of the ankle hourly b. Keep the affected extremity in a dependent position c. Wrap a loose dressing around the affected ankle d. Apply cold compresses to the extremity intermittently

D. Apply cold compresses to the extremity intermittently--- Cold minimizes swelling and erythema to the affected area. Therefore, the nurse should instruct the client to apply cold compresses for no more than 20 minutes at a time.

A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which of the following actions should the nurse take? a. Have the client gently blow clots from the nose every 5 min b. Instruct the client to sit with his head hyperextended c. Apply ice compresses to the back of the client's neck d. Apply lateral pressure to the client's nose for 10 min

D. Apply lateral pressure to the client's nose for 10 min---- The nurse should apply direct, lateral pressure to the nose for 10 minutes to control epistaxis. If after 10 minutes the epistaxis continues, the client might require nasal packing or other interventions.

A nurse is caring for a client who is suspected to have tuberculosis. Which of the following findings should the nurse expect? a. Recent weight gain b. High fever c. Rhinitis d. Blood-streaked sputum

D. Blood-streaked sputum--- The nurse should expect blood-streaked sputum in a client who has tuberculosis. Sputum cultures are used to diagnose pulmonary tuberculosis.

A nurse in an acute care facility is planning care for a client who is alert but temporarily immobile due to a total hip arthroplasty. Which of the following interventions should the nurse plan to take to prevent a complication of immobility? a. Move the client from supine to a low Fowler's position every 2-3 hr to help prevent orthostatic hypotension b. Limit fluid intake to 1 L (33.8 oz) in 24 hr to help prevent dependent edema c. Encourage the client to turn from side to side every 3-4 hr to help prevent respiratory complications d. Instruct the client to perform foot and leg exercises every 1-2 hr while awake to help prevent thrombophlebitis

D. Instruct the client to perform foot and leg exercises every 1-2 hr while awake to help prevent thrombophlebitis---- Antiembolic exercises (e.g. flexion of the knees and rolls and pumps of the feet and ankles) every 1-2 hours help prevent thrombophlebitis, which is a complication of immobility.

A charge nurse is monitoring a newly licensed nurse who is caring for a postoperative client who is receiving morphine through a PCA pump. Which of the following actions by the newly licensed nurse requires intervention? a. Instructing the client to administer a PCA dose prior to a dressing change b. Providing increased fluids while the client is using the PCA pump c. Informing the client's partner that only the client should administer the PCA doses d. Maintaining the client on bed rest while the PCA pump is in use

D. Maintaining the client on bed rest while the PCA pump is in use--- Use of a PCA pump does not prevent ambulation following surgery. Early ambulation should be encouraged. The nurse should instruct the client to sit at the side of the bed prior to standing to reduce the risks of orthostatic hypotension and falls.

The nurse determines that instruction regarding prevention of future urinary tract infections (UTIs) has been effective for a 22-year-old female patient with cystitis when the patient states which of the following? a. I can use vaginal antiseptic sprays to reduce bacteria. b. I will drink a quart of water or other fluids every day. c. I will wash with soap and water before sexual intercourse. d. I will empty my bladder every 3 to 4 hours during the day.

D. Voiding every 3 to 4 hours is recommended to prevent UTIs. Use of vaginal sprays is discouraged. The bladder should be emptied before and after intercourse, but cleaning with soap and water is not necessary. A quart of fluids is insufficient to provide adequate urine output to decrease risk for UTI.

A patient is scheduled for a cardiac catheterization with coronary angiography. Before the test, the nurse informs the patient that: a. it will be important to lie completely still during the procedure. b. a flushed feeling may be noted when the contrast dye is injected. c. monitored anesthesia care will be provided during the procedure. d. arterial pressure monitoring will be required for 24 hours after the test.

b. a flushed feeling may be noted when the contrast dye is injected.

A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected findings? a. Hypertension b. Flushing of skin c. Oliguria d. Bradypnea

c. Oliguria

A nurse is preparing to care for a client who is in balanced skeletal traction to stabilize a femur fracture. Which of the following actions should the nurse include in the client's plan of care? a. Offering the client a diet high in fluid and fiber b. Encouraging active range of motion of the affected leg c. Removing the weights prior to repositioning the client d. Inspecting pin sites every 24 hr for drainage

A. Offering the client a diet high in fluid and fiber---- A client who is immobile is at risk of constipation. The nurse should encourage a diet high in fluid and fiber to promote gastrointestinal function. Incorrect Answers: B. Active range of motion of the unaffected limbs is encouraged to prevent muscle wasting; however, active range of motion of a limb in traction is not feasible, as the traction apparatus limits mobility. C. Once the weights are in place, the nurse should not remove them. D. The nurse should plan to inspect the client's pin sites at least every 8 to 12 hours due to the risk of infection.

A nurse is teaching a client with Barrett's esophagus who is scheduled to undergo an esophagogastroduodenoscopy (EGD). Which of the following statements should the nurse include in the teaching? a. "This procedure is performed to measure the presence of acid in your esophagus." b. "This procedure can determine how well the lower part of your esophagus works." c. "This procedure is performed while you are under general anesthesia." d. "This procedure can determine if you have colon cancer."

B. "This procedure can determine how well the lower part of your esophagus works."---An EGD is useful in determining the function of the esophageal lining and the extent of inflammation, potential scarring, and strictures.

A nurse is preparing to administer packed RBCs to a client who is anemic. Which of the following actions should the nurse take? (Select all that apply.) A. Insert a 23-gauge angiocatheter with an IV adaptor B. Check to determine the packed RBCs are less than 1 week old C. Administer the packed RBCs over a 6-hr period D. Ask another nurse to check the packed RBCs' label against the medical record E. Prime the transfusion tubing with 0.9% sodium chloride

B. Check to determine the packed RBCs are less than 1 week old D. Ask another nurse to check the packed RBCs' label against the medical record E. Prime the transfusion tubing with 0.9% sodium chloride The nurse should check to determine that the packed RBCs are less than 1 week old; if the blood is older, the RBCs become fragile, break easily, and release potassium into the blood steam. In addition, the nurse should ask another nurse to check the packed RBCs label against the medical record for safety verification. The nurse should ensure that the client's complete name and identification number match and that the blood group name and number are correct. If there is any type of discrepancy, the nurse should not infuse the blood and should notify the blood bank. Finally, the nurse should prime the transfusion tubing with 0.9% sodium chloride. Other solutions such as Ringer's lactate and dextrose in water can cause clotting or hemolysis of the packed RBCs.

A nurse is providing preoperative teaching for a client with colorectal cancer who is scheduled to undergo colostomy placement with a perineal wound. Which of the following statements by the client indicates an understanding of the teaching? a. "Not having any more rectal pain will be a relief." b. "I will need to sit on a rubber donut when I am in the chair." c. "I can have only liquids for 2 days before the surgery." d. "The colostomy will start working about 7 days after the surgery."

C. "I can have only liquids for 2 days before the surgery."---The client should consume a full or clear liquid diet for 24 to 48 hours before the surgery to decrease bulk. The client should consume a low-residue diet for several days prior to surgery to decrease peristalsis.

Which assessment of a 62-year-old patient who has just had an intravenous pyelogram (IVP) requires immediate action by the nurse? a. The heart rate is 58 beats/minute. b. The patient complains of a dry mouth. c. The respiratory rate is 38 breaths/minute. d. The urine output is 400 mL after 2 hours.

C. The increased respiratory rate indicates that the patient may be experiencing an allergic reaction to the contrast medium used during the procedure. The nurse should immediately assess the patients oxygen saturation and breath sounds. The other data are not unusual findings following an IVP.

A nurse is caring for a client who takes warfarin 2.5 mg PO daily and has an INR of 6.2. The nurse should anticipate a prescription from the provider for which of the following medications? a. Protamine sulfate b. Fondaparinux c. Vitamin K d. Bivalirudin

C. Vitamin K---The nurse should anticipate the provider to prescribe vitamin K for a client who has an INR of 6.2. Vitamin K antagonizes warfarin's actions, which can reverse warfarin-induced inhibition of clotting factor synthesis.

A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD) and is experiencing shortness of breath. Which of the following actions should the nurse perform first? A. Monitor the client's arterial blood gas results B. Instruct the client to perform controlled coughing C. Teach the client how to use pursed-lip breathing D. Place the client in an upright position

D. Place the client in an upright position---Using the airway, breathing, and circulation (ABC) approach to client care, the nurse should place the client in an upright position to facilitate chest expansion and proper diaphragmatic contraction. Positioning the client upright will also assist with mobilizing secretions that might be impeding airflow.

The nurse is caring for a patient who is 2 days post MI. The patient reports that she is experiencing chest pain when she takes a deep breath. Which action would be a priority? a. Notify the provider STAT and obtain a 12-lead ECG. b. Obtain vital signs and auscultate for a pericardial friction rub. c. Apply high-flow O2 by face mask and auscultate breath sounds. d. Medicate the patient with as-needed analgesic and reevaluate in 30 minutes.

b. Obtain vital signs and auscultate for a pericardial friction rub.

A nurse is demonstrating colostomy care to a client who has a new colostomy. Which of the following actions should the nurse teach the client to perform? (Select all that apply.) a. Use antimicrobial ointment on the peristomal skin b. Empty the bag when it is one-third to one-half full c. Cut the skin barrier opening a little larger than the ostomy d. Wash the peristomal skin with mild soap and water e. Apply the skin barrier while the skin is slightly moist

B. Empty the bag when it is one-third to one-half full C. Cut the skin barrier opening a little larger than the ostomy D. Wash the peristomal skin with mild soap and water Allowing the bag to become too full can cause leakage.

A nurse is reviewing the laboratory values of a client who is receiving a continuous IV heparin infusion and has an aPTT of 90 sec. Which of the following actions should the nurse prepare to take? a. Administer vitamin K b. Reduce the infusion rate c. Give the client a low-dose aspirin d. Request an INR

B. Reduce the infusion rate---- An aPTT of 90 seconds is outside the expected reference range of 60 to 80 seconds, which can cause anticoagulation. The nurse should contact the provider, reduce the infusion rate, and assess the client for bleeding.

A nurse is assessing a client who has an exacerbation of herpes zoster. Which of the following manifestations of the client's skin should the nurse expect? a. Confluent, honey-colored, crusted lesions b. A large, tender nodule located on a hair follicle c. Unilateral, localized, nodular skin lesions d. A fluid-filled vesicular rash in the genital region

C. Unilateral, localized, nodular skin lesions--- Herpes zoster, or shingles, results from the reactivation of a dormant varicella virus. It is the acute, unilateral inflammation of the dorsal root ganglion. The infection typically develops in adults and produces localized vesicular lesions confined to a dermatome. It produces localized, nodular skin lesions.

A nurse is providing discharge teaching to a client who has aplastic anemia. Which of the following statements indicates that the client understands the instructions? a. "I need to stay active to prevent blood clots in my legs." b. "If I have a bad headache, I can take aspirin to get rid of it." c. "I should eliminate uncooked foods from my diet for now." d. "I should eat more iron-fortified cereal to strengthen my blood."

C. "I should eliminate uncooked foods from my diet for now."---The client can help prevent infection by eating thoroughly cooked foods. Fresh fruit, vegetables, eggs, meat, and fish can harbor microorganisms that cooking destroys, so the client should avoid raw foods.

A nurse is reviewing laboratory values for an adult client who has sickle cell anemia and a history of receiving blood transfusions. For which of the following complications should the nurse monitor? a. Hypokalemia b. Lead poisoning c. Hypercalcemia d. Iron toxicity

D. Iron toxicity--- A client who has received several blood transfusions is at risk of hemosiderosis, which is the excess storage of iron in the body. Excessive iron can come from overuse of supplements or from receiving frequent blood transfusions as in sickle cell anemia.