Focus on Adult Health Exam

A nurse is caring for a client who has just had a plaster leg cast applied. Which measure does the nurse implement to prevent the development of compartment syndrome?

Elevating the limb and applying ice to the affected leg Rationale: Controlling edema helps prevent compartment syndrome. This is best achieved with the use of elevation and the application of ice. The other options are incorrect.

A client hospitalized with an abdominal aortic aneurysm (AAA) suddenly complains of severe back and flank pain. The nurse notes on the cardiac monitor that the client's heart rate has increased from 80 to 110 beats/min. The nurse should:

Immediately contact the health care provider Rationale: The signs and symptoms in the question are indicative of rupture of the AAA. Typical signs and symptoms of rupture include back and flank pain, ecchymosis of the flank and perianal areas, a pulsating abdominal mass, lightheadedness, nausea, and signs of shock. This is an emergency situation, and the client requires simultaneous resuscitation and preparation for immediate surgical repair. The other options are incorrect and would delay necessary treatment.

A client sustains a fractured femur and pelvic fractures in a motor vehicle crash. For which signs and symptoms, indicative of hypovolemic shock, does the nurse monitor the client closely? Select all that apply.

Oliguria Tachycardia Hypotension Rationale: Clients who sustain fractures of the femur, pelvis, thorax, and spine are at risk for hypovolemic shock. Bone fragments can damage blood vessels, leading to hemorrhage into the abdominal cavity and the thigh. This can occur with closed as well as open fractures. Signs of hypovolemic shock include tachycardia, hypotension, and diminished urine output. Fever and bradypnea are not associated with hypovolemic shock.

A client with severe heart failure suddenly becomes tachycardic, shows signs of air hunger, and is extremely anxious. The nurse listens to the client's breath sounds and suspects pulmonary edema. The nurse should first:

Place the client in a high Fowler position Rationale: Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles in the bases. The nurse would immediately place the client in a high Fowler's position to ease the client's breathing. The nurse would not leave the client or ask the nursing assistant to stay with the client. Although furosemide would be prescribed, the first action, of the options presented, would be to reposition the client.

A nurse is caring for a client who has been fitted with a continuous bladder irrigation system. During the nurse's 8-hour shift, total infusion of bladder irrigant is 1075 mL. At the end of the 8-hour shift, the nurse calculates that 2050 mL of output was emptied from the Foley catheter drainage bag. How many milliliters of true urine output does the nurse document?

975 Rationale: If the total volume emptied from the Foley catheter was 2050 mL and 1075 mL was bladder irrigant, the amount of true urine was 975 mL. To obtain this answer, you must subtract 1075 mL of bladder irrigant from the total emptied (2050 mL).

A nurse is interpreting a central venous pressure (CVP) reading from a client in whom right ventricular failure has been diagnosed. From this diagnosis, the nurse would expect that the most likely result is a pressure of

14 cm H2O Rationale: CVP measurements are used to monitor blood volume and the adequacy of venous return to the heart. The CVP measures pressures from the right atrium or central veins. The normal CVP is 7 to 12 cm H2O. An increased CVP reading may indicate right ventricular failure. A low CVP reading may indicate hypovolemia. A reading of 4 cm H2O is low. Readings of 8 and 11 cm H2O are normal. A reading of 14 cm H2O is increased.

A nurse caring for a client with a diagnosis of peptic ulcer is monitoring the client for signs of perforation. Which findings would cause the nurse to suspect perforation? Select all that apply.

Abdominal rigidity Sudden sharp pain in the midepigastrium Rationale: Perforation, a surgical emergency, is characterized by sudden sharp intolerable pain, beginning in the midepigastric area and spreading over the abdomen, which then becomes rigid and board-like. Tachycardia, not bradycardia, may occur as hypovolemic shock develops. Nausea and vomiting may occur, but vomiting will not necessarily be projectile in nature and the vomitus will not necessarily contain bile. Diarrhea is not an associated finding.

A client who sustained an extensive full-thickness burn injury is being admitted to the nursing unit. Which prescription by the health care provider would the nurse question?

Administer morphine sulfate 6 mg intramuscularly every 3 hours as needed Rationale: The intravenous route is the preferred route of administration of opioids to a burned client because of the potential for problems with absorption from the muscle and stomach. When fluid balance is stabilized, oral opioid agents may be used. The other options are all appropriate interventions for the client with an extensive burn injury.

Radiation therapy is prescribed for a client with a brain tumor. Which side effects would the nurse expect the client to experience? Select all that apply.

Alopecia Dizziness Rationale: Because radiation is a local treatment, most side effects are site specific, depending on the organs and tissues that are within or close to the treatment field. The client undergoing irradiation of the brain will most likely experience such early side effects as earache, headache, dizziness, hair loss, and erythema. Cough, dysphagia, and hoarseness occur with radiation to the lung, mediastinum, or esophagus.

A nurse planning care for a client who has undergone transurethral resection of the prostate (TURP) remembers that the most common cause of postoperative pain is:

Bladder spasms Rationale: Bladder spasms may occur after TURP because of postoperative bladder distention or irritation by the balloon of the indwelling urinary catheter. The nurse administers antispasmodic medications as prescribed to treat this type of pain. Because the prostate is accessed through the urethra, there is no incision in a TURP. Bleeding within the bladder and tension on the Foley catheter are not common causes of pain. Some surgeons purposely prescribe the application of tension to the catheter for a few hours after surgery to help control bleeding.

A nurse is admitting a client with a diagnosis of chronic kidney disease(CKD) to the hospital. Which early sign of CKD does the nurse expect to note during assessment?

Blood pressure of 168/94 mm Hg Rationale: Hypertension and changes in urine characteristics are often the first signs of CKD. Fatigue, lethargy, and pruritus are also early symptoms. It is important to assess the blood pressure because hypertension in the client with CKD can lead to heart failure as a result of increased cardiac workload in conjunction with fluid overload. Restlessness, a temperature of 99.8° F (37.7° C), and a pulse of 110 beats/min are not findings specifically associated with CKD.

A nurse instructs a client with diabetes mellitus and hypertension in illness management and lists carbohydrate-containing beverages that the client may consume when he cannot tolerate food orally. The nurse determines that the client needs additional instruction if he states that he should consume:

Canned orange juice Rationale: A diabetic client who is unable to tolerate food because of illness should take in approximately 15 g of carbohydrate every 1 to 2 hours. Ginger ale, apple juice, and regular cola each provide 13 to 15 g of carbohydrate in a half-cup serving. Items that are canned are generally high in sodium and should not be used by the client with hypertension.

The wife of a client with type 1 diabetes mellitus calls the nurse in the health care provider's office about her husband. She states that her husband is sleepy, that his skin is warm and flushed, and that his breathing is faster than normal. The nurse instructs the wife to:

Check his blood glucose level Rationale: The client's signs and symptoms are consistent with hyperglycemia. The wife should first obtain a blood glucose reading, which the nurse would then report to the health care provider. Calling an ambulance or bringing him to the health care provideroffice may be done AT A later time if required. The client's temperature and pulse rate are not germane to the client's immediate problem.

Levothyroxine sodium is prescribed for a client with hypothyroidism, and the nurse provides information to the client about the medication. Which occurrences does the nurse tell the client to report to the health care provider? Select all that apply.

Chest pain Palpitations Rapid heart rate Rationale: The client taking levothyroxine sodium may have manifestations of hypothyroidism if the dosage is inadequate or may experience manifestations of hyperthyroidism if the dosage is too high. Thyroid preparations increase metabolic rate, oxygen demands, and demands on the heart, which may result in angina and cardiac dysrhythmias. The client should be instructed to report chest pain, palpitations, or a rapid heart rate immediately. Lethargy, constipation, and weight gain are symptoms of hypothyroidism, which should improve with medication therapy (e.g., levothyroxine sodium).

A client is undergoing anticonvulsant therapy with phenytoin. Which laboratory parameter does the nurse monitor most closely in this client?

Complete blood count (CBC) Rationale: Phenytoin is an anticonvulsant. The nurse closely monitors the CBC of a client taking the drug because hematological side effects of this therapy include blood dyscrasias such as agranulocytosis, leukopenia, and thrombocytopenia. Liver function tests, a CBC, and a platelet count should be performed before therapy is begun and periodically during therapy. The potassium level, creatinine, and BUN are not affected by the use of phenytoin.

A nurse is assessing a client admitted to the emergency department with a diagnosis of diabetic ketoacidosis (DKA). The nurse observes the client for respirations that are:

Deep and rapid Rationale: The client in diabetic ketoacidosis exhibits Kussmaul's respirations, which are rapid and deep. They occur as the body tries to eliminate carbon dioxide to compensate for the acidosis. As ketoacidosis improves, this pattern of respiration resolves. The nurse monitors the client's respiratory status as part of the assessment of the client's overall status.

A nurse educator conducts an informational session for emergency department nurses about smallpox. Which statements by the nurse educator are correct? Select all that apply.

Early clinical manifestations include influenza-like symptoms. Vaccinating within 3 days of exposure lowers the risk of active disease. Th infected person is infectious from the onset of the rash until the scabs separate. Rationale: Clinical manifestations of smallpox include sudden onset of influenza-like symptoms, including fever, malaise, headache, prostration, severe back pain, and, less often, abdominal pain and vomiting. Two to 3 days later, the temperature falls and the client feels somewhat better, at which time the characteristic rash appears, first on the face, hands, and forearms and then, after a few days, on the trunk. Lesions also develop in the mucous membranes of the nose and mouth and ulcerate very soon after their formation, releasing large amounts of virus into the mouth and throat. Smallpox is transmitted from person to person in infected aerosols and air droplets, especially if the symptoms include coughing. A person is considered infectious at the onset of the rash and until the rash scabs over, which is approximately 3 weeks. Airborne precautions are required even if the nurse has been vaccinated against smallpox, because the vaccine does not give reliable lifelong immunity. Those vaccinated within 2 or 3 days of exposure have a lesser risk of active disease.

A nurse is developing a plan of care for an older client with diabetic neuropathy of the lower extremities resulting from type 2 diabetes mellitus. Which problem does the nurse recognize as the highest priority for this client?

Increased risk for injury Rationale: The client with diabetic neuropathy of the lower extremities has a diminished sensation in the legs and feet. This client is at risk for tissue injury and for falls as a result of this nervous system impairment. Therefore the highest priority nursing problem is increased risk for injury. Increased risk of depression and change in body image are more psychosocial in nature and, as such, are secondary needs. A lower level of physical activity may be a problem but is not the priority.

A nurse is caring for a 25-year-old married client who will undergo bilateral orchidectomy for testicular cancer. On which psychosocial concern directly related to the surgery does the nurse place priority in formulating the postoperative plan of care for the client?

Ineffective role performance Rationale: In a client who is to undergo bilateral orchidectomy, the nurse would assign priority to loss of reproductive ability as a psychological concern. The radical effects of this surgery in this area make it likely that the client will have some difficulty adjusting to this consequence of the surgery. The other options are not related directly to the surgery but might be cause for concern if the client experiences difficulty adjusting to the effects of the surgery.

A client who is undergoing hemodialysis is receiving epoetin alfa. With which nutrients does the nurse instruct the client to supplement his diet to enhance the effects of therapy? Select all that apply.

Iron Folic acid Rationale: To form healthy red blood cells, which is the purpose of epoetin alfa, the body needs adequate iron, folic acid, and vitamin B12. Although the client would be encouraged to implement intake of all of the nutrients identified in the options, iron and folic acid are specifically needed to enhance the hematocrit and increase the benefit of epoetin alfa.

A client with cancer is admitted to the hospital for a chemotherapy treatment with intravenous bleomycin sulfate. Which nursing assessment would be given the highest priority while the chemotherapy is being administered?

Lung sounds Rationale: Bleomycin sulfate, an antineoplastic medication, can cause interstitial pneumonitis that may progress to pulmonary fibrosis. Pulmonary function studies, along with hematologic, hepatic, and renal function parameters, need to be monitored. The nurse must monitor lung sounds for dyspnea and crackles indicating pulmonary toxicity. The medication should be discontinued immediately if pulmonary toxicity occurs. Although the parameters in the other options may need to be monitored, they are not the priority with this medication.

A nurse is assessing a dyspneic client who has been found to have Guillain-Barré syndrome. Which arterial blood gas findings would cause the nurse to conclude that the client is experiencing hypoxemic respiratory failure?

PaO2 of 50 mm Hg (6.625 kPa), PaCO2 of 40 mm Hg (5.31 kPa) Rationale: The normal PaO2 is 80 to 100 mm Hg (10.6-13.33 kPa) and the normal PaCO2 is 35 to 45 mm Hg (4.66-5.98 kPa). Hypoxemic respiratory failure is characterized by a low PaO2 (less than 55 mmHg; 7.28kPa ) and a normal or low Paco2. The only option that correlates with the characteristics of this type of respiratory failure is the Pao2 of 50 mm Hg (6.625 kPa), and PaCO2 of 40 mm Hg (5.31 kPa).

A nurse is caring for a client who underwent mastectomy 1 day ago. To help restore arm function on the affected side, the nurse encourages the client to use that arm to:

Perform finger and elbow flexion and extension exercises Rationale: Immediately after mastectomy the client is encouraged to move the fingers and hands and to flex and extend the elbow. The client may also use the arm for self-care, provided that the client does not raise the arm above shoulder level or abduct the shoulder until the postoperative drains have been removed. The health care provider will prescribe the time frame for additional exercises for the arm on the affected side.

A tuberculin skin test (TST) is administered to a client with a diagnosis of HIV infection. Forty-eight hours after administration, the nurse checks the test site (see image).

Positive Rationale: The tuberculin, or TST, test is a reliable determinant of tuberculosis (TB) infection. A reaction measuring 5 mm or more in diameter is considered positive in a client with HIV infection. A reaction measuring 10 mm or more in diameter is considered positive in a non-immunosuppressed client. In this instance, the area of induration measures 9 mm, indicating a positive reaction. A positive reaction does not mean that active disease is present, but it does indicate exposure to TB or the presence of inactive (dormant) disease.

A nurse is providing dietary instructions to the spouse of a client with newly diagnosed AIDS who is being discharged from the hospital. The nurse instructs the spouse to:

Serve foods at room temperature Rationale: The AIDS client may experience problems with nutrition as a result of the side effects of medications, anorexia, nausea and vomiting, altered taste, impaired swallowing and chewing, diarrhea, fatigue, depression, or impaired cognition. Foods are best tolerated either cold or at room temperature. Spicy foods may be irritating and can aggravate nausea. Peanut butter, a sticky food, should be avoided in the client having difficulty swallowing. Milk and milk products can exacerbate diarrhea.

The nurse is teaching a client with newly diagnosed diabetes mellitus who has been prescribed NPH insulin how to recognize the signs of hypoglycemia. The client states that he must look for certain signs and symptoms in the late afternoon, indicating to the nurse that he has understood the instructions. What are these signs and symptoms? Select all that apply.

Shakiness Blurred vision Feelings of hunger Rationale: The client taking NPH insulin experiences peak medication effects 6 to 12 hours after administration. When the medication's action peaks, the client is at risk of hypoglycemia if food intake is insufficient. The nurse teaches the client to be alert for signs and symptoms of hypoglycemia, including anxiety, confusion, difficulty concentrating, blurred vision, cold sweats, headache, increased pulse, shakiness, and hunger. The other options are signs and symptoms of hyperglycemia

A nurse educator conducts an informational session for hospital nurses about skin anthrax. Which statements by the nurse educator are correct? Select all that apply.

Skin anthrax can lead to septicemia if it goes untreated. Symptoms may appear as soon as 24 hours after exposure. Contact precautions are not always necessary with skin anthrax Rationale: Skin anthrax is transmitted through direct contact when spores from contaminated products enter the skin through cuts or abrasions. Person-to-person spread does not occur; therefore, contact precautions may not always be necessary. Symptoms may appear as early as 24 hours or as long as up to 7 days after exposure. Antibiotic treatment cures the skin infection, but, left untreated, skin anthrax results in overwhelming septicemia and death. Inhalation anthrax, transmitted through the inhalation of spores, begins with mild, nonspecific upper respiratory and flulike symptoms, including fever, muscle aches, and fatigue.

A client has been taking pyrazinamide (PMS Pyrazinamide) for 2 months. Which culture result does the nurse monitor as an indicator that the medication may soon be discontinued?

Sputum Rationale: Pyrazinamide is an antitubercular medication that is given in conjunction with other antitubercular medications. The prescriber may discontinue its use if sputum cultures become negative. Urine, blood, and wound cultures are not associated with the use of this medication.

A client with myocardial infarction is being monitored closely for signs of cardiogenic shock. For which signs of this type of shock is the nurse alert? Select all that apply.

Tachycardia Restlessness Hypotension Increased central venous pressure (CVP) Rationale: Manifestations of cardiogenic shock include tachycardia; hypotension; urine output of less than 30 mL/hr; cold, clammy skin; poor peripheral pulses; agitation; restlessness or confusion; pulmonary congestion; tachypnea; chest pain; and increased CVP.

A nurse is administering a dose of oral pyridostigmine bromide to a client with myasthenia gravis. What does the nurse ask the client to do before administering the medication?

Take sips of water Rationale: Myasthenia gravis can affect the ability to swallow, so the nurse must determine the client's ability to swallow before administering oral medication. In this situation, there is no reason for the client to lie on her right side or to look to the ceiling to swallow medication. Likewise, there is no specific reason for the client to void before taking this medication.

A nurse is evaluating goal achievement for a client in skeletal traction. Which finding would indicate to the nurse that the goals require revision?

The client has a bowel movement every 5 days. Rationale: Expected outcomes for the client in skeletal traction include clear lung sounds, intact skin, a bowel movement every other to every third day, and the absence of thrombophlebitis, a disorder marked by calf or groin tenderness, unilateral swelling of the affected extremity, and pain. The client should also be performing active range of motion of uninvolved joints.

A nurse prepares to treat frostbite of the toes of a homeless man who was brought to the emergency department by the police. Which action by the nurse is appropriate?

Continuously rewarming the toes in a warm-water bath for 15 to 20 minutes Rationale: Acute frostbite is ideally treated with rapid and continuous rewarming of the tissue in a warm-water bath (90˚ to 107˚ F [32.2 to 41.7˚C]) for 15 to 20 minutes or until flushing of the skin occurs. Slow thawing and interrupted periods of warmth are avoided because they contribute to increased cellular damage. Dry heat should never be applied, nor should the frostbitten areas be rubbed or massaged as part of the warming process; these actions may produce further tissue injury.

A client with chronic arterial occlusive disease has a history of intermittent claudication. Which question does the nurse ask to assess the degree to which the client is affected by this condition?

"Is your leg pain sharp, and does it occur with exercise?" Rationale: Intermittent claudication, characterized by the sudden onset of leg pain with exercise that is relieved by rest, is a classic symptom of peripheral arterial insufficiency. Venous insufficiency is characterized by an achy type of leg pain that intensifies as the day progresses. Chest pain may occur for a variety of reasons, including angina pectoris and heartburn.

A client arrives in the emergency department after sustaining a chemical splash to the eye. The nurse immediately flushes the eye with copious amounts of normal saline solution for 15 minutes and then tests the pH of eye, using litmus paper. The nurse should continue the saline flushes until the pH test reads:

7.40 Rationale: First aid after a chemical burn to the eye consists of irrigation of the eye with copious amounts of tap water for at least 5 minutes. As soon as the initial irrigation is complete, the victim should be rushed to the nearest medical facility. On arrival, eye irrigation should be resumed with water or normal saline for 15 to 20 minutes or until all invasive material is gone and litmus paper reveals a pH of about 7.40. A quick test with litmus can be performed before, during, and after irrigations to determine the pH and to ascertain whether the substance was acid or alkaline. The normal body pH is 7.40.

A client is experiencing frequent premature ventricular contractions (PVCs). To which assessment would the nurse give priority?

Peripheral perfusion Rationale: Peripheral pulses may be diminished or absent with PVCs because the decreased stroke volume of the premature beats may decrease peripheral perfusion. It is essential for the nurse to determine whether the premature complexes are resulting in perfusion. This is done by palpating the carotid, brachial, or femoral arteries while observing the monitor for widened complexes or by auscultating for the apical heart sounds. PVCs may be caused by cardiac disorders or any number of physiological stressors, including infection, illness, surgery, and trauma, as well as the intake of caffeine, nicotine, or alcohol. Although laboratory results, the cause of the PVCs, and the client's temperature may all be components of the assessment, they are not priorities.

A client with acute kidney injury (AKI) has a prescription for oral sodium polystyrene sulfonate. Which serum electrolyte value does the nurse recognize as the cause for this prescription?

Potassium 5.9 mEq/L (5.9 mmol/L) Rationale: The normal potassium range is 3.5 to 5.0 mEq/L (3.5-5.0 mmol/L), so this client is experiencing hyperkalemia. Of all of the electrolyte imbalances that accompany AKI, hyperkalemia is the most serious, because it can lead to cardiac dysrhythmias and death. If the potassium level rises too high, sodium polystyrene sulfonate may be given to produce excretion of potassium through the gastrointestinal tract. Each of the other values presented in the other options falls within the normal reference range.

A client who sustained a major burn injury is beginning to take an oral diet again. Which between-meal menu selections meet the client's needs for wound healing and tissue repair? Select all that apply.

Whole-milk shake and granola Baked potato topped with cheese Cheese and whole-wheat crackers Rationale: To facilitate healing and meet continued high metabolic needs, the client with a major burn should eat a diet high in calories, protein, and carbohydrates. This type of diet also keeps the client in positive nitrogen balance. Foods such as milkshakes, granola, cheese, and whole-wheat products are acceptable choices. Though fresh fruits and vegetables and skim milk are high in nutrients, higher-calorie foods, including versions of dairy products prepared with whole milk, are preferable in this situation.

A client with deep vein thrombus (DVT) is undergoing anticoagulant therapy with warfarin sodium (Coumadin). The client's prothrombin time is 18 seconds, with a control of 11 seconds, and the International Normalized Ratio (INR) is 2.0. The nurse recognizes these results as:

Within the therapeutic range Rationale: The therapeutic range for prothrombin time (PT) is 1.5 to 2 times the control for clients at high risk for thrombus. This client's control value means that the therapeutic range for would be 16.5 to 22 seconds. Therefore the result is within the therapeutic range. The client receiving warfarin sodium for DVT should have an INR between 2.0 and 3.0.

A client is scheduled to have blood obtained for a serum digoxin determination. The nurse should arrange to have the blood sample drawn:

8 hours after the dose is given Rationale: Blood for measurement of the serum digoxin level is most often drawn immediately before the next dose, although it may also be drawn 6 to 8 hours after a dose. Recall that the purpose of the laboratory test is to measure the serum concentration of the medication to ensure that it is in the therapeutic range. Drawing the blood 8 hours after the last dose was given ensures that the level is not falsely increased. The optimal therapeutic range for digoxin is is 0.5 to 0.8 ng/mL(0.64 to 1.02 nmol/L).

A nurse is caring for a client who is experiencing spinal shock after sustaining a spinal cord injury. The nurse monitors the client for gastrointestinal complications, watching for:

A distended abdomen with an absence of bowel sounds Rationale: After spinal cord injury, paralytic ileus —characterized by the absence of bowel sounds and abdominal distention — may develop. Stress ulcers, revealed by the detection of occult blood in stool or nasogastric tube aspirate, are also possible. Diarrhea and flatulence are not gastrointestinal complications associated with spinal cord injuries.

A client is found to have hypoparathyroidism. Which nutritional supplement does the nurse, teaching the client about measures to manage the disorder, tell the client to take on a daily basis?

Calcium carbonate with vitamin D Rationale: Hypoparathyroidism is an endocrine disorder in which parathyroid function is decreased. The client with hypoparathyroidism is likely to have low calcium and high phosphate levels and should consume a diet high in calcium but low in phosphorus. Additionally, the generally used treatment is calcium supplementation (either as calcium carbonate or calcium citrate) coupled with vitamin D supplementation. Vitamin C supplementation is not a treatment measure for this disorder. Beta-carotene is incorrect, because a client with hypoparathyroidism typically has an increased phosphorus level

A nurse is monitoring a client who sustained a blunt chest injury when she hit the steering wheel in a motor vehicle crash. Which findings would cause the nurse to suspect flail chest? Select all that apply.

Cyanosis Chest pain Increasing dyspnea Asymmetric chest movements Rationale: The clinical manifestations of flail chest include severe chest pain; asymmetric (paradoxical) chest movements; oscillation of the mediastinum; increasing dyspnea; rapid, shallow respirations; accessory muscle breathing; restlessness; decreased breath sounds on auscultation; cyanosis; and anxiety related to difficulty breathing.

A nurse is reviewing laboratory results for a client who has been taking digoxin for the treatment of heart failure. The nurse notes that the report indicates a serum digoxin level of 0.8 ng/mL (1.02 nmol/L). The nurse would most appropriately:

Document the laboratory result Rationale: The optimal therapeutic serum digoxin range is 0.5 to 0.8 ng/mL (0.64 to 1.02 nmol/L).. A level of 0.8 ng/mL (1.02 nmol/L) is within the therapeutic range. Therefore the nurse would document the laboratory result. Contacting the health care provider, repeating the test, and monitoring the client for signs of toxicity are not necessary at this time, because the result is normal.

a nurse is reviewing laboratory results for a client who has been taking digoxin for the treatment of heart failure. the nurse notes that the report indicates a serum digoxin level of 1.5 ng/mL. the nurse would most appropriately take which action?

Document the laboratory result.

A nurse is caring for a client who is undergoing lumbar puncture (LP). In which position should the nurse place the client after the procedure?

Dorsal recumbent Rationale: After LP, the client should remain in a supine or dorsal recumbent position for 4 to 12 hours or as prescribed by the health care provider. This position helps prevent headache. Elevating or lowering the head after LP may increase intracranial pressure, resulting in spinal headache.

A client is recovering from acute respiratory distress syndrome (ARDS). Which entry in the medical record is the indicator of greatest improvement to the nurse?

Partial pressure of arterial oxygen (Pao2) of 84 mm Hg (11.13 kPa) with no infiltrates on chest radiography Rationale: The primary laboratory value used in establishing a diagnosis of ARDS is a reduced partial pressure of arterial oxygen, or PaO2 value, determined with the use of arterial blood gas measurement. The chest x-ray shows the diagnostic diffuse haziness, or "white-out" (ground-glass), appearance of the lung. In this case, the indicator of greatest improvement in the client's condition is an increased oxygen level and a chest x-ray showing clearing of prior abnormalities. A PaO2 of 80 to 100 mm Hg (10.6-13.33 kPa) is normal, and the chest x-ray should be clear (or without infiltrates or haziness). The normal pulmonary capillary wedge pressure is 8 to 13 mm Hg. However, in the client with ARDS the PCWP is usually low to normal. Therefore a PCWP of 10 mm Hg would not provide an indication of improvement. A PCWP of 20 mm Hg is high, the type of value that is seen with increased left ventricular pressure.

A client is receiving heparin sodium by way of continuous intravenous (IV) infusion. For which adverse effect of this therapy does the nurse monitor the client? Select all that apply.

Petechiae Hematuria Tarry stools Rationale: The client who receives continuous IV heparin is at risk for bleeding. The nurse assesses the client for signs of bleeding, including bleeding from the gums, petechiae, ecchymoses on the skin, cloudy or pink-tinged urine, tarry stools, and body fluids that test positive for occult blood. Tinnitus, hematuria, and increased pulse rate are not side effects of this medication.

A nurse is reviewing the laboratory results of a client with cytomegalovirus retinitis who is receiving foscarnet sodium. Which laboratory test result that will identify a toxic effect of the medication, does the nurse check?

Serum creatinine Rationale: Foscarnet sodium is an antiviral medication. Renal impairment is a major risk with the use of this medication. The serum creatinine level is checked before therapy, two or three times per week during induction therapy, and at least weekly during maintenance therapy. This medication may also cause decreases in the levels of calcium, magnesium, phosphorus, and potassium in the bloodstream. Therefore these parameters are measured with the same frequency. Sedimentation rate, liver function studies, and CD4+ T-cell count are not used to detect toxic effects of this medication.

A nurse is monitoring a client with a head injury for signs of diabetes insipidus (DI). Which finding would cause the nurse to suspect that this complication is developing?

Serum sodium level 155 mEq/L (155 mmol/L) Rationale: One complication of head injury is diabetes insipidus (DI), which may occur with insult to the hypothalamus, the antidiuretic hormone storage vesicles, or the posterior pituitary gland. In DI the urine specific gravity ranges from 1.003-1.030 and the serum osmolarity and serum sodium level are high. Large quantities of very dilute urine are excreted, putting the client at risk for severe dehydration. Normal osmolarity ranges from 275 to 295 mOsm/kg (275 to 295 mmol/kg). The normal sodium range is 135 to 145 mEq/L (135-145 mmol/L). The other options are signs of syndrome of inappropriate antidiuretic hormone, which is a complication of intracranial surgery.

A nurse is conducting an assessment of a client with angina pectoris. The client reports that the anginal pain is triggered by exercise and relieved by rest or nitroglycerin. In the client's record, the nurse notes that the client is experiencing:

Stable angina Rationale: Stable angina is induced by exercise and relieved by rest or nitroglycerin. Variant angina, or Prinzmetal angina, is prolonged and severe and occurs at the same time each day, most often in the morning. Unstable angina occurs with lower and lower levels of activity or at rest, is less predictable, and is often a precursor of myocardial infarction. Because the client is complaining of anginal pain, nonanginal pain is incorrect.

A nurse assessing the skin of a client who is immobile notes this change in appearance of the skin in the sacral area: The nurse documents this finding as a:

Stage I pressure ulcer Rationale: In a stage I pressure ulcer, the skin is reddened but intact. In a stage II pressure ulcer, there is partial-thickness skin loss involving the epidermis or dermis. The ulcer is superficial and may be characterized as an abrasion, blister, or shallow crater. A deep crater is seen in stage III, and, in stage IV, sinus tracts have developed.

A nurse is monitoring a client who is taking spironolactone for the treatment of hypertension. Which findings denote adverse effects of the medication? Select all that apply.

Tall T waves Prolonged PR interval Hyperactive bowel sounds Rationale: Spironolactone is a potassium-sparing diuretic. Potassium-sparing diuretics can cause hyperkalemia. Cardiovascular manifestations of hyperkalemia include tall T waves, widened QRS complexes, prolonged PR intervals, and flat P waves. Other cardiovascular manifestations include an irregular heart rate, decreased blood pressure, and ectopic heartbeats. Muscle twitches occur in hyperkalemia. Hyperactive bowel sounds and diarrhea also occur in hyperkalemia. Constipation, hyporeflexia, and shallow respirations are signs of hypokalemia.

A nurse provides dietary instructions to a client with viral hepatitis whose laboratory results indicate liver impairment. The nurse teaches the client:

That most calorie intake should consist of foods high in carbohydrates Rationale: If liver function is not impaired, a well-balanced diet is adequate. In this case, because liver impairment has been confirmed, protein and sodium intake are limited. Most calories should come from carbohydrates. A low-fat, high-carbohydrate diet may be best tolerated.

A nurse is checking a client's closed chest drainage system and notes rapid bubbling in the water seal chamber. The nurse checks the system for an air leak but does not find one. The nurse interprets this to indicate that:

There is an incision or tear in the pulmonary pleura Rationale: Rapid bubbling in the absence of an air leak indicates considerable loss of air, such as that from an incision or tear in the pulmonary pleura. The health care provider is notified immediately so that appropriate measures may be taken to prevent collapse of the lung or mediastinal shift. A resolving pneumothorax may be indicated by intermittent bubbling in the water seal chamber with respiration. The nurse's finding of continuous bubbling in the water seal chamber indicates that the leak is between the client and the water seal. Continuous bubbling does not indicate a problem with the suction being applied to the system.

Benztropine mesylate is prescribed for a client with Parkinson's disease. For which gastrointestinal (GI) side effects of the medication does the nurse monitor the client? Select all that apply.

Dry mouth Constipation Rationale: Common GI side effects of benztropine therapy include constipation and dry mouth. Hypoactive, rather than hyperactive, bowel sounds might occur. Increased appetite and mucositis are not associated with this medication.

A nurse is conducting an admission assessment of a client hospitalized with a diagnosis of Meniere's disease. Which question would elicit information specific to the attacks that occur with this disorder?

"Do you have a feeling of fullness in your ear?" Rationale: Meniere's disease results from a disturbance in the fluid of the endolymphatic system. The cause of the disturbance is unknown. Attacks may be preceded by a feeling of fullness in the ear or by tinnitus. Headaches, difficulty speaking, and momentary losses of consciousness are not associated with this disorder.

Cyclophosphamide is prescribed for a client with a diagnosis of breast cancer. The nurse has provided instructions to the client regarding the medication. Which statement by the client indicates an understanding of this chemotherapeutic regimen?

"I need to increase my fluid intake to 2000 to 3000 mL a day." Rationale: Hemorrhagic cystitis is a toxic effect of cyclophosphamide. The client should be instructed to drink copious amounts of fluid while taking this medication and should also monitor the urine blood. The medication should be taken on an empty stomach unless gastrointestinal upset occurs. Hyperkalemia may result from the use of the medication; therefore the client would not be encouraged to increase potassium intake (i.e., bananas, orange juice). The client would not be instructed to alter her sodium intake.

A nurse provides instructions to a client who is taking allopurinol for the treatment of gout. Which statements by the client indicate an understanding of the medication? Select all that apply.

"I shouldn't drink coffee or tea anymore." "I need to drink at least 8 glasses of fluid every day." Rationale: Clients taking allopurinol are encouraged to drink at least 8 glasses of fluid a day. Coffee and tea are avoided because they can increase the level of uric acid in the body. Allopurinol is to be given with milk or immediately after meals to ease gastric distress. If the client experiences a rash, irritation of the eyes, or swelling of the lips or mouth, he or she should contact the health care provider, because these are all signs of hypersensitivity. The client should not take large doses of vitamin C while taking allopurinol, because kidney stones could develop.

A nurse in the emergency department is assessing a client who sustained an open leg fracture in a fall from a ladder. Which question is most important for the nurse to ask the client?

"When was your last tetanus vaccine?" Rationale: With an open fracture, the client is at risk for osteomyelitis, gas gangrene, and tetanus. The nurse must ask the client about the date of her last tetanus vaccine to ensure that prophylaxis is active. "Have you ever had a tuberculin test?" "Have you had a chest x-ray recently?" and "When was your last physical examination?" will not elicit information associated with this client's injury.

A client with AIDS is admitted to the hospital with a diagnosis of histoplasmosis, and the nurse monitors the client for signs of progression of the disease. Which finding indicates progression of histoplasmosis?

Enlargement of the lymph nodes Rationale: Histoplasmosis usually starts as a respiratory infection in the client with AIDS. It then becomes disseminated, giving rise to enlargement of the lymph nodes, spleen, and liver. The nurse will also note dyspnea, fever, cough, and weight loss. Complaints of nuchal rigidity, headache, and blurred vision are unrelated to the findings noted in histoplasmosis but may be noted in cryptococcosis, a severe debilitating meningitis (and, occasionally, a disseminated disease) in AIDS.

Cefuroxime axetil 1 g in 50 mL of normal saline solution, is to be administered over 30 minutes. The drop factor is 15 gtt/mL. At how many drops per minute does the nurse set the flow rate?

25

An antibiotic mixed in 100 mL of normal saline solution is to be administered over half an hour. The drop factor is 10 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round your answer to the nearest whole number.)

33

Hepatitis A vaccine is prescribed for a client who is planning a trip out of the country. The nurse tells the client that:

A booster dose is needed 6 to 12 months after the initial injection Rationale: Hepatitis A vaccine contains inactivated hepatitis A virus. A single dose of this vaccine is given intramuscularly; a booster dose is administered 6 to 12 months after the initial injection. Active immunity to hepatitis B is provided by the hepatitis B vaccine (Engerix-B, Recombivax-HB). Hepatitis A vaccine is not available in an oral form.

A client infected with HIV has a T4 count of 150/mm3 and a low CD4+/CD8+ ratio. On the basis of these values, the nurse concludes that the client is:

A risk for opportunistic infection Rationale: The percentage and number of CD4+ (T4) and CD8+ (T8) cells are an important part of an immune profile. Individuals with HIV disease usually have a lower-than-normal number of CD4 cells. The normal CD4+ count is between 500 and 1600 cells/mm3. The normal ratio of CD4+ to CD8+ cells is approximately 2:1. In HIV infection, because of the low number of CD4+ cells, this ratio is low. A low CD4+ cell count and a low CD4+/CD8+ ratio are associated with increased incidence of clinical manifestations of the disease, and the client is at risk for opportunistic infection. The nurse uses this information in planning infection-control measures for the client. The remaining options are incorrect interpretations.

On the first day after undergoing total knee arthroplasty, the client tells the nurse that he is experiencing pain when he extends his leg. The nurse should:

Administer an analgesic and evaluate the response Rationale: Pain with knee extension is a common complaint of clients after knee arthroplasty. This is because before surgery the client placed the knee in flexion to reduce pain, resulting in flexion contracture. The nurse should encourage the client to keep the knee extended and administer analgesics as needed. Putting the joint through its full range of motion may be more than the client can tolerate; also, the client usually has a continuous passive motion machine that controls the degree of flexion and extension of the joint. There is no reason to contact the health care provider immediately.

A client has a prescription to have blood drawn from the radial artery for a set of arterial blood gas (ABG) determinations. For which test does the nurse look for a positive result before the blood is drawn?

Allen test Rationale: The Allen test is performed before blood is drawn for assessment of arterial blood gases. The radial and ulnar arteries are occluded in turn, then released, after which the distal circulation is assessed. If the result is positive, the client has adequate circulation and that site may be used. The Trousseau sign is an indication of the presence of carpopedal spasms, denoting hypocalcemia. The presence of the Brudzinski sign indicates nuchal rigidity. The Babinski reflex is used to assess neurological dysfunction.

A nurse is monitoring a client who is attached to a cardiac monitor. The monitor alarm sounds, and the nurse, examining the screen, notes no ECG complexes. The nurse would first:

Assess the client Rationale: A sudden loss of ECG complexes indicates either ventricular asystole or possibly electrode displacement. Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate intervention. The nurse would assess the client first. If, after assessing the client, the nurse feels that there is an absence of ventricular activity, a code (rapid response team) should be called and emergency response measures initiated.

A client complains of a rapid heartbeat and shortness of breath. While watching the client's cardiac monitor, the nurse notes the following pattern: The nurse interprets this finding as:

Atrial fibrillation Rationale: Atrial fibrillation is a dysrhythmia arising when ectopic foci in the atrium discharge impulses at a rate of 400 beats/min or faster. There are usually no definable P waves; these impulses are so rapid that they cause the atria to quiver instead of contracting regularly, producing irregular wavy deflections. Because ventricular depolarization is fairly normal in atrial fibrillation, the QRS complexes appear normal. Atrial flutter is marked by the "sawtooth" appearance of P waves that may or may not be regular. Ventricular fibrillation and ventricular tachycardia do not feature normal QRS complexes.

A nurse is providing dietary instructions to a client with chronic obstructive pulmonary disease (COPD) who is experiencing a loss of appetite and complains of feeling "too full to eat." What does the nurse encourage the client to do? Select all that apply.

Avoid drinking fluids before and during meals Select foods that are easy to chew and are not gas forming Rationale: COPD is a progressive and irreversible condition characterized by diminished inspiratory and expiratory capacity of the lungs. Instruct the client who complains of feeling too full to eat, to avoid drinking fluids before and during the meal. Dry foods such as crackers stimulate coughing; foods such as milk and chocolate may increase the thickness of saliva and secretions. Cheese is constipating and should also be avoided by the client. The nurse should also teach the client about foods that are easy to chew and do not encourage the formation of gas; for this reason, broccoli, which is a gas-forming food, should be avoided.

A client is receiving digoxin for the treatment of heart failure. For which signs of digoxin toxicity does the nurse monitor the client? Select all that apply.

Bradycardia Visual disturbances Rationale: The signs and symptoms of toxicity include abdominal pain, nausea and vomiting, diarrhea, headaches, visual disturbances (e.g., blurred, yellow, or green vision; halos around lights), confusion, bradycardia, and other dysrhythmias. The other options are unrelated to digoxin therapy.

A nurse participating in a free health screening at the local mall obtains a random blood glucose level of 190 mg/dL (10.6 mmol/L) and a total cholesterol level of 210 mg/dL (5.4 mmol/L) in an otherwise healthy client. What should the nurse tell the client to do next?

Call his health care provider to have these values rechecked as soon as possible Rationale: Adult diabetes mellitus may be diagnosed on the basis of symptoms (e.g., polydipsia, polyuria, polyphagia) or laboratory values. An abnormal glucose tolerance test, a random plasma glucose level greater than 200 mg/dL (11.1 mmol/L), and a fasting plasma glucose level greater than 140 mg/dL (7.8 mmol/L) on two separate occasions are all diagnostic of diabetes mellitus. The total cholesterol should be less than 200 mg/dL (5.2 mmol/L). Confirmation of this client's results is needed to ensure appropriate diagnosis and therapy.

A hospitalized client has just been found to have acute kidney injury (AKI). The laboratory calls the nursing unit and reports that the client has a serum potassium level of 6.4 mEq/L (6.4 mmol/L). On the basis of this laboratory finding, the nurse should first:

Call the health care provider Rationale: The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5-5.0 mmol/L). The client with hyperkalemia is at risk for cardiac dysrhythmias and resultant cardiac arrest. Because of this, the health care provider must be notified at once so that the client may receive definitive treatment. The nurse would check the client's sodium level and encourage the client to decrease intake of potassium-rich foods, but these are not priority nursing interventions. Fluid intake would not be increased, because this would contribute to fluid overload and wouldn't effectively lower the serum potassium level.

A nurse is caring for a client who has just undergone thyroidectomy. Which technique is the best way for the nurse to assess the surgical site for bleeding?

Checking for moisture on the back of the dressing over the client's neck and shoulders Rationale: Thyroid surgery may be complicated by hemorrhage, respiratory distress, parathyroid gland injury (resulting in hypocalcemia and tetany), damage to the laryngeal nerves, and thyroid storm. Hemorrhage is most likely during the 24 hours after surgery. If the client is bleeding after surgery, gravity will cause the blood to seep down the sides of the dressing and drain onto the underlying bed linens even as the top of the dressing remains clean and dry. Asking the client whether the dressing feels wet and replacing the dry sterile dressing every 2 hours are not the best actions. Replacing the dressing frequently when it is not warranted could also increase the risk of infection.

A nurse is developing a plan of care for a client who has had a stroke and is experiencing homonymous hemianopsia. Which interventions does the nurse include in the care plan to help the client to overcome this deficit?

Encouraging the client to turn the head from side to side to scan the complete range of vision Rationale: Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and conducts client teaching from within the intact field of vision. The nurse encourages the use of the client's own eyeglasses, if they are available. Discouraging the client from using a walker when ambulating and teaching the client to perform active range-of-motion exercises are unrelated to this deficit.

A nurse is preparing to teach a client with newly diagnosed chronic kidney disease (CKD) about the disease and its management. The client's ability to learn is diminished as a result of uremia and anxiety. The nurse makes it a priority to include which when conducting teaching sessions with this client?

Family members Rationale: The client with CKD is often faced with such barriers to learning as anxiety and the effects of uremia, including short attention span and memory deficits. The effects of uremia effects usually improve once hemodialysis has begun. The presence of family is helpful, because the family must understand the disease and treatment and may help reinforce information with the client after the formal teaching session is over. The presentation of information should be simple, direct, and aimed at the educational level of the client. Charts and diagrams and printed materials may be helpful but are not the priority. Research articles will not be helpful to the client.

A nurse is caring for a client who has just undergone craniotomy with an infratentorial incision. In which position does the nurse expect that the health care provider will prescribe the client to be placed?

Flat and on the side Rationale: The client who has undergone infratentorial craniotomy should be kept flat and placed on either side for 24 to 48 hours. This will prevent pressure on the incision site, which is located in the neck. It also prevents the exertion of pressure on the internal tumor excision site by higher cerebral structures. The client who has undergone supratentorial craniotomy would be positioned with the head of the bed elevated 30 degrees to promote venous drainage.

For which findings, early signs of increased intracranial pressure (ICP), does the nurse caring for a client who sustained a head injury monitor the client? Select all that apply.

Headache Decreased level of consciousness Rationale: Early signs of increased ICP include a decreasing level of consciousness (this is the earliest and most sensitive sign), a headache that intensifies with coughing or straining, pupillary changes or visual disturbances, and contralateral motor or sensory losses. Late signs include changes in vital signs (e.g., widened pulse pressure, slowed pulse); shallow, slowed respirations; irregular periods of apnea; hiccups; fever without a source of infection; vomiting; and posturing.

A nurse is teaching a client with newly diagnosed diabetes mellitus how to perform fingerstick blood glucose measurements. The nurse tells the client to:

Hold the finger in a dependent position and massage the finger toward the puncture site Rationale: Before performing a fingerstick for blood glucose measurement, the client should wash the hands, using warm water to stimulate the circulation to the area. The finger is punctured near the side, not the center, because there are fewer nerve endings along the side of the finger. The puncture is only deep enough to obtain an adequate size of a drop of blood; an excessively deep puncture may result in pain and bruising. The arm should be allowed to hang dependently, and the finger may be massaged to promote obtaining a good-sized drop of blood. The site is cleaned with alcohol or an antiseptic swab and allowed to dry completely before puncture, because alcohol can cause hemolysis of blood. To help prevent infection, a lancet or blood-letting device is used once and then discarded.

A nurse caring for a client with leukemia who is undergoing chemotherapy reviews the client's laboratory results and notes that the client has thrombocytopenia. Which interventions does the nurse implement when caring for the client? Select all that apply.

Inspecting all stools for occult blood Correct Measuring the client's abdominal girth every day Providing the client with an electric razor for shaving Avoiding the administration of intramuscular injections Rationale: A client who has thrombocytopenia is at risk for bleeding, and interventions are aimed at protecting the client from injury and detecting bleeding so that appropriate interventions may be initiated. The nurse should inspect all stools, urine, drainage, and vomit for blood and test them for occult blood. The abdominal girth is measured daily because increases in abdominal girth may indicate internal hemorrhage. As a means of reducing the risk of bleeding, intramuscular injections, which can cause trauma to the tissues and result in hematoma formation, are avoided. Additionally, an electric razor is used. The incorrect interventions for this question would be implemented if the client had a low white blood cell or neutrophil count and was at risk for infection.

A client arrives at the emergency department and reports a buzzing sound in his ear. The client tells the nurse that an insect flew into the ear. Which intervention does the nurse take first to remove the insect?

Instilling lidocaine into the ear Rationale: Insects that make their way into an ear are killed before removal unless they can be coaxed out with the use of a flashlight or a humming noise. Mineral oil, diluted alcohol, or lidocaine (not water) is instilled into the ear canal (or an ether-soaked cotton ball is placed in the ear) to suffocate the insect, which is then removed with the use of ear forceps. When the foreign object is vegetable matter, irrigation is not used, because this material expands with hydration, worsening the impaction becomes worse. Antibiotics may or may not be prescribed after removal of the insect.

A nurse is reviewing the nursing care plan for a client who has seizure precautions in place. Which intervention documented in the plan of care should the nurse question?

Keep a padded tongue blade at the bedside. Rationale: Seizure precautions vary somewhat from agency to agency, but usually an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed may be padded, and the bed is kept in the lowest position. The client has IV access in place to facilitate rapid administration of anticonvulsant medications must be administered. A padded tongue blade, however, should not be kept at the bedside. Forcing a tongue blade or anything else into the mouth during a seizure is likely to result in harm to the client who bites down during seizure activity. Risks include airway blockage resulting from improper placement and chipping of the client's teeth with a subsequent risk of aspiration of tooth fragments. If the client has an aura before the seizure, the nurse may have enough time to place an oral airway before seizure activity begins.

A nurse caring for a client with a spinal cord injury is watching for signs of autonomic dysreflexia. For which manifestation of this complication does the nurse monitor the client?

Nasal stuffiness and headache Rationale: The client with a spinal cord injury is at risk for autonomic dysreflexia if the injury is located above the level of T7. The condition is characterized by severe throbbing headache, flushing of the face and neck, bradycardia, nasal stuffiness, and sudden severe hypertension. Other signs include blurred vision, nausea, and sweating. This life-threatening syndrome is triggered by a noxious stimulus below the level of the injury.

A nurse performs a fingerstick glucose test on a client who is receiving (Total)parenteral nutrition (TPN) and obtains a reading of 410 mg/dL(22.8 mmol/L). On the basis of this finding, the nurse would most appropriately:

Notify the health care provider Rationale: Hyperglycemia is one complication of TPN. Because the glucose reading is increased, the nurse would immediately notify the health care provider and await further instructions. Stopping the TPN feeding, decreasing the flow rate of the TPN feeding, and administering a dose of NPH insulin would not be implemented without a health care provider's prescription. A sliding-scale dose of regular (not NPH) insulin might be prescribed to keep the blood glucose level between 180 and 200 mg/dL (10 to 11.1 mmol/L).

A nurse is caring for a client with a cervical spine injury to whom Crutchfield tongs have been applied. Which intervention listed in the nursing care plan would the nurse question?

Obtaining help from another nurse to remove the weights when repositioning the client Rationale: Crutchfield tongs are applied after holes have been drilled in the client's skull. Local anesthesia is used for this procedure. Weights, used to exert pulling pressure on the longitudinal axis of the cervical spine, are attached to the tongs. Serial x-rays of the cervical spine are taken and weights gradually added until the x-ray reveals that the vertebral column has been properly realigned. Thereafter, the weight may be gradually reduced as prescribed to a point that maintains alignment. The client with Crutchfield tongs is placed on a Stryker frame, RotoRest bed, or other specialized bed. The nurse ensures that weights hang freely and that the weight in use matches the current prescription. The nurse also inspects the integrity and position of the ropes and pulleys. If the client complains of severe muscle pain, the weights may be too heavy or the client may require realignment. The nurse reports the pain to the health care provider if realignment fails to reduce the discomfort. The nurse does not remove the weights to administer care.

A nurse is assessing a client's fluid balance on the day after craniotomy. Which laboratory result would the nurse report to the health care provider?

Plasma osmolarity 265 mOsm/kg (265 mmol/kg) Rationale: The normal plasma osmolarity is 275 to 295 mOsm/kg (275 to 295 mmol/kg).. A value greater than 295 mOsm/kg (295 mmol/kg) indicates dehydration; a value less than 275 mOsm/kg (275 mmol/kg) indicates overhydration. After craniotomy, the goal is to keep the plasma osmolarity on the high side of normal as a means of helping control cerebral edema. Because a plasma osmolarity of 265 mOsm/kg (265 mmol/kg) is low, the client is overhydrated and at risk for cerebral edema. The nurse should report this finding. Each of the other options represents a normal or expected finding.

A nurse provides discharge instructions to a client who was hospitalized for an acute attack of Meniere's disease. Which statements by the nurse are correct? Select all that apply.

Position changes should be made slowly. Underwater swimming should be avoided. It is best to switch to decaffeinated tea and coffee If an acute attack occurs, sit down and keep the eyes closed. Rationale: Meniere's disease results from a disturbance in the fluid of the endolymphatic system. The cause of the disturbance is unknown. If an acute attack of vertigo occurs, the client is instructed to immediately lie down on a firm surface if possible, loosen clothing, and close the eyes until the acute vertigo stops. Between attacks, the client may resume normal activities but should avoid underwater swimming, which may cause a loss of orientation. The nurse encourages the client to follow a low-salt diet and to avoid excessive use of caffeine, sugar, monosodium glutamate, and alcohol. The client should be taught to avoid sudden head movements or position changes.

A nurse is studying the results of periodic serum laboratory studies in a client with diabetic ketoacidosis (DKA) who is receiving an intravenous insulin infusion. Which finding should prompt the nurse to contact the health care provider?

Potassium 3.1 mEq/L (3.1 mmol/L) Rationale: The client with DKA initially becomes hyperkalemic as potassium leaves the cells in response to a lowered pH. Once fluid replacement and insulin therapy are started, the potassium level drops quickly because potassium is carried into the cells along with glucose and insulin and because potassium is excreted in the urine once rehydration has occurred. Therefore the nurse must carefully monitor the client's serum potassium results and report hypokalemia (i.e., potassium 3.1 mEq/L, 3.1 mmol/L) immediately. A blood glucose reading of 290 mg/dL (16.2 mmol/L)is high and is the reason that the client is receiving the insulin infusion. Normally the blood glucose level is higher than 300 mg/dL (16.7 mmol/L)in DKA, so a value of 290 mg/dL (16.2 mmol/L)indicates improvement in the client's condition. A serum pH of 7.33 is slightly low, reflecting the metabolic acidosis that accompanies DKA. A sodium value of 137 mEq/L (137 mmol/L)is within the normal range; serum sodium values in DKA fluctuate and may be low, normal, or high.

A home care nurse, assessing the skin of a client, notes the following rash beneath the skin: Which precaution will the nurse immediately institute before completing the assessment?

Putting on a gown and gloves Rationale: Scabies presents as vesicle or pustule irritations, burrows, or rash of the skin, especially in the webbing between the fingers. When a client is infested with scabies, a gown and gloves should be worn for close contact. A mask and head covering are not necessary. Transmission by way of clothing and other inanimate objects is uncommon. Scabies is usually transmitted from person to person by way of direct skin contact. All of the client's contacts should be treated for the infestation at the same time.

A nurse is preparing to care for a client who just returned from the recovery room after a Billroth II procedure. Which intervention in the plan of care does the nurse question?

Reposition the nasogastric (NG) tube if drainage ceases. Rationale: In a Billroth II resection, an anastomosis is constructed between the proximal remnant of the stomach and the proximal jejunum. Patency of the NG tube is critical in preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless specifically asked to do so by the health care provider, because the tube is placed directly over the suture line. NPO status, active range-of-motion exercises, and coughing and deep-breathing exercises are all appropriate postoperative interventions.

A nurse teaches a client with gastroesophageal reflux disease (GERD) about measures to manage the disease. What does the nurse encourage the client to do to obtain relief of the symptoms? Select all that apply.

Use chewing gum and oral lozenges Elevate the head of the bed at least 6 to 8 inches (15 to 20 cm) for sleep Rationale: The discomfort of reflux is aggravated by positions that compress the abdomen and the stomach. These positions include lying prone or supine, especially after a meal. The client should be advised to elevate the head of the bed at least 6 to 8 inches (15 to 20 cm) for sleep. The client is also encouraged to eat four to six small meals a day to prevent abdominal fullness and subsequent reflux. The client is also taught to avoid foods, such as chocolate, peppermint, tomatoes, coffee, and tea, because they that decrease lower esophageal sphincter pressure and increase the likelihood of reflux. Chewing gum or oral lozenges, may help clients with mild symptoms of GERD because it increases saliva production.

A client is scheduled to undergo insertion of an inferior vena cava (IVC) filter in 2 days. Which medication should the nurse anticipate to withhold as prescribed during the preoperative period?

Warfarin sodium Rationale: The nurse should anticipate that the surgeon will prescribe the warfarin sodium to be withheld in the period just before insertion of an IVC filter. This medication is often withheld before surgery to minimize the risk of intraoperative hemorrhage. The other medications may also be withheld by request of the surgeon, but usually they are discontinued as part of an "NPO [nothing by mouth] after midnight" prescription.

A client with phantom limb pain has decided to use transcutaneous electrical nerve stimulation (TENS) as prescribed by the health care provider, and the nurse provides instructions regarding the use of the TENS unit. Which statements by the client indicate a need for further instruction regarding this pain-relief measure? Select all that apply.

"I need to put the electrodes on the areas that you marked." "I'm not happy about having to stay in the hospital for this treatment." Rationale: The TENS unit is a battery-powered stimulator that is worn externally. The purpose of electrical stimulation is to modify the pain stimulus by blocking or changing a painful stimulus with stimulation, causing the client to perceive it as less painful. The client controls the system, thus reducing the need for analgesics. It is attached to the skin with the use of electrodes. The client needs to learn to adjust placement of the surface electrodes and the intensity and timing of the stimuli to maximize pain reduction or relief. It is not necessary that the client remain in the hospital for this treatment.

A nurse has taught a client with chronic obstructive pulmonary disease (COPD) about positions that will ease breathing during dyspneic episodes. Which statement by the client indicates a need for further instruction?

"I should lie flat on my side in a fetal position." Rationale: The client with COPD should not lie flat on his side in a fetal position, because this position restricts movement of a large area of the client's chest wall. Instead, the client should use any of the positions identified in the other options, which all allow upward movement of the diaphragm, maximal chest expansion, and decreased use of the accessory muscles of respiration.

Glargine insulin is prescribed for a client with type 1 diabetes mellitus. What does the nurse tell the client about this type of insulin? Select all that apply

It does not have a peak effect. It is usually given once daily, at bedtime. It usually has a 24-hour duration of action Rationale: Glargine insulin, a long-acting basal insulin analog, has an onset of action of 1 to 2 hours, with no peak effect, and a duration of action of more than 24 hours. It is usually given once daily, preferably at bedtime. Glargine insulin may not be mixed in a syringe with other insulin.

Cyclobenzaprine has been prescribed for a hospitalized client to treat painful muscle spasms caused by a damaged intervertebral disk. The nurse would withhold the medication and question the prescription if the client had a concurrent prescription for:

Tranylcypromine Rationale: The client should not receive cyclobenzaprine if he has taken a monoamine oxidase (MAO) inhibitor such as tranylcypromine or phenelzinewithin the preceding 14 days. The combination of the two drugs could produce hypertensive crisis or seizures. The medications listed in the other options are not contraindications to the use of cyclobenzaprine.

A nurse is monitoring a client with myocardial infarction for signs of left ventricular heart failure. The nurse specifically monitors the client for:

Pulmonary congestion Rationale: Most heart failure begins with failure of the left ventricle and progresses to failure of both ventricles. Decreased tissue perfusion stemming from poor cardiac output and pulmonary congestion resulting from increased pressure in the pulmonary vessels indicate left ventricular failure. In right ventricular failure, the right ventricle is unable to empty completely. Increased volume and pressure develop in the systemic veins, and systemic congestion and peripheral edema develop. Edema in the legs and feet, jugular vein distention, and abdominal distention are signs of right ventricular heart failure.

A nurse is caring for a client who has had an estrogen receptor-positive breast tumor surgically removed. The client is told that follow-up with hormonal therapy will be prescribed. The nurse outlines a teaching plan, knowing that client will most likely receive:

Tamoxifen citrate Rationale: Tamoxifen citrate is the usual choice of treatment in postmenopausal women who with estrogen receptor-positive tumors. It is an anti-estrogen medication that blocks the estrogen receptor sites of malignant cells and thus inhibits the growth-stimulating effects of estrogen. Aromatase inhibitor drugs, including anastrozole and letrozole, interfere with the enzyme that synthesizes endogenous estrogen. Because aromatase inhibitors do not block the production of estrogen by the ovaries, they would be of little benefit in this client's case. Raloxifene is used to reduce the risk of breast cancer in postmenopausal women by blocking estrogen receptors in the breast without stimulating endometrial growth

A nurse provides information regarding postoperative restrictions and arm care to a client who has undergone mastectomy of the left breast with axillary lymph node dissection. What does the nurse tell the client to do? Select all that apply.

Use mild soaps and lotions on the left arm Apply sunscreen to the arm whenever she is outside Wear protective gloves when working in the garden Rationale: The client is at risk for edema and infection as a result of the lymph node dissection. Meticulous skin care with mild soaps and lotions is given to the extremity. The client should avoid activities that might increase edema, such as carrying heavy objects or having the blood pressure taken on the affected arm. The client should also use a variety of techniques to avoid trauma to the affected arm. Examples include using a well-maintained electric razor to shave under the arms, wearing gloves when working in the garden, wearing rubber gloves when washing dishes or doing housework, using potholders when cooking, and protecting the arm from such traumas as pinpricks and sunburn.

A nurse preparing an intravenous (IV) infusion for a client with leukemia is adding a chemotherapeutic agent to the IV solution. Which safety measure does the nurse implement while preparing this infusion?

Wearing gloves and a gown and preparing the medication in a biological safety cabinet Rationale: Several organizations, including the federal Occupational Safety and Health Administration, have prepared guidelines for the safe preparation, handling, and disposal of antineoplastics. These guidelines include the need to wear gloves and gowns during preparation and administration of chemotherapy and the use of a biologic safety or laminar flow cabinet for preparation. Sterile gloves, masks, and head coverings are not necessary for chemotherapy preparation.

The result of two enzyme-linked immunosorbent assays (ELISA) performed to detect HIV is positive. Which diagnostic test does the nurse anticipate will be prescribed next?

Western blot Rationale: If the results of two ELISA tests are positive, the Western blot is performed to confirm the findings. If the Western blot result is positive, the client is considered positive for HIV and therefore infected with the HIV virus. The CD4+ T-count, which identifies the T-helper lymphocyte count, is performed to determine progression and treatment. Bone marrow biopsy is not a used to diagnose HIV infection.