Hurst Adult Health Quiz #1

A 35 year old client, concerned about weight, asks a clinic nurse, "What is my BMI?" The client weighs 135 pounds and is 5 feet 2 inches tall. Determine the client's BMI to the nearest tenth?

BMI = 24.7 Formula: BMI = (703 x weight in pounds) ÷ (height in inches)2 BMI = (703 x 135) ÷ (62)2 BMI = (94,905) ÷ (3,844) BMI = 24.689 BMI = 24.7

The nurse, caring for a client post motor vehicle accident who sustained multiple crushing injuries, suspects that the client may be developing disseminated intravascular coagulation (DIC). Which assessment findings by the nurse suggest that the client is developing this complication? 1. Chest pain 2. Frothy sputum 3. Intermittent claudication 4. Subcutaneous emphysema 5. Petechiae 6. Blood oozing from chest tube insertion site

5,6 5., & 6. Correct: Petechiae are red dots on the surface of the skin seen because of minute hemorrhages within the dermal or submucosal layers of the skin. Oozing blood from invasive catheter sites is one sign of DIC. The client can have minor oozing of blood to bleeding from every orifice and into the tissues. 1. Incorrect: Chest pain may be a symptom of MI, or pulmonary embolus. It is not typical of DIC. 2. Incorrect: Think pulmonary edema and pulmonary embolus with frothy sputum. 3. Incorrect: Intermittent claudication is severe leg pain associated with decreased oxygenation to the leg muscles. 4. Incorrect: Subcutaneous emphysema is air under the skin, typically seen with chest tubes or tracheostomy insertion.

The nurse is caring for a burn client in the emergent phase. The client becomes extremely restless while on a ventilator. What is the priority nursing assessment? 1. Patency of endotracheal tube. 2. Adventitious breath sounds. 3. Fluid in the ventilator tubing. 4. Ventilator settings.

1 1. Correct: With restlessness, think hypoxia so the nurse should start assessment with airway first. Check for patency of the ET tube. If this is patent, then the other options would be next. 2. Incorrect: This is the next best answer, but hypoxia and airway comes first. 3. Incorrect: This is the third step. Rule out the other two before checking tubing for kinks or obstructions. 4. Incorrect: Start with the client first. Then move toward the ventilator. Always assess the client first.

A nurse receives a client in the post anesthesia care unit following application of a long leg cast to the left leg due to a fractured tibia and fibula. Which interventions should the nurse initiate? 1. Elevate foot of bed 30 degrees. 2. Palpate bilateral pedal pulses. 3. Apply ice packs to fracture site. 4. Mark break through bleeding. 5. Assess client's ability to move toes

2,3,4,5 2., 3., 4., & 5. Correct: The priority nursing assessment focuses on any intervention that maintains good circulation to the extremity and prevents complications that can impair mobility. This must include checking distal pulses in both legs to compare the strength of the pulse on both the affected and unaffected side. The nurse should also decrease swelling and risk of compartment syndrome by applying ice to fracture site, assess for bleeding, and check for tingling, coldness, numbness, and ability to move toes; in other words - neurovascular/sensation checks. 1. Incorrect: The affected leg should be elevated, but not both. The nurse should place the affected leg on a pillow and not raise the foot of the bed since this would raise both extremities.

What physical changes should the nurse discuss with a client who is entering menopause? 1. Loss of bone density 2. Loss of muscle mass 3. Improved skin elasticity 4. A reduction in waist size 5. Increased fat tissue

1,2,5 1., 2. & 5. Correct: Changes associated with menopause, with its dramatic decline in estrogen, include loss of muscle mass, increased fat tissue leading to thicker waist, dryness of the skin and vagina, hot flashes, sleep abnormalities, and mood changes . 3. Incorrect: A decrease in turgor and elasticity may occur as we grow older. Skin becomes dry and thin and collagen levels decrease after menopause. 4. Incorrect: There is increased abdominal fat. The waist size swells relative to hips after menopause.

The nurse is irrigating an acid chemical burn on a client's arm. Which would indicate to the nurse that irrigation can be stopped? 1. Client's pain rating has decreased from 6 to 2 on a 0 to 10 pain scale. 2. The pH value of the runoff solution is 7.0. 3. Client reports a burning sensation in the affected arm. 4. Capillary refill is less than 2 seconds in the affected arm.

2 2. Correct: A pH of 7 is nonacidic, so the solution's pH indicates that the acid chemical has been removed 1. Incorrect: Pain could indicate acid is still present. 3. Incorrect: A burning sensation may indicate acid is still present. 4. Incorrect: Capillary refill is not an indication that all acid has been removed.

A client receiving chemotherapy for lung cancer reports increased fatigue. The family confirms client is sleeping most of the day and night. What priority action would the nurse take? 1. Discuss the risks of immobility with client and family. 2. Check current lab values of hematocrit and hemoglobin. 3. Suggest family seek counseling for the client's depression. 4. Request a referral from the healthcare provider for physical therapy.

2 2. CORRECT: The side effects of chemotherapy can impact all body systems, including the blood and circulatory system. The nursing process requires the nurse to first assess and gather data before proceeding with a plan. Though fatigue in cancer clients can have many causes, the nurse should check current laboratory results for decreased RBCs, hematocrit or hemoglobin caused by chemotherapy. Decreased levels of these elements are a side effect of chemotherapy and could definitely contribute to fatigue or exhaustion. 1. INCORRECT: While the nurse may want to discuss many topics with client or family, effects of immobility does not address the present issue of exhaustion or fatigue. The nursing process always begins with collection of data. 3. INCORRECT: Individuals respond to a terminal disease in different ways but certainly depression is common. Though a possible symptom of depression can be constantly sleeping, the nurse has not collected evidence to support that assumption. Potential physical causes for behavioral changes must be eliminated first. 4. INCORRECT: This action is premature since the nurse has not completed an assessment or collected data. While physical therapy may help to strengthen the client, an exact cause for the fatigue must first be established.

What interventions should the nurse include in the care plan of a client admitted with Guillain-Barre syndrome? 1. Assess for descending paralysis. 2. Keep a sterile tracheostomy at the bedside. 3. Monitor for heart rate above 120/min. 4. Maintain in side-lying, supine position. 5. Have client perform active range of motion (ROM) every 2 hours while awake.

2,3 2. & 3. Correct: This client is at risk for respiratory paralysis as the disease progresses. An emergency tracheostomy may need to be performed so the nurse should watch out for imminent signs of respiratory failure. Signs include heart rate that is more than 120 bpm or lower than 70 bpm and respiratory rate of more than 30 bpm. The nurse should assess for signs of respiratory distress and prepare for intubation if needed. 1. Incorrect: Ascending paralysis should be assessed for with this disease. Paralysis begins in the lower extremities and moves upward. 4. Incorrect: The client should be assisted to a position with head of bed elevated for full chest excursion. 5. Incorrect: The nurse should perform passive range of motion exercises. Active exercise should be avoided during the acute phase as the client is easily fatigued and muscles are weak. Passive ROM stimulates circulation, improves muscle tone and increases joint mobilization.

Which assessment by the nurse indicates a tension pneumothorax? 1. Sudden hypertension and bradycardia 2. Productive cough with yellow mucus 3. Tracheal deviation and dyspnea 4. Sudden development of profuse hemoptysis and weakness

3 3. Correct: Yes, as pleural pressure on the affected side increases mediastinal displacement occurs with resultant respiratory and cardiovascular compromise. Symptoms of tension pneumothorax include dyspnea, chest pain radiating to the shoulder, tracheal deviation, decreased or absent breath sounds on the affected side, neck vein distention and cyanosis. 1. Incorrect: Hypoxia causes tachycardia rather than bradycardia. The client would more likely to be hypotensive due to decreased cardiac output. 2. Incorrect: Yellow mucus indicates infection, such as from pneumonia. This does not indicate a tension pneumothorax. 4. Incorrect: Profuse hemoptysis and weakness may indicate a serious condition such as a ruptured vessel, but it is not an indication of a mediastinum shift.

Two hours post chest tube insertion, the nurse notes 100 mL of dark bloody drainage in the collection chamber of the closed drainage unit (CDU). What action should the nurse take? 1. Document the findings. 2. Notify the primary healthcare provider. 3. Decrease the amount of suction. 4. Use a padded hemostat to clamp the chest tube.

1 1. Correct: A chest tube is inserted to remove air, blood, or exudate from the pleural space. So 100 mL of dark bloody drainage would not be unusual over the first two hours after insertion. Drainage may range from 100 to 300 mL/hr within the first 2 hours. Documentation is required and continued hourly follow-up. 2. Incorrect: It is not necessary to notify the primary healthcare provider at this time. There is nothing in the stem to indicate that the client is in distress. 3. Incorrect: Suction does not need to be decreased or increased. You want just enough suction to have gentle continuous bubbling in the suction control chamber. 4. Incorrect: You only clamp the chest tube as a last resort and only long enough to find a leak in the system. Clamping a chest tube is dangerous and can lead to a tension pneumothorax.

Which statement by the nurse would be the correct response to a client who is postmenopausal with a uterus when the client asks about temporary hormonal therapy for hot flashes? 1. "Hormonal therapy with a combination of low doses of estrogen and progestin may be prescribed." 2. "Unopposed estrogen hormonal therapy would be most appropriate." 3. "Hormonal therapy is an outdated treatment and can no longer be prescribed so you should try an alternative such as ginseng." 4. "Hormonal therapy is not an option for women with a uterus so you may need to consider a hysterectomy."

1 1. Correct: Estrogen and progestin are prescribed for women who have not had a hysterectomy.​ 2. Incorrect: Only women who no longer have a uterus can take estrogen without progestin.​ 3. Incorrect: Few data exists about the safety and effectiveness of alternative treatments. 4. Incorrect: Combination therapy for women with a uterus; and estrogen alone for women without a uterus.​

A client with type II diabetes reports normal blood glucose levels at bedtime and high blood glucose levels in the morning for the past week. What instruction would the nurse give the client? 1. Monitor blood sugar around 2am. 2. Decrease bedtime snacking. 3. Decrease intermediate acting insulin. 4. Increase intermediate acting insulin.

1 1. Correct: Morning hyperglycemia may be the result of dawn's phenomenon or the Somogyi effect. The client must take their blood sugar between two and three o'clock in the morning for several days to determine the cause of morning hyperglycemia. If the client has decreased blood sugar between two and three o'clock in the morning, suspect Somogyi effect. 2. Incorrect: This is an intervention; assessment should come first. The nurse must determine the cause of morning hyperglycemia in order to treat the condition appropriately. 3. Incorrect: This is an intervention; assessment should come first. The nurse must determine the cause of hyperglycemia in order to treat the condition appropriately. An appropriate intervention for a client with Somogyi effect would be to decrease the evening dose of intermediate acting insulin, however, the nurse must first determine that the client is in fact experiencing the Somogyi effect. 4. Incorrect: This is an intervention; assessment should come first. Increasing the intermediate acting insulin would not be appropriate action for a client experiencing Somogyi effect.

A client has arrived in the emergency department with partial thickness burns to 52 percent of the body. Which central venous pressure (CVP) reading would the nurse anticipate? 1. 1 mm of Hg 2. 2 mm of Hg 3. 6 mm of Hg 4. 10 mm of Hg

1 1. Correct: Normal CVP is 2-6mmHg. This CVP reading indicates fluid volume deficit. A client with 52 percent of the body burned with partial thickness burns would lose fluid from the vascular space out into the tissues resulting in fluid volume deficit. 2. Incorrect: This is a normal CVP reading. Normal CVP is 2 to 6 mm of Hg. 3. Incorrect: This is a normal CVP reading. Normal CVP is 2 to 6 mm of Hg. 4. Incorrect: An increased CVP reading indicates fluid volume excess. There is no indication in the stem that the client is experiencing a fluid volume excess.

A nurse is caring for a nonambulatory client who must be decontaminated after a chemical exposure event. What nursing action will prevent further chemical exposure? 1. Don appropriate personal protective equipment (PPE). 2. Remove only contaminated clothes. 3. Avoid decontaminating the eyes. 4. Use hot water during decontamination.

1 1. Correct: PPE should be donned prior to contact with the client to prevent contamination of the healthcare worker. The nurse must protect themselves from exposure of the chemical. 2. Incorrect: All clothes, jewelry, and personal belongings should be removed and placed into appropriate containers. There is no way to be certain which articles of clothing are contaminated and which are not. 3. Incorrect: Decontaminate the eyes with a saline solution via nasal cannula or Morgan lens. Preventing cornea damage is very important. 4. Incorrect: Hot water is unnecessary unless the client is hypothermic during decontamination procedures. Hot water causes vasodilation.

A farm worker comes into the clinic reporting headache, dizziness, and muscle twitching after working in the fields. What condition does the nurse suspect? 1. Pesticide exposure 2. Heat stroke 3. Anthrax poisoning 4. Gastroenteritis

1 1. Correct: These are symptoms of pesticide exposure when combined with the details given of coming from the fields. Death can result from severe acute pesticide poisoning. 2. Incorrect: The data provided does not lead the nurse to suspect heat stroke. The stem does not tell the temperature the farmer is working in. Heat stroke signs and symptoms include increased sweating, tachypnea and temperature greater than 105.8°F (41.0°C). 3. Incorrect: The data provided does not lead the nurse to suspect anthrax poisoning. The worker has been outside in a field. This is not a risk factor for anthrax exposure. Inhalation anthrax develops when you breathe in anthrax spores. It's the most deadly way to contract the disease, and even with treatment it is often fatal. Initial signs and symptoms of inhalation anthrax include: Flu-like symptoms, such as sore throat, mild fever, fatigue and muscle aches, which may last a few hours or days. Mild chest discomfort, Shortness of breath, Nausea, Coughing up blood, Painful swallowing 4. Incorrect: The data provided does not lead the nurse to suspect gastroenteritis. These signs and symptoms do not go with gastroenteritis. Gastroenteritis signs and symptoms include diarrhea, nausea, vomiting, fever and abdominal cramping.

For a client with a major burn, which evaluation criterion identified by the nurse best indicates that fluid resuscitation has been effective during the first 24 hours of care? 1. Urine output of 860 mL / 24 hours. 2. Increase in weight from preburn weight. 3. Heart rate of 122 beats per minute 4. Central venous pressure of 18 mm

1 1. Correct: Urine output is the best indicator of adequate fluid replacement during the first 24 hours. 2. Incorrect: The weight is not a good indicator now because of the large volume of fluids being infused. These extra fluids would increase the weight. Edema is a problem because of third spacing. 3. Incorrect: The heart rate should come down with adequate fluid replacement. 4. Incorrect: The CVP reading is too high. This indicates that too many fluids have been given.

The nurse has determined that a bedridden client diagnosed with a stroke is at risk for venous thromboembolism (VTE). What interventions should the nurse initiate? 1. Measure the calf and thigh daily. 2. Apply sequential compression device to legs. 3. Position paralyzed leg with each distal joint higher than the proximal joint. 4. Place a trochanter roll at the hip. 5. Perform passive range of motion exercises once daily. 6. Monitor for pain by assessing Homan's sign.

1,2,3 1., 2., & 3. Correct: Assessment for VTEs is accomplished by measuring the calf and thigh daily, observing swelling, noting unusual warmth of the leg, and asking the client about pain in the calf. Prevention of VTEs include the use of sequential compression devices for bedridden clients. This device helps promote venous return. Positioning the paralyzed leg with each distal joint higher than the proximal joint will prevent dependent edema. 4. Incorrect: A trochanter roll does not prevent VTEs. They are used for the prevention of external hip rotation. 5. Incorrect: Passive range of motion exercises should be done several times a day to promote venous return and muscle tone. Once a day is not adequate. 6. Incorrect: Routinely checking the Homan's sign can actually cause a clot to dislodge. The nurse should not perform this procedure.

The nurse, caring for a client who has chronic renal failure, suspects that the client is experiencing anxiety. Which statements by the client would validate the nurse's suspicion? 1. "I do not think I can continue working." 2. "My husband has taken over the house cleaning and cooking." 3. "I fear I am dying." 4. "I have an "uneasy" feeling most of the time." 5. "Most of the time I feel very 'down and blue'."

1,2,3,4

he homecare nurse is instructing a client with chronic obstructive pulmonary disease (COPD) about the importance of a nutritious diet to avoid weight loss. The nurse knows that teaching has been effective when the client selects which foods for a breakfast menu? 1. Scrambled eggs 2. Cheese omelet 3. Sliced banana 4. Orange juice 5. Whole milk 6. Dry toast

1,2,3,4 1., 2., 3. & 4. Correct: Maintaining weight and nutrition is vital to the health of clients with (COPD). Extreme fatigue along with excessive mucus production decreases the client's ability to eat complete, well-balanced meals, leading to weight loss or malnourishment. Therefore, the nurse would instruct the client to eat small, frequent meals high in protein and fiber. Good sources of protein include eggs, cheese, fish and poultry, beans and even nuts. Fresh fruit such as bananas along with non-carbonated beverages such as orange juice are excellent breakfast food choices. 5. Incorrect: Although milk and dairy products like yogurt could be considered part of a healthy breakfast, it is recommended that COPD clients use 1% or 2 % milk products to avoid increasing mucus production. This client should select the orange juice from the choices provided. 6. Incorrect: Dry toast provides little nutrient value, and may actually increase coughing because of its brittle nature. Coughing quickly leads to exhaustion rather than eating. This client would benefit more from a more palatable choice such as muffin or French toast.

A client is being evaluated for possible Rheumatoid Arthritis (RA). Which lab data and assessment findings by the nurse would be indicative of RA? 1. Joint pain, swelling, and warmth. 2. Decreased movement in joints. 3. Presence of Rheumatoid factor on lab analysis. 4. Presence of Dupuytren's contractures. 5. Elevated erythrocyte sedimentation rate (ESR). 6. Presence of Cyclic Citrullinated Peptide Antibody.

1,2,3,5,6 1., 2., 3., 5., & 6. Correct: Classic features of RA include joint pain, swelling, and tenderness worsened by movement and stress placed on joint. Morning stiffness that often lasts for one hour or more and limited movement in joints are common manifestations as well. The Rheumatoid Factor is present in 80% of adults who have rheumatoid arthritis. The ESR blood test is elevated with RA and is used to determine if an abnormal level of inflammation exists in the body. The cyclic citrullinated peptide antibody, if present, helps to confirm the diagnosis of RA and may indicate the risk of having severe symptoms. Levels that are at a moderate to high level may indicate that the client is at increased risk for damage to the joints. 4. Incorrect: Dupuytren's contractures are a type of hand deformity where a layer of tissue under the skin in the palms of the hands is affected. Hard knots form in the palm areas and eventually create a thick cord that can pull one or more of the fingers into a bent position. However, this is not associated with RA.

Calculator A client with a history of alcoholism arrives at the clinic reporting severe abdominal pain with nausea and vomiting. What additional findings would make the nurse suspect the client may have pancreatitis? 1. Bruising at the umbilicus. 2. Fever with tachycardia. 3. Positive Trousseau sign. 4. Pain radiating to back. 5. Vague pain at night.

1,2,4 1, 2 and 4. CORRECT: Whether the client is experiencing acute or chronic pancreatitis, symptoms are severe and distinct. Bruising around the umbilicus is referred to as "Cullen's Sign", indicating internal bleeding. Because of inflammation in the pancreas, the client generally becomes febrile and pain can cause tachycardia. Considering the location of the pancreas, the client frequently experiences pain that radiates from the mid-gastric area to the back. 3. INCORRECT: Trousseau's sign is an indication of low levels of calcium in hypocalcemia, occurring as a hand spasm when the nurse takes the client's blood pressure. This sign does not relate to pancreatitis. 5. INCORRECT: Pain caused by pancreatitis is quite severe and continuous, not just at night. Vague night-time pain could be secondary to many disorders, but not pancreatitis.

Which interventions should be included in the nutritional teaching plan to accomplish the goal of a diet lower in fat? 1. Use 2% milk instead of whole milk. 2. Eat air-popped popcorn instead of potato chips. 3. Eat more red meat instead of fish. 4. Incorporate plant sources of protein. 5. Use olive oil instead of vegetable oil when frying.

1,2,4 1., 2. & 4. Correct: Two percent milk can reduce the amount of fat consumed daily, not only in milk that the client drinks, but also in foods that contain milk as an ingredient. Air-popped corn contains no fat unless butter is added after popping. The client still is able to have a crunchy snack without the fat. Plant proteins such as kidney, black, or lima beans are good sources of protein without the fat from a meat source. 3. Incorrect: Red meats are high in fat. Chicken, fish, and seafood are better meat choices. 5. Incorrect: Olive oil is low in saturated fat but still a source of fat. While olive oil may be a healthier choice, all fats have essentially the same number of calories per serving. The goal is to reduce the amount of fat in the diet.

What symptoms of meningeal irritation would the nurse anticipate when performing an assessment on a newly admitted client with a diagnosis of bacterial meningitis? 1. Positive Kernig's sign 2. Positive Brudzinski's sign 3. Presence of Babinski's reflex 4. Photophobia 5. Severe headache 6. Nuchal rigidity

1,2,4,5,6 1., 2., 4., 5., & 6 Correct: Brudzinski's sign is the involuntary lifting of the legs when the neck is passively flexed (head is lifted off the examining surface). Kernig's sign is positive when the thigh is bent at the hip and knee at 90 degree angles and attempts to extend the knee are painful, resulting in resistance. Both of these signs are thought to indicate meningeal irritation. These seem to be caused when the motor roots become irritated as they pass through inflamed meninges, and the roots are brought under tension. Photophobia (sensitivity to bright light), severe, unrelenting headache, and nuchal rigidity (stiff neck) are all believed to be due to irritation of the meninges. 3. Incorrect: Babinski reflex is a normal reflex in infants up to age 2, but is a pathological reaction in adults. It is often indicative of severe damage to the central nervous system but is not indicative of meningeal irritation.

A client's central venous pressure (CVP) reading has changed significantly from the last hourly reading. Which data would the nurse assess that reflect changes in the CVP reading? 1. Heart sounds 2. Skin turgor 3. Temperature 4. Nail bed color 5. EKG rhythm 6. Urinary output

1,2,6 1., 2. & 6. Correct: The CVP reading reflects the client's fluid volume status. If the CVP is elevated, indicating FVE, then the nurse is likely to hear S3 sounds when auscultating the heart sounds. The client's skin turgor and urine output would reflect the client's fluid volume status. 3. Incorrect: The CVP reading reflects the client's fluid volume status. The client's temperature would not reflect the client's fluid volume status. 4. Incorrect: The CVP reading reflects the client's fluid volume status. The nail bed color would not reflect the client's fluid volume status. 5. Incorrect: The CVP reading reflects the client's fluid volume status. The EKG rhythm would not reflect the client's fluid volume status.

The nurse is providing teaching for a client who is being scheduled for outpatient 24 hour electrocardiogram monitoring using a Holter monitor. What should the nurse tell the client to avoid while monitoring is in progress? 1. Taking a shower or bath 2. Performing daily exercises 3. Working around high voltage equipment 4. Being screened at airport security 5. Eating foods that are sources of potassium

1,3,4 1., 3., and 4. Correct: The nurse should teach this client to continue the usual activities while wearing the monitor with a few exceptions. The monitor should be kept dry to ensure that it functions properly. The client should avoid taking a shower or bath or swimming while wearing the monitor. The electrodes could also become detached from the skin if they get wet, which would also interfere with the accuracy of the reading. The client should be advised to not work around high voltage equipment because areas of high voltage can interfere with the function of the electrocardiogram monitoring. In addition, magnetic fields, such as those used for airport screenings, can interfere with the function of the Holter monitor and should be avoided. 2. Incorrect: This client should be encouraged to continue regular routine unless otherwise directed by the primary healthcare provider. The client can perform the usual daily exercise, but should be advised to avoid activities that may cause excessive perspiration that could lead to the electrodes becoming loosened from the skin. 3. Incorrect: There are generally no dietary restrictions while wearing the Holter monitor unless otherwise prescribed by the primary healthcare provider.

A client requires external radiation therapy. The nurse knows external radiation may cause which problems? 1. Pancytopenia 2. Leukocytosis 3. Erythema 4. Fever 5. Fatigue

1,3,5 1., 3. & 5. Correct: Effects of radiation therapy include, but are not limited to pancytopenia (marked decrease in the number of RBCs, WBCs and platelets), erythema (redness of the skin), and fatigue.2. Incorrect: Leukocytosis is an increase in WBCs. External radiation causes pancytopenia which is a decrease in the number of blood cells including WBCs. 4. Incorrect: Fever is not typically seen with external radiation.

A nurse is teaching a client who has frequent urinary tract infections how to prevent future infections. What statement by the client would indicate to the nurse that treatment has been successful? 1. "I will go to the bathroom as soon as the urge to void hits me." 2. "It is important for me to drink five to six 8 ounce glasses of water every day." 3. "I should eat foods such as plums and prunes to increase the acidity of my urine." 4. "Nylon underwear should be worn when I am free from infection." 5. "When I clean after voiding, I will discard toilet paper after each swipe."

1,3,5 1., 3., & 5. Correct: Holding urine can lead to stasis of urine and increasing the risk for infection. Foods such as eggs, cheese, meat and poultry, whole grains, cranberries, plums and prunes, and tomatoes tend to increase the acidity of urine. Acidic urine is less likely to allow for bacterial growth. Discarding toilet paper after each swipe will decrease exposure and accidental introduction of bacteria into the urinary meatus. 2. Incorrect: Emphasize the importance of drinking eight to ten 8 ounce glasses per day. Water helps flush bacteria from the urinary tract. 4. Incorrect: Cotton underwear is recommended. The natural fibers work to wick moisture away from the skin which discourages yeast growth.

The nurse is teaching a client who is at risk for developing a stroke. What primary prevention strategies should the nurse include? 1. Promote a diet rich in fruits and vegetables. 2. Provide instruction on benefits of carotid endarterectomy. 3. Limit sodium intake to 2 grams/day. 4. Engage in low intensity exercise once a week. 5. Avoid tobacco products. 6. Decrease alcohol consumption to two drinks per day.

1,3,5,6 1., 3., 5., & 6. Correct: These strategies are considered primary prevention strategies that can decrease the risk of developing a stroke. 2. Incorrect: This would be considered secondary prevention: early diagnosis and treatment to prevent stroke. 4. Incorrect: The client needs 3-4 sessions per week of moderate-vigorous intensity aerobic physical exercise to reduce stroke risk factors. Session should last an average of 40 minutes. Moderate intensity exercise is typically defined as sufficient to break a sweat or noticeably raise heart rate (e.g. walking briskly, using an exercise bicycle). Vigorous intensity exercise includes activities such as jogging.

The nurse is sharing best practice for preventing pressure injuries in clients. What should the nurse include? 1. Use moisturizer daily on dry skin. 2. Massage reddened skin areas. 3. Prevent shearing by maintaining the head of bed at 45 degrees or higher. 4. Place rubber ring (donut) under client's sacral area. 5. Position client at 30 degree tilt when placed on side.

1,5 1., & 5. Correct: Moist skin is more pliable than dry skin, so keep dry skin moist by applying moisturizer daily. A good plan for positioning is the 30 degree rule. This plan ensures that the client is positioned and propped so that whatever part of the body is elevated is tilted back to no more than a 30 degree angle to the mattress rather than resting directly on a dependent body prominence. This rule applies to side lying and head of bed elevation positions. 2. Incorrect: Do not massage reddened skin areas. This can damage capillary beds and increase tissue necrosis. 3. Incorrect: Do not keep the head of bed elevated above 30 degrees to prevent shearing. If the client requires greater head elevation because of respiratory problems, they should be tilted up above 30 degrees with pillows behind the back to keep pressure off the sacral/coccyx area. 4. Incorrect: Do not place rubber ring (donut) under client's sacral area. This can cause pressure to the area and can damage capillary beds and increase tissue necrosis. There are products that redistribute tissue load, such as specialty bed mattresses and seat cushions.

The nurse is teaching a group of high school students about car accident prevention. Who would the nurse include as the highest risk for a motor vehicle crash (MVC)? 1. Males who have just turned 19 years of age. 2. Drivers who have recently acquired a driver's license. 3. A group of students that carpool to the senior prom. 4. Female students who drive to weekly football games.

2 2. Correct: According to the Centers for Disease Control and Prevention(CDC), crash risk is particularly high during the first year that teenagers are eligible to drive. Though teenagers who are 19 years old, carpooling to the senior prom, and driving to weekly football games are also at risk for an MVC, they are not the highest-risk teenage group. 1. Incorrect: The risk for all teens is higher than any other driving group, however, by the age of 19, the teen has generally been driving for several years and the statistical risk of having an accident drops. 3. Incorrect: Carpooling to the senior prom does not by itself increase a teen's risk for having a wreck. Driving while under the influence of alcohol will, so a designated driver is key. 4. Incorrect: Driving to a football game weekly does not by itself increase a teen's risk for having an accident. The female gender does not increase the risk of MVC.

A female client receiving chemotherapy for breast cancer reports vomiting, stomatitis, and a 10 pound weight loss over the past month. The primary healthcare provider orders an antiemetic and daily mouthwashes. When the home care nurse evaluates the client one week later, what change described by the client would best indicate improvement? 1. Eating three meals daily. 2. Weight gain of two pounds. 3. No further mouth pain. 4. Improved skin turgor.

2 2. Correct: Chemotherapy typically causes gastrointestinal disturbances severe enough to interfere with a client's ability to eat or absorb nutrients. A ten pound weight loss over one month is significant but expected because of the reported vomiting and stomatitis. A weight gain of two pounds in a week would be the best specific indicator of improvement. 1. Incorrect: The ability to eat three meals daily does not mean that the client is actually absorbing those nutrients successfully. This option suggests that the antiemetic is working well, but there is not enough evidence to demonstrate significant client improvement. 3. Incorrect: The client's denial of any further mouth pain signifies that the mouthwashes have decreased mouth inflammation and stomatitis. While this is a positive change in the client's condition, it is not the best evidence noted by the nurse. 4. Incorrect: Skin turgor specifies the hydration status of a client. Since this client had previously been vomiting, improved skin turgor would indicate the antiemetic is working well and the client is able to retain fluids. While this is a positive change, it is not the most significant indicator of client improvement.

Which nursing intervention represents secondary prevention level? 1. Teaching the effects of alcohol to elementary school children. 2. Providing care for abused women in a shelter. 3. Leading a group of adolescents in drug rehabilitation. 4. Ensuring medication compliance in a client with schizophrenia.

2 2. Correct: Providing care for clients in a shelter for abused women indicates that a problem has been identified and is being monitored to prevent the problem from getting worse. The focus of secondary prevention is early detection, use of referral services, and rapid initiation of treatment to stop the progress of the disease. 1. Incorrect: This is primary prevention which is aimed at reducing the incidence of mental or physical disorders within the population. 3. Incorrect: This is tertiary prevention which is designed to restore self-suffering and to limit complications and disabilities associated with a disease state, such as substance abuse or mental illness. 4. Incorrect: This is tertiary prevention which is designed to restore self-suffering and to limit complications and disabilities associated with a disease state, such as substance abuse or mental illness.

The nurse is caring for a client diagnosed with heat exhaustion. Which finding by the nurse suggests a problem? 1. Temperature 101 degrees F (38.3 degrees C) 2. Hot, dry skin 3. Profuse sweating 4. Headache

2 2. Correct: The body cools itself by sweating and allowing that sweat to evaporate. This requires enough fluid in the body to make sweat, air circulating across the skin, and low enough air humidity to allow that sweat to evaporate. 1. Incorrect: With heat stroke the body's temperature reaches more than 104 degrees F (40 degrees C). 3. Incorrect: Sweating is seen in heat exhaustion. Sweating stops with heat stroke. 4. Incorrect: Clients with heart exhaustion usually have flu like symptoms with headache, weakness, nausea and/or vomiting.

A client has received discharge education post extracapsular cataract surgery. Which statement made by the client indicates to the nurse that further teaching is needed? 1. "A protective eye patch will be needed for 24 hours." 2. "I will notify my primary heathcare provider for any amount of discharge, redness or scratchy feeling because these symptoms are abnormal." 3. "I will clean the surgical eye with a clean tissue, wiping once from the inner aspect of the closed eye to the outer eye." 4. "When sleeping, I will avoid lying on the same side of my affected eye."

2 2. Correct: This is an incorrect statement by the client. Slight morning discharge, some redness, and a scratchy feeling may be expected for a few days." Clients are instructed to report any pain that is unrelieved, redness around the eye, nausea or vomiting to the primary healthcare provider. 1. Incorrect: This is a true statement and does not require intervention. Following surgery, the eye is covered with a patch and a metal or plastic shield for protection from light and trauma. 3. Incorrect: This is the correct way to clean the surgical eye. Cleaning from the inner to outer canthus avoids entrance of microorganisms into the lacrimal duct. 4. Incorrect: This is a correct action. Increased intraocular pressure needs to be avoided. Clients are instructed to avoid sleeping on the operative side.

A nurse educator has completed an educational program on interpreting arterial blood gases (ABGs). The educator recognizes that education has been successful when a nurse selects which set of ABGs as metabolic acidosis? 1. pH - 7.32, PaCO2 - 48, HCO3 - 23 2. pH - 7.29, PaCO2 - 42, HCO3 - 19 3. pH - 7.5, PaCO2 - 30, HCO3 - 22 4. pH - 7.35, PaCO2 - 35, HCO3 - 26

2 2. Correct: This set of ABGs reflects the presence of metabolic acidosis. The pH is low (acidic) and the bicarb is low (decreased buffering ability). The carbon dioxide is normal. 1. Incorrect: This is respiratory acidosis. The pH is low (acidic) and the PaCO2 is high. The bicarb is normal. 3. Incorrect: This is respiratory alkalosis. The pH is increased (alkaline) and the PaCO2 is low. The bicarb is normal. 4. Incorrect: This is an example of normal ABGs.

What preferred lab value would the nurse expect to see the primary healthcare provider prescribe for a client admitted with generalized malnutrition? 1. Albumin 2. Prealbumin 3. Iron 4. Calcium

2 2. Correct: The preferred lab value to screen for generalized malnutrition is prealbumin. This assessment is preferred because it decreases more quickly when nutrition is not adequate. 1. Incorrect: Albumin is a major serum protein that is below normal in clients who have inadequate nutrition. However, it can take weeks to drop. 3. Incorrect: Low serum iron and anemia indicate an iron deficiency. Again, the prealbumin will decrease sooner than other lab values that assess nutrition level. 4. Incorrect: Older women may have low calcium levels which place them at risk for bone demineralization. But, prealbumin provides more data on generalized nutrition.

A client with tuberculosis (TB) has been coming to the health department for directly observed therapy (DOT) for the past month. Today, the client states, "I don't think I need to come back anymore. I am feeling much better now." What should the nurse tell the client? 1. "You have taken your medication long enough so, the primary healthcare provider should discontinue it today." 2. "If you stop taking your medication now, your disease could become resistant to this medication, making it harder for you to be cured." 3. "I will be required to have you arrested if you do not come back for further treatment." 4. "Just let us decide when you should stop taking the medication."

2 2. Correct: This is true regarding TB treatment. The Medication has to be taken for the entire course. The minimal length of time for therapy is 3 months. 1. Incorrect: Treatment usually lasts 4-7 months. If the medication regimen is not strictly and continuously followed, the disease may become drug-resistant. It is not the nurse's place to determine when enough medication has been taken. 3. Incorrect: The nurse needs to discuss the reason for continuing to take the medication. This step is premature and intimidating. Also, threatening to have the client arrested will not likely maintain a good patient-nurse relationship. 4. Incorrect: This statement is non-therapeutic and dismissive of the client. This does not address the client's statement of thinking they have had enough medicine and should stop.

A client returns to the unit post scleral buckling of the right eye. Which nursing interventions should the nurse include? 1. Approach client from the right side. 2. Place personal items within easy reach. 3. Maintain eye patch over right eye. 4. Administer antiemetic for reports of nausea. 5. Assist client to turn, cough, and deep breathe every 2 hours. 6. Place client prone for 1 hour.

2,3,4 2., 3., & 4. Correct: Place all personal articles and the call light within easy reach. These measures prevent stretching and straining by the client. An eye patch or shield will prevent injury to the affected eye. We do not want the client to vomit, so administer an antiemetic for reports of nausea. Vomiting will increase intraocular pressure. 1. Incorrect: Approach the client on the unaffected side. This approach facilitates eye contact and communication. 5. Incorrect: The goal is to prevent anything that will increase intraocular pressure. That means coughing should be avoided. 6. Incorrect: Lying prone will increase intraocular pressure. After surgery for a detached retina, the client is positioned so that the detachment is dependent. For example, if the outer portion of the right retina is detached, the client is positioned on the right side. Positioning so that the detachment is inferior maintains pressure on that area of the retina, improving its contact with the choroid.

What dietary information should the nurse provide to a client diagnosed with Celiac disease? 1. "The most cost effective way to follow the lactose free diet is to eat more fruits and vegetables." 2. "Creamed based canned soups are a source of hidden wheat." 3. "You can eat foods containing fax, corn, or rice." 4. "Avoid foods and beverages that contain malt." 5. "Do not eat traditional wheat products such as pasta."

2,3,4,5 2., 3., 4., & 5. Correct: Soups and sauces are one of the biggest sources of hidden gluten, as many companies use wheat as a thickener. It is always a good idea to read the label of any pre-prepared or canned soups and sauces, paying special attention to those that are cream based. Grains that are naturally gluten free include rice, corn, potato, quinoa, kasha, flax, and nut flours. Malt flavoring or extract, which contains gluten may be found in cornflakes and puffed rice cereal. It is also found in beers, ales, and malt vinegars. As a rule, traditional wheat products such as pastas, breads, crackers, and other baked goods are not gluten-free. However, there are many gluten-free options available that use alternative flours and grains. 1. Incorrect: The client who has Celiac disease is prescribed a gluten free diet rather than a lactose free diet.

A client diagnosed with primary pulmonary hypertension is admitted to the hospital. What does the nurse expect the client to mention when reviewing the client's current treatment regimen? 1. Aminoglycosides 2. Calcium channel blockers 3. Digoxin 4. Diuretics 5. Oxygen 6. Vasodilators

2,3,4,5,6 2., 3., 4., 5., & 6. Correct: Calcium channel blockers are given to help relax the muscles in the walls of the blood vessels. Digoxin can help the heart beat stronger and pump more blood. It can help control the heart rate if dysrhythmias are experienced. Diuretics are prescribed to eliminate excess fluid from the body. Oxygen therapy may be prescribed to treat pulmonary hypertension, especially if the client lives at a high altitude or has sleep apnea. Vasodilators are used to open narrowed blood vessels. 1. Incorrect: Aminoglycosides are antibiotics used to treat infections.

What interventions should the nurse initiate while caring for a client who has a cooling blanket in place? 1. Assess temperature every hour. 2. Perform comparison check with another thermometer periodically. 3. Assess client skin condition hourly. 4. Turn blanket off when temperature is at goal temperature. 5. Observe for signs of chilling.

2,3,5 2., 3., & 5. Correct. Perform comparison check with another thermometer periodically to ensure there is no problem associated with equipment failure. For cooling treatments, extended periods of cooling can cause areas of decreased perfusion, skin burns, and tissue injury. Chilling can increase metabolism and body needs. 1. Incorrect: Check the client's temperature every 15 minutes. If the client is cooled too quickly, chilling, increased metabolism, and adverse reactions may occur. 4. Incorrect: The blanket will not immediately return to room temperature and will continue to cool the client even after it is turned off. Turning it off shortly before the goal temperature is achieved will prevent altering the client's core temperature beyond the desired outcome.

A client reporting right thigh pain is admitted to a local hospital with a diagnosis of deep vein thrombosis (DVT). During the admission assessment, the client develops new signs/symptoms. The nurse would be most concerned about what sign/symptom? 1. Swelling along vein of leg 2. Right foot begins to tingle 3. Restlessness 4. Warmth over affected area

3 3. CORRECT. A change in client's behavior or level of consciousness indicates possible decreased oxygenation to the brain. When there is a known DVT, the nurse would be concerned about a potential stroke from a clot that has broken off from the main thrombus. 1. INCORRECT. The client has just been diagnosed with a right thigh DVT; therefore, symptoms are still evolving. It is not unusual for edema to continue to increase, though the nurse should observe carefully for additional issues. 2. INCORRECT. Tingling of the foot on the affected side is expected since the affected thigh edema and the clot are compressing the circulation and nerves that extend into the foot. The nurse must monitor the situation carefully to prevent further complications. 4. INCORRECT. Pain and warmth are typical early signs of a DVT. Additionally, the tissue becomes red and inflamed from the internal edema. The nurse is aware some of the client's symptoms are still evolving, so this sign is not the most alarming at this time.

A home care nurse is assessing a client with a forearm cast recently applied for a displaced radial fracture. What client comment should the nurse consider the priority concern? 1. "The cast feels tight on my arm." 2. "There is an odd smell inside my cast." 3. "I can't open up my fingers this morning." 4. "The pain medicine is not relieving my pain."

3 3. CORRECT. All the reported problems have the potential to be serious and must be investigated; however, one problem has already occurred and could permanently impair the client's mobility. The inability to extend fingers, particularly in a casted extremity, is a contracture resulting from prolonged ischemia of muscle tissues. Swelling inside the cast causes muscles to shorten and scar, leading to deformities or contractures called Volkmann contractures. Mild cases may be treated with splinting and exercise but severe cases need surgical intervention and possible even transplanted tissues with no guarantee of restored dexterity or mobility. 1. INCORRECT. Obviously a 'really tight' sensation of the arm is of great concern, since swelling could be an early indication of compartment syndrome. However, the nurse should seek further clarification from the client regarding the "tightness" and its exact location. Another problem is of even greater concern. 2. INCORRECT. Many odors could emanate from casting material, from skin breakdown to the odor of drying cast material. The client may even have put something down inside the cast so the smell should definitely be investigated. However, the nurse has greater priority at the moment. 4. INCORRECT. There are many reasons pain medication may not relieve discomfort, including too low a dose or patient noncompliance with medication regime. On-going pain should certainly be investigated as a potential sign of greater problems but this is not the nurse's priority at this time.

A hospitalized client diagnosed with rheumatoid arthritis is receiving IV methylprednisolone every six hours. What is the best method for the nurse to provide client safety? 1. Place "fall precautions" sign above client's bed. 2. Change the intravenous site for steroids daily. 3. Restrict any visitors with visible illnesses. 4. Put client on full contact precautions.

3 3. CORRECT: Rheumatoid arthritis is an autoimmune disease that affects not only body joints but also organs of the body. Receiving methylprednisolone as treatment further suppresses the immune system, making the client even more at risk of infection. Restricting visitors with colds, respiratory problems and other infectious processes is the best method to protect the client. 1. INCORRECT: The question states the diagnosis is rheumatoid arthritis, but there is no indication the client is unsteady or needs to be on "Fall Precautions". Although the client is fatigued and has brittle bones, there is no evidence the client needs assistance ambulating. A sign is not necessary. 2. INCORRECT: Most facilities have policies to change an IV site at specific intervals, usually every three days. Changing the site daily exposes the client to an increased chance of infection from the invasive procedure. Steroids do not irritate veins and do not require frequent site changes. 4. INCORRECT: There is no rationale for contact precautions since the client's disease process is not contagious. The main concern is to protect the client from other individuals.

The nurse is caring for a client admitted with heart failure associated with an acute MI. At which time point did the nurse begin to intervene incorrectly? 1. 1115 2. 1120 3. 1125 4. 1130

3 3. Correct: At 1125, the nurse failed to follow protocol for nitroglycerin infusion. The nurse increased the IV rate by 6 mL/hr (going from 10-20 mcg/min). 1. Incorrect: The nurse mixed the nitroglycerin appropriately and connected the tubing at the correct IV site. The infusion rate was started at 3 mL/hr which delivered the appropriate starting dose at 5 mcg/min. 2. Incorrect: At 1120 the client is still hurting and the BP is above 120 systolic, so the nitroglycerin infusion can be increased by 5 mcg/min which would increase the rate to 6 mL/hr. 4. Incorrect: At 1130 the client is still hurting and the BP is above 120 systolic, so the nitroglycerin infusion can be increased by 5 mcg/min which would increase the rate to 15 mL/hr.

The nurse is preparing to administer scheduled medications for a client. Which medication would require clarification prior to administration? 1. Digoxin 2. Sacubitril/valsartan 3. Bumetanide 4. Potassium chloride

3 3. Correct: Bumetanide is a loop diuretic. What is worrisome about giving this medication is the fact that the client is allergic to sulfonamides. It is contraindicated because there is a cross-sensitivity with thiazides and sulfonamides. 1. Incorrect: Digoxin is a cardiac glycoside. There is nothing in the chart or other medications that prevent this medication from being administered. 2. Incorrect: Sacubitril/valsartan is a combination medication used to reduce the risk of cardiovascular death and hospitalization for heart failure. The client should not take this medication within 36 hours before or after taking any ACE inhibitor or other ARB medication. Watch for hypotension, hyperkalemia, and impaired renal function. There are no indications of adverse effects in this question. 4. Incorrect: Administering potassium chloride is acceptable since this client is on a loop diuretic which depletes potassium and digoxin. You do need to monitor for hyperkalemia as well since the client is on sacubitril/valsartan. The serum potassium level is normal in this client.

A client diagnosed with a hemorrhagic stroke is being transferred to the medical unit from the intensive care unit. Which nursing intervention should the nurse initially implement? 1. Administer an osmotic diuretic. 2. Complete a neurological assessment. 3. Maintain the head of the bed at 30 degrees. 4. Instruct the client to take a stool softener daily.

3 3. Correct: Hemorrhagic strokes are the result of ruptured vessel bleeding in the cranial cavity. This action will result in increased intracranial pressure (ICP). ICP can cause a decrease in the brain's metabolism and hypoxia of the brain tissue. The head of the bed should be elevated to decrease the increased intracranial pressure which can reduce damage to the brain. The intervention of raising the head of the bed to 25 -30 degrees is directly related to a decrease in ICP. 1. Incorrect: An osmotic diuretic is administered to increase the osmotic effect on the kidneys which will decrease ICP. An osmotic diuretic is initiated during the acute care protocol for a stroke. 2. Incorrect: A neurological assessment would be done upon admission to the medical unit. But maintaining the head of the bed at 30 degrees is the initial action. 4. Incorrect: The readiness of the client to learn should be evaluated prior to initiating teaching. Due the client's immediate transfer from ICU, this is not the apparent time to begin to the initiate client teaching. Ways to avoid straining during a bowel movement instruction is not the priority nursing intervention.

A client is admitted to the hospital reporting chills, fatigue and left lower leg pain for nearly a week. During initial assessment, the nurse notes wide-spread swelling and redness of left ankle in addition to a fever of 103.5° F (39.72° C). Which admission order should the nurse implement first? 1. Perform sterile wound care to lower leg. 2. Start I.V. for administration of antibiotics. 3. Place client on bedrest with left leg elevated. 4. Draw blood for serial cultures and lab work.

3 3. Correct: Osteomyelitis is a serious inflammation of bone tissue caused when bacteria or fungus has entered the body through an open wound, an infected prosthetic, or even animal bite. Symptoms include fever, chills, nausea, and fatigue with decreased mobility in the affected extremity. The client can quickly become septic as the illness spreads through the system. Bedrest along with massive doses of antibiotics are necessary to prevent the spread of the infection, resulting in possible bone death or even amputation. 1. Incorrect: Since the nurse is in the process of admitting this client, wound care is not a priority action. There are more urgent orders to be implemented in order to stabilize the client. 2. Incorrect: Intravenous antibiotics are generally prescribed for up to six weeks, and the client may need a PICC line to continue antibiotic therapy in the home setting. While starting an I.V. line for antibiotic administration is important, this is not the most crucial first action. 4. Incorrect: Lab tests can provide valuable diagnostic information about clients with osteomyelitis. The Healthcare provider would most likely order a complete blood count (CBC) and sediment rate, expecting elevations in both. Blood cultures would also confirm whether the infection has become systemic. However, a venipuncture can wait until a more important action has been completed.

A nurse is caring for a client on the second day after a thoracotomy. The client reports incisional pain. The nurse assesses the client and evaluates the vital signs. Based on the data documented in the chart, what action should the nurse take first? 1. Have client cough and deep breathe. 2. Administer acetaminophen for fever 3. Administer the prescribed analgesic 4. Assist the client to ambulate.

3 3. Correct: The client described in this question is post thoracotomy. With ANY post-op client, the number one concern, especially as a brand new nurse, is preventing pneumonia. A thoracotomy is very painful and the client is unlikely to breathe deep unless the pain is relieved. Temperature of 100º F/37.8ºC, HR 92, respirations 24, bilateral crackles (indicating atelectasis) all reveal this client is heading for pneumonia. 1. Incorrect: Coughing and deep breathing exercises are exactly what the client needs, but the client will not cough and deep breathe if it hurts. Give pain medication first. 2. Incorrect: Acetaminophen is not potent enough to relieve pain. The goal is to "fix the problem". The problem is that the client is not properly deep breathing due to pain. 4. Incorrect: Assisting the client to ambulate is a good idea, but the nurse has to fix the problem, and the problem is that the client is not deep breathing.

The nurse is assigned to bathe a client diagnosed with dementia. Which nursing intervention should the nurse implement? 1. Increase the volume of the television. 2. Finish the bath as soon as possible. 3. Clean the face and hair at the end of the bath. 4. Delegate another nurse to distract the client.

3 3. Correct: The client with dementia begins to be separated from reality. Gradually the client will decrease their ability to perform activities of daily living. These steps in the bathing process should be performed last because bathing the face and washing their hair may upset the client. 1. Incorrect: Because the client is having difficulty processing sensory input, the loud volume on the television will increase the anxiety of the client. The television should be turned off during the bath. 2. Incorrect: Finishing the bath as soon as possible does not address the client's inability to process the bath procedure. The client's bath should not be rushed. The nurse should proceed with the bath in a calm and controlled manner that will reduce the client's anxiety. 4. Incorrect: Options that transfer nursing responsibility to other members of the healthcare team usually are incorrect.

A nurse is caring for a client admitted to the hospital for a total hip replacement. In preparing the post-operative plan of care for this client, the nurse recognizes which goal as the highest priority? 1. Prevent complications of shock. 2. Prevent dislocation of prosthesis. 3. Prevent respiratory complications. 4. Prevent skin breakdown.

3 3. Correct: The postoperative client with a total hip replacement is at risk for thromboembolism and fat emboli which can travel to the lungs and cause respiratory distress. Without proper turning, coughing, and deep breathing, pneumonia and atelectasis may occur. So preventing respiratory complications is high on the priority list. Remember the ABCs - airway, breathing, then circulation. Preventing respiratory complications is the highest priority because of the possibility of sudden death from the complications of deep vein thrombosis and pulmonary embolism. 1. Incorrect: This client is at risk for hemorrhage and/or hematoma formation related to surgical trauma to blood vessels (the hip is a very vascular area) and use of anticoagulants or antiplatelet agents before and after surgery. So the nurse will need to monitor for shock caused by loss of volume. The nurse should monitor drains, wound dressings, and intake and output. But remember, Airway and Breathing take priority. 2. Incorrect: Dislocation of the prosthesis is another complication to worry about. It will cause pain and possible deformity and is very important, but airway is the priority. Dislocation of the hip prosthesis is related to weakness of the hip muscles, improper positioning or movement of the operative extremity, and/or noncompliance with weight-bearing limitations.4. Incorrect: The client is at risk for skin breakdown if not turned and repositioned properly or ambulated as soon as prescribed. However, Airway is still the priority for this client.

A client reports excruciating paroxysmal facial pain occurring after feeling a cool breeze and drinking cold beverages. Based on this client's reports, what disorder does the nurse suspect? 1. Bell's palsy 2. Submucous cleft palate 3. Trigeminal neuralgia 4. Temporomandibular joint disorder (TMD)

3 3. Correct: Trigeminal neuralgia is an ongoing pain condition that affects the trigeminal nerve in the face. People who have this condition say the pain feels like an intense electric shock. The pain is triggered by things such as brushing teeth, washing the face, shaving, or putting on makeup. Even a light breeze against the face might trigger the onset of pain. 1. Incorrect: Bell's palsy is a condition in which the muscles on one side of the face become weak or paralyzed. It affects only one side of the face at a time, causing it to droop or become stiff on that side. It is caused by trauma to the facial nerve. 2. Incorrect: A submucous cleft palate (SMCP) results from a lack of normal fusion of the muscles within the soft palate as the fetus is developing in utero. An SMCP can include a very wide or split (bifid) uvula, translucency of the tissue along the middle of the soft palate, and a notch in the back of the hard palate. 4. Incorrect: The temporomandibular joint is a hinge that connects the jaw to the temporal bones of the skull. It allows the jaw to move up and down and side to side, so a person can talk, chew, and yawn. Pain or tenderness in the face, jaw joint area, neck and shoulders, and in or around the ear when chewing, speaking, or opening the mouth wide are signs/symptoms of TMD.

A client is being discharged with halo traction. What should the nurse teach the client and family about home management of this traction? 1. Showering is permitted once a week with assistance. 2. Apply baby lotion under the halo vest to prevent irritation. 3. Sleep in whatever position is found to be most comfortable. 4. Never pull on any part of the halo traction. 5. Clean around pins at least once daily with a new q-tip for each pin site.

3,4,5 3., 4., & 5. Correct: The client may sleep in whatever position is most comfortable. The placement of a rolled-up towel, or pillow, either under the neck, if on back, or under the cheek, if side lying, may be helpful. Never pull on any part of the halo traction. It can damage or loosen the traction. Pin care is done to prevent infection. At home, clean around pins at least once daily with q-tips. Use a new q-tip for each pin site to decrease contamination from one pin site to another. Do not use ointments or antiseptics unless prescribed. 1. Incorrect: Client should never attempt a shower since there is no reliable way to keep vest liner dry. Take sponge baths or sit in a bathtub with about 2-3 inches (5.08-7.62 cm) of water. Use towels or plastic to keep vest from getting wet. 2. Incorrect: Do not use soaps, creams, lotions, or powders beneath the vest as these may irritate the skin.

A client with a history of eczema has been admitted with cellulitis of the left forearm. Which admission order should the nurse question immediately? 1. Start IV of normal saline at 100 mL per hour. 2. Keep left arm elevated on pillow at all times. 3. Apply ice packs to affected area every shift. 4. Ibuprophen 800 mg po every 6 hours prn pain.

3 3. Correct: Cellulitis is a bacterial skin infection resulting in warm, redden and edematous tissue, sometimes accompanied by fever and chills. Swelling in the affected area impedes blood flow and increases pain. In order to decrease the edema, warm, moist compresses are used to stimulate circulation and speed reabsorption of the fluid within the tissue. This order should be questioned immediately. 1. Incorrect: An infection serious enough to require hospitalization indicates this client is either septic or may need intravenous antibiotics. Fluids are a primary treatment for sepsis along with bedrest and antibiotics. A basic solution of normal saline at 100/mL per hour would be an appropriate order for this client. 2. Incorrect: The swelling characteristic in cellulitis in painful and diminishes circulation to the area. Elevation on one or two pillows at all times helps to improve blood flow so that healing can take place. In some facilities, clients are provided with a wedge shaped cushion that provides better support of the affected area. This order is appropriate. 4. Incorrect: Ibuprophen provides relief from both pain and inflammation associated with cellulitis. A dose of 800 milligrams by mouth every 6 hours as needed for pain would be appropriate for this client. This is not an order the nurse should question.

A nurse is planning to teach a group of adult males in their 40's about health care promotion recommendations. Which recommendations should the nurse include? 1. Do bi-annual skin self-exam to check for new moles or changes in moles. 2. Comprehensive eye exam every 5 years starting at age 45. 3. Limit alcohol intake to no more than two drinks per day. 4. Yearly physical exam from a health care provider. 5. Get at least 30 minutes of moderate physical exercise on most days of the week.

3, 5 3, & 5. Correct: If a client must drink alcohol, they should do so only in moderation. For men, that means up to two drinks a day for men age 65 or younger and one drink a day for men over age 65. The risk of various types of cancer, such as liver cancer, appears to increase with the amount of alcohol ingested and the length of time that one has regularly been drinking. Too much alcohol can also raise blood pressure. Physical exercise can go a long way toward managing stress and controlling weight. Controlling stress and obesity can decrease the risk of many health risks such as heart disease, diabetes, and stroke. 1. Incorrect: Do monthly skin self-exam to check for new moles or changes in moles. 2. Incorrect: Comprehensive eye exam every 2 years is recommended. Changes in vision is a relatively common problem for people in their 40s. They may find that glasses are needed for the first time in their life. They may need glasses to see at a distance or for reading. 4. Incorrect: Physical exam every 2-3 years when no health issues exist including height, weight, and BMI. Routine blood tests, urinalysis and mental health screening is conducted at this time.

Which signs and symptoms will the nurse include when teaching a client about indicators of recurrent nephrotic syndrome? 1. Dysuria 2. Hematuria 3. Foamy urine 4. Periorbital edema 5. Weight loss

3. & 4. Correct: Foamy urine, which may be caused by excess protein in the urine, is seen with nephrotic syndrome. Swelling (edema), particularly around the eyes (periorbital) and in the ankles and feet, is a symptom. 1. Incorrect: Dysuria would be a symptom of disorders such as kidney stone or UTI, rather than nephrotic syndrome. 2. Incorrect: Proteinuria rather than hematuria is seen. 5. Incorrect: Weight gain is seen with renal disorders due to poor renal function and increased fluid volume.

A client reports dizziness and weakness while walking down the hall. The nurse notes the client's cardiac rhythm displayed on the telemetry monitor. What actions should the nurse take? Exhibit 1. Have client ambulate back to bed. 2. Initiate 100% oxygen per nonrebreather mask. 3. Obtain client's blood pressure. 4. Prepare for cardioversion. 5. Auscultate lung sounds. 6. Administer nitroglycerin 1 tab SL.

3. & 5. Correct: The client is dizzy and weak. This client is at risk for falling, so think safety and get the client back in bed. Use a wheelchair to accomplish this. Then obtain the client's BP. It may be low indicating poor tissue perfusion to the vital organs. One cause of premature ventricular contractions (PVCs) includes heart failure, so assess the lungs for adventitious sounds. 1. Incorrect: This client is dizzy and weak. Having the client ambulate back to the bed is a safety risk. The client could fall. 2. Incorrect: Oxygen may abate the PVCs; however, it should be initiated at 2 liters/NC rather than at 100%. Start with the least amount of oxygen that could relieve symptoms. 4. Incorrect: Cardioversion is not indicated with an underlying rhythm that is normal (NSR) with PVCs. Oxygen may decrease the PVCs. If not, medication can be administered to decrease the rate of the PVCs. 6. Incorrect: Nitroglycerin would be given if the client is experiencing chest pain or is suspected of having an MI. Get the client back in bed and provide the client with oxygen at 2 L/NC first.

Two days after a client has a chest tube inserted, the nurse notes constant bubbling in the water seal chamber. What action should the nurse take? 1. Do nothing since this is normal. 2. Decrease the amount of suction. 3. Replace CDU unit with another one. 4. Notify primary healthcare provider.

4 4. CORRECT: The water seal chamber is the middle of the three chambers and helps to create the one-way flow of drainage and air from the client to the CDU. The water seal chamber should bubble only intermittently when the client coughs, sneezes or breathes, creating a fluctuation of the water known as "tidaling". Constant bubbling in that chamber indicates an air leak somewhere in the system. Because the nurse cannot fix this independently, the primary healthcare provider must make that determination. 1. INCORRECT: The water seal chamber helps create the one-way flow of drainage and air from the pleural space to the CDU. Constant bubbling in that chamber is not normal. 2. INCORRECT: Constant bubbling in the water seal chamber is not controlled by the amount of suction. Decreasing suction would not alter the type of bubbling in the middle chamber. 3. INCORRECT: Though the nurse may discover damage to the CDU unit itself, simply replacing the unit with a new one may not correct the problem in the water seal chamber.

The nurse is teaching a community education class on alternative therapies. Which alternative therapy that uses substances found in nature should the nurse include? 1. Energy therapies. 2. Mind-body interventions. 3. Body-based methods. 4. Biologically-based therapies.

4 4. Correct: Biologically-based therapies use substances found in nature such as herbs, foods, and vitamins. 1. Incorrect: Energy therapies use energy fields. Substances found in nature are biologically-based therapies. 2. Incorrect: Mind-body interventions use the mind to help affect the function of the body. Substances found in nature are biologically-based therapies. 3. Incorrect: Body-based methods use movement of the body. Substances found in nature are biologically-based therapies.

Which client should the nurse recognize as being at greatest risk for the development of cancer? 1. Smoker for 30 plus years 2. Body builder taking steroids and using tanning salons 3. Newborn with multiple birth defects 4. Older individual with acquired immunodeficiency syndrome

4 4. Correct: Cancer has a high incidence in the immune deficiency client and in the older adult with both of these risk factors together, this one is the highest risk for cancer. 1. Incorrect: Although smoking is a known environmental carcinogen, this one risk factor alone is not the highest risk. 2. Incorrect: These are known environmental carcinogens, but do not rank as highly as aging and immune deficiency. 3. Incorrect: Birth defects are not a risk factor for cancer.

A client is admitted for management of ulcerative colitis. What sign/symptom would be of immediate concern to the nurse? 1. Tenesmus 2. Hyperactive bowel sounds 3. Ten bloody diarrhea stools in 8 hours 4. Abdominal guarding

4 4. Correct: Guarding is a completely involuntary response of the muscles. In other words, you have no control over it. It's a sign that your body is trying to protect itself from pain. It can be a symptom of a very serious and even life-threatening medical condition. 1. Incorrect: Tenesmus is the urge to move your bowels even if you've just emptied your colon. This is a common symptom of an ulcerative colitis flair and would not be of immediate concern to the nurse. 2. Incorrect: Hyperactive bowel sounds can mean there is an increase in intestinal activity. This may happen with diarrhea or after eating. This client has ulcerative colitis so hyperactive bowel sounds during a flare is expected. 3. Incorrect: The colon is ulcerated and unable to absorb water, so 10-20 bloody diarrhea stools are the most common symptom of ulcerative colitis and would not be of immediate concern to the nurse.

In what position should the nurse place a client diagnosed with gastric reflux? 1. Orthopneic 2. Semi-Fowler's 3. Sims' 4. Reverse Trendelenburg

4 4. Correct: The entire bed is tilted with the foot of the bed lower than the head of the bed. This position promotes gastric emptying and prevents esophageal reflux. 1. Incorrect: Orthopneic position has the client sit in the bed or at the bedside. A pillow is placed on the over-bed table, which is placed across the client's lap. The client rests arms on the over-bed table. This position allows for chest expansion and is especially beneficial to clients with COPD. 2. Incorrect: The head of the bed is elevated 30 degrees. This position is useful for clients who have cardiac, respiratory, and neurological problems and is often optimal for clients who have a nasogastric tube in place. 3. Incorrect: Sims' or semi-prone position has the client on the side halfway between lateral and prone positions. Weight is on the anterior ileum, humerus, and clavicle. The lower arm is behind the client while the upper arm is in front. Both legs are flexed but the upper leg is flexed at a greater angle than the lower leg at the hip as well as at the knee. This is a comfortable sleeping position for many clients, and it promotes oral drainage.

A client with a terminal illness, asks the nurse about palliative care. What would be the nurse's best response? 1. Palliative care is a holistic way of finding a cure for a serious illness. 2. Palliative care begins when the client has 3 months or less to live. 3. Palliative care will require you to change to a palliative care healthcare provider. 4. Palliative care prevents and treats symptoms and side effects of disease and treatments.

4 4. Correct: This is a correct statement. The goal of palliative care is to help the client living with a chronic, life threatening illness. It focuses on the client's symptoms and the relief of these symptoms. Palliative care helps the client obtain their best quality of life throughout the course of their illness. 1. Incorrect: Palliative care is not aimed at cure. It is provided to clients who have chronic, life threatening illnesses. 2. Incorrect: Palliative care can begin at diagnosis. Hospice care is usually offered when the person has 6-12 months or less to live. 3. Incorrect: The client does not need to give up his or her primary healthcare provider. This is not a requirement of palliative care.

A renal transplant client has received discharge education. Which statement by the client indicates that further teaching is necessary? 1. "I will need to notify my primary healthcare provider if I develop a fever." 2. "I need to check my BP daily and report an increased B/P." 3. "I will tell my primary healthcare provider if I become easily fatigued." 4. "I will be on steroids for 3 months, then I will not have to take them."

4 4. Correct: This statement indicates a need for further teaching. Doses of immunosupressive agents are often adjusted, but the client will be required to take some form of immunosuppressive therapy for the entire time that the client has the transplanted kidney. 1. Incorrect: Yes, fever is a sign of post transplant rejection. Additional signs and symptoms include oliguria, edema, increasing blood pressure, weight gain and swelling or tenderness over the transplanted kidney, flu-like symptoms, shortness of breath and/or fatigue. 2. Incorrect: Yes, hypertension is a sign of post transplant rejection. Additional signs and symptoms include oliguria, edema, increasing blood pressure, weight gain and swelling or tenderness over the transplanted kidney, flu-like symptoms, shortness of breath and/or fatigue. 3. Incorrect: Yes, fatigue is a sign of post transplant rejection. Additional signs and symptoms include oliguria, edema, increasing blood pressure, weight gain and swelling or tenderness over the transplanted kidney, flu-like symptoms, shortness of breath.

Which statement by a client would indicate to the nurse that education about gastroesophageal reflux disease (GERD) has been successful? 1. It would be better for me to eat 3 small meals a day. 2. I need to avoid eating foods high in purine. 3. When going to sleep, I should lie on my side. 4. My last daily meal should not be within 2 hours of bedtime.

4 4. Correct: To avoid reflux the client should not eat within 2 hours of bedtime. Late night meals may increase discomfort and should be avoided.1. Incorrect: The client should eat at least 6 smaller meals per day to help decrease reflux. Small, frequent meals help prevent over distention of the stomach. 2. Incorrect: The client with GERD should avoid high fat foods and increase high protein foods in an effort to lose weight. Eliminate foods high in purine with disorders such as gout. 3. Incorrect: The client should sleep with the HOB elevated on six inch blocks and several pillows under the upper body. Gravity fosters esophageal emptying.

A nurse is providing care to a post-operative parathyroidectomy client. Which occurrence takes highest priority? 1. Psychoses 2. Renal calculi 3. Positive Trousseau's sign 4. Laryngospasm

4 4. Correct: Yes, airway is most important here. But don't pick it just because it sounds scary all by itself. Think about the why. When the parathyroids are removed, calcium is affected because these glands help control calcium levels in the blood. 1. Incorrect: This is disturbing, and important, but AIRWAY is priority. 2. Incorrect: Renal calculi can cause problems and lead to pain and possibly renal failure but are not as important as airway obstruction. 3. Incorrect: A positive Trousseau's sign is seen with hypocalcemia but is not the highest priority. Airway is the most important in this question.

A nurse caring for a client diagnosed with osteomyelitis instructs an experienced unlicensed assistive personnel (UAP) to obtain vital signs on the client. Which value should the nurse tell the UAP to report immediately? 1. Heart rate 98/min 2. Respirations 22/min 3. Blood pressure 138/82 4. Temperature 101°F (38.3°C)

4. Correct: An elevated temperature indicates infection and inflammation and should be reported to the healthcare provider. The client may need IV antibiotics. 1. Incorrect: This is within normal limits. 2. Incorrect: Although slightly above normal (16-20/min), this respiratory rate does not indicate a problem for this client. 3. Incorrect: This is within normal limits.