Med Surg HESI Practice Exam

Small bowel obstruction is a condition characterized by which finding?

Severe fluid and electrolyte imbalances. Rationale Among the findings characteristic of a small bowel obstruction is the presence of severe fluid and electrolyte imbalances.

What types of medications should the nurse expect to administer to a client during an acute respiratory distress episode?

Bronchodilators and steroids. Rationale Besides supplemental oxygen, this client with ARDS needs medications to widen air passages, increase air space, and reduce alveolar membrane inflammation, such as bronchodilators and steroids.

The nurse is taking a history of a newly diagnosed Type 2 diabetic who is beginning treatment. Which subjective information is most important for the nurse to note?

An allergy to sulfa drugs. Rationale An allergy to sulfa drugs may make the client unable to use some of the most common antihyperglycemic agents (sulfonylureas). The nurse needs to highlight this allergy for the healthcare provider.

A client's susceptibility to ulcerative colitis is most likely due to which aspect in the client's history?

Jewish European ancestry. Rationale Ulcerative colitis is 4 to 5 times more common among individuals of Jewish European or Ashkenazi ancestry.

A client who is HIV positive asks the nurse, "How will I know when I have AIDS?" Which response is best for the nurse to provide?

"AIDS is diagnosed when a specific opportunistic infection is found in an otherwise healthy individual." Rationale AIDS is diagnosed when one of several processes defined by the CDC is present in an individual who is not otherwise immunosuppressed (PCP, candidacies, cryptococcus, cryptosporidiosis, Kaposi's sarcoma, CNS lymphomas) and/or a CD4+ T cell countless than 200 (normal count 1,000).

A client who is receiving chemotherapy asks the nurse, "Why is so much of my hair falling out each day?" Which response by the nurse best explains the reason for alopecia?

"Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant." Rationale The common adverse effects of chemotherapy (nausea, vomiting, alopecia, bone marrow depression) are due to chemotherapy's effect on the rapidly reproducing cells, both normal and malignant.

The nurse is completing an admission interview and assessment on a client with a history of Parkinson's disease. Which question provides information relevant to the client's plan of care?

"Have you ever been 'frozen' in one spot, unable to move?" Rationale Clients with Parkinson's disease frequently experience difficulty in initiating, maintaining, and performing motor activities. They may even experience being rooted to a spot and unable to move, refer to as being "frozen" in one spot.

A 20-year-old female client calls the nurse to report a lump she found in her breast. Which response is the best for the nurse to provide?

"Most lumps are benign, but it is always best to come in for an examination." Rationale The nurse advising the client to come in provides the best response because it addresses the client's anxiety most effectively and encourages prompt and immediate action for a potential problem.

A 57-year-old male client is scheduled to have a stress-thallium test the following morning and is NPO after midnight. At 0130, he is agitated because he cannot eat and is demanding food. Which response is best for the nurse to provide to this client?

"The test you are having tomorrow requires that you have nothing by mouth tonight." Rationale Being direct and explaining to the client that the test requires him to be NPO, is the most therapeutic statement because the nurse is responding to the client's question and providing him the reason why.

After the fourth dose of gentamicin sulfate (Garamycin) IV, the nurse plans to draw blood samples to determine peak and trough levels. When are the best times to draw these samples?

5 minutes before and 30 minutes after the next dose. Rationale Peak drug serum levels are achieved 30 minutes after the completion of the IV infusion of gentamicin sulfate. The best time to draw a trough is the closest time to the next administration.

Which finding should the nurse identify as most significant for a client diagnosed with polycystic kidney disease (PKD)?

3+ bacteria in urine. Rationale Urinary tract infections (UTI) for a client with PKD require prompt antibiotic therapy to prevent renal damage and scarring which may cause further progression of the disease, so bacteria in the urine is the most significant finding at this time.

In assessing cancer risk, the nurse identifies which woman as being at greatest risk of developing breast cancer?

A 50-year-old whose mother had unilateral breast cancer. Rationale The most predictive risk factors for development of breast cancer are over 40 years of age and a positive family history (occurrence in the immediate family, i.e., mother or sister). Other risk factors include nulliparity, no history of breastfeeding, early menarche and late menopause, but are not considered as predictive as a positive history of an immediate family member and over 40 years old.

A client taking a thiazide diuretic for the past six months has a serum potassium level of 3. The nurse anticipates which change in prescription for the client?

A potassium supplement will be prescribed. Rationale This client's potassium level is too low (normal is 3.5 to 5). Taking a thiazide diuretic often results in a loss of potassium, so a potassium supplement needs to be prescribed to restore a normal serum potassium level.

While working in the emergency room, the nurse is exposed to a client with active tuberculosis. When should the nurse plan to obtain a tuberculin skin test?

Four to six weeks after the exposure. Rationale A tuberculin skin test is effective 4 to 6 weeks after an exposure, so the individual with a known exposure should wait 4 to 6 weeks before having a tuberculin skin test.

A female client requests information about using the calendar method of contraception. Which assessment is most important for the nurse to obtain?

An accurate menstrual cycle diary for the past 6 to 12 months. Rationale The fertile period, which occurs 2 weeks prior to the onset of menses, is determined using an accurate record of the number of days of the menstrual cycles for the past 6 months, so it is most important to emphasize to the client that accuracy and being compliant in recording the menstrual diary is the basis of the calendar method.

A male client who smokes two packs of cigarettes a day states he understands that smoking cigarettes is contributing to the difficulty that he and his wife are having in getting pregnant and wants to know if other factors could be contributing to their difficulty. What information is best for the nurse to provide? (Select all that apply.)

Alcohol consumption can cause erectile dysfunction. Low testosterone levels affect sperm production. Cessation of smoking improves general health and fertility. Rationale Use of tobacco, alcohol, and marijuana may affect sperm counts. Sperm count is also negatively affected by low testerone levels and obesity.

The nurse is assisting a client out of bed for the first time after surgery. What action should the nurse do first?

Allow the client to sit with the bed in a high Fowler's position. Rationale The first step is to raise the head of the bed to a high Fowler's position, which allow venous return to compensate from lying flat and the vasodilation effects of perioperative drugs. This helps prevent the client from becoming light-headed and decreases the chance of a client fall.

A client with diabetes mellitus is experiencing polyphagia. Which outcome statement is the priority for this client?

Adequate cellular nourishment. Rationale Diabetes mellitus Type 1 is characterized by hyperglycemia that precipitates glucosuria and polyuria (frequent urination), polydipsia (excessive thirst), and polyphagia (excessive hunger). Polyphagia is a consequence of cellular malnourishment when insulin deficiency prevents utilization of glucose into the cell for energy, so the outcome statement should include stabilization of adequate cellular nutrition which is done by providing the insulin supplement the client needs.

A female client taking oral contraceptives reports to the nurse that she is experiencing calf pain. What action should the nurse implement?

Advise the client to notify the healthcare provider for immediate medical attention. Rationale Calf pain is indicative of thrombophlebitis, a serious, life-threatening complication associated with the use of oral contraceptives which requires further assessment and possibly immediate medical intervention.

Two days postoperative, a male client reports aching pain in his left leg. The nurse assesses redness and warmth on the lower left calf. What intervention would be most helpful to this client?

Advise the client to remain in bed with the leg elevated. Rationale The client is exhibiting symptoms of deep vein thrombosis (DVT), a complication of immobility. The initial care includes bedrest and elevation of the extremity.

During an interview with a client planning elective surgery, the client asks the nurse, "What is the advantage of having a preferred provider organization insurance plan?" Which response is best for the nurse to provide?

An individual may select healthcare providers from outside of the PPO network. Rationale The financial implication of selecting a provider from outside of the network is the feature most relevant to the average consumer. The nurse must have knowledge about PPOs, which provides the option for the consumer to select a Healthcare Provider (HPO) from within the PPO network (in-network) at a reduced cost versus higher cost for selecting an out-of-network HCP.

Which intervention should the nurse implement for a female client diagnosed with pelvic relaxation disorder?

Encourage the client to perform Kegel exercises 10 times daily. Rationale Pelvic relaxation disorders are structural disorders resulting from weakening support tissues of the pelvis. Kegel exercises helps strengthen the surrounding muscles.

A client taking furosemide (Lasix), reports difficulty sleeping. What question is important for the nurse to ask the client?

At what time do you take your medication?" Rationale The nurse needs to first determine at what time of day the client takes the Lasix. Because of the diuretic effect of Lasix, clients should take the medication in the morning to prevent nocturia which may be the reason for the sleep difficulties.

During suctioning, a client with an uncuffed tracheostomy tube begins to cough violently and dislodges the tracheostomy tube. Which action should the nurse implement first?

Attempt to reinsert the tracheostomy tube. Rationale The nurse should attempt to reinsert the tracheostomy tube by using a hemostat to open the tracheostomy or by grasping the retention sutures (if present) to spread the opening in insert a replacement tube (with its obturator) into the stoma. Once in place, the obturator should immediately be removed.

A female client is brought to the clinic by her daughter for a flu shot. She has lost significant weight since the last visit. She has poor personal hygiene and inadequate clothing for the weather. The client states that she lives alone and denies problems or concerns. What action should the nurse implement?

Collect further data to determine whether self-neglect is occurring. Rationale Changes in weight and hygiene may be indicators of self-neglect or neglect by family members. Further assessment is needed before notifying social services or discussing a need for counseling.

Which milestone indicates to the nurse successful achievement of young adulthood?

Completes education and becomes self-supporting. Rationale Transitioning through young adulthood is characterized by establishing independence as an adult, and includes developmental tasks such as completing education, beginning a career, and becoming self-supporting (B). (A and C) are characteristic of adolescence. Although strong bonds with parents are an expected finding for this age group, the need for support and approval (D) indicates dependency, which is a developmental delay.

An elderly client is admitted with a diagnosis of bacterial pneumonia. The nurse's assessment of the client will most likely reveal which sign/symptom?

Confusion and tachycardia. Rationale The onset of pneumonia in the elderly may be signaled by general deterioration, confusion, increased heart rate or increased respiratory rate due to the decreased oxygen- carbon dioxide exchange at the alveoli, known as the V-Q mismatch.

A 58-year-old client who has been post-menopausal for five years is concerned about the risk for osteoporosis because her mother has the condition. Which information should the nurse offer?

Calcium loss from bones can be slowed by increasing calcium intake and exercise. Rationale Post-menopausal females are at risk for osteoporosis due to the cessation of estrogen secretion, but a regimen including calcium, vitamin D, and weight-bearing exercise can help prevent further bone loss.

The nurse notes that the only ECG for a 55-year-old male client scheduled for surgery in two hours is dated two years ago. The client reports that he has a history of "heart trouble," but has no problems at present. Hospital protocol requires that those over 50 years of age have a recent ECG prior to surgery. What nursing action is best for the nurse to implement?

Call for an ECG to be performed immediately. Rationale According to the hospital policy, clients over the age of 50 and/or with a history of cardiovascular disease, should receive ECG evaluation prior to surgery, generally 24 hours to two weeks before. The nurse needs to first arrange for an ECG to be performed immediately prior to surgery.

The nurse is caring for a client with a continuous feeding through a percutaneous endoscopic gastrostomy (PEG) tube. Which intervention should the nurse include in the plan of care?

Check for tube placement and residual volume q4 hours. Rationale Tube placement and residual volume should be checked every four hours for clients on continuous feeding. If the gastric residual is more than 200mL for an adult client; stop the feeding and re-check the gastric residual one hour later. If the residual still remains more than 200mL; continue to keep the feeding on hold and contact the client's health care provider.

A client who is fully awake after a gastroscopy asks the nurse for something to drink. After confirming that liquids are allowed, which assessment action should the nurse consider a priority?

Check the client's gag and swallow reflexes. Rationale Following gastroscopy, a client should remain nothing by mouth until the effects of local anesthesia have dissipated and the airway's protective reflexes, gag and swallow reflexes have returned.

The nurse is assessing a client with bacterial meningitis. Which assessment finding indicates the client may have developed septic emboli?

Cyanosis of the fingertips. Rationale Septic emboli secondary to meningitis commonly lodge in the small arterioles of the extremities, causing a decrease in circulation to the hands which may lead to gangrene.

The nurse is interviewing a male client with hypertension. Which additional medical diagnosis in the client's history presents the greatest risk for developing a cerebral vascular accident (CVA)?

Diabetes mellitus. Rationale According to the National Stroke Association (2013), history of diabetes mellitus poses the greatest risk for developing a CVA, 2-4Xs more than those who do not have diabetes mellitus. The reason for this occurrence is related to the excess glucose circulating throughout the body not being utilizing by the cells of the body, leading to the increased fatty deposits or clots inside the blood vessels in the brain or neck, eventually causing a stroke.

The nurse assesses a client with advanced cirrhosis of the liver for signs of hepatic encephalopathy. Which finding would the nurse consider an indication of progressive hepatic encephalopathy?

Difficulty in handwriting. Rationale A daily record in handwriting may provide evidence of progression or reversal of hepatic encephalopathy leading to coma (D). (A) is a sign of ascites. (B) are not seen with hepatic encephalopathy. (C) does not indicate an increase in serum ammonia level which is the primary cause of hepatic encephalopathy.

A client experiencing uncontrolled atrial fibrillation is admitted to the telemetry unit. What initial medication should the nurse anticipate administering to the client?

Digoxin (Lanoxin). Rationale Digoxin (Lanoxin) is administered for uncontrolled, symptomatic atrial fibrillation resulting in a decreased cardiac output. Digoxin slows the rate of conduction by prolonging the refractory period of the AV node, thus slowing the ventricular response, decreasing the heart rate, and effecting cardiac output.

The nurse is caring for a client with a stroke resulting in right-sided paresis and aphasia. The client attempts to use the left hand for feeding and other self-care activities. The spouse becomes frustrated and insists on doing everything for the client. Based on this data, which nursing diagnosis should the nurse document for this client?

Disabled family coping related to dissonant coping style of significant person. Rationale A stroke affects the whole family and in this case the spouse probably thinks that she is helping and needs to feel that she is contributing to the client's care. Her help is noted as being incongruent with attempts of self-care by the client thereby disabling family coping.

A 49-year-old female client arrives at the clinic for an annual exam and asks the nurse why she becomes excessively diaphoretic and feels warm during nighttime. What is the nurse's best response?

Discuss perimenopause and related comfort measures. Rationale The perimenopausal period begins about 10 years before menopause with the cessation of menstruation at the average ages of 52 to 54. Lower estrogen levels causes FSH and LH secretion in bursts (surges), which triggers vasomotor instability, night sweats, and hot flashes, so discussions about the perimenopausal body's changes, comfort measures, and treatment options should be provided.

The nurse is teaching a female client who uses a contraceptive diaphragm about reducing the risk for toxic shock syndrome (TSS). Which information should the nurse include? (Select all that apply.)

Do not leave the diaphragm in place longer than 8 hours after intercourse. Replace the old diaphragm every 3 months. Rationale The diaphragm needs to remain against the cervix for 6 to 8 hours to prevent pregnancy but should not remain for longer than 8 hours to avoid the risk of TSS. The diaphragm should be replaced every 3 months to maintain integrity.

A client is admitted to the medical intensive care unit with a diagnosis of myocardial infarction. The client's history indicates the infarction occurred ten hours ago. Which laboratory test result would the nurse expect this client to exhibit?

Elevated CK-MB. Rationale The cardiac isoenzyme CK-MB (C) is the one of the cardiac markers to indicate myocardial damage in the presence of MI symptoms and after a positive troponin. The troponin levels will elevate within 2-3 hours indicating myocardial ischemia, followed by the CK-MB cardiac markers within 6-9 hours, peaking within 12 to 20 hours after myocardial infarction (MI).

When providing discharge teaching for a client with osteoporosis, the nurse should reinforce which home care activity?

Elimination of hazards to home safety. Rationale Discussion about fall prevention strategies is imperative for the discharged client with osteoporosis so that advice about safety measures in the home should be done such as the elimination of throw rugs and proper lighting to minimize trip hazards and falls.

Which postmenopausal client's complaint should the nurse refer to the healthcare provider?

Episodes of vaginal bleeding. Rationale Postmenopausal vaginal bleeding may be an indication of endometrial cancer, which should be reported to the healthcare provider.

A postmenopausal client asks the nurse why she is experiencing discomfort during intercourse. What response is best for the nurse to provide?

Estrogen deficiency causes the vaginal tissues to become dry and thinner. Rationale Estrogen deprivation decreases the moisture-secreting capacity of vaginal cells, so vaginal tissues tend to become thinner, drier, and the rugae become smoother which reduces vaginal stretching that contributes to dyspareunia. The discomfort during intercourse, primary cause can be contributed to the decrease in estrogen hormone levels.

A male client receives a local anesthetic during surgery. During the post-operative assessment, the nurse notices the client is slurring his speech. Which action should the nurse take?

Evaluate his blood pressure, pulse, and respiratory status. Rationale Slurred speech in the post-operative client who received a local anesthetic is an atypical finding and may indicate neurological deficits that require further assessment, so obtaining the client's vital signs will provide information about possible cardiovascular complications, such as stroke.

A client has undergone insertion of a permanent pacemaker. When developing a discharge teaching plan, the nurse writes a goal of, "The client will verbalize symptoms of pacemaker failure." Which symptoms are most important to teach the client?

Feelings of dizziness. Rationale Feelings of dizziness may occur as the result of a decreased heart rate, leading to a decreased cardiac output which may be an indication of pacemaker failure.

What is the correct procedure for performing an opthalmoscopic examination on a client's right retina?

From a distance of 12 to 15 inches and slightly to the side, shine the light into the client's pupil. Rationale The client should focus on a distant object behind the examiner who should stand at 12-15 inches away and to the side of his/her line of vision. The examiner should hold the ophthalmoscope firmly against his/her face and then direct it at the client's pupil.

A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg. Which action should the nurse implement?

Give an antihypertensive medication. Rationale Most ischemic strokes occur during sleep when baseline blood pressure declines or blood viscosity increases due to minimal fluid intake. Completed strokes usually produce neurologic deficits within an hour, and the client's current elevated blood pressure requires antihypertensive medication.

A middle-aged male client with diabetes continues to eat an abundance of foods that are high in sugar and fat. According to the Health Belief Model, which event is most likely to increase the client's willingness to become compliant with the prescribed diet?

He visits his diabetic brother who just had surgery to amputate an infected foot. Rationale The loss of a limb due to diabetes by a family member should be the strongest event or "cue to action" and is most likely to increase the client's perceived seriousness of the disease.

Which symptoms should the nurse expect a client to exhibit who is diagnosed with a pheochromocytoma?

Headache, diaphoresis, and palpitations. Rationale Pheochromocytoma is a catecholamine secreting non-cancerous tumor of the adrenal medulla, and a headache, profuse sweating and palpitations is the typical triad of symptoms depending upon the relative proportions of epinephrine and norepinephrine secretion. Surgical removal of the tumor is the only treatment.

An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that his tongue is somewhat cracked and his eyeballs are sunken into his head. What nursing intervention is indicated?

Help the client to determine ways to increase his fluid intake. Rationale The nurse should suggest creative methods to increase the intake of fluids, such as having disposable fruit juices readily available. Clients with COPD should be encouraged to have at least three liters of fluids a day to help keep their mucus thin. As the disease progresses, these clients often reduce fluid intake because of shortness of breath experience while drinking and due to the fact, they may be on diuretics related to heart involvement with the disease and may purposely limit their fluid intake to decrease the need for elimination.

The nurse is receiving report from surgery about a client with a penrose drain who is to be admitted to the postoperative unit. Before choosing a room for this client, which information is most important for the nurse to obtain?

If the client's wound is infected. Rationale Penrose drains provide a sinus tract or opening and are often used to provide drainage of an abscess. The fact that the client has a penrose drain should alert the nurse to the possibility that the client is infected. To avoid contamination of another postoperative client, it is most for the nurse to verify the condition of the wound and if infected, important to place client in a private room.

A client is placed on a mechanical ventilator following a cerebral hemorrhage, and vecuronium bromide (Norcuron) 0.04 mg/kg q12 hours IV is prescribed. What is the priority nursing diagnosis for this client?

Impaired communication related to paralysis of skeletal muscles. Rationale To increase the client's tolerance of endotracheal intubation and/or mechanical ventilation, a skeletal-muscle relaxant, such as vecuronium, is usually prescribed. Impaired communication is a serious outcome because the client cannot communicate his/her needs due to intubation and diaphragmatic paralysis caused by the drug.

A 32-year-old female client complains of severe abdominal pain each month before her menstrual period, painful intercourse, and painful defecation. Which additional history should the nurse obtain that is consistent with the client's complaints?

Inability to get pregnant. Rationale Dysmenorrhea, dyspareunia, and difficulty or painful defecation are common symptoms of endometriosis, which is the abnormal displacement of endometrial tissue in the dependent areas of the pelvic peritoneum. A history of infertility is another common finding associated with endometriosis.

The nurse is providing dietary instructions to a 68-year-old client who is at high risk for development of coronary heart disease (CHD). Which information should the nurse include?

Increase intake of soluble fiber to 10 to 25 grams per day. Rationale To reduce risk factors associated with coronary heart disease, the daily intake of soluble fiber should be increased to between 10 and 25 gm. According to the American Heart Association, soluble fibers helps reduce the LDL cholesterol levels.

The nurse knows that lab values sometimes vary for the older client. Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old male?

Increased protein in the urine, slightly increased serum glucose levels. Rationale As older adults aged, the protein found in urine slightly rises as a result of kidney changes and the serum glucose increases slightly, also due to changes in the kidney. The specific gravity declines by age 80 from 1.032 to 1.024.

A client has a staging procedure for cancer of the breast and ask the nurse which type of breast cancer has the poorest prognosis. Which information should the nurse offer the client?

Inflammatory with peau d'orange. Rationale Inflammatory breast cancer onset is very rapid and a very rare form of breast cancer and is considered the most aggressive form of breast malignancies. It is often mistaken for a breast infection because it has a thickened appearance like an orange peel (peau d'orange), causing the breast to become swollen and tender.

A 51-year-old truck driver who smokes two packs of cigarettes a day and is 30 pounds overweight is diagnosed with having a gastric ulcer. What content is most important for the nurse to include in the discharge teaching for this client?

Information about smoking cessation. Rationale Smoking has been associated with ulcer formation, and stopping or decreasing the number of cigarettes smoked per day is an important aspect of ulcer management.

The nurse is working with a 71-year-old obese client with bilateral osteoarthritis (OA) of the hips. What recommendation should the nurse make that is most beneficial in protecting the client's joints?

Initiate a weight-reduction diet to achieve a healthy body weight. Rationale Achieving a healthy weight is critical to protect the joints of clients with OA. Weight loss for obese clients will take off the excess pressure that weight bearing joints such as the hips and knees are exposed to and reduce the wear and tear of the joints.

A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L. Which action is most important for the nurse to implement?

Initiate continuous cardiac monitoring. Rationale Hypokalemia (normal 3.5 to 5 mEq/L) causes changes in myocardial irritability and ECG waveform, so it is most important for the nurse to initiate continuous cardiac monitoring to identify ventricular ectopy or other life-threatening dysrhythmias. After cardiac monitoring is initiated, then the potassium chloride should be given so that the effects of potassium replacement on the cardiac rhythm can be monitored.

A client receiving cholestyramine (Questran) for hyperlipidemia should be evaluated for what vitamin deficiency?

K. Rationale This drug is administered to help lower the triglycerides levels. One of the side effects clients should be monitored for an increased prothrombin time and prolonged bleeding times which would alert the nurse to a vitamin K deficiency. These drugs reduce absorption of the fat soluble (lipid) vitamins A, D, E, and K.

A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which assessment finding should the nurse expect this client to exhibit?

Lower left quadrant pain and a low-grade fever. Rationale Left lower quadrant pain occurs with diverticulitis because the sigmoid colon is the most common area for diverticula, and the inflammation of diverticula causes a low-grade fever.

A client is admitted for further testing to confirm sarcoidosis. Which diagnostic test provides definitive information that the nurse should report to the healthcare provider?

Lung tissue biopsy. Rationale Sarcoidosis is an inflammatory condition that is characterized by the formation of widespread granulomatous lesions involving a pulmonary primary site. Although chest radiography identifies sarcoidosis, lung tissue biopsy obtained by bronchoscopy or bronchoalveolar lavage provides definitive confirmation.

The nurse is planning care to prevent complication for a client with multiple myeloma. Which intervention is most important for the nurse to include?

Maintain a fluid intake of 3 to 4 L per day. Rationale Multiple myeloma is a malignancy of plasma cells that infiltrate bone causing demineralization and hypercalcemia, so maintaining a urinary output of 1.5 to 2 L per day requires an intake of 3 to 4 L (C) to promote excretion of serum calcium. Although the client is at risk for pathologic fractures due to diffuse osteoporosis, mobilization and weight bearing should be encouraged to promote bone reabsorption of circulating calcium, which can cause renal complications.

During lung assessment, the nurse places a stethoscope on a client's chest and instructs him/her to say "99" each time the chest is touched with the stethoscope. What would be the correct interpretation if the nurse hears the spoken words "99" very clearly through the stethoscope?

May indicate pneumonia. Rationale This test (whispered pectoriloquy) demonstrates hyperresonance and helps determine the clarity with which spoken words are heard upon auscultation. Normally, the spoken word is not well transmitted through lung tissue, and is heard as a muffled or unclear transmission of the spoken word. Increased clarity of a spoken word is indicative of some sort of consolidation process (e. g., tumor, pneumonia), and is not a normal finding.

How should the nurse position the electrodes for modified chest lead one (MCL I) telemetry monitoring?

Negative polarity left shoulder, positive polarity right chest nipple line, ground left chest nipple line. Rationale In MCL I monitoring, the positive electrode is placed on the client's mid-chest to the right of the sternum, and the negative electrode is placed on the upper left part of the chest. The ground may be placed anywhere, but is usually placed on the lower left portion of the chest.

Despite several eye surgeries, a 78-year-old client who lives alone has persistent vision problems. The visiting nurse is discussing home safety hazards with the client. The nurse suggests that the edges of the steps be painted which color?

Medium yellow. Rationale The color yellow is the easiest for a person with failing vision to see.

During assessment of a client with amyotrophic lateral sclerosis (ALS), which finding should the nurse identify when planning care for this client?

Muscle weakness. Rationale Amyotrophic lateral sclerosis (ALS) is characterized by a degeneration of motor neurons in the brainstem and spinal cord and are manifested by muscle weakness and wasting.

Which assessment finding by the nurse during a client's clinical breast examination requires follow-up?

Newly retracted nipple. Rationale A newly retracted nipple, compared to a life-long finding, may be an indication of breast cancer and requires additional follow-up.

A client with a 16-year history of diabetes mellitus is having renal function tests because of recent fatigue, weakness, elevated blood urea nitrogen, and serum creatinine levels. Which finding should the nurse conclude as an early symptom of renal insufficiency?

Nocturia Rationale As the glomerular filtration rate decreases in early renal insufficiency, metabolic waste products, including urea, creatinine, and other substances, such phenols, hormones, electrolytes, accumulate in the blood. In the early stage of renal insufficiency, polyuria results from the inability of the kidneys to concentrate urine and contribute to nocturia.

The nurse is assessing a client who smokes cigarettes and has been diagnosed with emphysema. Which finding would the nurse expect this client to exhibit?

Normal skin coloring. Rationale The differentiation between the "pink puffer" and the "blue bloater" is a well-known method of differentiating clients exhibiting symptoms of emphysema (normal color but puffing respirations) from those exhibiting symptoms of chronic bronchitis (edematous, cyanotic, shallow respirations).

Which client should the nurse recognize as most likely to experience sleep apnea?

Obese older male client with a short, thick neck. Rationale Sleep apnea is characterized by lack of respirations for 10 seconds or more during sleep and is due to the loss of pharyngeal tone which allows the pharynx to collapse during inspiration and obstructs air flow through the nose and mouth. Risk factors which increase the condition of sleep apnea include: excessive weight, increases the risk 4Xs more than normal weighing individuals; neck circumference, thicker necks have narrower airways; individuals with inherited narrower airways; males in general are more prone to sleep apnea; females risk increase with being overweight and post-menopausal; increased age (geriatrics); family history; use of alcohol, sedatives or tranquilizers; smokers and those who suffer from nasal allergies.

A 67-year-old woman who lives alone tripped on a rug in her home and fractured her hip. Which predisposing factor probably led to the fracture in the proximal end of her femur?

Osteoporosis resulting from hormonal changes. Rationale The most common cause of a fractured hip in elderly women is osteoporosis, resulting from reduced calcium in the bones as a result of hormonal changes in later life.

An elderly male client comes to the geriatric screening clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg which is warm to the touch and suspects it might be thrombophlebitis. Which type of pain would further confirm this suspicion?

Pain in the calf upon exertion which is relieved by rest and elevating the extremity. Rationale Thrombophlebitis pain is relieved by rest and elevation of the extremity. It typically occurs with exercise at the site of the thrombus, and is aggravated by placing the extremity in a dependent position, such as standing in one place.

What instruction should the nurse give a client who is diagnosed with fibrocystic changes of the breast?

Perform a breast self-exam (BSE) procedure monthly. Rationale Fibrocystic changes in the breast are related to excess fibrous tissue, proliferation of mammary ducts and cyst formation that cause edema and nerve irritation. These changes obscure typical diagnostic tests, such as mammography, due to an increased breast density. Women with fibrocystic breasts should be instructed to carefully perform monthly BSE and consider changes in any previous "lumpiness." Fibrocystic disease does not increase the risk of breast cancer. Cyst size fluctuates with the menstrual cycle, and typically lessens after menopause, and responds with a heightened sensitivity to circulating estrogen.

Which intervention should the nurse plan to implement when caring for a client who has just undergone a right above-the-knee amputation?

Place a large tourniquet at the client's bedside. Rationale A large tourniquet should be placed in plain sight at the client's bedside, in the event severe bleeding occurs. The purpose is to have the tourniquet available to applied to the residual limb to control bleeding if hemorrhaging was to occur. The residual limb should not be placed on a pillow because a flexion contracture of the hip may result and the client should be encouraged to lie in the prone position to prevent flexion contracture of the hip.

When teaching diaphragmatic breathing to a client with chronic obstructive pulmonary disease (COPD), which information should the nurse provide?

Place a small book or magazine on the abdomen and make it rise while inhaling deeply. Rationale Diaphragmatic or abdominal breathing uses the diaphragm instead of accessory muscles to achieve maximum inhalation and to slow the respiratory rate. The client should protrude the abdomen on inhalation and contract it with exhalation, so placing a book or magazine, helps the client visualize the rise and fall of the abdomen.

The nurse is assessing a client with chronic kidney disease (CKD). Which finding is most important for the nurse to respond to first?

Potassium 6.0 mEq. Rationale Hyperkalemia (normal serum level, 3.5 to 5.5 mEq) is a serious electrolyte disorder that can cause fatal arrhythmias, so the elevation of the potassium level is a nursing priority.

In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the laboratory test results to indicate a decreased serum level of which substance?

Potassium. Rationale Clients with primary hyperaldosteronism exhibit a profound decline in the serum levels of potassium (hypokalemia). Hypertension, along with the hypokalemia are the most prominent and universal signs for this condition. If both of these findings are present, there is 50% likelihood the client to be diagnosed with hyperaldosteronism.

A splint is prescribed for nighttime use by a client with rheumatoid arthritis. Which statement by the nurse provides the most accurate explanation for use of the splints?

Prevention of deformities. Rationale Splints may be used at night by clients with rheumatoid arthritis to prevent deformities caused by muscle spasms and contractures.

During a health fair, a 72-year-old male client tells the nurse that he is experiencing shortness of breath. Auscultation reveals crackles and wheezing in both lungs. Suspecting that the client might have chronic bronchitis, which classic symptom would the nurse expect this client to have?

Productive cough with grayish-white sputum. Rationale Smoking is the most common cause of chronic bronchitis, one of the diseases comprising the diagnosis of COPD, it is characterized by a productive cough with grayish-white sputum. Smokers generally experience this cough when they first awaken and rise in the morning.

A client with heart disease is on a continuous telemetry monitor and has developed sinus bradycardia. In determining the possible cause of the bradycardia, the nurse assesses the client's medication record. Which medication is most likely the cause of the bradycardia?

Propanolol (Inderal). Rationale Inderal is a beta adrenergic blocking agent, which causes decreased heart rate and decreased contractility.

A client who was in a motor vehicle collision was admitted to the hospital and the right knee was placed in skeletal traction. The nurse has documented this nursing diagnosis in the client's medical record: "Potential for impairment of skin integrity related to immobility from traction." Which nursing intervention is indicated based on this diagnosis statement?

Provide back and skin care while maintaining the traction. Rationale Maintaining skin integrity and providing back care is difficult when a client is in traction, but must be performed and is the correct intervention to maintain the client's skin integrity.

A client has been taking oral corticosteroids for the past five days because of seasonal allergies. Which assessment finding is of most concern to the nurse?

Purulent sputum. Rationale Steroids cause immunosuppression, and a purulent sputum is an indication of infection, so this symptom is of greatest concern.

The healthcare provider prescribes aluminum and magnesium hydroxide (Maalox), 1 tablet PO PRN, for a client with chronic kidney disease (CKD) who is complaining of indigestion. What intervention should the nurse implement?

Question the healthcare provider's prescription. Rationale Magnesium agents are not usually used for clients with CKD due to the risk of hypermagnesemia, so this prescription should be questioned by the nurse.

A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep. Which recommendation by the nurse is most effective to assist the client?

Raising the head of the bed on blocks. Rationale Raising the head of the bed on blocks (reverse Trendelenburg position) to reduce reflux and subsequent aspiration is the most non-pharmacological effective recommendation for a client experiencing severe gastroesophageal reflux during sleep.

An adult client is admitted to the hospital burn unit with partial-thickness and full-thickness burns over 40% of the body surface area. In assessing the potential for skin regeneration, what should the nurse remember about full-thickness burns?

Regenerative function of the skin is absent because the dermal layer has been destroyed. Rationale Full-thickness burns destroy the entire dermal layer. Included in this destruction is the regenerative tissue. For this reason, tissue regeneration does not occur, and skin grafting is necessary.

After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated urinary output of 54 ml for the last 2 hours. What priority nursing action should be implemented?

Report the findings to the surgeon. Rationale An adult who weighs 132 pounds (60 kg) should produce about 60 ml of urine hourly (1 ml/kg/hour). Dark, concentrated, and low volume of urine output should be reported to the surgeon.

During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving. What action should the nurse take first?

Reposition the head to validate that the head is in the proper position to open the airway. Rationale The most frequent cause of inadequate aeration of the client's lungs during CPR is the improper positioning of the head resulting in occlusion of the airway. The nurse should reposition the client's head and attempt to ventilate again, looking for the rise and fall of the chest.

A client with cirrhosis develops increasing pedal edema and ascites. What dietary modification is most important for the nurse to teach this client?

Restrict salt and fluid intake. Rationale Salt and fluid restrictions are the first dietary modifications for a client who is retaining fluid as manifested by edema and ascites.

A client with multiple sclerosis has experienced an exacerbation of symptoms, including paresthesias, diplopia, and nystagmus. Which instruction should the nurse provide?

Schedule extra rest periods. Rationale Exacerbations of the symptoms of MS occur most commonly as the result of fatigue and stress. The client should be encouraged to schedule extra rest periods to help reduce the symptoms.

The nurse is assessing a client's laboratory values following administration of chemotherapy. Which lab value leads the nurse to suspect that the client is experiencing tumor lysis syndrome (TLS)?

Serum calcium of 5 mg/dl. Rationale TLS results in hyperkalemia, hypocalcemia, hyperuricemia, and hyperphosphatemia. A serum calcium level of 5 (B), which is low, is an indicator of possible tumor lysis syndrome. (A, C, and D) are not particularly related to TLS.

A 46-year-old female client is admitted for acute renal failure secondary to diabetes and hypertension. Which test is the best indicator of adequate glomerular filtration?

Serum creatinine. Rationale Creatinine is a product of muscle metabolism that is filtered by the glomerulus, and blood levels of this substance are not affected by dietary or fluid intake. An elevated creatinine strongly indicates nephron loss, reducing filtration.

In preparing to administer intravenous albumin to a client following surgery, what is the priority nursing intervention? (Select all that apply.)

Set the infusion pump to infuse the albumin within four hours. Administer through a large gauge catheter. Monitor hemoglobin and hematocrit levels. Assess for increased bleeding after administration. Rationale Albumin should be infused within four hours because it does not contain any preservatives. Any fluid remaining after four hours should be discarded. Albumin administration does not require blood typing. Vital signs should be monitored periodically to assess for fluid volume overload. A large gauge catheter allows for fast infusion rate, which may be necessary. Hemodilution may decrease hemoglobin (HgB) and hematocrit (HCT) levels, so the HgB and HCT levels should be monitored. While monitoring for bleeding because of the increased blood volume and blood pressure.

The nurse working in a postoperative surgical clinic is assessing a woman who had a left radical mastectomy for breast cancer. Which factor puts this client at greatest risk for developing lymphedema?

She sustained an insect bite to her left arm yesterday. Rationale A radical mastectomy interrupts lymph flow, and the increased lymph flow that occurs in response to the insect bite increases the risk for the occurrence of lymphedema.

The nurse working on a telemetry unit finds a client unconscious and in pulseless ventricular tachycardia (VT). The client has an implanted automatic defibrillator. What action should the nurse implement?

Shock the client with 200 joules per hospital policy. Rationale The client must be externally shocked 200 joules per hospital policy to restore an effective cardiac rhythm. The automatic defibrillator is obviously malfunctioning.

The nurse is assessing a client who has a history of Parkinson's disease for the past 5 years. What symptoms would this client most likely exhibit?

Shuffling gait, masklike facial expression, and tremors of the head. Rationale Parkinson's Disease is one of the most common neurologic progressive disorder of the older client. Shuffling gait, masklike facial expression, and tremors of the head and hands are common clinical features of Parkinsonism.

In preparing a discharge plan for a 22-year-old male client diagnosed with Buerger's disease (thromboangiitis obliterans), which referral is most important?

Smoking cessation program. Rationale Buerger's disease is strongly related to smoking or the use of some other form of tobacco which affects the circulation in the arms and legs leading to infection and gangrene and sometimes amputation of the affected area. The most effective means of controlling symptoms and disease progression is through smoking cessation. The cause of Buerger's disease is unknown; a genetic predisposition is possible, but unproven.

In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the laboratory test results to indicate an increased serum level of which substance?

Sodium. Rationale Clients with primary aldosteronism exhibit an increase in serum sodium levels (hypernatremia) and have profound decline in the serum levels of potassium (hypokalemia)--hypertension is the most prominent and universal sign. Antidiuretic hormone is decreased with diabetes insipidus. Glucose is not affected by primary aldosteronism.

A female client receiving IV vasopressin (Pitressin) for esophageal varice rupture reports to the nurse that she feels substernal tightness and pressure across her chest. Which PRN protocol should the nurse initiate?

Start an IV nitroglycerin infusion. Rationale Vasopressin is used to promote vasoconstriction, thereby reducing bleeding from the esophageal varice. Vasoconstriction of the coronary arteries can lead to angina and myocardial infarction, and should be counteracted by IV nitroglycerin per prescribed protocol.

A 58-year-old client, who has no health problems, asks the nurse about the Pneumovax vaccine. The nurse's response to the client should be based on which information?

The immunization is administered once to older adults or persons with a history of chronic illness. Rationale It is recommended by the CDC (Dec 2016) that persons over 65 years of age and those with a history of chronic illness receive the vaccine once in a lifetime.

Which description of symptoms is characteristic of a client diagnosed with trigeminal neuralgia (tic douloureux)?

Sudden, stabbing, severe pain over the lip and chin. Rationale Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock, in the area innervated by one or more branches of the trigeminal nerve (5th cranial). Women are more often afflicted with this condition and generally occurs in clients over the age of 50 years old.

The nurse is preparing a teaching plan for a client who is newly diagnosed with Type 1 diabetes mellitus. Which signs and symptoms should the nurse describe when teaching the client about hypoglycemia?

Sweating, trembling, tachycardia. Rationale Sweating, dizziness, and trembling are signs of hypoglycemic reactions related to the release of epinephrine as a compensatory response to the low blood sugar.

The nurse formulates the nursing diagnosis of, "Urinary retention related to sensorimotor deficit" for a client with multiple sclerosis. Which nursing intervention should the nurse implement?

Teach the client techniques of intermittent self-catheterization. Rationale Bladder control is a common problem for clients diagnosed with multiple sclerosis. A client with urinary retention should receive instructions about self-catheterization to prevent bladder distention.

When preparing a client who has had a total laryngectomy for discharge, what instruction is most important for the nurse to include in the discharge teaching?

Tell the client to carry a medic alert card stating that he is a total neck breather. Rationale It is imperative that total neck breathers carry a medic alert notice so, that if they have a cardiac arrest, mouth-to-neck breathing can be done.

A client with early breast cancer receives the results of a breast biopsy and asks the nurse to explain the meaning of staging and the type of receptors found on the cancer cells. Which explanation should the nurse provide?

The tumor's estrogen receptor guides treatment options. Rationale Treatment decisions and prediction of prognosis are related to the tumor's receptor status, such as estrogen and progesterone receptor status which commonly are well-differentiated, have a lower chance of recurrence, and are receptive to hormonal therapy. Tumor staging designates tumor size and spread of breast cancer cells into axillary lymph nodes, which is one of the most important prognostic factors in early-stage breast cancer.

The nurse is planning to initiate a socialization group for older residents of a long-term facility. Which information would be most useful to the nurse when planning activities for the group?

The usual activity patterns of each member of the group. Rationale An older person's level of activity is a determining factor in adjustment to aging as described by the Activity Theory of Aging. The most useful information initially would be an assessment of each individual's adjustment to the aging process.

The nurse is teaching a female client about the best time to plan sexual intercourse in order to conceive. Which information should the nurse provide?

Two weeks before menstruation. Rationale Ovulation typically occurs 14 days before menstruation begins during a typical 28 day cycle. Sexual intercourse should occur within 24 hours of ovulation for an increase chance of conception to occur. High estrogen levels occur during ovulation and increase the vaginal mucous membrane characteristics to become more "slippery" and stretchy, along with a rise in basal temperature. The timing during the day is not as significant in determining conception as the day before and after ovulation.

What discharge instruction is most important for a client after a kidney transplant?

Use daily reminders to take immunosuppressants. Rationale After a renal transplantation, acute rejection is a high risk for several months. The organ recipient will have to take immunosuppressive therapy for the rest of their lives, such as corticosteroids and azathioprine (Imuran), to prevent organ transplant rejection. Discharge instructions include measures, such as daily reminders, to ensure the client takes these medications regularly to prevent organ rejection from occurring.

A client who is sexual active with several partners requests an intrauterine device (IUD) as a contraceptive method. Which information should the nurse provide?

Using an IUD offers no protection against sexually transmitted diseases (STD), which increase the risk for pelvic inflammatory disease (PID). Rationale The use of an IUD provides the client with no protection from STDs.

Healthcare workers must protect themselves against becoming infected with HIV. The Center for Disease Control has issued guidelines for healthcare workers in relation to protection from HIV. These guidelines include which recommendation?

Wear gloves when coming in contact with the blood or body fluids of any client. Rationale The CDC guidelines recommend that healthcare workers use gloves when coming in contact with blood or body fluids from any client since HIV is infectious before the client becomes aware of their exposure and/or symptomatic.

The nurse is planning care for a client with newly diagnosed diabetes mellitus that requires insulin. Which assessment should the nurse identify before beginning the teaching session?

Willingness of the client to learn the injection sites. Rationale If a client is incapable or does not want to learn, it is unlikely that learning will occur, so motivation is the first factor the nurse should assess before teaching.

Which information about mammograms is most important to provide a post-menopausal female client?

Yearly mammograms should be done regardless of previous normal x-rays. Rationale There are different recommendations from different agnecies. For a client with no risk factors, the earliest breast screening recommendation is a yearly mammogram at the age 40 and till the age of 54. After that every two years.The American College of OB/GYN still recommend starting mammograms starting at the age of 40 and yearly screeenings.The American Cancer Society new guidelines recommend starting at the age of 45 and thereafter till the age of 54 years old, then every two years. The US Preventive Services Task Force Services (USPSTS) recommends starting at the age of 50 years old and screenings every two years thereafter.

A client is admitted to the hospital with a medical diagnosis of pneumococcal pneumonia. The nurse knows that the prognosis for gram-negative pneumonias (such as E. coli, Klebsiella, Pseudomonas, and Proteus) is very poor because

gram-negative organisms are more resistant to antibiotic therapy. Rationale The gram-negative organisms are very resistant to drug therapy which makes recovery very difficult and has become a world-wide concern in which the World Health Organization is keeping a very close surveillance on these occurrences.

The nurse would be correct in withholding a dose of digoxin in a client with congestive heart failure without specific instruction from the healthcare provider if the client's

serum potassium level is 3. Rationale Hypokalemia can precipitate digitalis toxicity in persons receiving digoxin which will increase the chance of dangerous dysrhythmias (normal potassium level is 3.5 to 5.5 mEq/L).

A 77-year-old female client is admitted to the hospital. She is confused, has no appetite, is nauseated and vomiting, and is complaining of a headache. Her pulse rate is 43 beats per minute. Which question is a priority for the nurse to ask this client or her family on admission? "Does the client

take digitalis?" Rationale Although it is important to obtain a complete medication history, the symptoms described are classic for digitalis toxicity, and assessment of this problem should be made promptly. Elderly persons are particularly susceptible to digitalis intoxication which manifests itself in such symptoms as anorexia, nausea, vomiting, diarrhea, headache, and fatigue.

A client has taken steroids for 12 years to help manage chronic obstructive pulmonary disease (COPD). When making a home visit, which nursing function is of greatest importance to this client? Assess the client's

temperature. Rationale It is very important to check the client's temperature. Long term use of steroids use COPD clients is effective in suppressing inflammation in their airways making it easier for them to breath, but at the same time suppresses the immune system, placing the client at risk for infection.