Medical surgical proctored exam

A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longer certain he wants to have the procedure. Which of the following responses should the nurse make?

* "Bypass surgery must be very frightening for you." Rationale: This response is therapeutic because it shows empathy and focuses on the client's feelings in a nonthreatening way, and it encourages the client to express his feelings.

A nurse is reinforcing teaching with a client who has a new diagnosis of fibromyalgia. Which of the following client statements indicates the need for further teaching?

* "Fibromyalgia causes joint inflammation." Rationale: Clients who have fibromyalgia may report joint discomfort; however, fibromyalgia is a non-inflammatory disorder and does not cause joint inflammation.

The nurse is collecting data on a client who has multiple sclerosis. Which of the following findings should the nurse expect?

*Involuntary movement of the eyes Rationale: Nystagmus, or involuntary movement of the eyes, is a manifestation of multiple sclerosis.

A nurse is collecting data from a client who has peptic ulcer disease. Which of the following findings is a manifestation of gastrointestinal perforation?

*Severe upper abdominal pain Rationale: Sudden, severe abdominal pain that radiates to the shoulder is a manifestation of gastrointestinal perforation.

A nurse is caring for a client who has paraplegia and is on an intermittent urinary catheterization program. Which of the following findings indicates to the nurse the need to catheterize the client?

*Suprapubic discomfort Rationale: Suprapubic discomfort is an indicator of bladder distention. The nurse should perform intermittent catheterization when bladder distention is present to prevent bladder trauma.

A nurse is caring for a client who comes to the clinic to be tested for tuberculosis (TB) after a close family contact tests positive. Which of the following measures should the nurse anticipate preparing for this client?

*Tuberculin skin test Rationale: The nurse should anticipate preparing the client to receive the tuberculin skin test (TST). The TST is an accurate screening tool for the presence of tuberculosis in an individual; however, it does not distinguish between previous exposure and active illness. The TBT requires multiple visits to the clinic, one to receive the injection and another visit, 48-72 hours later, to have the test read by a qualified health professional.

A nurse is caring for a client who has second- and third-degree burns and a prescription for a high-calorie, high-protein diet. Which of the following menu choices should the nurse recommend?

*Turkey and cheese sandwich with scalloped potatoes Rationale: This menu choice is composed primarily of complete, high-quality proteins and large quantities of carbohydrates. Therefore, the nurse should recommend this selection to meet the prescribed dietary regime.

A nurse is assisting with the care of a client who is in hemorrhagic shock and has a prescription for packed red blood cells. Which type of blood can be administered to the client while awaiting blood from a type and cross-match?

*Type O Rationale: Type O blood can be given to clients who have any of the four blood types.

A nurse is reviewing data for a client who has a head injury. Which of the following findings should indicate to the nurse that the client might have diabetes insipidus?

*Urine output 650 mL/hr Rationale: Diabetes insipidus is an endocrine disorder of the anterior pituitary gland. A decrease in antidiuretic hormone results in an increasingly high output of very dilute urine.

A nurse is checking the suction control chamber of a client's chest tube and notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?

*Verify that the suction regulator is on. Rationale: The nurse should verify that the suction regulator is turned on because low continual bubbling will occur when the suction is on and there are no kinks in the tubing.

A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following of the following findings should the nurse expect?

*Oliguria Rationale: Oliguria is present in hypovolemic shock as a result of decreased blood flow to the kidneys.

A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect?

*Hardened skin Rationale: Hardened, tight skin is an expected finding with scleroderma. In addition to rigid skin and subcutaneous tissues, the distal extremities stiffen and lose mobility. It can also cause disorders of the heart, lungs and kidneys.

A nurse is assisting with the care of a client who has infective endocarditis. Which of the following manifestations should the nurse identify as a complication of this disorder?

* Dyspnea Rationale: Emboli is a serious complication due to emboli arising in the right heart chambers which will terminate in the lungs, causing dyspnea, and left-chamber emboli may travel anywhere in the arteries, reaching the spleen, kidneys, brain, lungs, or extremities

A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

* "I should avoid injecting insulin into my thigh if I am going to go running." Rationale: The nurse should reinforce that the client should avoid injecting insulin into an area that will soon be exercised to avoid increasing the absorption rate of the insulin.

A nurse is caring for an older adult client who has left-sided heart failure. Which of the following findings should the nurse expect?

*Frothy sputum Rationale: Left-sided heart failure reduces cardiac output and raises pulmonary venous pressure. Manifestations include hacking cough, frothy sputum, wheezing, fatigue, and weakness.

A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect?

*Peripheral edema Rationale: Peripheral edema is caused by weakness in the right side of the heart, allowing blood to back up into the venous system and leak into interstitial tissues.

A nurse is talking with a client who has to come to the clinic for HIV testing. The nurse should explain to the client that, after the laboratory has the enzyme immunoassay (EIA) results, it will use which of the following tests to confirm the diagnosis?

*Western blot assay Rationale: The Western blot assay confirms seropositivity when the EIA (formerly, the enzyme-linked immunosorbent assay, or ELISA) has a positive result.

A nurse is caring for a client who has just had a bronchoscopy. Which of the following actions should the nurse take?

*Withhold food and liquids until the client's gag reflex returns. Rationale: Until the gag reflex returns, the client is at high risk for aspirating food or fluids, therefore the nurse should withhold food and liquids until the client's gag reflex returns.

A nurse is reinforcing teaching for a client who is scheduled for a bronchoscopy. Which of the following statements should the nurse include in the teaching?

*Your neck will be placed in a hyperextended position during the procedure." Rationale: The nurse should reinforce to the client that his neck will be placed in a hyperextended position. Hyperextension brings the pharynx into alignment with the trachea and allows insertion of the scope without trauma.

A nurse is collecting data from a client in the health clinic who is reporting epigastric pain. Which of the following statements made by the client should the nurse identify as being consistent with peptic ulcer disease?

* "I feel so much better after eating." Rationale: A client who has peptic ulcer disease usually experiences pain when the stomach is empty, 2 to 3 hr after meals or in the middle of the night. It is usually relieved by eating.

A nurse is reinforcing teaching with a client who has been newly diagnosed with chronic open angle glaucoma. Which of the following statements by the client indicates an understanding of the teaching?

* "I should call the clinic before taking any over-the-counter medications." Rationale: Taking over-the-counter medications that dilate the pupil could cause the client who has chronic open angle glaucoma to experience an increase in intraocular pressure. The nurse should instruct the client to always check with the provider before using over-the-counter medications.

A nurse is caring for a client who has recurrent kidney stones and a history of diabetes mellitus. The client is scheduled for an intravenous pyelogram (IVP). The nurse should collect additional data about which of the following statements made by the client?

* "I took my metformin before breakfast." Rationale: The nurse should identify clients taking metformin are at risk for lactic acidosis when receiving

A nurse is reinforcing discharge instructions with a client who has hepatitis A. Which of the following statements by the client indicates an understanding of the teaching?

* "I will abstain from sexual intercourse." Rationale: The client who has hepatitis A should abstain from sexual intercourse during the infectious period.

A nurse is caring for a client who has increased intracranial pressure. Which of the nursing interventions should the nurse take?

*Elevate the head of the bed 30°. Rationale: The nurse should elevate the head of the bed 15° to 30° to reduce intracranial pressure.

A nurse is reinforcing discharge teaching with a client who is postoperative following a cataract extraction from the left eye with placement of an intraocular lens implant. Which of the following statements by the client indicates a need for further teaching?

* "I will change my eye patch dressing every other day." Rationale: The client should change the eye patch dressing at least every day.

A nurse is reinforcing teaching for a client who is to have a myelogram. Which of the following statements indicates the client understands the teaching?

* "I will not eat or drink anything for 8 hours before the procedure." Rationale: The client should remain NPO for 4 to 8 hours before the procedure to prevent any movement that could occur from the client being nauseated or vomiting during the procedure.

A nurse is evaluating discharge instructions for a client following a right cataract extraction. Which of the following client statements indicates the teaching is effective?

* "I will take a stool softener until my eye is healed." Rationale: The client should avoid straining during bowel movements to prevent an increase in intraocular pressure.

A nurse is reinforcing discharge teaching with a client who had a total abdominal hysterectomy and a vaginal repair. Which of the following statements by the client indicates a need for further teaching?

* "I will take a tub bath instead of a shower." Rationale: To reduce the risk of infection, the client should avoid tub baths following a total abdominal hysterectomy.

A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The nurse should recognize that which of the following statements by the client indicates a need for further teaching?

* "I will wear stockings with elastic tops." Rationale: The nurse should reinforce with the client to avoid constrictive clothing that can impair circulation.

A nurse is reinforcing teaching for a client about following a low-purine diet to manage gout. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

* "I'll eliminate liver from my diet." Rationale: Clients who have gout should avoid organ meats such as liver because of their high purine content.

A nurse is reinforcing teaching with a client who has cholelithiasis and is scheduled for an endoscopic retrograde cholangiopancreatography. Which of the following statements made by the client indicates an understanding of the teaching?

* "I'll have an endoscope put down my throat so they can see my gallbladder." Rationale: For an endoscopic retrograde cholangiopancreatography, the provider passes a flexible fiberoptic endoscope through the client's esophagus to visualize gastrointestinal structures.

A nurse caring for a client who is recovering from a stroke. The client states "I feel like less of a man. My wife says she is thankful I am alive but I'm sure this is not how she expected us to spend our retirement years." Which of the following is an appropriate response?

* "In what ways do you feel like you are less of a man?" Rationale: The nurse should use the therapeutic technique of restating or rephrasing to encourage the client to state his concerns in greater detail.

A nurse is caring for a client who has hemiplegia following a stroke. The client's adult son is distressed over his mother's crying and condition. Which of the following responses should the nurse make?

* "It must be hard to see your mother so ill and upset." Rationale: This response is therapeutic because it demonstrates empathy and acknowledges the son's feelings of helplessness and powerlessness.

A nurse is reinforcing teaching with a client about the use of transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statements by the client indicates the need for further teaching?

* "It's unfortunate that I have to be in the hospital for this treatment." Rationale: TENS units are portable. The client can use his TENS unit at home or wherever he chooses.

A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for an escharotomy and wants to know what the procedure involves. Which of the following statements is appropriate for the nurse to make?

* "Large incisions will be made in the burned tissue to improve circulation." Rationale: An escharotomy is a surgical incision made to release pressure and improve circulation in a part of the body that has had a deep burn and is experiencing significant swelling. The swelling that occurs secondary to burn injuries that completely encircle a body part, such as an arm or the chest, can cause tightness and constriction of underlying tissue and can shut off circulation in the affected area. Making surgical incisions into the burned tissue allows the skin to expand and re-establish circulation.

A nurse is reinforcing teaching about preventing long-term complications of retinopathy and neuropathy with an older adult client who has diabetes mellitus. Which of the following actions is the most important for the nurse to include in the teaching?

* "Maintain stable blood glucose levels." Rationale: The greatest risk for the client is injury from hyperglycemia that contributes to neuropathic disease, microvascular complications, and risk factors for macrovascular complications. Therefore, the most important action is for the client to maintain stable blood glucose levels.

A nurse is caring for a client scheduled for a bone marrow biopsy. The client expresses fear about the procedure and asks the nurse if the biopsy will hurt. Which of the following responses should the nurse make?

* "The biopsy can be uncomfortable, but we will try to keep you as comfortable as possible." Rationale: This response is therapeutic because it gives the client the information that she needs to cope, and reassures the client of the plan to address her comfort, and allows for further communication of concerns by the client.

A nurse is teaching an assistive personnel about attaching a footboard to the bed of a client who is immobile. Which of the following information should the nurse include in the teaching?

* "The footboard will help to prevent plantar flexion." Rationale: The nurse should teach that the purpose of a footboard is to prevent plantar flexion contracture or foot drop

A nurse is caring for a client who is receiving hemodialysis. Which of the following client measurements should the nurse compare before and after dialysis treatment to determine fluid losses?

*Body weight Rationale: The nurse should weigh the client prior to and following dialysis in order to determine the amount of fluid losses/gains from dialysis. Each kilogram (2.2 lb) of weight gained or lost is equal to 1 L of fluid.

A nurse is reinforcing teaching with a client who is scheduled for a blood test to measure her thyroid-stimulating hormone (TSH) level. Which of the following statements should the nurse give?

* "The test determines whether your thyroid gland is overactive, appropriately active, or underactive." Rationale: This statement describes this test, which helps determine thyroid status and helps monitor the effectiveness and dosage of thyroid hormone replacement therapy.

A nurse is reinforcing teaching with a client who is taking warfarin about monitoring its therapeutic effect. The nurse should issue which of the following statements about the provider's use of the international normalized ratio (INR)?

* "This is a standardized test, so it eliminates the variations different laboratories report in prothrombin times." Rationale: The nurse should reinforce to the client that the INR is a standardized test, which means that the result will be the same, no matter which laboratory performs this test.

A nurse is reinforcing teaching with a client who is scheduled for a thallium scan. When talking with the client about this procedure, which of the following statements should the nurse give?

* "This test detects damage to the heart muscle." Rationale: The nurse should reinforce to the client that a thallium scan is a radionuclide type of imaging that uses radioisotopes such as thallium to evaluate coronary artery perfusion and detect myocardial ischemia and infarction.

A nurse is reinforcing teaching about a tonometry examination with a client who has manifestations of glaucoma. Which of the following statements should the nurse include in the teaching?

* "This test will measure the intraocular pressure of the eye." Rationale: A tonometry examination provides a precise and simple way to measure intraocular pressure. This is a component of a comprehensive eye examination and is crucial for clients who have glaucoma or who are at high risk for developing intraocular hypertension.

A nurse is reinforcing teaching to a female client who has acute cystitis and is to start therapy with phenazopyridine. Which of the following information should the nurse give to the client?

* "Wear a protective pad under clothing to prevent staining." Rationale: The nurse should reinforce that this medication will cause the urine to change to an orange or red color that can stain clothing.

A nurse is reinforcing teaching with a client who has glaucoma. Which of the following statements should the nurse make?

* "Without treatment, glaucoma can cause blindness." Rationale: The nurse should explain that without treatment, glaucoma can result in blindness due to irreversible damage to the retina and optic nerve.

A nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if there will be a lot of pain during the procedure. Which of the following responses should the nurse make?

* "You may feel some cramping during the procedure." Rationale: The nurse should reinforce the use of breathing exercises to decrease the effects of cramping during the procedure. This response by the nurse is therapeutic because it appropriately addresses the client's concerns.

A nurse is reinforcing teaching about an esophagogastroduodenoscopy with a client who has upper gastric pain. Which of the following statements should the nurse include in the teaching?

* "You will remain NPO for 8 hours before the procedure." Rationale: The nurse should include in the teaching for the client to remain NPO for 8 hr before the procedure to have the stomach free of food contents, decrease vomiting, and decrease the risk for aspiration.

A nurse is reinforcing preoperative teaching to a client who is undergoing total hip replacement surgery. Which of the following statements should the nurse include in the teaching?

* "You will use a special soap to shower with the evening before your surgery." Rationale: The nurse should instruct the client that the evening before the surgery, he will shower with a bacteriostatic soap to decrease the risk of infection in the new joint.

A nurse is caring for a client who has cirrhosis. When delivering the client's lunch tray, which of the following food selection requires intervention by the nurse?

* 1slice of ham on whole wheat bread Rationale: Ham is high in sodium and can increase fluid retention, leading to edema. Clients who have cirrhosis are prone to edema as the osmotic pressures change due to a decrease in plasma albumin.

A nurse is caring for a client who just had cataract surgery. Which of the following comments from the client should the nurse report to the provider?

* I need something for the horrible pain in my eye." Rationale: Following cataract surgery, the client should expect only mild pain, and should immediately report any severe pain in the eye. Severe eye pain after surgery might indicate an increase in intraocular pressure, which can disrupt the surgical site and cause permanent damage to the eye if the client does not receive treatment promptly.

A nurse is assisting with the care of a client who was admitted to the emergency department with reports of chest pain and severe epigastric distress. The nurse should anticipate that in the presence of an acute myocardial infarction the client's creatinine kinase-MB (CK-MB) is expected to peak how many hours after the onset of chest pain?

*24 hr Rationale: The nurse can anticipate that CK-MB will peak 18 to 24 hr after the onset of chest pain when acute myocardial infarction occurs.

A nurse is collecting data from four clients who have wounds. The nurse should recognize that which of the following clients has a manifestation of a wound infection?

*A client who has swelling and tenderness around the wound Rationale: Manifestations of infection include purulent drainage, swelling, warmth, tenderness around the wound, and a failure to heal.

A nurse is caring for a client who has a seizure disorder and reports experiencing an aura. The nurse should recognize the client is experiencing which of the following conditions?

*A sensory warning that a seizure is imminent Rationale: n aura is a sensory warning that a seizure is imminent. The aura can be similar to a hallucination and may involve any of the senses. The client can report "hearing bells", "seeing lights", or "smelling something".

A nurse is collecting data from a client who has mitral stenosis. Which of the following findings is a manifestation of this condition?

*Dyspnea on exertion Rationale: Due to narrowing of the valve, pressure in the lungs leads to dyspnea on exertion

A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge resection of the left lung and has a chest tube to suction. Which of the following is the priority finding the nurse should report to the provider?

*Abdomen is distended Rationale: When using the airway, breathing, circulation approach to client care, the nurse should recognize the presence of abdominal distention has the potential to compromise the client's respiratory status as the distention increases abdominal pressure on the diaphragm and impairs ventilation. This is the priority finding for the nurse to report

A nurse is caring for a client who is postoperative following a right total hip arthroplasty. In which of the following positions should the nurse place the client's right leg?

*Abduction Rationale: When caring for a client following a total hip arthroplasty, the nurse should abduct the affected extremity to prevent dislocation.

A nurse is caring for a client who is being evaluated for endometrial cancer. Which of the following findings should the nurse expect the client to report?

*Abnormal vaginal bleeding Rationale: The nurse should expect the client to experience abnormal vaginal bleeding, including postmenopausal bleeding and bleeding between normal periods. Abnormal vaginal bleeding is the most common finding in endometrial cancer in premenopausal women.

A nurse is assisting with the care of a client who has multiple injuries following a motor vehicle crash. The nurse should monitor for which of the following manifestations of a pneumothorax?

*Absence of breath sounds Rationale: A client who has a pneumothorax will have diminished or absent breath sounds on the affected side due to partial or total collapse of the lung.

A nurse in the emergency department is assisting with the care of a client who is comatose. The provider suspects ketoacidosis. Which of the following findings should the nurse expect?

*Acetone odor to breath Rationale: Acetone odor to breath is an expected finding for ketoacidosis.

A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take?

*Add thickener to fluids. Rationale: The nurse should thicken fluids to make them easier to swallow and prevent aspiration.

A nurse is assisting with the plan of care for a client who has a three-way urethral catheter connected to continuous bladder irrigation following a suprapubic and transurethral resection of the prostate. Which intervention should the nurse include in the plan of care?

*Adjust the flow rate of the irrigation fluid so that the urine is light pink. Rationale: The purpose of the three-way catheter with irrigation is to promote hemostasis and urinary drainage. The nurse should adjust the flow rate so that the urine is pink- tinged.

A nurse is reinforcing discharge teaching with an older adult client who has peripheral artery disease (PAD). Which of the following instructions should the nurse include in the teaching?

*Adjust the thermostat so that the environment is warm. Rationale: The client's instructions should include keeping the environment warm to prevent vasoconstriction. Wearing gloves, warm clothes, and socks will help prevent vasoconstriction.

A nurse is assisting with the plan of care for a client who has leukemia and whose platelet count is 50,000 mm3. Which of the following interventions should the nurse include in the plan of care?

*Administer a stool softener. Rationale: This client's platelet count is below the expected reference range and the client is at risk for bleeding. The nurse should administer a stool softener to prevent constipation, since constipation can lead to rectal bleeding.

A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent postoperative complications which of the following actions should be reinforced during the teaching?

*Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises. Rationale: The nurse should administer analgesics prior to initiating any exercise program for the client who has had joint arthroplasty. It is important that analgesics are administered in time for the medication to work before the start of the exercise program to ensure discomfort is minimized.

A nurse is caring for a client who was admitted with major burns to the head, neck, and chest. Which of the following complications should the nurse identify as the greatest risk to the client?

*Airway obstruction Rationale: Burns to the head, neck, and chest may involve damage to the pulmonary tree due to heat as well as smoke and soot inhalation. This kind of damage can result in severe respiratory difficulty. A burn to the chest may limit expansion of the thoracic cage, resulting in impaired breathing. Therefore, using the airway, breathing, circulation (ABC) priority-setting framework nursing measures to maintain airway patency are the priority nursing actions.

A nurse is caring for a client who has partial-thickness and full-thickness burns of his head, neck, and chest. The nurse should recognize which of the following is the priority risk to the client?

*Airway obstruction Rationale: When using the airway, breathing, circulation approach to client care, the nurse determines that the priority risk to this client is airway obstruction. Burns in this area can involve damage to the upper airway, resulting in swelling and respiratory compromise. The nurse should monitor the client for manifestations of respiratory distress.

A nurse in an emergency department is assisting with the care of a client who is unconscious and has trauma to multiple systems following a motor vehicle crash. Which of the following actions should the nurse take first?

*Airway protection Rationale: When using the airway, breathing, circulation approach to client care, the nurse should place the priority on protecting the client's airway.

A nurse is preparing a young adult client who has a hearing impairment for surgery. Which of the following actions should the nurse take?

*Allow the client to keep her hearing aids in. Rationale: The nurse should allow the client to retain possession of her hearing aids so that she will be able to hear and understand instructions given to her. The nurse should notify the surgical team and place a note on the front of the chart and the pre-operative checklist indicating that hearing aids were left in.

A nurse is changing the dressing on a client's wound. The nurse should recognize that which of the following findings is an indication of a wound infection?

*Edema Rationale: Manifestations of infection include purulent drainage, swelling, warmth, tenderness around the wound, and a failure to heal.

A nurse is caring for a client following an open reduction and internal fixation of a fractured femur. Which of the following findings is the nurse's priority?

*Altered level of consciousness Rationale: When using the airway, breathing, circulation approach to client care, the nurse determines that the priority finding is for the nurse to monitor the client's altered level of consciousness. A fracture of one of the long bones of the body places the client is at risk for fat embolism, which causes a decrease in oxygenation and alters the client's level of consciousness.

A nurse is collecting data from a client who was bitten by a tick one week ago. Which of the following client manifestations should the nurse identify as an indication of the development of Lyme disease?

*An expanding circular rash Rationale: Early Lyme disease is characterized by fever, flu-like manifestations, and erythema migrans, an expanding circular (bull's-eye) rash that often develops at the bite site.

A nurse in a provider's office is collecting data from a client who reports a red rash on her face, fever, weight loss and joint pain. The nurse should plan to prepare the client for which of the following laboratory tests?

*Antinuclear antibody (ANA) titer Rationale: This client has common manifestations seen with systemic lupus erythematosus (SLE). Typically the ANA titer is elevated in clients who have SLE.

A nurse is reinforcing teaching with a client has a new diagnosis of aplastic anemia. When discussing the pathology of this disease, which of the following instructions should the nurse include in the teaching?

*Aplastic anemia results from decreased bone marrow production of RBCs." Rationale: Aplastic anemia is a hypoproliferative anemia resulting from decreased production of RBCs within the bone marrow.

A nurse in the emergency department is assisting with the care of a client who has a deep laceration on her left lower forearm and is bleeding heavily from the wound. Which of the following actions should the nurse take first?

*Apply pressure directly to the wound. Rationale: The greatest risk to this client is injury from hemorrhaging; therefore, the priority intervention is to control bleeding and apply direct pressure to the area or to the artery proximal to the wound.

A nurse is caring for a client who has Alzheimer's disease. The nurse discovers the client entering the room of another client, who becomes upset and frightened. Which of the following actions should the nurse take?

*Attempt to determine what the client was looking for. Rationale: Clients who have Alzheimer's disease frequently exhibit wandering behavior when they have an unmet need. The nurse should attempt to discover the reason for the client's wandering, which could include a need for toileting, uncontrolled pain, or searching for a familiar object.

A nurse is caring for a client who is postoperative and requesting something to drink. The nurse reads the client's postoperative prescriptions, which include, "Clear liquids, advance diet as tolerated." Which of the following actions should the nurse take first?

*Auscultate the client's abdomen. Rationale: The first action the nurse should take using the nursing process is to collect data by listening to the client's abdomen to determine the presence of bowel sounds before offering a choice of clear liquids. A common postoperative complication is paralytic ileus or delayed gastric emptying due to decreased peristalsis. Administering liquids to a client who does not have bowel sounds can cause the client to vomit.

A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching?

*Avoid bending at the waist. Rationale: The nurse should reinforce that the client should avoid bending at the waist as this increases intraocular pressure; the client should be instructed to flex the knees and crouch instead.

A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy established. Which of the following instructions should the nurse include in the teaching?

*Avoid medications in capsule or enteric form. Rationale: The client should not take medications in capsule or enteric form because the medication may enter the pouch undigested.

The nurse is reinforcing teaching regarding diet to a client who has had a myocardial infarction. Which of the following diet choices by the client indicates an understanding of the teaching?

*Baked turkey and salad Rationale: The nurse should reinforce that skinless poultry that is baked, not fried, is a good food choice that is high in protein yet low in fat. The salad provides a serving of vegetables and is a healthy choice provided the salad dressing is also low in fat and sugar.

A nurse is reinforcing teaching with a client who takes furosemide and has a serum potassium level of 3.1 mEq/L. Which of the following foods should the nurse instruct the client to include in his daily diet?

*Bananas Rationale: The client's potassium level is low, most likely due to his diuretic therapy. In addition to the potassium supplements the provider might prescribe, the client should increase his daily intake of foods that have a high potassium content, such as bananas, orange juice, spinach, and fish. The provider might also prescribe potassium supplements in addition to or instead of increasing dietary potassium.

A nurse is reinforcing teaching with a middle adult female client who has fibrocystic breast disease. The nurse should emphasize to the client that manifestations of this disease are present at which of the following times?

*Before menstruation begins Rationale: Manifestations of benign fibrocystic breast changes include painful breasts, smooth moveable lumps, and possible nipple discharge and tend to worsen premenstrually. Reducing salt and caffeine intake sometimes helps.

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions is the priority for the nurse to take?

*Begin oxygen therapy. Rationale: When using the airway, breathing, circulation approach to client care, the nurse determines that the priority is administering oxygen therapy to the client to alleviate difficulty breathing and treat hypoxia

A nurse is caring for a client who is conscious and has an airway obstruction. Which of the following actions should the nurse take?

*Begin the Heimlich maneuver. Rationale: The nurse should immediately begin the Heimlich maneuver on a conscious client who has an airway obstruction and should continue until the obstruction is clear or the client loses consciousness.

A nurse is collecting data from a client who has rheumatoid arthritis. Which of the following is an expected finding for this client?

*Boutonniere deformity Rationale: Rheumatoid arthritis is a chronic, inflammatory autoimmune disorder which primarily affects the synovia (lining of the joints). Boutonniere deformity is a manifestation of rheumatoid arthritis in which a finger is flexed or bent inward towards the palm at the lowest (most proximal) joint and then extended outward away from the palm at the furthest (most distal) joint. This deformity arises due to the loss of collagen (connective tissue) in the joints.

A nurse in a provider's office is collecting data from a client who has hypothyroidism. Which of the findings should the nurse expect?

*Bradycardia Rationale: Reduced thyroid hormone levels (hypothyroidism) reduce the body's metabolic rate and thus slow down various body functions. Bradycardia reflects slowed cardiovascular function.

A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching?

*Breathe in through her nose and out through pursed lips. Rationale: The nurse should reinforce that pursed-lip breathing slows expiration, prevents collapse of alveoli, and helps the client to control the rate and depth of respirations.

A nurse is assisting with the care of a client who is brought to the emergency department and has burn injuries. Which of the following findings should the nurse identify the client has a deep partial-thickness burn?

*Burned area red in color with eschar present Rationale: This finding indicates a deep partial-thickness burn. Additional findings may include moderate edema and reports of pain.

A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease. The client becomes agitated and combative when the nurse approaches him. Which of the following actions should the nurse plan to take?

*Calmly ask the client if he would like to listen to some music. Rationale: The nurse should remain calm to avoid agitating the client further. By offering to play music, the nurse may be able to distract the client and then reintroduce the idea of morning care.

A nurse is caring for a client who has a hemoglobin of 10.8 g/dL and a hematocrit of 30%. The nurse should expect the client is at risk for which of the following conditions?

*Cellular hypoxia Rationale: The client's laboratory results indicate anemia, which places the client at risk for cellular hypoxia

A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland. Which of the following actions should the nurse include in the plan?

*Change the nasal drip pad as needed. Rationale: The nurse should change the nasal drip pad as needed because the client will have nasal packing and bloody nasal drainage until the surgical site is healed.

A nurse is assisting with the plan of care for an older adult client who is 4 hr postoperative following an open reduction and internal fixation of a fractured femur. Which of the following interventions should the nurse include in the plan of care?

*Check capillary refill in the affected extremity every 4 hr. Rationale: The client is at risk for neurovascular compromise. For a client who is 4 hr postoperative, the nurse should check the capillary refill in the affected extremity every 2 to 4 hr.

A nurse is caring for a client immediately followina a cardiac catheterization with a remoral artery approach. Which of the followina actions should tne nurse take?

*Check pedal oulses every 15 min. Rationale: The Observation or a client who has undergone a cardiac cathetenzation includes monitoring the client's pulses below the puncture site.

A nurse is assisting with the care of a client 2 hr postoperative following a cardiac catheterization. Which of the following actions should the nurse take?

*Check the client's distal pulses in both legs. Rationale: The nurse should check the client's distal pulses of both extremities to ensure adequate blood flow is being perfused to both legs

A nurse assisting with the care of a client who is receiving treatment following a motor vehicle crash. Which of the following actions should the nurse take to determine the client's level of alertness?

*Check the client's eye opening in response to verbal stimuli. Rationale: Checking the client's eye opening response to verbal stimuli is an appropriate method to check alertness.

A nurse suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following is the priority intervention by the nurse?

*Check the client's respiratory rate. Rationale: When using the airway, breathing, circulation approach to client care, the nurse should place the priority on assessing the client's lung sounds. Checking the client's respiratory rate can determine if the client is in respiratory distress.

A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse perform first?

*Check the client's temperature. Rationale: The first action the nurse should take using the nursing process is to collect data from the client and check the client's temperature to determine if the client has a fever, as this is a manifestation of meningitis. D. Administer an oral analgesic. Rationale: The nurse should adminis

A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first?

*Check the client's vital signs. Rationale: When using the airway, breathing, circulation approach to client care, the nurse should place the priority on obtaining vital signs. Nausea is a manifestation of digoxin toxicity, along with other manifestations such as muscle weakness, confusion, abdominal cramping, and changes in vision.

A nurse caring for a client at risk for increased intracranial pressure is monitoring the client for manifestations that indicate that the pressure is increasing. To do this, the nurse should check the function of the third cranial nerve by performing which of the following data-collection activities?

*Checking pupillary responses to light Rationale: Cranial nerve III, the oculomotor nerve, is responsible for pupillary responses to light. Indications that intracranial pressure is increasing include lethargy, decreasing consciousness, tachypnea, hypertension, bradycardia, bounding pulse, and changes in the pupils, such as a sluggish response to light and dilation of one or both pupils.

A nurse is contribution to the plan of care for a client who is 12 hr postoperative following a right radical mastectomy with closed suction drains present. The nurse should expect that the client will be unable to perform which of the following activities with her right arm?

*Combing her hair Rationale: The nurse should recognize that combing the hair requires abduction of the arm. This movement is avoided for the client who is in the immediate postoperative period until the drains have been removed. Activities requiring abduction and rotation of the shoulder may resume following healing of the surgical site.

A nurse is reviewing the preadmission laboratory test results of a female client who is to undergo a total abdominal hysterectomy. The nurse notes the client's erythrocyte sedimentation rate is 15 mm/hr. Which of the following actions should the nurse take?

*Continue reviewing the preoperative test results. Rationale: The client's erythrocyte sedimentation rate (ESR) is below 20 mm/hr, which is within expected reference range for a female client, therefore there is no need for the nurse to take any specific action. An increased ESR can indicate severe anemia, or inflammation due to an infection which may indicate a need to postpone elective surgery.

A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first?

*Cover the client's wound with a moist, sterile dressing. Rationale: According to evidence-based practice, the nurse's first action should be to cover the wound with a moist, sterile dressing to prevent entry of bacteria into the wound and to keep the tissue moist.

A nurse is contributing to the plan of care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse recommend for inclusion in the plan of care?

*Decrease the client's fluid intake. Rationale: The nurse should restrict fluids for a client who has cirrhosis and ascites due to the client's risk for increased fluid retention.

A nurse is collecting data from a client who has a possible cataract. Which of the following manifestations should the nurse expect the client to report?

*Decreased color perception Rationale: Visual manifestations associated with cataracts can include decreased color perception and decreased visual acuity, even in daylight.

A nurse is caring for a client newly diagnosed with ovarian cancer. Which of the following reactions from the client should the nurse initially expect?

*Denial Rationale: According to evidenced-based practice, the nurse should expect the client to first exhibit behaviors of denial following a cancer diagnosis or with other type of loss. This initial stage of grieving is often a self-protective behavior used until the client tis ready to acknowledge and deal with the grief-causing issue.

A nurse is caring for a client who was admitted to the emergency department immediately following a snake bite to her forearm. The client suspects that the snake was venomous. Which of the following nursing interventions is appropriate?

*Determine the need for a tetanus immunization. Rationale: Clients who have a puncture wound to the skin due to a snakebite are at risk for tetanus because the fangs of the snake can be contaminated with bacteria from soil or feces. Therefore, the nurse should ask the client when she had her last tetanus immunization.

A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse notes there has not been any urinary output in the last hour. Which of the following actions should the nurse perform first?

*Determine the patency of the tubing. Rationale: The first action the nurse should take when using the nursing process is to determine the patency of the tubing by assessing for kinks in the tubing or the presence of clots. A lack of drainage may be the result of kinked drainage tubing, a blood clot, or tissue blocking the drainage tubing.

Based on a client's recent history, a nurse suspects that a client is beginning menopause. Which of the following questions should the nurse ask the client to help confirm the client is experiencing manifestations of menopause?

*Do you sleep well at night?" Rationale: Menopause causes vasomotor instability, which can cause night sweats and sleep disturbances. Therefore, this is an appropriate question for the nurse to ask.

A nurse is planning to change an abdominal dressing for a client who has an incision with a drain. Which of the following actions should the nurse plan to take?

*Don clean gloves to remove the dressing. Rationale: Standard precautions require the nurse to don clean gloves whenever there is a possibility of coming into contact with secretions. Sterile gloves are not necessary until applying the new sterile dressing

A nurse is reinforcing teaching with a female client about preventing urinary tract infections (UTIs). Which of the following instructions should the nurse include?

*Drink 16 oz of cranberry juice each day. Rationale: The nurse should instruct the client to drink fluids that acidify the urine, such as cranberry juice.

A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect?

*Drop in systolic BP more than 10 mm Hg on inspiration Rationale: The nurse should expect the client who has constrictive pericarditis to have a decrease in systolic pressure by more than 10 mm Hg during inspiration, which is paradoxical blood pressure. This is also an expected finding for a client who has pulmonary hypertension or pericardial tamponade.

A nurse in a community clinic is collecting data from an older adult client who has a body mass index of 17.5. When evaluating the client for dehydration, the nurse should look for which of the following indications of fluid-volume deficit?

*Dry mucous membranes Rationale: With older adult clients, reliable indicators of dehydration include dry mucous membranes in the nose and mouth, concentrated urine, speech incoherence, and weakness of the extremities.

A nurse is caring for a client who is postoperative following vascular surgery. Which of the following manifestations should indicate to the nurse that the client has developed a thrombus?

*Dull, aching calf pain Rationale: The nurse should identify that a dull, aching calf pain is a manifestation of a deep-vein thrombosis. Other manifestations are edema, warmth, and redness in the calf.

A nurse is caring for a client who has been placed in halo traction to immobilize his cervical spine. Which of the following actions should the nurse take?

*Elevate the head of the bed. Rationale: To keep the client from migrating toward the head of the bed while using cervical halter traction, the nurse should elevate the head of the bed.

A nurse is caring for a client who has liver cirrhosis with ascites and bleeding esophageal varices. Which of the following laboratory findings indicates that the client's gastrointestinal (GI) tract is digesting and absorbing blood?

*Elevated BUN Rationale: The nurse should identify that as the body digests blood, BUN rises. An elevated BUN is an indication of GI bleeding.

A nurse is reviewing the laboratory report of a client who is receiving treatment for a high fever and a viral infection. Which of the following findings should the nurse expect?

*Elevated T-cell count Rationale: A high T-cell count (greater than 2,500/mm3, also known as lymphocytosis) occurs with a viral infection or a chronic disease such as lymphoma. These cells (along with B cells) fight chronic bacterial and acute viral infections.

A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching?

*Empty the ostomy pouch when it is 2/3 full. Rationale: The ileal conduit cannot store urine the way the bladder did; urine will flow continuously into a collecting device. Emptying the device when the pouch is 2/3 full will prevent leakage, skin irritation, and infection.

A nurse is caring for a client who has COPD. Which of the following actions should the nurse take?

*Encourage the client to drink 8 glasses of water a day. Rationale: The nurse should instruct the client to drink 6 to 8 glasses of noncaffeinated beverages to thin bronchial secretions.

A nurse is caring for a client who is receiving chemotherapy for treatment of ovarian cancer and experiencing nausea. Which of the following actions should the nurse take?

*Encourage the client to drink a carbonated beverage 1 hr before meals. Rationale: The nurse should instruct the client to drink a carbonated beverage 1 hr before or after meals to reduce the risk for nausea

A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction. Which of the following actions should the nurse take?

*Ensure the client's weights are hanging freely from the bed. Rationale: The nurse should ensure that the client's weights are hanging freely from the bed to maintain the client in proper body alignment and should never be removed without a provider prescription or the development of a life-threatening situation that requires removal.

A nurse is caring for a client following the application of an aquathermia pad. Which of the following manifestations should the nurse identify as an indication that the client has a superficial burn?

*Erythema Rationale: Erythema is a manifestation of a superficial burn.

A nurse is caring for a male client who reports nausea and vomiting and is receiving IV fluid therapy. The client's BUN is 32 mg/dL, creatinine 1.1 mg/dL, and hematocrit 50%. Which of the following actions should the nurse take?

*Evaluate urine output for amount and urine for specific gravity. Rationale: These results indicate that the client is dehydrated. Specific gravity and urine output measurements can support the laboratory findings. The higher the specific gravity, the more dehydrated the client.

A nurse is collecting data from a client who is having an acute asthma exacerbation. When auscultating the client's chest, the nurse should expect to hear which of the following sounds?

*Expiratory wheeze Rationale: Expiratory wheezing is associated with air movement through narrowed airways, as with the bronchospasm associated with asthma.

A nurse is reinforcing teaching with an older adult client who has had a newly inserted permanent pacemaker. Which of the following manifestations should the nurse include in the teaching as a pacemaker malfunction that the client should report to the provider?

*Fatigue Rationale: Pacemaker malfunction causes bradycardia and a drop in cardiac output. This can cause hypoxia, with classic manifestations of weakness, fatigue, and dizziness.

A nurse is caring for a client who has heart failure and respiratory arrest. Which of the following actions should the nurse take first?

*Feel for a carotid pulse. Rationale: The priority action the nurse should take when using the compressions-airway-breathing approach to client care is to feel for a carotid pulse for 5 to 10 seconds to determine the immediate need for chest compressions.

A nurse is collecting data from a client who has skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites?

*Fever Rationale: Manifestations of inflammation and infection at the pin sites include fever, purulent drainage, odor, loose pins, and tenting of the skin around the pin sites.

A nurse is assisting with meal planning for a client who has hypothyroidism. The nurse should reinforce with the client that she should increase her daily intake of which of the following nutrients?

*Fiber Rationale: Constipation is a classic manifestation of hypothyroidism; therefore, this client should increase her fiber and fluid intake to help prevent constipation.

A nurse is contributing to the plan of care for a client who has a gastrostomy tube through which he is receiving continuous enteral feedings. Which of the following interventions should the nurse include in the plan?

*Flush the tube with 30 mL of water every 4 hr. Rationale: The nurse should flush the gastrostomy tube with 30 to 60 mL of water every four hours to provide free water to the client and prevent dehydration

A nurse is reinforcing teaching with the family of a client who has primary dementia. Which of the following manifestations of dementia should the nurse include in the teaching?

*Forgetfulness gradually progressing to disorientation Rationale: Dementia usually appears first as forgetfulness. Loss of functioning progresses slowly from impaired language skills and difficulty with ordinary, daily activities to severe memory loss and complete disorientation with withdrawal from social interaction.

A nurse is collecting data on a client who has hyperthyroidism. Which of the following manifestations should the nurse expect the client to report?

*Frequent mood changes Rationale: Hyperthyroidism develops when the thyroid gland produces an excess of the thyroid hormones that regulate the metabolic rate. Nervousness and frequent mood changes; hand tremors; a rapid, pounding, irregular heartbeat are common manifestations of hyperthyroidism

A nurse is reinforcing teaching with a client about cancer prevention and plans to address the importance of foods high in antioxidants. Which of the following foods should the nurse include in the teaching?

*Fresh berries Rationale: The nurse should include fresh berries (blackberries, strawberries, blueberries, and cranberries), coffee, kale, and dark chocolate as food sources high in antioxidants.

A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm3. Which of the following food items brought by the family should the nurse prohibit from being given to the client?

*Fresh fruit basket Rationale: The nurse should instruct the client's family that certain food products such as fresh fruit and vegetables should be excluded from the client's diet to reduce the risk of foodborne illness. An alternative to the fresh fruits would be a package of dried fruits.

A nurse is assisting with the care of a client who is postoperative and has a closed-wound drainage system in place. Which of the following actions should the nurse take?

*Fully recollapse the reservoir after emptying it. Rationale: To reestablish the vacuum, the reservoir must be compressed fully after it is emptied.

A nurse is assisting with the plan of care for a client who had an upper endoscopy 1 hr ago. The nurse should place the priority on monitoring which of the following?

*Gag reflex Rationale: The greatest risk to this client is aspiration immediately after an upper endoscopy; therefore, monitoring gag reflex is the priority action.

A nurse is assisting to monitor a client who is receiving a blood transfusion. Which of the following findings should the nurse report to the charge nurse as an indication of an allergic blood transfusion reaction?

*Generalized urticaria Rationale: The nurse should recognize urticaria as an indicator of an allergic transfusion reaction. Other clinical manifestations include itching and possible signs of anaphylaxis.

A nurse collecting data from a client who has Meniere's disease? Which of the following is an expected finding for this client?

*Gradual hearing loss Rationale: An expected finding for a client who has Meniere's disease is tinnitus and gradual loss of hearing in one ear. Some clients also have hearing loss in both ears

A nurse is collecting data on a client's wound. The nurse observes that the wound surface is covered with soft, red tissue that bleeds easily. The nurse should recognize this is a manifestation of which of the following?

*Granulation tissue Rationale: Granulation tissue forms in healing wounds during the proliferative phase. Granulation tissue is soft, red tissue with a granular appearance that bleeds easily.

A nurse is caring for a client who has a large wound that has a vacuum-assisted closure device placed over it. Which of the following findings by the nurse indicates healing of the wound?

*Granulation tissue on the surface of the wound Rationale: As the wound heals, the nurse should expect the wound base to become redder as granulation tissue lines the surface of the wound. Therefore, this is an expected finding. The vacuum-assisted closure device assists in wound closure by applying a localized negative pressure to draw the edges of the wound together. The device consists of a suction tube embedded in a foam dressing. The foam dressing is applied to the wound bed and sealed in place with an occlusive dressing. The suction is then attached to the vacuum unit, causing the foam to collapse and resulting in drainage of excess fluids, and increasing circulation to the wound bed.

A nurse is caring for an older adult client who has colon cancer. The client asks the nurse several questions about his treatment plan. Which of the following actions should the nurse take?

*Help the client write down questions to ask his provider. Rationale: To empower the client in decision-making, the nurse should help the client write down questions to ask the provider. In doing this, the nurse acts as a client advocate to address the client's specific questions in a concrete, measurable way.

A nurse is in a provider's office is collecting data from an older adult client who has type 2 diabetes mellitus. Which of the following findings is a manifestation of hyperglycemia?

*History of poor wound healing Rationale: The presence of hyperglycemia leads to poor wound healing due to decreased blood supply to the tissue.

A nurse is collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

*Hypertension Rationale: Hypertension is an early manifestation of increased intracranial pressure. Other manifestations include restlessness, headache, and change in level of consciousness. The nurse should monitor and report manifestations of increased intracranial pressure.

A nurse is collecting data from a client who has alcohol use disorder and is experiencing metabolic acidosis. Which of the following manifestations should the nurse expect?

*Hyperventilation Rationale: The nurse should expect to find hyperventilation in a client who is experiencing metabolic acidosis. The system attempts to compensate or return the pH to normal by increasing the rate and depth of respirations

A nurse in the emergency department is collecting data from a client who was admitted following a bee sting. Which of the following findings should the nurse expect in a client who is experiencing anaphylaxis?

*Hypotension Rationale: Hypotension is an expected finding for a client who is experiencing anaphylaxis due to vasodilation.

A nurse is caring for a client who is receiving a unit of packed RBCs. About 15 min following the start of the transfusion, the nurse notes that the client is flushed and febrile, and reports chills. To help confirm that the client is having an acute hemolytic transfusion reaction, the nurse should observe for which of the following manifestations?

*Hypotension Rationale: Hypotension, tachycardia, tachypnea, low back pain, flushing, chills, and fever are manifestations of an acute hemolytic reaction to a blood transfusion.

A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should monitor the client for which of the following manifestations?

*Hypotension Rationale: The client who has diabetes insipidus produces excessive urine resulting in hypovolemia and hypotension. The nurse should monitor the client for hypotension and dehydration.

A nurse is reinforcing discharge teaching with a client who is postoperative following a cataract extraction. Which of the following statements by the client indicates an understanding of the teaching?

*I will bend at my knees if I need to pick something up off of the floor." Rationale: The client should avoid bending at the waist because this increases intraocular pressure. Bending at the knees is the correct way to pick something up off of the floor.

A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a kidney transplant. Which of the following laboratory findings should the nurse identify as the most important to report to the provider?

*Increase in serum creatinine Rationale: The nurse should identify the elevated serum creatinine level as the priority finding to report. Cyclosporine is nephrotoxic, so an increase in the creatinine and BUN levels can indicate the medication dosage is too high and must be decreased to recover renal function.

A nurse is caring for a client who is at risk for shock. Which of the following findings should the nurse expect?

*Increased blood pressure Rationale: Decreased blood pressure is a manifestation of shock.

A nurse is monitoring a client who has just had a thoracentesis to remove pleural fluid. Which of the following clinical manifestations should indicate to the nurse the client is experiencing a complication and the provider should be notified immediately?

*Increased heart rate Rationale: Clients can experience pulmonary edema or cardiovascular distress after mediastinal contents shift suddenly after the aspiration of a large amount of fluid. An increase in heart and respiratory rate, coughing up blood-tinged frothy sputum, along with tightness in the chest are some of the manifestations the client can develop. Any of these signs should be reported to the provider.

A nurse is monitoring a client for findings related to diabetes insipidus following a craniotomy. Which of the following findings should indicate a manifestation of this condition to the nurse?

*Increased urine output Rationale: Diabetes insipidus is a water metabolism disorder caused by a deficiency of antidiuretic hormone (ADH). This deficiency results in the excretion of large amounts of dilute urine. Dehydration and shock may ensue, resulting in a life-threatening situation for the client.

A nurse is caring for a client after a radical neck dissection. To which of the following should the nurse give priority in the immediate postoperative period?

*Ineffective airway clearance related to thick, copious secretions Rationale: According to the airway, breathing, circulation (ABC) priority-setting framework, the priority action is the client's need for adequate oxygenation. A client who has a new tracheostomy requires frequent suctioning in the early postoperative period because of copious secretions and the decreased effectiveness of the cough mechanism.

A nurse is collecting data from a client who has myasthenia gravis. Which of the following findings has the highest priority?

*Ineffective breathing pattern Rationale: The greatest risk to this client is respiratory depression. Therefore, an ineffective breathing pattern is the highest priority finding.

While collecting data from a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to the touch. Which of the following findings should the nurse identify as a complication to the client's condition?

*Infection Rationale: An area of warmth on a cast is an indication of an infection; therefore, the nurse should report this finding to the provider.

A nurse is assisting with the care of a client in the emergency department and reports severe radiating chest pain and shortness of breath. The client appears restless, frightened, and slightly cyanotic. The provider prescribes oxygen by nasal cannula at 4 L/min stat, cardiac enzyme levels, IV fluids, and a 12-lead ECG. Which of the following actions should the nurse take first?

*Initiate oxygen therapy. Rationale: The greatest risk to the client's safety is myocardial ischemia; therefore, the first action the nurse should take is initiate oxygen therapy.

The nurse is caring for a client who has a bowel obstruction and a new prescription for the insertion of a nasogastric tube. Which of the following interventions should the nurse take when inserting the nasogastric tube?

*Instruct the client to place his chin to his chest and swallow. Rationale: The nurse should instruct the client to place his chin to his chest and swallow to facilitate insertion of the nasogastric tube after it reaches the oropharynx. This position directs the tube toward the posterior pharynx and esophagus rather than the larynx and the bronchus.

A nurse is reinforcing teaching with a client who has a new prescription for epoetin alfa. The nurse should reinforce to the client to take which of the following dietary supplements with this medication?

*Iron Rationale: Epoetin alfa treats anemia by stimulating the production of red blood cells. Supplemental iron is needed for the production of hemoglobin and red blood cells by the bone marrow. The client should take supplemental iron when taking epoetin alfa.

A nurse is collecting data from a client who has atrial fibrillation. When documenting the quality of the client's pulse, which of the following terms should the nurse use?

*Irregular Rationale: With atrial fibrillation, multiple ectopic foci stimulate the atria to contract. The AV node is unable to transmit all of these impulses to the ventricles, resulting in a pattern of highly irregular ventricular contractions and thus an irregular pulse.

A nurse is assisting with the care of a client following a transurethral resection of the prostate (TURP) and has an indwelling urinary catheter. Which of the following actions should the nurse take?

*Irrigate the catheter as prescribed. Rationale: The nurse should irrigate the catheter to remove blood clots and maintain catheter patency.

A nurse is assisting with the care of a client who has a newly inserted chest tube. Which of the following actions should the nurse take?

*Keep the collection device below the client's chest level. Rationale: The nurse should keep the drainage system lower than the chest; this facilitates drainage and proper functioning of the chest tube.

A nurse is caring for a client who has a hemothorax following a motor-vehicle crash. The client has a chest tube connected to a closed drainage system. When assisting the client out of bed to a chair, which of the following actions should the nurse take?

*Keep the drainage system below the level of the chest. Rationale: The drainage system must be kept below the level of the chest to prevent interference with the functioning of the drainage device. Keeping the system lower than the chest uses gravity to help prevent backflow of blood and other fluids into the pleural space.

A nurse is assisting with the care of a client who is hypovolemic due to blood loss following a motor-vehicle crash and needs a blood transfusion immediately. The nurse should anticipate a prescription for which of the following IV solutions while awaiting blood from a type and cross-match?

*Lactated Ringer's Rationale: Lactated Ringer's solution is administered to the client who has hypovolemic shock because it contains electrolytes and expands plasma volume.

A nurse is assisting with caring for a client who has a new concussion following a motor-vehicle crash. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

*Lethargy Rationale: An early manifestation of increased intracranial pressure is lethargy. The nurse should monitor and report any changes in the client's level of consciousness, such as restlessness or disorientation, because these are early manifestations of increased intracranial pressure.

An acute care nurse is caring for an adult client who is undergoing evaluation for a possible brain tumor. While performing a neurological examination, which of following findings is the earliest indicator of the client's cerebral status?

*Level of consciousness Rationale: The first action the nurse should take using the nursing process is to collect data about the client's level of consciousness, as this finding is the earliest indicator of the client's cerebral status.

A nurse is caring for a client who has tuberculosis and is about to start taking pyrazinamide. The nurse should identify that the client needs which of the following tests while taking this medication therapy?

*Liver function tests Rationale: The nurse should identify that pyrazinamide can cause hepatotoxicity; therefore, the provider should monitor the client's liver function regularly while taking this medication.

A nurse is collecting data from a client who has open-angle glaucoma. Which of the following findings should the nurse expect?

*Loss of peripheral vision Rationale: The nurse should expect to find the client experiencing a gradual loss of peripheral vision with a narrowing of the visual field with open-angle glaucoma.

A nurse is reinforcing teaching with a client who has a new diagnosis of fibromyalgia. Which of the following information should the nurse include in the teaching ?

*Low-impact aerobics can help reduce episodes of pain. Rationale: The nurse should recommend that the client who has fibromyalgia engage in regular aerobic exercise to improve overall quality of life.

A nurse is contributing to the plan of care for an older adult client who is postoperative following a right hip arthroplasty. Which of the following interventions should the nurse include in the plan?

*Maintain abduction of the right hip. Rationale: The nurse should use an abductor pillow or other device to maintain abduction of the affected hip to prevent dislocation.

A nurse is contributing to the plan of care for a client to achieve the outcome of functional healing of a fracture. Which of the following nursing interventions is the highest priority to assist in meeting this outcome?

*Maintain immobilization and alignment for the client. Rationale: The nurse should maintain the prescribed immobilization and body alignment to keep the fracture fragments in close anatomical proximity, thereby promoting functional fracture healing; therefore, this intervention is the highest priority.

A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the following interventions should the nurse include in the plan of care?

*Maintain the client in Fowler's position. Rationale: The nurse should place the client in Fowler's position to reduce pressure on the diaphragm and to promote function of the nasogastric tube.

The nurse is caring for a client who has a pneumothorax and a water-seal chest tube drainage system to suction. Which of the following actions should the nurse take?

*Maintain the drainage container below the level of the client's chest. Rationale: Keeping the drainage collection container below the level of the client's chest prevents the back-flow of fluid into the client's chest.

A nurse is reinforcing teaching with a client who has osteoarthritis. To slow the degenerative process, which of the following interventions should the nurse recommend?

*Maintaining a BMI between 18.5 and 24.9 Rationale: A BMI between 18.5 and 24.9 is classified as a health weight. Osteoarthritis is the degeneration of the cartilage in the joints caused by prolonged wear and tear of the joint surfaces. Osteoarthritis most commonly affects the weight-bearing joints of the hips, knees, and spine. Maintaining a healthy, appropriate weight for height, or participating in a weight reduction program if the client is overweight, reduces the stress on the involved joints and slows the disease process.

A nurse is collecting data from client who has received chemotherapy to treat lung cancer. Which of the following adverse effects should the nurse report to the provider?

*Manifestations of infection Rationale: Chemotherapy to sites containing bone marrow (such as the sternum) can lower the white blood cell count (leukopenia), thus increasing the client's risk for infection. Screening the client for manifestations of infection should be reported to the provider.

A nurse is caring for a client who has acute kidney injury. The client's ABGS are:pH: 7.26PaCO2: 30 mm HgHCO3: 14 mEq/LWhich of the following acid-imbalances should the nurse identify the client is experiencing?

*Metabolic acidosis Rationale: Acute renal failure causes metabolic acidosis because clients cannot process and excrete the acidic substances the usual bodily functions produce every day. With metabolic acidosis, the pH is below 7.35, the PaCO2 is below 35 mm Hg or in the expected range, and the HCO3 is below 22 mEq/L.

A nurse is reviewing the arterial blood gas (ABG) results of a client. The client's ABGs are:pH: 7.6PaCO2: 40 mm HgHCO3: 32 mEq/L.Which of the following acid base conditions should the nurse identify the client is experiencing?

*Metabolic alkalosis Rationale: The nurse should identify that the client is experiencing metabolic alkalosis. The client's pH is above 7.45, the PaCO2 is within the expected reference range and the HCO3 is above 26 mEq/L.

A nurse is contributing to the plan of care for a client who has labyrinthitis. Which of the following interventions should the nurse include in the plan?

*Monitor client's cardinal fields of vision. Rationale: The nurse should assess for nystagmus, abnormal jerking movements of the eyes, by evaluating the six cardinal fields of gaze. Nystagmus is a manifestation of labyrinthitis.

A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following actions should the nurse take?

*Monitor intake and output hourly Rationale: The nurse should closely monitor the client for signs of fluid imbalance. This includes hourly monitoring of intake and output, along with daily weights. If there are sudden changes, or the urinary output is less than 30 mL/hr, the provider must be notified immediately.

A nurse is assisting with the plan of care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan of care?

*Monitor level of consciousness every 4 hr. Rationale: Clients with thrombocytopenia have a decreased platelet count, which puts them at risk for bleeding. An early indication of bleeding is a change in the level of consciousness and tachycardia. Therefore, the nurse should monitor the client's vital signs and level of consciousness every 4 hr.

A nurse is contributing to the plan of care for a client who has bone marrow suppression related to chemotherapy treatments. Which of the following interventions should the nurse include in the plan?

*Monitor oral mucosa daily. Rationale: The client who has bone marrow suppression experiences a decrease in erythrocytes, platelets, and leukocytes. The decrease in WBCs places the client at risk for the development of opportunistic infections; therefore, the nurse should monitor the client's oral mucosa daily for the development of sores or white patches and offer frequent oral care.

A nurse is contributing to the plan of care for a client who is admitted with a deep vein thrombosis (DVT) of the left leg. Which of the following interventions should the nurse include in the plan?

*Monitor platelet levels Rationale: The nurse should monitor platelet levels along with other laboratory results related to blood coagulability and the medication therapy for the treatment of a deep vein thrombosis. Initially, medications such as heparin or enoxaparin are administered; laboratory test would include PTT. Later, warfarin therapy may be initiated for which PT/INR would be monitored. Platelets are monitored because the client is at risk for heparin inducted thrombocytopenia, placing the client at risk for bleeding.

A nurse is reviewing the laboratory values for a client who takes spironolactone and notes that the client's serum potassium level is 6.8 mEq/L. The nurse notifies the provider and anticipates that the provider will provide which of the following instructions?

*Obtain a 12-lead ECG. Rationale: This client's potassium level is above the expected reference range. Because hyperkalemia can cause ECG changes, including ventricular dysrhythmias and cardiac arrest, it is essential to obtain a 12-lead ECG and to monitor for such changes.

Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

*Obtain a pair of slipper socks for the client. Rationale: Slipper socks with nonskid soles will help provide warmth and increase the client's level of comfort.

A nurse is caring for a client who has balanced skeletal traction with a Thomas splint for the treatment of a fracture of the femur. Which of the following actions should the nurse take to prevent skin breakdown?

*Pad the top of the splint with protective dressings. Rationale: The nurse should pad the top of the splint with protective dressings or soft cotton padding to prevent skin breakdown at the splint edge.

A nurse is collecting data from a client following the application of a leg cast for the treatment of a fracture. Which of the following findings should the nurse expect to find first if the cast is too tight?

*Pallor of the toes Rationale: The client who has a cast that is too tight may have pallor of the toes caused from inflammation and edema that puts pressure on the vascular system, tissues and nerves, which decreases blood flow and can lead to compartment syndrome. When this occurs, pallor of the toes is the initial finding. The nurse should immediately report this finding to the provider.

A nurse in an outpatient clinic is collecting data from a client who tells the nurse, "I have pain in my legs when I begin to walk, but the pain stops when I stop walking." Which of the following conditions should the nurse suspect?

*Peripheral vascular problems in both legs Rationale: This describes intermittent claudication, an indication of vascular deficiencies, often peripheral arterial disease.

A client who has a lower-leg cast reports skin irritation around the upper edge of the cast. Which of the following actions should the nurse take?

*Petal the edges of the cast. Rationale: Petaling the edges of the cast is a procedure that involves cutting strips of tape and applying them in an overlapping fashion around the edge of a cast. This reduces skin irritation from rough edges.

A nurse enters a client's room and finds the client on the floor in the clonic phase of a tonic-clonic seizure. Which of the following interventions should the nurse take?

*Place a pillow under the client's head. Rationale: The nurse should place a pillow or any soft padding under the client's head to protect the client from injury during the seizure.

A nurse is assisting a client who is postoperative following a total hip arthroplasty into a supine position. Which of the following actions is appropriate to prevent hip dislocation?

*Place a wedge pillow between the legs . Rationale: The nurse should place a wedge pillow or a different abduction device between the legs to prevent adduction, which can lead to possible dislocation.

A nurse is contributing to the plan of care for a client who is postoperative following peritoneal lavage for peritonitis. The client has a nasogastric tube to low-intermittent suction and closed-suction drains in place. Which of the following interventions should the nurse include in the plan?

*Place the client in a high Fowler's position. Rationale: The nurse should use measures to facilitate breathing in the client who has peritonitis. Placing the client into a high Fowler's position enhances lung expansion preventing respiratory complications and aids in localizing purulent abdominal materials.

A nurse is collecting data from a client who has increased intracranial pressure and is informed by the charge nurse that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe?

*Plantar flexion of the legs Rationale: Plantar flexion of the legs is an indicator of decorticate posturing and is a result of lesions of the corticospinal tracts.

A nurse is assisting with the care of a client who has adult respiratory distress syndrome (ARDS). Which of the following actions should the nurse take?

*Position the client in supine for ventilatory support Rationale: ARDS causes severe dyspnea and life-threatening alterations in blood gases; therefore, the nurse should placing the client in a prone position to allow the provider to intubate the client, providing ventilatory support to promote gas exchange and help relieve the client's dyspnea.

A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record?

*Postictal phase Rationale: The postictal phase is the recovery period following a tonic-clonic seizure. The client might be confused or agitated after a seizure and might sleep for several hours.

A nurse is collecting data from a client who has acute gastroenteritis. Which of the following data collection findings should the nurse identify as the priority?

*Potassium 2.5 mEq/L Rationale: When using the airway, breathing, circulation approach to client care, the nurse determines that the priority finding is a potassium level of 2.5 mEq/dL. In the presence of fluid volume deficit, potassium depletion can occur. Complications from hypokalemia include cardiac and respiratory manifestations.

A nurse is collecting data from a client who has systemic lupus erythematosus. Which of the following findings is the highest priority to report to the provider?

*Presence of peripheral edema Rationale: The client who has systemic lupus erythematosus is at greatest risk for death from lupus nephritis; therefore, according to the safety and risk reduction priority-setting framework, findings that indicate an impairment of renal function are the highest priority to report

A nurse is assisting with the care of a client who is postoperative following surgical repair of a fractured mandible. The client's jaw is wired shut to repair and stabilize the fracture. The nurse should recognize which of the following is the priority action?

*Prevent aspiration. Rationale: When using the airway, breathing, circulation approach to client care, the nurse should determine the priority action is to prevent aspiration. Since the client's jaws are wired together, aspiration is a risk if the client vomits. Therefore, the client should receive medication for nausea, as indicated, and wire cutters and suction are kept at the bedside at all times in case of vomiting or difficulty breathing.

A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia?

*Prevent bladder distention. Rationale: Autonomic dysreflexia can occur in clients who have a spinal cord injury at or above the T-6 level. Autonomic dysreflexia can occur as a result of an irritation, or stimulus to the nervous system below the level of injury. Triggers of autonomic dysreflexia include bladder distention, insertion of rectal suppository, enemas, or a sudden change in position

A nurse is contributing to the plan of care for a client who is postoperative following a total hip arthroplasty. Which of the following information should the nurse include?

*Prevent hip flexion of the affected extremity. Rationale: The nurse should implement measures to prevent hip flexion of the affected extremity due to the risk of dislocation.

A nurse is contributing to the plan of care for a client who has a spinal cord injury at level C8 who is admitted for comprehensive rehabilitation. Which of the following long-term goals is appropriate with regard to the client's mobility?

*Propel a wheelchair equipped with knobs on the wheels. Rationale: A client who has an injury at C8 has full use of the shoulders and arms but will likely experience hand weakness. The addition of knobs on the wheels will help the client use the wheelchair more effectively.

A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions?

*Provide humidified oxygen. Rationale: Increasing fluid intake as tolerated and providing adequate humidification can help thin secretions safely.

The nurse is contributing to the plan of care for a client who is 4 hr postoperative following a vaginal hysterectomy. Which of the following interventions should the nurse include in the plan of care?

*Provide tub baths for perineal comfort. Rationale: The nurse should provide frequent perineal care to minimize skin breakdown and the possibility of infection to the client who has had a vaginal hysterectomy; however, tub baths are contraindicated until vaginal bleeding has stopped.

A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the client's wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found?

*Purulent Rationale: Purulent describes drainage that is thick yellow, green, or brown in color.

A nurse is contributing to the plan of care for a client who has a terminal illness. Which of the following interventions should the nurse identify as the priority?

*Schedule pain medication on a routine basis. Rationale: The priority action the nurse should take when using Maslow's hierarchy of needs is to meet the client's safety and security needs. By scheduling the client's pain medication on a routine basis, the nurse can prevent acute pain exacerbations.

A nurse is assisting with planning care for a client who is recovering from a left-hemispheric stroke. Which of the following interventions should the nurse include in the plan?

*Re-establish communication. Rationale: A stroke is an interruption of the blood supply to a part of the brain, resulting in oxygen-deprived brain tissue. The left hemisphere is usually dominant for language. Because this client had a left-hemispheric stroke, the nurse can anticipate that the client will have some degree of aphasia and will require communication-focused nursing interventions and speech therapy to re-establish communication.

A nurse is caring for a client during the immediate postoperative period following thoracic surgery. When administering an opioid analgesic for pain, the nurse should explain that the medication should have which of the following effects?

*Reducing anxiety Rationale: Besides pain relief, postoperative opioid analgesics can help reduce anxiety and create feelings of well-being.

A nurse is caring for a client who has a serum potassium level of 5.5 mEq/L. The provider prescribes polystyrene sulfonate. Which of the following ECG results should indicate to the nurse that the medication has been effective?

*Reduction of T wave amplitude Rationale: The nurse should identify that the polystyrene sulfonate should bring the potassium level back to the expected reference range. Hyperkalemia causes peaked T waves and a widened QRS on ECG, so resolution of the potassium imbalance should restore these ECG changes to baseline.

An older adult client on an orthopedic unit has an intracapsular fracture of the right hip following a fall. The client is in Buck's traction and will have hip prosthesis surgery in the morning. The nurse should reinforce with the client that this type of traction promotes which of the following outcomes?

*Relief from muscle spasms Rationale: Buck's traction immobilizes the fractured bone to relieve muscle spasms at the fracture site and thereby relieve pain. Any movement of fracture fragments induces severe muscle spasms and triggers pain.

The nurse is assisting with the care of a client who is postoperative following a bowel resection and just arrived to the unit from PACU. Which of the following actions should the nurse take?

*Remove the anti-embolic stockings for 20 min. every 8 hr. Rationale: The nurse should frequently check the anti-embolic stockings and sequential compression devices to ensure they fit appropriate and the compression devices are working. These improve the venous return of blood from the legs and prevent stasis in the lower extremities which helps prevent the development of deep vein thrombosis. The stockings should be removed for 20 min every 8 hr to allow the circulation of air to the skin and for the nurse to perform a full skin assessment.

A nurse in a provider's office is collecting data for a 45-year-old client who is having manifestations associated with perimenopause. Which of the following findings should the nurse expect?

*Report of dryness with vaginal intercourse Rationale: Perimenopause includes the years surrounding menopause. During this time the ovaries produce less estrogen, and a woman's menstrual periods cease. Because of the changes in the vagina, some women may have dryness, discomfort, or pain during vaginal intercourse.

A nurse is collecting data from a client whose arterial blood gas values reveal a pH of 7.24, PaCO2 of 53, and an HCO3- of 24. The nurse should prepare to treat the client for which of the following acid-base imbalances?

*Respiratory acidosis Rationale: In analyzing blood gases, the nurse should first determine if the result is acidosis (pH less than 7.35) or alkalosis (pH greater than 7.45). A pH of 7.24 is decreased. Therefore, this is acidosis. The next step is to look at the PaCO2 (expected reference range 35 to 45) and the HCO3- (expected reference range 22 to 26). A PaCO2 of 53 is elevated (greater than 45) and the HCO3- of 24 is within the expected reference range. Therefore, if the pH is decreased, the PaCO2 is elevated and the HCO<sun>3- is within the expected reference range, the client is experiencing respiratory acidosis.

A nurse is collecting data from a client who has shallow respirations and a respiratory rate of 9/min. Which of the following acid-base imbalances should the nurse expect?

*Respiratory acidosis Rationale: Respiratory acidosis represents an increase in the acid component, carbon dioxide, due to inadequate excretion, and an increase in the hydrogen ion concentration (decreased pH) of the arterial blood. A major cause of this imbalance is hypoventilation.

A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of 7/min. The arterial blood gas (ABG) values include: pH 7.22 PaCO<small>2</small> 68 mm Hg Base excess -2 PaO<small>2</small> 78 mm Hg Oxygen saturation 80% Bicarbonate 28 mEq/L</br> Which of the following interpretations of the ABG values should the nurse make?

*Respiratory acidosis Rationale: The nurse should identify the client who has respiratory problems such as obstruction or depression of the respiratory system as at risk for the development of respiratory acidosis. The expected pH range is 7.35 to 7.45. The pH of 7.22 indicates that this client is acidotic. The pH is decreased while the PaCO2 is elevated. Therefore, the correct interpretation of the results is that the client is in respiratory acidosis.

A nurse is caring for a client whose arterial blood gas results show the following results:pH: 7.2PaCO2: 50 mm HgHCO3: 24 mEq/LThe nurse should identify the client is experiencing which of the following acid-base conditions?

*Respiratory acidosis Rationale: With uncompensated respiratory acidosis, the client's pH is below 7.35, the PaCO2 is above 45 mm Hg, and the HCO3 is within the expected reference range.

A home health nurse is assisting with the plan of care for an older adult client who had cataract surgery recently. Which of the following information should the nurse include in the plan of care?

*Rest in semi-Fowler's position." Rationale: The client should rest in a semi-Fowler's position to prevent increasing intraocular pressure.

A nurse is reinforcing teaching about Russell's traction with a newly licensed nurse. Which of the following statements should the nurse make?

*Russell's traction uses a sling under the knee to treat a fracture of the femur." Rationale: Russell's traction is a type of skin traction which incorporates a sling under the knee that is connected by a rope to an overhead bar pulley.

A nurse is caring for a client whose history reveals the clinical manifestations of pernicious anemia. The nurse should anticipate a prescription for which of the following diagnostic tests?

*Schilling test Rationale: Pernicious anemia is caused by a deficiency of the intrinsic factor which is essential to the absorption of vitamin B12. The Schilling test is used to measure the client's ability to absorb vitamin B12. Low levels of B12 indicate a low level of the intrinsic factor and subsequently deficiency of vitamin B12.

While admitting a client for a cardiac catheterization, the nurse asks the client about allergies. Which of the following client food allergies should the nurse report to the provider prior to the procedure?

*Shellfish Rationale: The greatest risk to the client is an allergic reaction to the iodine-containing contrast agent the client will receive IV for the procedure. (Shellfish also contains iodine.) The nurse should notify the provider so a prescribed preventative medication can be administered to the client prior to the contrast agent being given.

A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of the hypothermia blanket?

*Shivering Rationale: The hypothermia blanket can cause shivering if the client is cooled too quickly. Shivering can cause the client's temperature to increase.

A nurse is caring for a client who is scheduled to undergo thoracentesis. In which of the following positions should the nurse place the client for the procedure?

*Sitting, leaning forward over the bedside table. Rationale: Thoracentesis is aspiration of fluid or air from the pleural space. The nurse should place the client in a sitting position and leaning over a bedside table to ensure that the diaphragm is dependent. This facilitates the removal of accumulated fluid, which tends to pool in the bases of the pleural space.

A nurse is discussing skeletal and skin traction with a newly licensed nurse. Which of the following statements should the nurse identify as an indication that the newly licensed nurse understands these therapies?

*Skeletal traction is better than skin traction for reducing a fracture." Rationale: Skeletal traction allows for reduction and alignment of a fracture. Skin traction decreases muscle spasms common with a fracture.

A nurse is reviewing the preadmission laboratory test results of a client who is scheduled for a carotid endarterectomy in 3 days. Which of the following results should the nurse report to the provider?

*Sodium 151 mEq/L Rationale: This sodium level result reflects hyponatremia, as the expected reference range is 136 to 145 mEq/L. The nurse should report this result to the provider.

A nurse is reinforcing teaching with a client who is having difficulty using an incentive spirometer. Which of the following instructions should the nurse include in the teaching?

*Start slowly and increase volume over several sessions. Rationale: The nurse should advise the client to start very slowly and gradually increase the volume. It also helps to take several slow, deep breaths in between incentive spirometer inhalations.

A nurse is monitoring a client receiving packed RBCs. The nurse notices facial flushing, and the client reports lower back pain. Which of the following actions is the priority for the nurse to take?

*Stop the transfusion. Rationale: The greatest risk to this client is further injury from a blood transfusion reaction; therefore, the priority action for the nurse to take is to stop the transfusion. Even a small additional amount of blood can worsen the client's reaction, so the nurse should stop the transfusion immediately.

A nurse is collecting data from a client who has a right hemothorax and a water-seal chest tube drainage system to closed suction. For which of the following findings should the nurse contact the charge nurse?

*Subcutaneous emphysema is present on the client's right chest wall. Rationale: The presence of subcutaneous emphysema is indicative of an air leak between the lung and the chest tube and should be reported to the charge nurse.

A nurse is caring for a client who is unconscious following a stroke. Which of the following nursing interventions is of highest priority ?

*Suction saliva from the client's mouth. Rationale: The greatest risk to the unconscious client is inability to independently maintain a clear airway. The client is at risk for ineffective airway clearance; therefore, the priority nursing action is to maintain the client's airway.

A nurse is reinforcing health teaching about skin cancer with a group of clients. Which of the following risk factors should the nurse identify as the leading cause of non-melanoma skin cancer?

*Sun exposure Rationale: According to evidenced-based practice, the nurse should identify exposure to the sun as the leading cause of non-melanoma skin cancer. Ultraviolet light radiation from the sun can cause cancerous changes in the skin. Decreased ozone protection has increased the amount of radiation exposure and increased the risk of cancer for clients regardless of skin color.

A nurse is reinforcing teaching to a client who is scheduled for an intravenous pyelogram. Which of the following should the nurse include in the teaching?

*Take a laxative the evening before the procedure. Rationale: Stool or gas in the bowel may make it difficult to visualize the renal system during an intravenous pyelogram, so typically the bowel is cleansed the day before.

A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching?

*Take temperature once a day. Rationale: The nurse should reinforce to the client to take his temperature once a daily to identify if a temperature is present due to the client's altered immune system.

An older adult client in a long-term care facility has dementia and begins to have frequent episodes of urinary incontinence. After the provider finds no medical cause for his incontinence, which of the following interventions should the nurse initiate to manage this behavior?

*Take the client to the bathroom on an every-2-hr schedule. Rationale: It is important to attempt measures that might help prevent incontinence before resorting to measures that can cause complications like infection and skin breakdown. For some clients, regular toileting can help manage this problem.

A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis and is to start taking neostigmine. Which of the following instructions should the nurse include in the teaching?

*Take the medication 45 minutes before eating. Rationale: The nurse should instruct the client to take the medication before eating to allow the medication time to work and limit difficulty chewing and swallowing.

A nurse is reinforcing teaching with a client who has myasthenia gravis and has a new prescription for pyridostigmine orally. Which of the following instructions should the nurse include?

*Take the medication 45 minutes before eating." Rationale: Clients who have myasthenia gravis have impaired ability to swallow. The client should take the medication 45 minutes before meals to maximize the effect of the medication.

A nurse in a provider's office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include?

*Take this medication between meals. Rationale: Although taking iron supplements with food can decrease adverse effects, it also drastically reduces the absorption of iron. Therefore, the nurse should instruct the client that taking iron is most effective when supplements are taken in between meals.

A nurse is caring for a client who is postoperative following foot surgery and is not to bear weight on the operative foot. The nurse enters the room to discover the client hopped on one foot to the bathroom, using an IV pole for support. Which of the following actions should the nurse take?

*Tell the client to remain in the bathroom after toileting and obtain a wheelchair. Rationale: The greatest risk to the client is falling. Since the client is already in the bathroom, the nurse should allow the client to void, and then return the client to bed safely in a wheelchair to prevent a fall.

A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client's right nostril. Which of the following actions should the nurse take first?

*Test the drainage for glucose. Rationale: The greatest risk to a client who has a basal skull fracture is injury from cerebral spinal fluid (CSF) leak; therefore, the nurse should first test the drainage for glucose.

A nurse is assisting with the care of a client who was admitted to the telemetry unit after he experienced chest pain, dyspnea and diaphoresis. Which of the following ECG findings is a manifestation of acute myocardial infarction?

*The ST segment is above the isoelectric line. Rationale: Myocardial infarction is classified as ST elevation (MI STEMI) or non-ST elevation (MI NSTEMI). ST elevation is a manifestation of MI STEMI.

A nurse is collecting data from an older adult client who is preoperative for a total hip arthroplasty. For which of the following findings should the nurse notify the provider?

*The client has an abscessed tooth. Rationale: The nurse should assess for and report any sign of infection in the preoperative client as this increases the risk of surgery and postoperative surgical site infection.

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

*The client opens his eyes when spoken to. Rationale: A GCS of 3-5-5 indicates that the client opens his eyes in response to speech, is oriented, and is able to localize pain.

A nurse at an outpatient surgery center is reinforcing discharge teaching with a client's partner following surgical removal of a cataract. Which of the following information should the nurse include in the teaching?

*The client should wear dark glasses while outdoors. Rationale: Following surgical removal of a cataract, the nurse should instruct the client and partner to wear sunglasses when outside until pupil reaction returns.

A nurse is assisting with planning an immunization clinic for older adult clients. Which of the following information should the nurse plan to include about influenza?

*The composition of the influenza vaccine changes yearly. Rationale: Influenza outbreaks occur annually and the prevalent influenza viruses change yearly. Consequently, the previous year's influenza immunization will not protect a client exposed to the current year's influenza strains.

A nurse is reinforcing teaching with a client who reports right shoulder pain following a laparoscopic cholecystectomy. Which of the following statements should the nurse make?

*The pain will dissipate if you ambulate frequently." Rationale: The client who has right shoulder pain following the procedure should ambulate as soon and as much as possible to dissipate the carbon dioxide gas that was injected into the abdominal cavity to visualize and access the abdominal structure. The carbon dioxide causes referred pain in the clavicle and shoulder area.

A nurse is reinforcing teaching with a client who has glaucoma. Which of the following statements should the nurse make?

*The purpose of this device is to immobilize the cervical spine." Rationale: A client who has an injury to the cervical spine may have a halo fixation device to provide immobilization of the cervical spine.

A client returns to the surgical unit from the PACU in skeletal traction. The nurse should take action to correct which of the following problems with the traction setup?

*The weights rest against the foot of the bed. Rationale: Weights that rest against the foot of the bed or on the floor do not apply the traction essential for reducing the fracture and immobilizing the bone.

A nurse is collecting data on a client who has a surgical wound healing by secondary intention. Which of the following findings should the nurse report to the charge nurse?

*The wound has a halo of erythema on the surrounding skin. Rationale: A ring of redness on the surrounding skin can indicate underlying infection, and the nurse should report any indication of infection such as purulent drainage, swelling, warmth, or strong odor.

A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for the nurse report to the provider?

*Thick, red-colored urine Rationale: The nurse should recognize viscous drainage that is red in color may indicate hemorrhage and should be reported to the provider immediately.

A nurse is reinforcing teaching with an older adult client who has been newly diagnosed with a heart murmur. Which of the following statements should the nurse make?

*This indicates turbulent blood flow through a valve." Rationale: Turbulent blood flow through a valve generates a murmur, possibly due to a malfunctioning valve, increased blood flow, or a type of defect in the structures of or around the heart.

A nurse is caring for a client who is scheduled for a blood sampling for a serum creatinine level. The client asks the nurse, "What is the purpose for this test?" Which of the following responses should the nurse give?

*This test will inform your provider how your kidneys are functioning." Rationale: The nurse should inform the client that the purpose for the serum creatinine level is to determine the functioning of the client's kidneys.

A nurse is reinforcing teaching about placement of a prosthesis with a client who is having a below the knee amputation. Which of the following information should the nurse include in the teaching?

*This will improve your ability to ambulate sooner." Rationale: The nurse should explain that the purpose of a prosthesis immediately following surgery is to promote postoperative ambulation

A nurse is reinforcing teaching about breast self-examination (BSE) with a client who has a regular menstrual cycle. The nurse should instruct the client to perform BSE at which of the following times?

*Three to seven days after menses stops Rationale: The client should plan to perform breast self-examination about 3 to 7 days after menstruation, when the breasts are least tender and not engorged.

A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily following a myocardial infarction. The nurse should instruct the client that aspirin is prescribed for clients who have coronary artery disease for which of the following effects?

*To prevent blood clotting Rationale: Aspirin is used to prevent clot formation by reducing platelet aggregation. Therefore, the nurse should instruct the client the aspirin is prescribed for clients who have coronary artery disease to prevent myocardial infarction caused by clots in the coronary arteries.

A nurse is assisting with the admission of a client who has an open wound that is infected from community-acquired methicillin-resistant staphylococcus aureus (CA-MRSA). The client's wound has not responded to treatment with surgical drainage. The nurse should anticipate that the client will require which of the following interventions?

*Trimethoprim/sulfamethoxazole Rationale: CA-MRSA is typically caused by strains of staphylococcus. Trimethoprim/sulfamethoxazole is a combination antimicrobial medication that is used frequently to treat CA-MRSA.

A nurse is reviewing the laboratory findings of a client who experienced an acute myocardial infarction 6 days ago. Which of the following laboratory values should the nurse expect to remain elevated at this time?

*Troponin T Rationale: Following an acute myocardial infarction, the client's Troponin T level elevates in 1 to 3 hr, peaks in 24 to 36 hr, and remains elevated for 10 to 14 days.

A nurse is reviewing the plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse recommend?

*Wash daily with an antibacterial soap. Rationale: The nurse should plan to have the client wash the area daily with an antibacterial soap to promote tissue health and treat the infection.

A nurse is caring for a client who is postoperative and has developed atelectasis. Which of the following findings should the nurse expect?

*increasing dyspnea Rationale: Atelectasis is a closure or collapse of the alveoli due to obstruction or hypoventilation, causing shortness of breath and pleural pain.