NCLEX - PN Questions

A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic?

"You seem very distressed over learning you have asthma." Clients who have learned they have a chronic illness may exhibit denial, anger, or sarcasm because of the fear associated with the chronic illness. It is important for the nurse to convey an accepting attitude to enhance mutual respect and trust. Asking the client if asthma will kill them paraphrases the client's words but is somewhat sarcastic. Telling the client that you will not work with them is punitive in its approach and threatens the client. Informing the client that asthma is a treatable condition lectures the client and does not deal directly with the client's expressed concerns.

Isotretinoin is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed?

.Triglyceride level Isotretinoin can elevate triglyceride levels. Blood triglyceride levels should be measured before treatment and periodically thereafter until the effect on the triglycerides has been evaluated. Options 1, 3, and 4 do not need to be monitored specifically during this treatment.

A child is diagnosed with scarlet fever. A nurse collects data regarding the child. Which of the following is a clinical manifestation of scarlet fever?

Pastia's sign Pastia's sign is a rash seen among children with scarlet fever that will blanch with pressure, except in areas of deep creases and in the folds of joints. The tongue is initially coated with a white furry covering with red projecting papillae (white strawberry tongue). By the fourth to fifth day, the white strawberry tongue sloughs off and leaves a red, swollen tongue (strawberry tongue). The pharynx is edematous and beefy red in color. Option 2 is associated with poliomyelitis. Options 3 and 4 are characteristics of diphtheria.

A nurse reviews the results of a Mantoux test performed on a 3-year-old child. The results indicate an area of induration that measures 10 mm. The nurse would interpret these results as:

Positive An induration that measures 10 mm or more is considered to be a positive result for children who are younger than 4 years old and for those with chronic illness or with a high risk for environmental exposure to tuberculosis. A reaction of 5 mm or more is considered to be a positive result for those in the highest-risk groups. Repeat tests are not done, especially when a positive reaction occurs.

A nurse is reviewing the record of a child with a diagnosis of pyloric stenosis. Which data would the nurse expect to note as having been documented in the child's record?

Projectile vomiting Clinical manifestations of pyloric stenosis include projectile, nonbilious vomiting; irritability; hunger and crying; constipation; and signs of dehydration, including a decrease in urine output.

A nurse is caring for a client who is receiving oxytocin (Pitocin) to induce labor. The nurse discontinues the oxytocin infusion and notifies the registered nurse if which of the following is noted on data collection of the client?

Uterine hyperstimulation Oxytocin stimulates uterine contractions, and it is one of the common pharmacological methods used to induce labor. An adverse effect associated with the administration of the medication is the hyperstimulation of uterine contractions. Therefore, oxytocin infusion must be stopped when any signs of uterine hyperstimulation are present. Fatigue and drowsiness may be caused by the labor experience. Early decelerations of the fetal heart rate are a reassuring sign and do not indicate fetal distress

The registered nurse reviews the results of the arterial blood gases with the licensed practical nurse (LPN) and tells the LPN that the client is experiencing respiratory acidosis. The LPN would expect to note which of the following on the laboratory result form?

pH 7.25, Pco2 50 mm Hg Rationale: The normal pH is 7.35 to 7.45, and the normal Pco2 value is 35 to 45 mm Hg. In respiratory acidosis, the pH is down and the Pco2 is up. Option 3 is the only option that reflects an acidotic condition. Options 1 and 4 reflect an elevated pH, which indicates an alkalotic condition. Option 2 reflects a normal blood gas result.

A client's arterial blood gases reveal a pH of 7.51 and a bicarbonate level of 31 mEq/L. The nurse prepares for the administration of which medication that should be prescribed to treat this acid-base disorder?

Acetazolamide is a diuretic used in the treatment of metabolic alkalosis. This medication causes excretion of sodium, potassium, bicarbonate, and water by inhibiting the action of carbonic anhydrase. Administration of sodium bicarbonate should aggravate the already existing condition and is contraindicated. Furosemide is a loop diuretic and spironolactone is a potassium-retaining diuretics. These are of no value when there is a need to excrete bicarbonate.

A nurse is told that a child with rheumatic fever (RF) will be arriving to the nursing unit for admission. Which question should the nurse ask the family to elicit information specific to the development of RF?

"Did the child have a sore throat or an unexplained fever within the past 2 months?" Rheumatic fever (RF) characteristically presents 2 to 6 weeks after an untreated or partially treated group A β-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines if the child has had a sore throat or an unexplained fever within the past 2 months. Options 1, 2, and 3 are unrelated to RF.

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn infant after admission to the nursery. The nurse suspects fetal alcohol syndrome (FAS) and is aware that which of the following additional signs would be consistent with FAS?

Abnormal palmar creases Features of newborn infants who are diagnosed with FAS include craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmar creases, and respiratory distress. Options 1, 3, and 4 are normal findings in the full-term newborn infant.

The client arrives at the emergency department after a burn injury that occurred in the basement at home, and an inhalation injury is suspected. Which of the following should the nurse anticipate as being prescribed for the client?

100% oxygen via a tight-fitting, nonrebreather face mask If an inhalation injury is suspected, the administration of 100% oxygen via a tight-fitting, nonrebreather face mask is prescribed until the carboxyhemoglobin level falls below 15%. With inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation is also assessed. Options 1, 2, and 3 are incorrect.

A nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client who just returned from the recovery room after a thoracotomy with wedge resection. Which findings would the nurse expect to note? Select all that apply.

50 mL of drainage in the drainage-collection chamber The drainage system is maintained below the client's chest. An occlusive dressing is in place over the chest-tube insertion site. Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation The bubbling of water in the water-seal chamber indicates air drainage from the client. This is usually seen when intrathoracic pressure is greater than atmospheric pressure, and it may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water-seal chamber may indicate an air leak, which is an unexpected finding. The fluctuation of water in the tube in the water-seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed, the lung has re-expanded, or no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction-control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room; however, drainage of more than 70 to 100 mL/hr is considered excessive and requires health care provider notification. The chest-tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.

Which client is most likely at risk to become a victim of elder abuse?

A 90-year-old woman with advanced Parkinson's disease Elder abuse is widespread and occurs among all subgroups of the population. It includes physical and psychological abuse, the misuse of property, and the violation of rights. The typical abuse victim is a woman of advanced age with few social contacts and at least one physical or mental impairment that limits her ability to perform activities of daily living. In addition, the client usually lives alone or with the abuser and depends on the abuser for care.

A client is taking cetirizine hydrochloride (Zyrtec). The nurse should check for which side effect of this medication?

A frequent side effect of cetirizine hydrochloride, an antihistamine, is drowsiness or sedation. Others include blurred vision, hypertension (and sometimes hypotension), dry mouth, constipation, urinary retention, and sweating.

A child is scheduled to receive a measles, mumps, and rubella (MMR) vaccine. The nurse who is preparing to administer the vaccine reviews the child's record. Which finding should make the nurse question the health care provider's prescription?

A history of an anaphylactic reaction to neomycin The MMR vaccine contains minute amounts of neomycin. A history of an anaphylactic reaction to neomycin is considered a contraindication to the MMR vaccine. The general contraindication to all immunizations is a severe febrile illness. The presence of a minor illness such as the common cold is not a contraindication. In addition, a history of frequent respiratory infections is not a contraindication to receiving a vaccine. A local reaction to an immunization is treated with cool packs for the first 24 hours after injection, and this is followed by warm or cool compresses if the inflammation persists.

A client arrives in the emergency department complaining of chest pain that began 4 hours ago. A troponin T blood specimen is obtained, and the results indicate a level of 0.6 ng/mL. The nurse interprets that this result indicates:

A level that indicates a myocardial infarction Troponins are regulatory proteins that are found in striated muscle. The troponins function together in the contractile apparatus for striated muscle in the skeletal muscle and the myocardium. Increased amounts of troponins are released into the bloodstream when an infarction causes damage to the myocardium. A troponin T level greater than 0.1 to 0.2 ng/mL is consistent with a myocardial infarction. A normal troponin I level is less than 0.6 ng/mL, whereas a level greater than 1.5 ng/mL is consistent with a myocardial infarction. A troponin T level of 0.6 is not normal, so option 1 is incorrect. Troponin T does not test for angina or gastritis; thus options 2 and 4 are incorrect.

The client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse assists with the examination of the client, knowing that a routine labor procedure that is contraindicated with this client's situation is:

A manual pelvic examination Painless vaginal bleeding is a sign of possible placenta previa. Digital examination of the cervix is contraindicated because it can lead to maternal and fetal hemorrhage. Leopold's maneuvers can reveal a nonengaged presenting part or malpresentation, both of which often accompany placenta previa because of the placenta filling the lower uterine segment. Hemoglobin and hematocrit values help estimate the amount of blood loss. External electronic fetal monitoring is crucial for evaluating the status of the fetus, which is at risk for severe hypoxia. Options 1, 3, and 4 are procedures that would not place the client at further risk.

A nurse is caring for a client with respiratory insufficiency. The arterial blood gas results indicate a pH of 7.50 and a Pco2 of 30 mm Hg, and the nurse is told that the client is experiencing respiratory alkalosis. Which of the following additional laboratory values would the nurse expect to note?

A potassium level of 3.2 mEq/L Clinical manifestations of respiratory alkalosis include tachypnea, mental status changes, dizziness, pallor around the mouth, spasms of the muscles of the hands, and hypokalemia. Options 1, 3, and 4 identify normal laboratory results.

Which of these clients are most likely to develop fluid (circulatory) overload? Select all that apply.

A premature infant,A 101-year-old man, A client on renal dialysis, A client with congestive heart failure Clients with cardiac, respiratory, renal, or liver diseases and older and very young clients cannot tolerate an excessive fluid volume. The risk of fluid (circulatory) overload exists with these clients

A client who is receiving a blood transfusion rings the call bell for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. The nurse interprets that the client is experiencing:

A transfusion reaction The signs and symptoms exhibited by the client are consistent with a transfusion reaction. With bacteremia, the client would have a fever, which is not part of the clinical picture presented. With fluid (circulatory) overload, the client would have crackles in addition to dyspnea. There is no correlation between the signs mentioned in the question and hypovolemic shock. The signs identified in the question are indicative of an allergic reaction, which is one type of blood transfusion reaction.

A nurse is monitoring an adult client for postoperative complications. Which of the following would be the most indicative of a potential postoperative complication that requires further observation?

A urinary output of 20 mL/hour Urine output is maintained at a minimum of at least 30 mL/hour for an adult. An output of less than 30 mL/hour for each of two consecutive hours should be reported to the surgeon. A temperature more than 37° C (100° F) or less than 36.1° C (97° F) and a falling systolic blood pressure less than 90 mm Hg are to be reported. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal.

A nurse is monitoring the daily weight of an infant with congestive heart failure (CHF). Which of the following alerts the nurse to suspect fluid accumulation and thus to the need to notify the registered nurse?

A weight gain of 1 lb in 1 day A weight gain of 0.5 kg (1 lb) in 1 day is a result of the accumulation of fluid. The nurse should monitor the urine output, monitor for evidence of facial or peripheral edema, check the lung sounds, and report the weight gain. Tachypnea and an increased BP would occur with fluid accumulation. Diaphoresis is a sign of CHF, but it is not specific to fluid accumulation, and it usually occurs with exertional activities

The nurse is providing instructions to a client with a diagnosis of rheumatoid arthritis (RA) who is receiving aspirin (acetylsalicylic acid [ASA]) 5 g orally daily. Which statement by the client would indicate an understanding of the instructions?

Aspirin is a nonsteroidal anti-inflammatory medication. Adverse reactions include gastrointestinal bleeding and/or gastric mucosal lesions, ringing in the ears (tinnitus), and generalized pruritus. Headache, dizziness, flushing, tachycardia, hyperventilation, sweating, and thirst also are adverse reactions. Options 1, 2, and 3 are incorrect client statements.

A client with rheumatoid arthritis is taking acetylsalicylic acid (aspirin) on a daily basis. Which medication dose should the nurse expect the client to be taking?

Aspirin may be used to treat the client with rheumatoid arthritis. It may also be used to reduce the risk of recurrent transient ischemic attack (TIA) or stroke ( brain attack) or reduce the risk of myocardial infarction (MI) in clients with unstable angina or a history of a previous MI. The normal dose for clients being treated with aspirin to decrease thrombosis and MI is 300 to 325 mg/day. Clients being treated to prevent TIAs are usually prescribed 1.3 g/day in 2 to 4 divided doses. Clients with rheumatoid arthritis are treated with 3.6 to 5.4 g/day in divided doses.

A nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. The nurse reviews the child's record for the laboratory results of the urine test and would most likely expect to note which of the following?

Bacteriuria Epispadias is a congenital defect that involves the abnormal placement of the urethral orifice of the penis. In clients with this condition, the urethral opening is located anywhere on the dorsum of the penis. This anatomical characteristic leads to the easy access of bacterial entry into the urine. Options 1, 3, and 4 are not characteristically noted with this condition.

Which should be included in the plan of care for a pregnant teenager to reinforce instructions regarding dental care?

Baking soda may irritate the gums, which are more likely to bleed because of the hormonal changes of pregnancy. Local anesthetics for minor dental work would not have adverse effects on the fetus. Tooth loss during pregnancy is not expected. The dental staff needs to know about the pregnancy so that care is taken during examinations and x-ray studies are avoided.

Rho(D) immune globulin (RhoGAM) is prescribed for a woman after the delivery of a newborn infant, and the nurse provides information to the woman about the purpose of the medication. The nurse determines that the woman understands the purpose of the medication if the woman states that it will protect her next baby from which of the following?

Being affected by Rh incompatibility Rh incompatibility can occur when an Rh-negative mother becomes sensitized to the Rh antigen. Sensitization may develop when an Rh-negative woman becomes pregnant with a fetus who is Rh positive. During pregnancy and at delivery, some of the baby's Rh-positive blood can enter the maternal circulation, thus causing the woman's immune system to form antibodies against the Rh-positive blood. The administration of Rho(D) immune globulin prevents the woman from developing antibodies against Rh-positive blood by providing passive antibody protection against the Rh antigen.

A 31-week preterm labor client dilated to 4 centimeters has been started on magnesium sulfate. Her contractions have stopped. If the client's labor can be inhibited for the next 48 hours, what medication does the nurse anticipate will be prescribed?

Betamethasone Betamethasone, which is a glucocorticoid, is given to stimulate fetal lung maturation. It is used for clients in preterm labor between 28 and 32 weeks' gestation if the labor can be inhibited for 48 hours. Nalbuphine (Nubain) is an opioid analgesic. Misoprostol (Cytotec) is a prostaglandin that is given to ripen and soften the cervix and to stimulate uterine contractions. Rho(D) immune globulin (RhoGAM) is given to RH-negative clients to prevent sensitization.

The nurse is caring for a postterm neonate immediately after admission to the nursery. The priority nursing action would be to monitor:

Blood glucose levels The most common metabolic complication in the postterm newborn is hypoglycemia, which can produce central nervous system abnormalities and mental retardation if it is not corrected immediately. Urinary output, although important, is not the highest priority action. The polycythemia contributes to increased bilirubin levels, usually beginning on the second day after delivery. Hemoglobin and hematocrit levels are monitored, because the postterm neonate may exhibit polycythemia; however, this also does not require immediate attention.

Methylergonovine (Methergine) is prescribed for a woman to treat postpartum hemorrhage. Before the administration of methylergonovine, the priority nursing action is to check the:

Blood pressure Methylergonovine, which is an ergot alkaloid, is an agent that is used to prevent or control postpartum hemorrhage by contracting the uterus. Methylergonovine causes continuous uterine contractions and may elevate the blood pressure. A priority before the administration of the medication is to check the blood pressure. The health care provider should be notified if hypertension is present. Although options 1, 3, and 4 may be components of the postpartum data collection procedures, option 2 is related specifically to the administration of this medication.

Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which of the following would indicate the presence of systemic toxicity from this medication?

Tinnitus Salicylic acid is absorbed readily through the skin, and systemic toxicity (salicylism) can result. Symptoms include tinnitus, dizziness, hyperpnea, and psychological disturbances. Constipation and diarrhea are not associated with salicylism.

A mother arrives at the emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected, and a nurse is monitoring the child continuously for signs of increased intracranial pressure (ICP). Which of the following is a late sign of increased ICP in this child?

Bradycardia A mother arrives at the emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected, and a nurse is monitoring the child continuously for signs of increased intracranial pressure (ICP). Which of the following is a late sign of increased ICP in this child?

The nurse is collecting data from a client who has been diagnosed with placenta previa. Choose the findings that the nurse would expect to note. Select all that apply.

Bright red vaginal bleeding Soft, relaxed, nontender uterus Painless bright red vaginal bleeding during the second or third trimester of pregnancy is a sign of placenta previa. The client will have a soft and relaxed nontender uterus. In clients with abruptio placentae, severe abdominal pain is present. Uterine tenderness accompanies placental abruption. Additionally, with abruptio placentae, the abdomen will feel hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability.

A nurse is caring for a client with hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dL. Which medication should the nurse prepare to administer as prescribed to the client?

Calcitonin (Miacalcin) Rationale: The normal serum calcium level is 8.6 to 10.0 mg/dL. This client is experiencing hypercalcemia. Calcium gluconate and calcium chloride are medications used for the treatment of tetany, which occurs as a result of acute hypocalcemia. In hypercalcemia, large doses of vitamin D need to be avoided. Calcitonin, a thyroid hormone, decreases the plasma calcium level by inhibiting bone resorption and lowering the serum calcium concentration.

A nurse reviews the record of an infant who is seen in the clinic. The nurse notes that a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF) is suspected. The nurse expects to note which most likely clinical manifestation of this condition in the medical record

Choking with feedings Any child who exhibits the "3 Cs"—coughing and choking during feedings and unexplained cyanosis—should be suspected of having TEF. Options 1, 2, and 4 are not specifically associated with TEF.

Which of the following laboratory results would verify the diagnosis of bacterial meningitis?

Cloudy cerebrospinal fluid with high protein and low glucose levels A diagnosis of meningitis is made by testing the cerebrospinal fluid (CSF) obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include increased pressure, cloudy cerebrospinal fluid, a high protein level, and a low glucose level.

A nurse assists with admitting a child with a diagnosis of acute-stage Kawasaki disease. When obtaining the child's medical history, which clinical manifestation is likely to be reported?

Conjunctival hyperemia During the acute stage of Kawasaki disease, the child presents with fever, conjunctival hyperemia, a red throat, swollen hands, a rash, and enlargement of the cervical lymph nodes. During the subacute stage, cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. During the convalescent stage, the child appears normal, but signs of inflammation may be present.

The nurse in the newborn nursery receives a telephone call to prepare for the admission of an infant born at 43 weeks' gestation with Apgar scores of 1 and 4. When planning for the admission of this infant, the nurse's highest priority should be to:

Connect the resuscitation bag to the oxygen outlet. The highest priority during the admission to the nursery of a newborn with low Apgar scores is airway support, which would involve preparing respiratory resuscitation equipment. The remaining options are also important, although they are of lower initial priority. The newborn infant will be placed on a cardiorespiratory monitor. Setting up an intravenous line with 5% dextrose in water would provide circulatory support and may be prescribed. The radiant warmer will provide an external heat source, which is necessary to prevent further respiratory distress.

Which data indicates to the nurse that a client may be experiencing ineffective coping?

Constantly neglects personal grooming Coping mechanisms are behaviors that are used to decreased stress and anxiety. In response to a death, ineffective coping is manifested by an extreme behavior that in some instances may be harmful to the individual, physically, psychologically, or both. Option 1 is indicative of a behavior that identifies an ineffective coping behavior as part of the grieving process. The remaining options identify effective coping behaviors.

An older client is taking multiple medications for a variety of health problems. The nurse should monitor the results of which most important laboratory test(s) when evaluating adverse effects of medication therapy in the older adult?

Creatinine should be most closely monitored because it relates to kidney function. Because many medications are excreted by the kidneys, that makes this the laboratory test of choice for ongoing monitoring. Option 3 is part of option 4, whereas arterial blood gases are not generally measured unless there is a specific problem with oxygenation.

When the nurse is collecting data from the older adult, which of the following findings would be considered normal physiological changes? Select all that apply.

Decline in visual acuity, Increased susceptibility to urinary tract infections, Increased incidence of awakening after sleep onset Anatomical changes to the eye affect the individual's visual ability, which leads to potential problems with activities of daily living. Light adaptation and visual fields are reduced. Respiratory rates are usually unchanged. The heart rate decreases, and the heart valves thicken. Age-related changes that affect the urinary tract increase an older client's susceptibility to urinary tract infections. Short-term memory may decline with age, but long-term memory is usually maintained. Changes in sleep patterns are consistent, age-related changes. Older persons experience an increased incidence of awakening after sleep onset.

A nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. The nurse notes that the client has a history of arthritis and has been taking acetylsalicylic acid (aspirin). The nurse reports the information to the surgeon and anticipates that the surgeon will prescribe which of the following?

Discontinue the aspirin 48 hours before the scheduled surgery. Anticoagulants alter normal clotting factors and increase the risk of hemorrhage. Aspirin has properties that can alter the clotting mechanism and should thus be discontinued at least 48 hours before surgery.

During the acute stage of Kawasaki disease, the child presents with fever, conjunctival hyperemia, a red throat, swollen hands, a rash, and enlargement of the cervical lymph nodes.

During the subacute stage, cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. During the convalescent stage, the child appears normal, but signs of inflammation may be present.

A nurse who is caring for a child with aplastic anemia reviews the laboratory results and notes a white blood cell (WBC) count of 6000 cells/ mm3 and a platelet count of 27,000 cells/mm3. Which nursing intervention should be incorporated into the plan of care?

Encourage quiet play activities. Precautionary measures to prevent bleeding should be taken when a child has a low platelet count. These include no injections, no rectal temperatures, the use of a soft toothbrush, and abstinence from contact sports or activities that could cause an injury. Strict isolation would be required if the WBC count was low. Naps and a diet high in iron are unrelated to the risk of bleeding.

A client has the following laboratory values: a pH of 7.55, an HCO level of 22 mm Hg, and a Pco2 of 30 mm Hg. What should the nurse do?

Encourage the client to slow down breathing Rationale: The client is in respiratory alkalosis based on the laboratory results of a high pH and a low Pco2 level. Interventions for respiratory alkalosis are the voluntary holding of breath or slowed breathing and the rebreathing of exhaled CO2 by methods such as using a paper bag or a rebreathing mask as prescribed. Option 1 would be incorrect, because the blood specimen has already been drawn, and the laboratory results have been completed. Options 2 and 3 are interventions for metabolic acidosis.

A client with a perforated gastric ulcer is scheduled for emergency surgery. The client cannot sign the operative consent form because he has been sedated with opioid analgesics. The nurse should take which action in the care of this client?

Every effort must be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. Telephone consent must be witnessed by two persons who hear the family member's oral consent. The two witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In emergencies the client may be unable to sign, and family members may not be available. In this type of situation, the health care provider is permitted legally to perform surgery without consent. Options 1 and 3 are not appropriate. In addition, actions that delay treatment in an emergency are not appropriate.

A nurse reviews the record of a child who was just seen by a health care provider (HCP). The HCP has documented a diagnosis of suspected aortic stenosis. Which clinical manifestation that is specifically found in children with this disorder should the nurse anticipate?

Exercise intolerance The child with aortic stenosis shows signs of exercise intolerance, chest pain, and dizziness when standing for long periods. Pallor may be noted, but it is not specific to this type of disorder alone. Options 2 and 4 are not related to this disorder.

The nurse in the emergency department is preparing to instill fluorescein into the eye of a client with the complaint of eye pain. The nurse understands that which is the rationale for the use of this medication?

Fluorescein is a water-soluble dye that produces an intense green color. This agent is applied to the surface of the eye to detect lesions of the corneal epithelium; intact areas of the cornea remain uncolored but abrasions and other defects turn bright green. The medication does not produce the actions identified by options 1, 2, or 3.

A nurse is monitoring a preterm labor client who is receiving magnesium sulfate intravenously. The nurse monitors for which adverse effect(s) of this medication? Select all that apply.

Flushing,Depressed respirations,Extreme muscle weakness Magnesium sulfate is a central nervous system depressant, and it relaxes smooth muscle, including the uterus. It is used to stop preterm labor contractions, and it is used for preeclamptic clients to prevent seizures. Adverse effects include flushing, depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, and elevated serum magnesium levels

A nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which of the following signs would be an indication of this diagnosis

Generalized muscle weakness Rationale: Generalized muscle weakness is seen in clients with hypercalcemia. Options 1,twitching 2, Positive Trousseau's sign and 3 Hyperactive bowel sounds identify signs of hypocalcemia.

A client with atrial fibrillation who is receiving maintenance therapy with warfarin sodium (Coumadin) has a prothrombin time (PT) of 30 seconds. The nurse anticipates that which of the following will be prescribed?

Holding the next dose of warfarin sodium The normal PT is 9.6 to 11.8 seconds for the adult male and 9.5 to 11.3 seconds for the adult female. Because the value stated is extremely high (and perhaps near the critical range), the nurse should anticipate that the client would not receive further doses at this time. If the level were too high, then the antidote (vitamin K) may be prescribed. Options 1,; adding a dose of heparin 3: Increasing the next dose of warfarin sodium, and 4 Administering the next dose of warfarin sodium would make the client more toxic and prone to bleeding.

The burn client is receiving treatments of topical mafenide acetate (Sulfamylon) to the site of injury. The nurse monitors the client, knowing that which of the following indicates that a systemic effect has occurred?

Hyperventilation Rationale: Mafenide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis. Clients receiving this treatment should be monitored for signs of an acid-base imbalance (hyperventilation). If this occurs, the medication should be discontinued for 1 to 2 days. Options 3 and 4 describe local rather than systemic effects. An elevated blood pressure may be expected from the pain that occurs with a burn injury.

A client in the postpartum unit complains of sudden, sharp chest pain. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action?

If pulmonary embolism is suspected, oxygen should be administered at 8 to 10 L by tight face mask. Oxygen is used to decrease hypoxia. The woman also is kept on bed rest with the head of the bed slightly elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client, but this action would not be the initial nursing action. An IV line also will be required, but this action would follow the administration of the oxygen.

A nurse is doing a routine assessment of a client's peripheral IV site. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that which of the following has probably occurred?

Infiltration An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. The pallor, coolness, and swelling are the result of IV fluid being deposited into the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The other three options identify complications that are likely to be accompanied by warmth at the site rather than coolness.

A nurse is assigned to care for a child who is scheduled for an appendectomy. Which prescriptions does the nurse anticipate will be prescribed? Select all that apply.

Initiate an intravenous line. Maintain nothing-by-mouth status. Administer intravenous antibiotics. Administer preoperative medications. During the preoperative period, enemas or laxatives should not be administered. In addition, heat should not be applied to the abdomen. Any of these interventions can cause the rupture of the appendix and resultant peritonitis. Intravenous fluids would be started, and the child should receive nothing by mouth while awaiting surgery. Antibiotics are usually administered because of the risk of perforation. Preoperative medications are administered as prescribed.

A child has a basilar skull fracture. Which of the following health care provider's prescriptions should the nurse question?

Insert an indwelling urinary catheter. Nasotracheal suctioning is contraindicated in a child with a basilar skull fracture. Because of the location of the injury, the suction catheter may be introduced into the brain. Fluids are restricted to prevent fluid overload. The child may require a urinary catheter for the accurate monitoring of intake and output. An IV line is maintained to administer fluids or medications, if necessary.

An adult female client has a hemoglobin level of 10.8 g/dL. The nurse interprets that this result is most likely the result of which of the following factors in the client's history?

Iron deficiency anemia The normal hemoglobin level for an adult female client is 12 to 15 g/dL. A low hemoglobin level usually indicates anemia. Iron deficiency anemia can result in lower hemoglobin levels. Options 1, 2, and 4 may increase hemoglobin. Heart failure and COPD may increase the hemoglobin level as a result of the body's need for more oxygen-carrying capacity. Dehydration may increase the hemoglobin level by hemoconcentration.

A variety of conditions, including dehydration, hypoxemia, infection, and exertion can stimulate the sickling process during the intrapartum period.

Maintaining adequate IV fluid intake and the administration of oxygen via face mask will help ensure a safe environment for both the mother and fetus during labor.

The client at 38 weeks' gestation is admitted to the birthing center in early labor. The client is carrying twins, and one of the fetuses is in a breech presentation. The nurse assists with planning care for the client and identifies which of the following as the lowest priority for the care of this client?

Measuring the fundal height Option 1 is a low priority, because fundal height should be measured at each antepartal clinic visit; it is not a priority of care during the intrapartum period. Options 2, 3, and 4 are all high priorities. The twins should be monitored by dual electronic fetal monitoring, and any signs of distress should be reported. Many health care providers choose to perform a cesarean birth if either of the twins is breech. The mother should have an intravenous line in place in case fluid or blood replacement is required.

Megestrol acetate (Megace), an antineoplastic medication, is prescribed for the client with metastatic endometrial carcinoma. The nurse reviews the client's history and contacts the registered nurse if which diagnosis is documented in the client's history?

Megestrol acetate (Megace) suppresses the release of luteinizing hormone from the anterior pituitary by inhibiting pituitary function and regressing tumor size. Megestrol is used with caution if the client has a history of thrombophlebitis. Gout, asthma, and myocardial infarction are not contraindications for this medication.

A nurse is caring for a client with severe diarrhea. The nurse monitors the client closely, understanding that this client is at risk for developing which acid-base disorder

Metabolic acidosis Intestinal secretions high in bicarbonate may be lost through enteric drainage tubes, an ileostomy, or diarrhea. The decreased bicarbonate level creates the actual base deficit of metabolic acidosis. Options Metabolic alkalosis, Respiratory acidosis, Respiratory alkalosis are unlikely to occur in a client with severe diarrhea.

A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation

Metabolic alkalosis Rationale: The loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid; this results in an alkalotic condition. Options 3 and 4 deal with respiratory problems. Option 1 relates to acidosis.

A nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L. Which of the following would the nurse note on the cardiac monitor as a result of this laboratory value?

Narrow, peaked T waves Rationale: A serum potassium level of 5.4 mEq/L is indicative of hyperkalemia. Cardiac changes include a wide, flat P wave; a prolonged PR interval; a widened QRS complex; narrow, peaked T waves; and a depressed ST segment.

A nurse is assigned to care for a child after a spinal fusion for the treatment of scoliosis. The child complains of abdominal discomfort and begins to have episodes of vomiting. On data collection, the nurse notes abdominal distention. Which action should the nurse take?

Notify the registered nurse (RN). A complication after the surgical treatment of scoliosis is superior mesenteric artery syndrome. This disorder is caused by mechanical changes in the position of the child's abdominal contents that result from the lengthening of the child's body. It results in a syndrome of emesis and abdominal distention that is similar to that which occurs with intestinal obstruction or paralytic ileus. Postoperative vomiting among children with body casts or among those who have undergone spinal fusion warrants attention because of the possibility of superior mesenteric artery syndrome. Therefore, the remaining options are incorrect.

A nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Choose the interventions that the nurse should perform. Select all that apply.

Notify the registered nurse. Prepare to administer morphine sulfate. Prepare to administer intravenous fluids. Prepare to administer 100% oxygen by face mask. The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. Hypercyanotic episodes often occur among infants with tetralogy of Fallot, and they may occur among infants whose heart defect includes the obstruction of pulmonary blood flow and communication between the ventricles. If a hypercyanotic episode occurs, the infant is placed in a knee-chest position immediately. The registered nurse is notified, who will then contact the health care provider. The knee-chest position improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to get into this position and relieve chronic hypoxia. There is no reason to call a code blue unless respirations cease. Additional interventions include administering 100% oxygen by face mask, morphine sulfate, and intravenous fluids, as prescribed.

The nurse has just been licensed and has begun to practice in an acute health care facility. The nurse knows that which nursing specialties will require more specific defined standards of care and skills?

Nurses are responsible for meeting the same standards as other nurses practicing in similar settings. Specialized nurses such as nurse anesthetists, ICU nurses, and certified nurse-midwives have specially defined standards of care and skills. Nurses who care for clients on medical surgical units do not usually require these specially defined standards of care and skills.

A nurse is collecting data about a child who has been admitted to the hospital with a diagnosis of seizures. The nurse checks for causes of the seizure activity by:

Obtaining a history regarding factors that may occur before the seizure activity Fever and infections increase the body's metabolic rate. This can cause seizure activity among children who are less than 5-years-old. Dehydration and electrolyte imbalance can also contribute to the occurrence of a seizure. Falls can cause head injuries, which would increase intracranial pressure or cerebral edema. Some medications could cause seizures. Specific gravity would not be a reliable test, because it varies, depending on the existing condition. Psychiatric illness has no impact on seizure occurrence or cause. Children do not remember what happened during the seizure itself.

A child is admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which findings would the nurse expect to observe? Select all that apply.

PallorEdemaAnorexiaProteinuria Nephrotic syndrome is a kidney disorder that is characterized by massive proteinuria, hypoalbuminemia, edema, elevated serum lipids, anorexia, and pallor. The urine volume is decreased, and the urine is dark and frothy in appearance. The child with this condition gains weight.

A 4-year-old child is hospitalized with a suspected diagnosis of Wilms' tumor. The nurse assists with developing a plan of care. The nurse questions which intervention that is written in the plan of care?

Palpating the abdomen for a mass Wilms' tumor is an intra-abdominal and kidney tumor. If Wilms' tumor is suspected, the mass should not be palpated. Excessive manipulation can cause seeding of the tumor and thus cause the spread of the cancerous cells. Hematuria, hypertension, and fever are clinical manifestations that are associated with Wilms' tumor.

A nurse is assisting with data collection from an infant who has been diagnosed with hydrocephalus. If the infant's level of consciousness diminishes, a priority intervention is:

Palpating the anterior fontanel A full or bulging anterior fontanel indicates an increase in cerebrospinal fluid collection in the cerebral ventricle. Apical pulse and blood pressure changes and proteinuria are not specifically associated with increasing cerebrospinal fluid in the brain tissue in an infant.

Methylergonovine (Methergine) is prescribed for a client with postpartum hemorrhage. Before administering the medication, a nurse contacts the health care provider who prescribed the medication if which of the following conditions is documented in the client's medical history?

Peripheral vascular disease Methylergonovine is an ergot alkaloid that is used to treat postpartum hemorrhage. Ergot alkaloids are avoided in clients with significant cardiovascular disease, peripheral vascular disease, hypertension, eclampsia, or preeclampsia, because these conditions are worsened by the vasoconstrictive effects of the ergot alkaloids. Options 1, 2, and 3 are not contraindications related to the use of ergot alkaloids.

The nurse caring for a client with abruptio placentae is monitoring the client for signs of disseminated intravascular coagulopathy (DIC). The nurse would suspect DIC if he or she observes:

Petechiae, oozing from injection sites, and hematuria DIC is a state of diffuse clotting in which clotting factors are consumed, which leads to widespread bleeding. Platelet counts are decreased, because they are consumed by the process. Coagulation studies show no clot formation (clotting times are thus prolonged), and fibrin plugs may clog the microvasculature diffusely rather than in an isolated area.

A nurse is checking the insertion site of a peripheral IV catheter. The nurse notes the site to be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter. The nurse interprets that this is likely the result of:

Phlebitis of the vein Phlebitis at an IV site results in discomfort at the site and redness, warmth, and swelling proximal to the IV catheter. The IV catheter should be removed, and a new IV line should be inserted at a different site. The remaining options are incorrect; the signs and symptoms in the question are not associated with these conditions.

A nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by the respiratory syncytial virus (RSV). Choose the interventions that would be included in the plan of care. Select all that apply.

Place the infant in a private room. Place the infant in a room near the nurses' station. The infant with RSV should be isolated in a private room or in a room with another child with RSV. The infant should be placed in a room near the nurses' station for close observation. The infant should be positioned with the head and chest at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and to decrease pressure on the diaphragm. Cool, humidified oxygen is delivered to relieve dyspnea, hypoxemia, and insensible water loss from tachypnea. Contact precautions (wearing gloves and a gown) reduce the nosocomial transmission of RSV.

A nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia is present?

Postural blood pressure changes Rationale: Postural blood pressure changes occur in the client with hyponatremia. Dry mucous membranes and intense thirst are seen in clients with hypernatremia. A slow, bounding pulse is not indicative of hyponatremia. In a client with hyponatremia, a rapid thready pulse is noted.

The client received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum, the client's systolic blood pressure (BP) dropped 20 points, the diastolic BP dropped 10 points, and her pulse is 120 beats per minute. The client is very anxious and restless. The nurse is told that the client has a vulvar hematoma. On the basis of this diagnosis, the nurse would plan to:

Prepare the client for surgery. The information provided in the question indicates that the client is experiencing blood loss. Surgery would be indicated for this complication to stop the bleeding. Options 1, 2, and 3 would not assist with controlling the bleeding in this emergency situation.

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. A nurse determines that the client is experiencing toxicity from the medication if which of the following is noted on data collection?

Respirations of 10 breaths per minute Magnesium toxicity can occur as a result of magnesium sulfate therapy. Signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression (respiratory rate less than 12 breaths per minute), a loss of deep tendon reflexes, and a sudden drop in the fetal heart rate, maternal heart rate, and blood pressure. Therapeutic serum levels of magnesium are 4 to 7.5 mEq/L or 5 to 8 mg/dL. Proteinuria of 3+ is likely to be noted in a client with preeclampsia.

A nurse is caring for a client with a diagnosis of chronic obstructive pulmonary disease (COPD). The nurse monitors the client for which acid-base imbalance that most likely occurs in clients with this condition

Respiratory acidosis Respiratory acidosis most often occurs as a result of primary defects in the function of the lungs or changes in normal respiratory patterns from secondary problems. Chronic respiratory acidosis is most commonly caused by COPD. Acute respiratory acidosis also occurs in clients with COPD when superimposed respiratory infection or concurrent respiratory disease increases the work of breathing. Options 1, 2, and 4 are not likely to occur unless other conditions complicate the COPD.

The nurse is told that the blood gas results indicate a pH of 7.50 and a Pco2 of 32 mm Hg. The nurse determines that these results indicate:

Respiratory alkalosis Rationale: The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite relationship will be seen between the pH and the Pco2, as is seen in option 4. In an alkalotic condition, the pH is increased. Options 1 and 3 indicate acidosis, and option 2 indicates a metabolic condition.

A nurse is reviewing a health care provider's prescription for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Which prescriptions documented in the child's record should the nurse question? Select all that apply.

Restrict fluid intake. Administer meperidine (Demerol) 25 mg for pain Sickle cell anemia is one of a group of diseases called hemoglobinopathies in which hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin S. It is caused by the inheritance of a gene for a structurally abnormal portion of the hemoglobin chain. Hemoglobin S is sensitive to changes in the oxygen content of the red blood cell, and insufficient oxygen causes the cells to assume a sickle shape; the cells become rigid and clumped together, thus obstructing capillary blood flow. Oral and intravenous fluids are important parts of treatment. Meperidine (Demerol) is not recommended for the child with sickle cell disease because of the risk for normeperidine-induced seizures. Normeperidine, which is a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. Therefore, the nurse would question the prescriptions for restricted fluids and meperidine for pain control. Positioning for comfort, avoiding strain in painful joints, oxygen, and a high-calorie, high-protein diet are important parts of the treatment plan.

A nurse is planning care for a child with hemolytic-uremic syndrome (HUS). The child has been anuric and will be receiving peritoneal dialysis treatment. The nurse plans to:

Restrict fluids, as prescribed. HUS is thought to be associated with bacterial toxins, chemicals, and viruses that cause acute renal failure in children. Clinical features of the disease include acquired hemolytic anemia, thrombocytopenia, renal injury, and central nervous system symptoms. A child with HUS who is undergoing peritoneal dialysis for the treatment of anuria will be on fluid restrictions. Pain is not associated with HUS, and potassium would be restricted rather than encouraged if the child was anuric. Peritoneal dialysis does not require an AV fistula (only hemodialysis does).

A nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of congestive heart failure (CHF). The nurse looks for which early sign of CHF?

Tachycardia The early signs of CHF include tachycardia, tachypnea, profuse scalp sweating, fatigue, irritability, sudden weight gain, and respiratory distress. A cough may occur with CHF as a result of mucosal swelling and irritation, but it is not an early sign. Pallor may be noted in the infant with CHF, but it is also not an early sign.

Preterm newborns are at risk for developing respiratory distress syndrome (RDS). The nurse monitors for the clinical signs associated with RDS, knowing that these signs include:

Tachypnea and retractions The newborn infant with RDS may present with clinical signs of cyanosis, tachypnea, apnea, nasal flaring, chest wall retractions, or audible grunts. Acrocyanosis is a bluish discoloration of the hands and feet that is associated with immature peripheral circulation, and it is not uncommon during the first few hours of life. Options 2, 3, and 4 do not indicate clinical signs of RDS.

After episiotomy and the delivery of a newborn, the nurse performs a perineal check on the mother. The nurse notes a trickle of bright red blood coming from the perineum. The nurse checks the fundus and notes that it is firm. The nurse determines that:

The bright red bleeding is abnormal and should be reported Lochial flow should be distinguished from bleeding that originates from a laceration or an episiotomy, which is usually brighter red than lochia and presents as a continuous trickle of bleeding, even though the fundus of the uterus is firm. This bright red bleeding is abnormal and needs to be reported. Therefore, the other options are incorrect interpretations.

A nurse is caring for a client who has just been admitted to the nursing unit after receiving flame burns to the face and chest. The nurse notes a hoarse cough and that the client is expectorating sputum with black flecks. The client's eyelashes and eyebrows are singed, and the eyelids are swollen. The client suddenly becomes restless, and his color becomes dusky. The nurse interprets this data as indicating which of the following?

The burn has probably caused laryngeal edema, which has occluded the airway. The client exhibits several warning signs of an inhalation injury: a history of a flame burn to the face, hoarseness, cough, carbonaceous sputum, singed facial hair, facial edema, and color change. Additionally, one of the cardinal signs of hypoxia is restlessness.

The nurse notes that the physical assessment findings for a client with meningeal irritation indicate a positive Brudzinski sign. The nurse understands that which observation was made?

The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. Brudzinski's sign is tested with the client in the supine position. The examiner flexes the client's head and there should be no reports of pain or resistance to the neck flexion. A positive Brudzinski's sign is observed if the client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. Kernig's sign also tests for meningeal irritation and is positive when the client flexes the legs at the hip and knee and complains of pain along the vertebral column when the leg is extended. Decerebrate posturing is abnormal extension and occurs when the arms are fully extended, forearms pronated, wrists and fingers flexed, jaws clenched, neck extended, and feet plantar-flexed. Decorticate posturing is abnormal flexion and is noted when the client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.

A nurse is reviewing the health records of assigned clients. The nurse plans care knowing that which client is at risk for fluid volume deficit?

The client with a colostomy Rationale: Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, ileostomy, and colostomy. A client with cirrhosis, CHF, or decreased kidney function is at risk for fluid volume excess.

A nurse is reviewing the health records of assigned clients. The nurse plans care knowing that which client is at the lowest risk for the development of third-spacing?

The client with diabetes mellitus Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. Common sites for third-spacing include the abdomen, pleural cavity, peritoneal cavity, and pericardial sac. Third-space fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Risk factors include liver or kidney disease, major trauma, burns, sepsis, wound healing, major surgery, malignancy, malabsorption syndrome, malnutrition, alcoholism, and older age.

A client with a chronic airflow limitation is experiencing respiratory acidosis as a complication. The nurse trying to enhance the client's respiratory status should avoid performing which action?

The client with respiratory acidosis is experiencing elevated carbon dioxide levels because of insufficient ventilation. The nurse would encourage the client to breathe slowly and deeply (not shallowly) to expand alveoli and to promote better gas exchange. The actions listed in options 1, 2, and 3 are helpful actions on the part of the nurse.

A nurse reviews electrolyte values and notes a sodium level of 130 mEq/L. The nurse understands that this sodium level would be noted in a client with which condition?

The client with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) Rationale: Hyponatremia is a serum sodium level less than 135 mEq/L. Hyponatremia can result secondary to SIADH. The client with an inadequate daily water intake, watery diarrhea, or diabetes insipidus is at risk for hypernatremia.

A client has returned to the nursing unit following abdominal hysterectomy. To most effectively gather data on the client's postoperative bleeding, the nurse would implement which intervention?

The nurse should roll the client to one side after checking the perineal pad and abdominal dressing. This allows the nurse to check the rectal area, where blood may pool by gravity, particularly if the client is lying supine.

A client who is receiving a blood transfusion rings the call bell for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. How should the nurse correctly interpret these findings?

The signs and symptoms exhibited by the client are consistent with a transfusion reaction. With bacteremia, the client would have a fever, which is not part of the clinical picture presented. With fluid (circulatory) overload, the client would have crackles in addition to dyspnea. There is no correlation between the signs mentioned in the question and hypovolemic shock. The signs identified in the question are indicative of an allergic reaction, which is one type of blood transfusion reaction.

The nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client states which?

There may be an increased risk for impulsive and/or aggressive behavior if a client is receiving command hallucinations to harm self or others. Talking about the auditory hallucinations can interfere with the subvocal muscular activity associated with a hallucination. Option 4 is a specific agreement to seek help and evidences self-responsible commitment and control over his or her own behavior.

A nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L. The nurse understands that a potassium value at this level would be noted with which condition

Traumatic burn Rationale: A serum potassium level that exceeds 5.1 mEq/L is indicative of hyperkalemia. Clients who experience the cellular shifting of potassium, as in the early stages of massive cell destruction (i.e., with trauma, burns, sepsis, or metabolic or respiratory acidosis), are at risk for hyperkalemia. The client with Cushing's syndrome or diarrhea and the client who has been overusing laxatives are at risk for hypokalemia.

A caregiver states that the client eats only about 25% of the food that is offered and seems to be losing weight. The caregiver asks the nurse about feeding the client by a tube into the stomach. Which initial response by the nurse would be appropriate

Weight loss and a dietary intake of only 25% indicate that alternative sources of nutritional intake should be sought. Tube feeding is an alternative for temporary or permanent nutritional maintenance. Enteral tube feedings are generally safer and significantly less costly than peripheral or parenteral nutrition. Option 1 is incorrect because tube feedings are often temporary measures. Option 3 may be correct; however, it is not the best response to a caregiver seeking initial information. Option 4 is unrelated to the situation

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. What type of adventitious lung sounds would the nurse expect to hear when collecting data related to the respiratory system for this client?

Wheezes Asthma is a respiratory disorder characterized by recurring episodes of dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway. Stridor is a harsh sound noted with an upper airway obstruction and often signals a life-threatening emergency. Diminished lung sounds are heard over lung tissue where poor oxygen exchange is occurring. A pleural friction rub is heard in individuals with pleurisy (inflammation of the pleural surfaces).