NCLEX Review

A nurse is preparing a client with a pleural effusion for a thoracentesis. The nurse should:

assist the client to a sitting position on the edge of the bed, leaning over the bedside table.

Which of the following medications would the nurse expect to be used to facilitate intubation of the client?

attacurium (Tracrium)

It is important for the nurse to assist a postsurgical client to sit up and turn his or her head to one side when vomiting in order to

avoid aspiration.

What is the normal pH range for arterial blood? a) 7 to 7.49 b) 7.35 to 7.45 c) 7.50 to 7.60 d) 7.55 to 7.65

b) 7.35 to 7.45

The physician prescribes triamcinolone (Azmacort) and salmeterol (Serevent) for a client with a history of asthma. What action should the nurse take when administering these drugs? a) Administer the triamcinolone and then administer the salmeterol. b) Administer the salmeterol and then administer the triamcinolone. c) Allow the client to choose the order in which the drugs are administered. d) Monitor the client's theophylline level before administering the medications.

b) Administer the salmeterol and then administer the triamcinolone.

When a client's ventilation is impaired, the body retains which substance? a) Sodium bicarbonate b) Carbon dioxide c) Nitrous oxide d) Oxygen

b) Carbon dioxide

A nurse is caring for a client with suspected upper GI bleeding. The nurse should monitor this client for:

black, tarry stools. Explanation: As blood from the GI tract passes through the intestines, bacterial action causes it to become black. Hemoptysis involves coughing up blood from the lungs. Hematuria is blood in the urine. Bright red blood in the stools indicates bleeding from the lower GI tract.

A client is prescribed rifampin (Rifadin), 600 mg P.O. daily. Which statement about rifampin is true? a) It's usually given alone. b) Its exact mechanism of action is unknown. c) It's tuberculocidal, destroying the offending bacteria. d) It acts primarily against resting bacteria.

c) It's tuberculocidal, destroying the offending bacteria.

The nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching? a) Make inhalation longer than exhalation. b) Exhale through an open mouth. c) Use diaphragmatic breathing. d) Use chest breathing.

c) Use diaphragmatic breathing.

A client admitted with multiple traumatic injuries receives massive fluid resuscitation. Later, the physician suspects that the client has aspirated stomach contents. The nurse knows that this client is at highest risk for: a) chronic obstructive pulmonary disease (COPD). b) bronchial asthma. c) adult respiratory distress syndrome (ARDS). d) renal failure.

c) adult respiratory distress syndrome (ARDS).

A client with herpes zoster is prescribed acyclovir (Zovirax), 200 mg by mouth every 4 hours while awake. The nurse should inform the client that this drug may cause:

diarrhea.

A client is taking spironolactone (Aldactone) to control her hypertension. Her serum potassium level is 6 mEq/L. For this client, the nurse's priority should be to assess her:

electrocardiogram (ECG) results. - Although changes in all these findings are seen in hyperkalemia, ECG results should take priority because changes can indicate potentially lethal arrhythmias such as ventricular fibrillation. It wouldn't be appropriate to assess the client's neuromuscular function, bowel sounds, or respiratory rate for effects of hyperkalemia.

On arrival at the intensive care unit, a critically ill client suffers respiratory arrest and is placed on mechanical ventilation. The physician orders pulse oximetry to monitor the client's arterial oxygen saturation (SaO2) noninvasively. Which vital sign abnormality may alter pulse oximetry values?

hypotension

A client is prescribed metformin (Glucophage) to control type 2 diabetes. The nurse should monitor for which life-threatening adverse reaction?

lactic acidosis

A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, the nurse should assign highest priority to:

maintaining a patent airway

Oncotic pressure refers to the

osmotic pressure exerted by proteins. - Oncotic pressure is a pulling pressure exerted by proteins, such as albumin. Osmolality refers to the number of dissolved particles contained in a unit of fluid. Osmotic diuresis occurs when the urine output increases due to excretion of substances such as glucose. Osmotic pressure is the amount of pressure needed to stop the flow of water by osmosis

Oncotic pressure refers to the

osmotic pressure exerted by proteins. - Oncotic pressure is a pulling pressure exerted by proteins, such as albumin. Osmolality refers to the number of dissolved particles contained in a unit of fluid. Osmotic diuresis occurs when the urine output increases due to excretion of substances such as glucose. Osmotic pressure is the amount of pressure needed to stop the flow of water by osmosis.

During the first few days of recovery from ostomy surgery for ulcerative colitis, which aspect should be the first priority of client care?

ostomy care

To evaluate a client's cerebellar function, a nurse should ask:

"Do you have any problems with balance?"

What is the most important postoperative instruction a nurse must give to a client who has just returned from the operating room after receiving a subarachnoid block?

"Remain supine for the time specified by the physician."

Adequate hourly urine output for a patient with an indwelling urinary catheter is

30 mL/hr.

young-old

65-74 years of age

A client in the emergency department complains of squeezing substernal pain that radiates to the left shoulder and jaw. He also complains of nausea, diaphoresis, and shortness of breath. What should the nurse do?

Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin.

A client has been diagnosed with AIDS. Which of the following statements correctly describes a secondary immune deficiency?

An interference develops in an already developed immune system.

The nurse identifies a nursing diagnosis of ineffective airway clearance related to pneumocystis pneumonia and increased bronchial secretions for a client with AIDS. Which of the following would be appropriate for the nurse to include in the client's plan of care?

Assist with chest physiotherapy every 4-6 hours

What is the term for the concentration of urea and other nitrogenous wastes in the blood?

Azotemia

Which of the following cell types are involved in humoral immunity?

B lymphocytes

Which of the following cells are capable of differentiating into plasma cells?

B lymphocytes

Which of the following areas is the most suitable area of the body for skin testing

Back

The nurse is examining a client's scalp for evidence of lice. The nurse should pay particular attention to which part of the scalp?

Behind the ears

A client arrives in the emergency department reporting shortness of breath. She has 3+ pitting edema below the knees, a respiratory rate of 36 breaths per minute, and heaving respirations. The nurse auscultates the client's lungs to reveal coarse, moist, high-pitched, and non-continuous sounds that do not clear with coughing. The nurse will document these sounds as which type?

Crackles

Which of the following ulcers is associated with extensive burn injury?

Curling's Ulcer

Which of the following is a late sign of hypoxia?

Cyanosis

Which of the following is a age-related change associated with the immune system?

Decreased antibody production

The nurse recognizes that the older adult is at risk for surgical complications due to:

Decreased renal function

Which of the following is a nasoenteric feeding tube?

Dobhoff

During the insertion of a rigid scope for bronchoscopy, a client experiences a vasovagal response. The nurse should expect:

Drop in the client's heart rate

You are the triage nurse in a walk-in clinic when a diabetic client visits the clinic and asks you to take her blood pressure (BP). The measurements are 150/90 mm Hg. Which of the following would the nurse expect as the treatment to normalize the client's BP?

Drug therapy

The most common symptom of esophageal disease is

Dysphagia

Atrial rate of 300 to 400

Electrocardiogram (ECG) characteristics of atrial fibrillation include which of the following?

A patient has been prescribed a digitalis preparation for heart failure. Which of the following should you, as her nurse, closely monitor when caring for this client?

Electrolyte and water loss

A patient with an ileostomy should avoid which of the following?

Enteric coated tablets

Which of the following medications requires the nurse to contact the pharmacist in consultation when the patient receives all oral medications by feeding tube?

Enteric coated tablets

A nurse is providing preoperative teaching to a client undergoing a cholecystectomy. Which topic should the nurse include in her teaching plan?

Increase respiratory effectiveness

Which of the following medication classifications are known to inhibit prostaglandin synthesis or release?

NSAIDs in large doses

Upon palpation of the sinus area, what would the nurse identify as a normal finding?

No sensation during palpation

Which health care profession has the ultimate responsibility to provide appropriate information regarding a nonemergent surgery?

Physician

When is the ideal time to discuss preoperative teaching

Preadmission visit

Which of the following is the hallmark of the diagnosis of nephrotic syndrome?

Proteinuria

The nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs? a) Inspection b) Chest X-ray c) Arterial blood gas (ABG) levels d)Auscultation

d)Auscultation

A patient has undergone a liver biopsy. Which of the following postprocedure positions is appropriate?

on the right side

A client is readmitted with an exacerbation of celiac disease 2 weeks after discharge. Which statement by the client indicates the need for a dietary consult?

"I didn't eat anything I shouldn't have; I just ate roast beef on rye bread."

A client is diagnosed with a hiatal hernia. Which statement indicates effective client teaching about hiatal hernia and its treatment?

"I'll eat frequent, small, bland meals that are high in fiber."

The nurse is talking with a client who is scheduled for a computed tomography (CT) colonography. Which client statement would indicate to the nurse that the client needs additional teaching about this procedure?

"My doctor will be able to remove any polyps he finds."

The client asks the nurse how the spinal anesthesia will be administered. The best response by the nurse is:

"The anesthesiologist will inject the anesthetic into the space around your lower spinal cord."

Surgical asepsis?

- Absence of microorganism in the surgical environment to reduce risk of infection.

Local anesthesia?

- Anesthesia injected into the tissues at the planned incision site!

What kind of solution is used to clean patient's skin?

- Antiseptic

Potential adverse effects of surgery and anesthesia? Blood?

- Hypotension - Thrombosis

CULTURAL DIVERSITY- Medications are prohibited for Muslim and Jewish faith? -Buddhist?

- Porcine based products (heparine or bovine) - Bovine

Regional anesthesia? (Where is it administered?)

- an anesthetic agent is injected around nerves so that the area supplied by these nerves is anesthetized.

Anoxia?

. an abnormally low amount of oxygen in the body tissues

Lower doses of anesthetic agents are required in elderly patiens due to (2 things)

1) Decreased tissue elasticity in the lung and cardiovascular system. 2) Reduced tissue mass

Anesthetic agent is administered through (IOI)

1) Intranasal intubation 2) Oral intubation 3) laryngeal mask airway.

153. A nurse is developing a plan of care for a client who is scheduled for surgery. The nurse w/include which of the following activites in the nuring care plan for the client on the day of surgery?

1. Have the client void immediately before surgery. (The nurse w/assist client w/voiding immediately before surgery so that bladder will be empty. Oral hygiene is allowed, but client s/not swallow any water. Client usually has restriction of food and fluids for 8 hrs. before surgery rather than 24 hrs. A slight increase in blood pressure and pulse is common during preoperative period; this is generally result of anxiety.

When monitoring a patient who has hypertension and chronic kidney disease, the target pressure for this individual should be less than which blood pressure reading?

130/80 mmHg

According to the DASH diet, how many servings of vegetables should a person consume per day?

4 to 5

Which of the following neurotransmitters are deficient in myasthenia gravis?

Acetylcholine

When caring for a client with severe impetigo, the nurse should expect which intervention in the plan of care?

Administering systemic antibiotics as prescribed

Decreased cardiac output and decreased systolic and diastolic blood pressure

After evaluating a client for hypertension, a physician orders atenolol (Tenormin), 50 mg P.O. daily. Which therapeutic effect should atenolol have?

middle-old

Ages 75-84

Partial hospitalization programs (PHPs)

All of the following are residential treatment settings except

When assisting the patient to interpret a negative HIV test result, the nurse informs the patient that the results mean which of the following?

Antibodies to HIV are not present in his blood.

A client has a blockage in the proximal portion of a coronary artery. After learning about treatment options, the client decides to undergo percutaneous transluminal coronary angioplasty (PTCA). During this procedure, the nurse expects to administer an:

Anticoagulant

To evaluate a client for hypoxia, the physician is most likely to order which laboratory test?

Arterial blood gas (ABG) analysis - Red blood cell count, sputum culture, total hemoglobin, and ABG analysis all help evaluate a client with respiratory problems. However, ABG analysis is the only test that evaluates gas exchange in the lungs, providing information about the client's oxygenation status.

Which of the following terms describes the involuntary flapping movements of the hands associated with metabolic liver dysfunction?

Asterixis

The nurse plays an important role in monitoring and managing potential complications in the patient who has recently undergone a coronary artery bypass graft (CABG). The nurse should be alert to which of the following respiratory complications?

Atelectasis

Which condition most commonly results in coronary artery disease (CAD)?

Atherosclerosis

Lesions in the temporal lobe may result in which of the following types of agnosia?

Auditory

Which assessment finding would be most consistent with advanced emphysema?

Barrel-shaped chest

Which type of leukocyte contains histamine and is an important part of hypersensitivity reactions?

Basophils

During a routine examination of a client's fingernails, the nurse notes a horizontal depression in each nail plate. When documenting this finding, the nurse should use which term?

Beau's line

Of the following terms, which is used to refer to the period of time during which mourning a loss takes place?

Bereavement

Diagnosis of Kaposi's sarcoma (KS) is made by which of the following?

Biopsy

More than 50% of individuals with this disease develop pernicious anemia:

CVID

A client with AIDS comes to the clinic reporting difficulty swallowing. He says, "It hurts so much when I swallow." Inspection reveals creamy white patches in the client's mouth. Which of the following would the nurse suspect?

Candidias

What part of the brain controls and coordinates muscle movement?

Cerebellum

The term for a reddened circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis is a

Chancre

A client has a nasogastric tube for continuous tube feeding. The nurse does all the following every shift to verify placement (select all options that apply):

Checks the pH of the gastric contents • Compares exposed tube length with original measurement • Visually assesses the color of the aspirate

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has:

Cirrhosis

Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus?

Confusion and Seizures - Classic signs of water intoxication include confusion and seizures, both of which are caused by cerebral edema. Weight gain will also occur. Sunken eyeballs, thirst, and increased BUN levels indicate fluid volume deficit. Spasticity, flaccidity, and tetany are unrelated to water intoxication.

A client appears to be breathing faster than during the last assessment. Which of the following interventions should the nurse perform?

Count the rate of respirations.

A son brings his father into the clinic, stating that his father's color has changed to bluish around the mouth. The father is confused, with a respiratory rate of 28 breaths per minute and scattered crackles throughout. The son states this condition just occurred within the last hour. Which of the following factors indicates that the client's condition has lasted for more than 1 hour?

Cyanosis

Infarction?

Death of tissue from deprivation of its blood supply.

A client is recovering from coronary artery bypass graft (CABG) surgery. Which nursing diagnosis takes highest priority at this time?

Decreased cardiac output related to depressed myocardial function, fluid volume deficit, or impaired electrical conduction

Low levels of the neurotransmitter serotonin lead to which of the following disease processes?

Depression

While conducting the physical examination during assessment of the respiratory system, which of the following does a nurse assess by inspecting and palpating the trachea?

Deviation from the midline

What safety actions does the nurse need to take for a patient on oxygen therapy who is undergoing magnetic resonance imaging (MRI)?

Ensure that no patient care equipment containing metal enters the room where the MRI is located.

Which of the following would be most appropriate for a client who is experiencing biliary colic?

Ensure that the client rests.

A client is prescribed an intravenous dose of iron dextran. The nurse

Ensures that epinephrine is available

Which drug will the physician most likely prescribe for the client admitted with a lorazepam (Ativan) overdose?

Flumazenil (Romazicon) Explanation: Flumazenil reverses the sedative effects of benzodiazepines such as lorazepam. The antidote for acetaminophen toxicity is acetylcysteine. It enhances conversion of toxic metabolites to nontoxic metabolites. Deferoxamine mesylate is the antidote for iron intoxication. Succimer is an antidote for lead poisoning.

Which of the following is a modifiable risk factor for transient ischemic attacks and ischemic strokes?

History of smoking

A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs?

Impaired gas exchange

Which of the following is one of the first clinical manifestations of esophageal cancer?

Increasing difficulty is swallowing

A patient diagnosed with diabetic ketoacidosis would be expected to have which type of respiratory pattern?

Kussmaul respirations

Which of the following medications is categorized as a loop diuretic?

Lasix

Which of the following is true statement regarding older patients, considering the age-related effects on their GI system?

Less control of rectal sphincter

HIV is harbored within which type of cell?

Lymphocyte

Upon discharge from the hospital, patients diagnosed with a myocardial infarction (MI) must be placed on all of the following medications except:

Morphine IV

An inappropriate nursing action implemented to keep the client safe includes:

Moving the client swiftly

Which cells are converted to red blood cells, white blood cells, and platelets?

Myeloid stem cells

A client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain?

Occipital

OR?

Operating Room!

Which of the following has not been implicated as a factor for noncompliance with antiretroviral treatment?

Past substance abuse

Once the operating team has assembled in the room, the circulating nurse calls for a "time out." What action should the nurse take during the time out?

Review the schedule procedure, site, and client

The nurse is collecting data on a client admitted with second- and third-degree burns on the face, arms, and chest. Which finding indicates a potential problem?

Urine output of 20 ml/hour

At what point does the preoperative period end?

When the client is transferred onto the operating table

Energizer

Which group member attempts to stimulate the group to action or decision?

Coumadin

Which medication is indicated for the patient with atrial fibrillation who is at high risk for stroke?

Pulmonary artery

Which of the follow arteries carries deoxygenated blood?

Promote symptom management

Which of the following interventions is appropriate for a psychiatric-mental health nurse at the basic level of practice?

Giving approval

Which of the following is an example of a nontherapeutic communication technique?

Patients who are taking beta-adrenergic blocking agents should be cautioned not to stop taking their medications abruptly because which of the following may occur?

Worsening angina

Bone marrow is soft tissue within specific bones which manufactures blood cells; that is, maintains a role in hematopoiesis. There are several structures in the hematopoietic and lymphatic systems that contribute to the manufacture of blood cells. Which of the following structures does not participate in blood cell production?

Yellow Bone Marrow

herpes zoster infection

aka shingles-- a viral disease of spinal ganglia-- is a dermatomally distributed skin lesion. Virus invades a spinal ganglion and is transported along the axon to the skin, where it produces an infection that causes a sharp burning pain in the dermatome supplied by the involved nerve. A few days later, the skin of the dermatome becomes red and vesicular eruptions appear.

Which client requires immediate nursing intervention? The client who:

presents with a rigid, boardlike abdomen.

The incidence of hospital-acquired pressure ulcers on the medical-surgical unit has increased. A nurse should inform the:

risk manager.

Scrub role?

-registered nurse, licensed practical nure and technicians who scrubs and dons sterile surgical attire, supplies and hands instruments to the surgeon.

During a vaginal examination of a client in labor, the obstetrician determines that the biparietal diameter of the fetal head has reached the level of the ischial spines. The most accurate documentation of this fetal station would be:

0 Explanation: When the largest diameter of the presenting part (typically the biparietal diameter of the fetal head) is level with the ischial spines, the fetus is at station 0. A station of -1 indicates that the fetal head is 1 cm above the ischial spines. At +1, it's 1 cm below the ischial spines. At +2, it's 2 cm below the ischial spines.

Surgical safety checklist: 1) Patient's ___ 2) Anesthesia ___ 3) Allergies?__or___ 4) Pulse ____ on patient and functioning? 5) Difficult aiway and ___risk? 6) Risk of blood ___?

1) Identity 2) Safety 3) Known or unknown? 4) oximeter 5) aspiration 6) Loss!

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

1. A uninary output of 20mL/Hour. Urine output is maintained at a minimum of at least 30 mL/hr. for an adult. An ouptut of less than 30mL/hr. for each ot 2 consecutive hrs. s/be reported to the physician. A temp. more than 100*F or less than 97*F and a falling systolic blood pressure <90mm 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.

163. A nurse monitors a postoperatve client for signs of complications. Which of the following signs w/the nurse determine to be indicative of a potential complication?

1. Increasing restlessness noted in a client is a sign that requires continuous and lose monitoring, because it could be a potential indication of a complication such as hemorhage or shock. Neg Homan's sign is normal. + sign indicative of thrombophlebitis. Faint bowel sounds in all 4 quadrants is normal. BP 120/70, pulse of 90 relativel normal.

166. A client who had abdominal surgery complains of feeling as though something gave way in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Select all nursing interventions that nurse w/take.:

1. Notify RN 2. Document the client's complaint. 3. Instruct the client to remain quiet. 4. Prepare the client for wound closure.

157. A client arrives to the surgical nursing unit after surgery. The initial nursing action is to check the:

1. Patency of the airway. If the airway is not patent, immediate measures must be taken for the survival of the client. After checking the client's airway, the nurse would then check the client's vital signs, and this w/be followed by checking the dressings, tubes and drains.

159. A nurse monitors the postoperative client frequently for the presence of secretion in the lungs, knowing that accumulated secretions can lead to:

1. Pneumonia The most common postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes a productive cough, dyspnea, and crackles. Pulmonary edema usually results from L-sided heart failure, and it can be caused by medications, fluid overload, and smoke inhalation. CO2 retention results from the inability to exhale CO2 in clients w/conditions such as COPD. Fluid imbalance can be a deficit or excess related to fluid loss or overload.

A dialysis client is prescribed erythropoietin (Epogen) to treat anemia associated with end-stage renal disease. The client weighs 147 lbs. The order is for Epogen 50 units/kg subcutaneously 3 times per week. The pharmacy supplied Epogen 3000 units/ml. How many milliliters will the nurse administer to the client? Round to the nearest tenth.

1.1

A nurse is preparing to administer a 500 mL bolus tube feeding to a patient. The nurse anticipates administering this feeding over which time frame?

10-15 minutes

A client is to receive intravenous immunoglobulin (IVIG). The infusion is started at 10 a.m. The nurse would be alert for signs and symptoms of an anaphylactic reaction during which time frame?

10:30 am and 11:00 am

A patient has a gastric sump tube inserted and attached to low intermittent suction. The physician has ordered the tube to be irrigated with 30 mL of normal saline every 6 hours. When reviewing the patient's intake and output record for the past 24 hours, the nurse would expect to note that the patient received how much fluid with the irrigation?

120 mL

In the immediate postoperative period, vital signs are taken at least every:

15 minutes.

Normally, approximately what percentage of the blood pumped by the right ventricle does not perfuse the alveolar capillaries?

2%

162. A nurse is checking a client's surgical incision and notes an increase in the amount of drainage, a separation of the incision line, and the appearance of underlying tissue. Which of the following is the intial action?

2. Apply sterile dressing soaked w/normal saline to the wound. Wound dehiscence is the separation of the wound edges at the suture line. S/sx include increased drainage and appearance of underlying tissues. It usually occurs as a complication 6-8 days. The client s/be instructed to remain quiet and to avoid coughing or straining, and he or she s/be positioned to prevent further stress on the wound. Sterile dressings soaked w/sterile normal saline s/be used to cover the wound. The physician needs to be notified.

156. A nurse obtains vital signs on a postoperative client who just returned to nursing unit. The client's BP is 100/60 mm Hg, the pulse 90 beats/min., and respiration rate is 20 breaths/min.. On basis of these findings,which of the following nursing actions s/be performed?

2. Continue to monitor vital signs. A slightly lower-than-normal BP and increased pulse rate are common after surgery. Warm blankets are applied to maintain the client's body temp. The level of consciousness can be determined by checking the client's response to light touch and verbal stimuli rather than by shaking the client. There is no reason to contact the RN immediately.

161. A nurse checks the client's surgical incision for signs of infection. Which of the following w/be indicative of a potential infection?

2. The presence of purulent drainage. S/Sx of a wound infection include warm, red, and tender skin around the incision. The client may have fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a wound that was contaminated before surgical exploration; it appears 3-6 days after surgery. Serous drainage is not indicative of a wound infection. A temp. of 98.8 F is not an abnormal finding in a postoperative client. The fact that a client feels cold is not indicative of an infection, although chills and fever are signs of infection.

Which of the following cerebrospinal fluid (CSF) pressure values would be indicative of increased intracranial pressure (ICP)?

22 mm Hg

A nurse measures the residual gastric volume of a patient receiving intermittent tube feedings. The patient's last residual volume was 250 mL. Which finding would lead the nurse to notify the physician?

225 mL

A client is receiving intravenous heparin to prevent blood clots. The order is for heparin 1,200 units per hour. The pharmacy sends 25,000 units of heparin in 500 mL of D5W. At how many mL per hour will the nurse infuse this solution? Enter the correct number ONLY.

24

The client has the intake and output shown in the accompanying chart for an 8-hour shift. What is the positive fluid balance?

260 mL

A client is diagnosed with genital herpes simplex. Concerned about spread of the virus to others, the nurse questions the client about recent sexual activity. What is the average incubation period for localized genital herpes simplex infection?

3 to 7 days

155. 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 physician and anticipates that the physician will prescribe which of the following?

3. Discontinue the aspirin 48 hrs. 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 s/thus be discontinued at least 48 hrs. before surgery.

A patient is receiving continuous tube feedings via a small bore feeding tube. The nurse irrigates the tube after administering medication to maintain patency. Which size syringe would the nurse use?

30 mL

Pharmacologic therapy frequently is used to dissolve small gallstones. It takes about how many months of medication with UDCA or CDCA for stones to dissolve?

6-12 months

In order to be effective, percutaneous transluminal coronary angioplasty (PTCA) must be performed within what time frame, beginning with arrival at the emergency department after diagnosis of myocardial infarction?

60 minutes

Weighing the client daily at the same time each day.

A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status?

Bibasilar crackles

A client is returning from the operating room after inguinal hernia repair. The nurse notes that he has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-sided heart failure?

Which of the following clients would be most susceptible to experiencing ketoacidosis?

A client with type I diabetes Explanation: The most common need for urine testing is the test for ketones if a client's blood glucose level is consistently high. Because only clients with type 1 diabetes are susceptible to diabetic ketoacidosis, these clients learn to test their urine for ketones if their blood glucose readings exceed 240 mg/dL.

A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse and has an elevated serum ammonia level. The nurse should suspect which situation?

A client's hepatic function is decreasing

Fistula?

A fistula is defined as the connection of two body cavities.

Dopamine

A nurse is developing a plan of care for a patient diagnosed with schizophrenia. The nurse integrates knowledge of this disorder, identifying which neurotransmitter as being primarily involved?

An 18-month-old male child is admitted to the pediatric unit with a diagnosis of celiac disease. What finding would the nurse expect in this child?

A protuberant abdomen Explanation: A child with celiac disease has a protuberant abdomen, diarrhea, steatorrhea, and anorexia, which result in malnutrition. A concave abdomen, bulges in the groin area, and a palpable abdominal mass aren't associated with celiac disease.

You are caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from?

A puncture at the radial artery

Anesthesia

A state of narcosis, analgesia, relazation and loss of reflexes.

Anesthetic agent?

A substance such as chemical or gas, used to unduce anesthesia.

A nurse educator is preparing to discuss immunodeficiency disorders with a group of fellow nurses. What would the nurse identify as the most common secondary immunodeficiency disorder?

AIDs

The nurse inserts a nasoduodenal tube for feeding of the client. To check best for placement, the nurse

Abdominal x-ray

Dowager's hump

Abnormal curvature in the upper thoracic spine.

The nurse working in the radiology clinic is assisting with a pulmonary angiography. The nurse knows that when monitoring clients after a pulmonary angiography, what should the physician be notified about?

Absent distal pulses

A 24-year-old athlete is admitted to the trauma unit following a motor-vehicle collision. The client is comatose and has developed ascites as a result of the accident. You are explaining the client's condition to his parents. In your education, what do you indicate is the primary function of the small intestine?

Absorb nutrients

Which of the following is the primary function of the small intestine?

Absorption

Altruism

According to Yalom (2005), there are 11 primary factors through which therapeutic changes occur in group psychotherapy. Which of the following factors correlates with learning to give to others?

A nurse correctly identifies a urine specimen with a pH of 4.3 as being which type of solution?

Acidic - Normal urine pH is 4.5 to 8.0; a value of 4.3 reveals acidic urine pH. A pH above 7.0 is considered an alkaline or basic solution. A pH of 7.0 is considered neutral.

Which of the following would be a factor that may decrease myocardial contractility?

Acidosis Explanation: Contractility is depressed by hypoxemia, acidosis, and certain medications, such as beta-adrenergic blocking medications. Contractility is enhanced by sympathetic neuronal activity, and certain medications, such as Lanoxin.

Which of the following would be considered an urgent surgical procedure?

Acute gallbladder infection

A client reports to the clinic, stating that she rapidly developed headache, abdominal pain, nausea, hiccuping, and fatigue about 2 hours ago. For dinner, she ate buffalo chicken wings and beer. Which of the following medical conditions is most consistent with the client's presenting problems?

Acute gastritis

Sodium

Admission lab values on a patient admitted with congestive heart failure are as follows: potassium 3.4 mEq/L; sodium 148 mEq/L; calcium 9.8 mg/dL; and magnesium 1.5 mEq/L. Which lab value is abnormal?

When do most perinatal HIV infections occur?

After exposure during delivery

Excessive probing

After reviewing the client's chart, the nurse sets up a time to speak with the client. The client has a history of severe psychological abuse by her mother, who has schizophrenia. The nurse plans to ask the client about the abuse and how it has affected her sense of self-esteem. This is an example of what kind of intervention?

Which of the following is a true statement regarding air pressure variances?

Air is drawn through the trachea and bronchi into the alveoli during inspiration.

Which of the following medications would the nurse expect the physician to order for a client with cirrhosis who develops portal hypertension?

Aldactone

While in a skilled nursing facility, a client contracted scabies, which is diagnosed the day after discharge. The client is living at her daughter's home, where six other family members are living. During her visit to the clinic, she asks a staff nurse, "What should my family do?" The most accurate response from the nurse is:

All family members will need to be treated.

Working hard to memorize the functions of the cranial nerves is a typical part of nursing school. Not only is it important to correlate the proper nerve number and name, but including the proper function makes this task quite a challenge! Which cranial nerves are enabling you to read this question?

All options are correct

A client has an increased number of eosinophils. Which of the following disorders would the nurse expect the client to have?

Allergy

Which intervention should the nurse implement in the client scheduled for aminocentesis?

Allow the client to void Explanation: Before amniocentesis, the client should void to empty the bladder, reducing the risk of bladder perforation. The client doesn't need to drink fluids before amniocentesis nor does she need to fast. The client should be placed in a supine position for the procedure.

In preparing the client for transfer to the operating room, which of the following actions by the nurse is inappropriate?

Allow the client to wear dentures.

Lactulose (Cephulac) is administered to a patient diagnosed with hepatic encephalopathy to reduce which of the following?

Ammonia

The digestion of carbohydrates is aided by

Amylase

That all behavior is meaningful and can be understood from the person's perspective

An adolescent has a history of self-mutilation. The nurse questions the client about her behavior. The nurse's questioning reflects which principle?

Axis II

An assigned client's diagnosis is paranoid personality disorder. Which axis, according to the , would the diagnosis be classified?

Covert

An assigned client's diagnosis is paranoid personality disorder. Which axis, according to the , would the diagnosis be classified?

Hypercarbia? (other name?) - Caused by?

An increased concentration of carbon dioxide in the blood. (hypercapnia) - Hypoventilation

Placing the client in a side-lying position

An unconscious client is at risk for aspiration. To decrease this risk, the nurse should place the client in a side-lying position when performing oral hygiene; doing so allows fluid to drain from the mouth, preventing aspiration. Swabbing the client's lips, teeth, and gums with lemon glycerin would promote tooth decay. Cleaning the tongue with gloved fingers wouldn't be effective in removing oral secretions or debris in an unconscious client. Placing the client in semi-Fowler's position would increase the risk of aspiration.

Which of the following statements is not accurate regarding an autograft?

Anticoagulation is necessary

A client is diagnosed with primary herpes genitalis. Which instruction should the nurse provide?

Apply acyclovir ointment to the lesions every 3 hours, six times per day for 7 days.

A client comes to the physician's office for treatment of severe sunburn. The nurse takes this opportunity to discuss the importance of protecting the skin from the sun's damaging rays. Which instruction would best prevent skin damage?

Apply sunscreen even on overcast days.

A client admitted to the hospital for an abdominal aneurysm repair tells a nurse that he has an advance directive. What action should the nurse take?

Ask the client for a copy of the advance directive to place on his chart. Explanation: Upon admission, a client should be asked if he has an advance directive and informed of his right to create one. If the client has an advance directive, a copy of the document must be placed in the medical record. It isn't enough just to note that the client has one. It would be incorrect to tell the client to give the directive to his lawyer or to imply that the directive isn't valid when surgery is being performed.

When caring for a client with an acute exacerbation of a peptic ulcer, the nurse finds the client doubled up in bed with severe pain to his right shoulder. The intial appropriate action by the nurse is to

Assess abdomen and vitals

An elderly client who lives at home with her daughter is admitted with unexplained bruises on her arms and legs. Which action should the nurse take first?

Assess the client thoroughly and complete the health history.

The client is postoperative following a graft reconstruction of the neck. It is most important for the nurse to

Assess the graft for color and temperature

A patient undergoing a skin test has been intradermally injected with a disease-specific antigen on the inner forearm. The patient becomes anxious because the area begins to swell. Which of the following may be used to decrease anxiety in this patient?

Assure the patient that this is a normal reaction

Which of the following would the nurse expect to assess in a client with hepatic encephalopathy?

Asterixis

A nurse assesses the abdomen of a newly admitted client. Which finding would necessitate further investigation?

Asymmetrical upper abdomen

Which of the following assessment should be completed if suspecting immune dysfunction in the neurosensory system?

Ataxia

Which of the following terms refers to the inability to coordinate muscle movements, resulting difficulty walking?

Ataxia

A nurse is preparing an in-service presentation about human immunodeficiency virus (HIV) for a group of new graduate nurses. As part of the presentation, the nurse is planning to describe the events that occur once HIV enters the host cell. Which of the following would the nurse describe as the first step?

Attachment

A nonresponsive client has a nasogastric tube to low intermittent suction due to gastrointestinal bleeding. It is most important for the nurse to

Auscultate lungs every 4 hours

Which of the following describes a valve used in replacement surgery that is made from the patient's own heart valve?

Autograft

To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction?

Avoid coffee and alcoholic beverages

A client visits the nurse complaining of diarrhea every time they eat. The client has AIDS and wants to know what they can do to stop having diarrhea. What should the nurse advise?

Avoid residue, lactose, fat, and caffeine.

For a child with a Wilms' tumor, which preoperative nursing intervention takes highest priority?

Avoiding abdominal palpation Explanation: Because manipulating the abdominal mass may disseminate cancer cells to adjacent and distant sites, the most important intervention for a child with a Wilms' tumor is to avoid palpating the abdomen. Restricting oral intake and monitoring acid-base balance are routine interventions for all preoperative clients; they have no higher priority in one with a Wilms' tumor. Isolation isn't required because a Wilms' tumor isn't infectious.

Which of the following is a key diagnostic indicator of heart failure (HF)?

BNP

A client is progressing through the first stage of labor. Which finding signals the beginning of the second stage of labor?

Bearing-down reflex Explanation: The second stage of labor is heralded by a bearing-down reflex with each contraction, increased bloody show, severe rectal pressure, and rupture of the membranes (if this hasn't already occurred). Passage of the mucus plug typically occurs during the latent phase of the first stage of labor. A change in uterine shape and a gush of dark blood occur during the placental separation phase of the third stage of labor.

The defibrillator won't deliver a shock if the synchronizer switch is turned on.

Before using a defibrillator to terminate ventricular fibrillation, a nurse should check the synchronizer switch. Why is this check so important?

The Emergency Department (ED) nurse is caring for a client with a possible acid-base imbalance. The physician has ordered an arterial blood gas (ABG). What is one of the most important indications of an acid-base imbalance that is shown in an ABG?

Bicarbonate - Arterial blood gas (ABG) results are the main tool for measuring blood pH, CO2 content (PaCO2), and bicarbonate. An acid-base imbalance may accompany a fluid and electrolyte imbalance. PaO2 and PO2 are not indications of acid-base imbalance. Carbonic acid levels are not shown in an ABG.

A group of nursing students are studying for a test over acid-base imbalance. One student asks another what the major chemical regulator of plasma pH is. What should the second student respond?

Bicarbonate-carbonic acid buffer system - The major chemical regulator of plasma pH is the bicarbonate-carbonic acid buffer system.

A client has been receiving intermittent tube feedings for several days at home. The nurse notes the findings as shown in the accompanying documentation. The nurse reports the following as an adverse reaction to the tube feeding:

Blood glucose level

In a patient diagnosed with increased intracranial pressure (IICP), the nurse would expect to observe which of the following respiratory rate or depth?

Bradypnea

In women, which of the following types of cancer exceeds colorectal cancer?

Breast

A nurse is performing a respiratory assessment on a client with pneumonia. She asks the client to say "ninety-nine" several times. Through her stethoscope, she hears the words clearly over his left lower lobe. What term should the nurse use to document this finding?

Bronchophony

A client has been receiving radiation therapy to the lungs and now has erythema, edema, and pain of the mouth. The nurse instructs the client to

Brush and floss daily

Agammaglobulinemia is also known as which of the following?

Bruton's Disease

An infant, age 3 months, undergoes surgical repair of a cleft lip. After surgery, the nurse should use which equipment to feed the infant?

Bulb syringe with tubing Explanation: An infant with a surgically repaired cleft lip must be fed with a bulb syringe with tubing or Breck feeder to prevent sucking or suture line trauma. The other options wouldn't prevent these actions.

When preparing to feed an infant with pyloric stenosis, which intervention is important?

Burp the infant frequently Explanation: Infants with pyloric stenosis usually swallow a lot of air from sucking on their hands and fingers because of their intense hunger (feedings aren't easily tolerated). Burping often lessens gastric distention and increases the likelihood the infant will retain the feeding. Feedings are given slowly with the infant lying in a semiupright position. Parental participation should be encouraged and allowed to the extent possible. Record the type, amount, and character of the vomit as well as its relation to the feeding. The amount of feeding volume lost is usually refed.

Which of the following is usually the most important consideration in decisions to initiate antiretroviral therapy?

CD4 Counts

Which pulse should the nurse palpate during rapid assessment of an unconscious adult?

Carotid

A nurse is preparing a client for a lumbar puncture. The client has heard about post-lumbar puncture headaches and asks what causes them. The nurse tells the client that these headaches are caused by which of the following?

Cerebral spinal fluid leakage at the puncture site

Which of the following is the most common presenting symptom of colon cancer?

Change in bowel habits

When caring for a patient with cirrhosis, which of the following symptoms should the nurse report immediately?

Change in mental status

Which of the following nursing interventions should a nurse perform when a patient with cardiomyopathy receives a diuretic?

Check for dependent edema regularly

A client with a feeding tube is to receive medication. The medication supplied is an enteric-coated tablet. Which of the following would be most appropriate?

Check with pharmacist to see if liquid form is available

You are caring for a client with a damaged tricuspid valve. You know that the tricuspid valve is held in place by which of the following?Chordae tendineae

Chordae tendineae Explanation: Attached to the mitral and tricuspid valves are cordlike structures known as chordae tendineae, which in turn attach to papillary muscles, two major muscular projections from the ventricles. Options B, C, and D are distractors for the question.

Which of the following is an accurate statement regarding cancer of the esophagus?

Chronic irritation of the esophagus is a known risk factor

During the acute phase of a burn, the nurse should assess which of the following?

Circulatory status

Which of the following is clinical manifestation of cholelithiasis?

Clay colored stools

A home care nurse is visiting a client with AIDS at home. During the visit, the nurse observes the caregiver providing care. Which of the following would alert the nurse to the need for additional teaching for the caregiver?

Cleaning around the anal area without wearing gloves

The client is admitted to the hospital with a diagnosis of acute glomerulonephritis. Which clinical manifestation would the nurse expect to find?

Cola colored urine

A client is scheduled for several diagnostic tests to evaluate her gastrointestinal function. After teaching the client about these tests, the nurse determines that the client has understood the teaching when she identifies which test as not requiring the use of a contrast medium?

Colonoscopy

The critical care nurse is giving report on a client they are caring for. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the on-coming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate?

Comatose

When assessing a client with glaucoma, the nurse expects which finding?

Complaints of halos around lights Explanation: Glaucoma is largely asymptomatic. Symptoms that occur can include loss of peripheral vision or blind spots, reddened sclera, firm globe, decreased accommodation, halos around lights, and occasional eye pain. Normal intraocular pressure is 10 to 21 mm Hg.

A 15-year-old client has been brought to the clinic by their mother and is suspected of having an immune system disorder. What tests would you expect to be ordered for this young client?

Complete Blood Count with differential

Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. Which condition would benefit from hyperbaric oxygen therapy?

Compromised skin graft

Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus?

Confusion and seizures - Classic signs of water intoxication include confusion and seizures, both of which are caused by cerebral edema. Weight gain will also occur. Sunken eyeballs, thirst, and increased BUN levels indicate fluid volume deficit. Spasticity, flaccidity, and tetany are unrelated to water intoxication.

Other than abstinence, what is the only proven method of decreasing the risk for sexual transmission of HIV infection?

Consistent and correct use of condoms

A nurse administered a full strength feeding with an increased osmolality through a jejunostomy tube to a client. Immediately following the feeding, the client expelled a large amount of liquid brown stool and exhibited a blood pressure of 86/58 and pulse rate of 112 beats/min. The nurse

Consult physician regarding decreasing to half-strength

Laboratory test results confirm that a client's wound is infected with methicillin-resistant staphylococcus aureus. Which type of isolation precautions should the nurse institute for this client?

Contact

A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies. Which type of isolation does this client require?

Contact isolation

A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies. Which type of isolation does this client require?

Contact isolation Explanation: A client with rabies requires contact isolation because the disease is highly transmissible through close or direct contact. Rabies isn't transmitted through the air, eliminating the need for strict isolation, which aims to prevent transmission of highly contagious or virulent infections spread by both air and contact. Respiratory isolation, used to prevent transmission only through the air, isn't sufficient for a client with rabies. Enteric isolation is inappropriate because rabies isn't transmitted through direct or indirect contact with feces.

A nurse assessing a client who underwent cardiac catheterization finds the client lying flat on the bed. His temperature is 99.8° F (37.7° C). His blood pressure is 104/68 mm Hg. His pulse rate is 76 beats/minute. She detects weak pulses in the leg distal to the puncture site. Skin on the leg is cool to the touch. The puncture site is dry, but swollen. What is the most appropriate action for the nurse to take?

Contact the physician and report her findings. Explanation: The client is probably developing a hematoma at the puncture site. The decreased pulses, swelling, and cool temperature in the leg are all classic signs that blood flow to that extremity is compromised. The nurse should notify the physician immediately to preserve the blood flow in the client's leg. Documenting findings and checking the client again in 1 hour, slowing the I.V. fluid, and encouraging the client to perform isometric leg exercises aren't appropriate actions for the nurse to take at this time.

Which of the following interventions would be most appropriate for a client who has undergone surgery for a liver disorder and has started shivering?

Cover the client with a light blanket.

is high in fruits and vegetables, moderate in low-fat dairy products, and low in animal protein.

DASH diet

A patient diagnosed with a pulmonary embolism (PE) would be expected to have which type of ventilation-perfusion?

Dead space

The nurse is collecting data on a geriatric client with senile dementia. Which neurotransmitter condition is likely to contribute to this client's cognitive changes?`

Decreased acetylcholine level Explanation: A decreased acetylcholine level has been implicated as a cause of cognitive changes in healthy geriatric clients and in the severity of dementia. Choline acetyltransferase, an enzyme necessary for acetylcholine synthesis, has been found to be deficient in clients with dementia. Norepinephrine is associated with aggression, sleep- wake patterns, and the regulation of physical responses to emotional stimuli, such as the increased heart and respiratory rates caused by panic.

Chronic illnesses may contribute to immune system impairment in various ways. Renal failure is associated with which of the following?

Deficiency in circulating lymphocytes

The nurse expects which of the following assessment findings in the client in the diuretic phase of acute renal failure?

Dehydration

In the divisions of the nervous systems, the basic structure is the neuron. The function of the neuron is determined by the direction of impulse transmission. Which part of the neuron is responsible for conducting impulses to the cell body?

Dendrites

Which of the following would be an indication for a transesophageal echocardiography (TEE)?

Determination of atrial thrombi Explanation: The TEE is an important diagnostic tool for determining if atrial or ventricular thrombi are present in patients with heart failure, valvular heart disease, and arrhythmias. The electrocardiogram (ECG) is a graphic recording of the electrical activity of the heart. Stress testing is used to evaluate the response of the cardiovascular system to increased demands for oxygen and nutrients. Thallium is used with exercise or pharmacologic stress testing to assess changes in myocardial perfusion at rest and after exercise.

The instructor in the anatomy and physiology class is talking about alveolar respiration. What would the instructor tell the class is the main purpose of alveolar respiration?

Determines amount of CO2 in the body

A 10-year-old child has been experiencing insatiable thirst and urinating excessively; his serum glucose is normal. Which condition is the child probably experiencing?

Diabetes insipidus Explanation: Polydipsia and polyuria with normal serum glucose are indicative of diabetes insipidus. Interview and laboratory results can determine whether the origin is neurogenic or nephrogenic. Type 1 or 2 diabetes mellitus present with an elevated serum glucose. A child with hyperthyroidism may present as dehydrated from the excessive sweating and rapid respirations that accompany this hypermetabolic state.

The nurse enters the room of a client who is being monitored with pulse oximetry. Which of the following factors may alter the oximetry results?

Diagnosis of peripheral vascular disease

All the following items are related to cancer. Which does not affect the immune system?

Diagnostic tests for cancer

Symptoms associated with pyloric obstruction include all of the following except:

Diarrhea

Which of the following is one of the primary symptoms of Irritable Bowel Syndrome (IBS)?

Diarrhea

Which of the following appears to be a significant factor in the development of gastric cancer?

Diet

Which of the following clinical manifestations should a nurse monitor for during a pulmonary angiography, which indicates an allergic reaction to the contrast medium?

Difficulty in breathing

A patient is exhibiting digitalis toxicity. Which of the following medications would the nurse expect to be ordered for this patient?

Digoxin

A patient has been diagnosed with congestive heart failure (CHF). The physician has ordered a medication to enhance contractility. The nurse would expect which medication to be ordered for the patient?

Digoxin (Lanoxin) Explanation: Contractility is enhanced by circulating catecholamines, sympathetic neuronal activity, and certain medications, such as Lanoxin. Increased contractility results in increased stroke volume. The other medications are classified as platelet-inhibiting medications.

Which of the following medications reverses digitalis toxicity?

Digoxin immune FAB (Digibind)

Which of the following are sympathetic effects of the nervous system?

Dilated pupils

The nurse is collecting data on whether the client has received all recommended immunizations for his age. Which immunizations should he have received between ages 4 and 6?

Diphtheria, tetanus, and acellular pertussis (DTaP), MMR, inactivated polio virus (IPV), and pneumococcal vaccine Explanation: Between ages 4 and 6 the child should receive DTaP, MMR, IPV, and Varicella vaccine. Hepatitis A is completed by age 2yrs. MMR alone is incomplete. H. influenzae, type B immunization is completed by age 15 months.

Which of the following actions by the nurse is appropriate?

Discarding an object that comes in contact with the 1-inch border

The nurse is caring for the client following surgery for a urinary diversion. The client refuses to look at the stoma or participate in its care. The nurse formulates a nursing diagnosis of:

Disturbed body image

A patient is being treated for diverticulosis. Which of the following information should the nurse include in this patient's teaching plan?

Drink at least 8 to 10 large glasses of fluid every day

A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to:

Drink liquids only between meals

During the insertion of a rigid scope for bronchoscopy, a client experiences a vasovagal response. The nurse should expect:

Drop in clients HR

Which of the following terms is an example of an X-linked recessive condition?

Duchenne MD

Which of the following is considered a stimulant laxative?

Dulcolax

A nurse should teach the client to watch for which complication of gastric resection?

Dumping syndrome Explanation: Dumping syndrome is a problem that occurs postprandially after gastric resection because ingested food rapidly enters the jejunum without proper mixing and without the normal duodenal digestive processing. Diarrhea, not constipation, may also be a symptom. Gastric or intestinal spasms don't occur, but antispasmodics may be given to slow gastric emptying.

When gastric analysis testing reveals excess secretion of gastric acid, which of the following medical diagnoses is supported?

Duodenal ulcer

Evaluation

During the evaluation step of the nursing process, the nurse determines whether the goals established in the plan of care have been achieved and evaluates the success of the plan. If a goal is unmet or partially met, the nurse reexamines the data and revises the plan. Data collection involves gathering relevant information about the patient. Planning involves setting priorities, establishing goals, and selecting appropriate interventions. Implementation involves providing actual nursing care.

A client suspected of having HIV has blood drawn for a screening test. What is the first test generally run to see if a client is, indeed, HIV positive?

ELISA

Which blood test confirms the presence of antibodies to HIV?

ELISA

Restlessness

Early in shock, hyperactivity of the sympathetic nervous system causes increased epinephrine secretion, which typically makes the client restless, anxious, nervous, and irritable. It also decreases tissue perfusion to the skin, causing pale, cool, clammy skin. An above-normal heart rate is a late sign of shock. A urine output of 30 ml/hour is within normal limits.

During the immune response, cytotoxic cells bind to invading cells, destroy the targeted invader and release lymphokines to remove the debris. Which type of T-cell lymphocyte is cytotoxic?

Effector T-cells

Examples are tonsillectomy, hernia repair, cataract extraction and lens implantation, hemorrhoidctomy, hip prosthesis, scar revision, facelift, mammoplasty

Elective surgery

Which of the following terms refer to a method of recording, in graphic form, the electrical activity of the muscle?

Electromyogram

A client is admitted to the healthcare facility suspected of having acute pancreatitis and undergoes laboratory testing. Which of the following would the nurse expect to find?

Elevated urine amylase levels

A physician suspects that a client has peptic ulcer disease. With which of the following diagnostic procedures would the nurse most likely prepare to assist?

Endoscopy

A school nurse is talking about infection with a high school health class. What would be the nurse's best explanation of the process of phagocytosis?

Engulfment and digestion of foreign material and bacteria

A group of students are reviewing material about endocrine system function. The students demonstrate understanding of the information when they identify which of the following as secreted by the adrenal medulla?

Epinephrine Explanation: The adrenal medulla secretes epinephrine and norepinephrine. The adrenal cortex manufactures and secretes glucocorticoids, mineralocorticoids, and small amounts of androgenic sex hormones. Glucagon is released by the pancreas.

A patient is receiving nasogastric tube feedings. The intake and output record for the past 24 hours reveals an intake of 3100 mL and an output of 2400 mL. The nurse identifies which nursing diagnosis as most likely?

Excess fluid volume

A nurse is caring for a client with aortic stenosis whose compensatory mechanisms of the heart have begun to fail. The nurse will monitor the client carefully for which initial symptoms?

Exertional dyspnea, orthopnea, pulmonary edema

An elderly client states, "I don't understand why I have so many caries in my teeth." The nurse assesses the following as placing the client at risk:

Exhibiting hemoglobin A1C 8.2

Your patient is being discharged home after mastoid surgery. You know that you will need to teach the patient about medication therapy. What will you include in this teaching? a) Anti-emetic medications b) Anti-inflammatory medications c) Expected effects and potential side effects d) Take the medication with food

Expected effects and potential side effects Correct Explanation: Patients require instruction about medication therapy, such as analgesics and antivertiginous agents (eg, antihistamines) prescribed for balance disturbance. Teaching includes information about the expected effects and potential side effects of the medication. Antiemetics and anti-inflammatory medications are not usually prescribed after mastoid surgery. Without having a medication named you would not know whether or not to take it with food.

A nurse is taking health history from a new client, which includes asking about a history of blood transfusions. This is important for which of the following reasons?

Exposure to foreign antigens may cause altered immune function.

An elderly client is diagnosed with cancer. While reviewing age-related changes in the immune system, the nurse identifies which of the following as having contributed to this client's condition?

Failure of lymphocytes to recognize mutant cell

Which of the following is an early warning symptom of acute coronary syndrome (ACS) and heart failure (HF)?

Fatigue Explanation: Fatigue is an early warning symptom of ACS, heart failure, and valvular disease. Other signs and symptoms of cardiovascular disease are hypotension, change in level of consciousness, and weight gain.

Which nursing assessment finding indicates that the client who has undergone renal transplant has not met expected outcomes?

Fever

What factor in plasma can be transformed from a liquid to a solid?

Fibrinogen

T-cells can be either regulator T cells or effector T cells. Regulator T cells are made up of helper and suppressor cells. What function are helper T-cells important in?

Fighting infection

Aneurysm rebleeding occurs most frequently during which timeframe after the initial hemorrhage?

First 2 weeks

When administering intravenous gamma globulin infusion, the nurse recognizes that which of the following complaints, if reported by the client, may indicate an adverse effect of the infusion?

Flank Pain

The nurse is preparing a teaching plan for a client with an immunodeficiency. Which of the following would the nurse emphasize as most important?

Frequent and thorough handwashing

A preschool-age child underwent a tonsillectomy 4 hours ago. Which data collection finding would make the nurse suspect postoperative hemorrhage?

Frequent swallowing Explanation: Frequent swallowing — an attempt to clear the throat of trickling blood — suggests postoperative hemorrhage. Emesis may be brown or blood-tinged after a tonsillectomy; only bright red emesis signals hemorrhage. The child may refuse fluids because of painful swallowing, not bleeding. Hemorrhage is associated with an increased, not decreased, heart rate.

enteric precautions

Gowns and gloves required, masks not required, protection from feces and urine.

An 89-year-old client lives in a long-term care facility where you practice nursing. The client has a hypertensive history and has fallen several times in the past two weeks. As his nurse, why is it important for you to encourage the client to rise slowly from a sitting or lying position?

Gradual changes in position provide time for the heart to increase rate of contraction to resupply oxygen to the brain. Explanation: It is important for the nurse to encourage the client to rise slowly from a sitting or lying position because gradual changes in position provide time for the heart to increase its rate of contraction to resupply oxygen to the brain.

A client begins clozapine (Clozaril) therapy after several other antipsychotic agents fail to relieve her psychotic symptoms. The nurse instructs her to return for weekly white blood cell (WBC) counts to monitor for which adverse reaction?

Granulocytopenia Correct Explanation: Clozapine can cause life-threatening neutropenia or granulocytopenia. To detect this adverse reaction, a WBC count should be performed weekly. Hepatitis, infection, and systemic dermatitis aren't adverse reactions of clozapine therapy.

Which of the following terms is used to describe the personal feelings that accompany an anticipated or actual loss?

Grief

Several children at a daycare center have been infected with hepatitis A virus. Which instruction by the nurse would reduce the risk of hepatitis A to other children and staff members?

Hand washing after diaper changes Explanation: Children in daycare centers are at risk of hepatitis A infection which is transmitted via fecal-oral route due to poor hand hygiene practices and poor sanitation. Isolation of sick children, use of masks during contact, and sterilization of all eating utensils would not be useful in breaking the chain of infection.

A patient is receiving parenteral nutrition. The current solution is nearing completion, and a new solution is to be hung, but it has not arrived from the pharmacy. Which action by the nurse would be most appropriate?

Hang a solution of dextrose 10% and water until the new solution is available.

The nurse recognizes the client has reached stage III of general anesthesia when the client:

Has small pupils that react to light

A nurse is caring for a client experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. What condition should the nurse suspect?

Heart failure

A nursing student is caring for a client with end-stage cardiomyopathy. The client's spouse asks the student to clarify one of the last treatment options available that the physician mentioned. After checking with the primary nurse, the student would most likely discuss which of the following?

Heart transplant

Which of the following therapies are for patient who have advanced heart failure (HF) after all other therapies have failed?

Heart transplant

Albumin is a protein in the plasma portion of the blood. Under normal conditions albumin cannot pass through the wall of a capillary. What significance is this for the vascular compartment?

Helps retain fluid in the vascular compartment.

Which type of jaundice seen in adults is the result of increased destruction of red blood cells?

Hemolytic

A client with severe peptic ulcer disease has undergone surgery and is several hours postoperative. During assessment, the nurse notes that the client has developed cool skin, tachycardia, and labored breathing; the client also appears to be confused. Which of the following complications has the client most likely developed?

Hemorrhage

A patient has an elevated serum ammonia level and is exhibiting mental status changes. The nurse should suspect which of the following conditions?

Hepatic encephalopathy

A 38-year-old female patient has begun to suffer from rheumatoid arthritis. She is also being assessed for disorders of the immune system. She works as an aide at a facility that cares for children infected with AIDS. Which of the following is the most important factor related to the patient's assessment?

Her use of other drugs

A 38-year-old female patient has begun to suffer from rheumatoid arthritis. She is also being assessed for disorders of the immune system. She works as an aide at a facility that cares for children infected with AIDS. Which of the following is the most important factor related to the patient's assessment?

Her use of other drugs.

Which of the following indicates that a client with HIV has developed AIDS?

Herpes simplex ulcer persisting for 2 months

A nurse is teaching a client who is having a valuloplasty tomorrow. The client asks what the advantage is for having a tissue valve replacement instead of a mechanical valve. The correct answer by the nurse is which of the following?

"A tissue valve is less likely to generate blood clots, and so long-term anticoagulation therapy is not required."

The client with polycystic kidney disease asks the nurse, "Will my kidneys ever function normally again?" The best response by the nurse is:

"As the disease progresses, you will most likely require renal replacement therapy."

A nurse and a nursing student are caring for a client with pericarditis and perform the physical assessment together. The client has a pericardial friction rub audible on auscultation. When the nurse and student leave the room, the student asks how to distinguish a pericardial from a pleural friction rub. The nurse's best response is which of the following?

"Ask the client to hold the breath while you auscultate; the pericardial friction rub will continue, while the pleural friction rub will stop."

A nurse is teaching an adolescent with type 1 diabetes about the disease. Which instruction by the nurse about how to prevent hypoglycemia would be most appropriate for the adolescent?

"Carry crackers or fruit to eat before or during periods of increased activity." Explanation: Hypoglycemia can usually be prevented if an adolescent with diabetes eats more food before or during exercise. Because exercise with adolescents isn't commonly planned, carrying additional carbohydrate foods such as crackers or fruit is a good preventive measure.

Which statement reflects appropriate documentation in the medical record of a hospitalized client?

"Client's skin is moist and cool." Explanation: Documentation should include data that the nurse obtains using only observations that are heard, seen, smelled, or felt. The nurse should record findings or observations precisely and accurately. Documentation of a leg ulcer should include its exact size and location. Documenting observed client behaviors or conversations is appropriate, but drawing conclusions about a client's feelings is not. Stating that the client had a good day doesn't provide precise enough information to be useful.

A nurse is caring for a client who has hypertension and diabetes mellitus. The client's blood pressure this morning was 150/92 mm Hg. He asks the nurse what his blood pressure should be. The nurse's most appropriate response is:

"Clients with diabetes should have a lower blood pressure goal. You should strive for 130/80 mm Hg."

You are caring for a client admitted with chronic bronchitis. The client is having difficulty breathing, and the family asks you what causes this difficulty. What would be your best response?

"Conditions such as chronic bronchitis cause thickening of the bronchial mucosa so it makes it harder to breathe."

A client admitted for treatment of a gastric ulcer is being prepared for discharge on antacid therapy. Discharge teaching should include which instruction?

"Continue to take antacids even if your symptoms subside."

The nurse is caring for a man who has experienced a spinal cord injury. Throughout his recovery, the client expects to gain control of his bowels. The nurse's best response to this client would be which of the following?

"Having a bowel movement is a spinal reflex requiring intact nerve fibers. Yours are not intact."

A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when he makes which statement?

"I sleep on three pillows each night"

A client with generalized anxiety disorder (GAD) is prescribed a benzodiazepine, but the client doesn't want to take the medication. Which explanation for this behavior would most likely be correct?

"I want to solve my problems on my own." Explanation: Many clients don't want to take medications because they believe that using a medication is a sign of personal weakness and that they can't solve their problems by themselves. Thinking that the psychiatrist dislikes them reflects paranoid thinking that isn't usually seen in clients with GAD. By waiting several weeks to take the medication, the client could be denying that the medication is necessary or beneficial. By focusing on the negative motives of family members, the client could be avoiding talking about himself.

A nurse is performing discharge teaching with a client who had a total gastrectomy. Which statement indicates the need for further teaching?

"I will have to take vitamin B12 shots up to 1 year after surgery."

A nurse is preparing a client for an exercise stress test the following morning. Which client statement indicates a need for additional teaching?

"I won't eat or drink anything after midnight tonight." Explanation: The client requires additional teaching if he states that he'll fast from midnight until the test. Clients need to abstain from eating and drinking for only 4 hours before the test. The client should refrain from smoking for several hours before the test. Although the physician may direct the client to avoid certain medications, it's more likely that the physician will direct the client to take all his normal medications. The client must sign a consent form before the test.

A home care nurse is caring for a client with complaints of epigastric discomfort who is scheduled for a barium swallow. Which statement by the client indicates an understanding of the test?

"I'll avoid eating or drinking anything 6 to 8 hours before the test."

A client has been admitted to undergo surgical repair of a torn Achilles' tendon. While meeting with the anesthesiologist, what statement from the client would indicate to the nurse that the anesthesiologist needs to clarify points?

"I'll receive procedural sedation."

A client undergoes extracorporeal shock wave lithotripsy. Before discharge, the nurse should provide which instruction?

"Increase your fluid intake to 2 to 3 L per day." Explanation: Increasing fluid intake flushes the renal calculi fragments through — and prevents obstruction of — the urinary system. Measuring temperature every 4 hours isn't needed. Lithotripsy doesn't require an incision. Hematuria may occur for a few hours after lithotripsy but then should disappear.

A nursing instructor tells the class that review of oral hygiene is an important component during assessment of the gastrointestinal system. One of the students questions this statement. Which of the following explanations from the nurse educator is most appropriate?

"Injury to oral mucosa or tooth decay can lead to difficulty in chewing food."

A nurse is caring for a patient with a Salem sump gastric tube attached to low intermittent suction for decompression. The patient asks, "What's this blue part of the tube for?" Which response by the nurse would be most appropriate?

"It is a vent that prevents backflow of the secretions."

You are the nurse working in an ambulatory surgery center. A teenage son of your clients ask you why so many people have surgery. What would be your best reply?

"Many people have diagnostic or short therapeutic surgical procedures."

A nurse and nursing student are caring for a client recovering from a lumbar puncture yesterday. The client reports a headache despite being on bedrest overnight. The physician plans an epidural blood patch this morning. The student asks how this will help the headache. The correct reply from the nurse is which of the following?

"The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid."

You are the hospice nurse caring for a client with pulmonary fibrosis who wants to die at home. The client is having difficulty breathing. The family asks why it is so hard for the client to breathe. What would be the nurse's best response?

"The fibrosis of the lungs makes the lungs stiff, which makes it harder to breathe.

A client with a peptic ulcer is diagnosed with Heliobacter pylori infection. The nurse is teaching the client about the medications prescribed, including metronidazole (Flagyl), omeprazole (Prilosec), and clarithromycin (Biaxin). Which statement by the client indicates the best understanding of the medication regimen?

"The medications will kill the bacteria and stop the acid production."

When assessing a client who reports recent chest pain, the nurse obtains a thorough history. Which client statement most strongly suggests angina pectoris?

"The pain occurred while I was mowing the lawn."

A mother and grandmother bring a 3-month-old infant to the well-baby clinic for a routine checkup. As the nurse weighs the infant, the grandmother asks, "Shouldn't the baby start eating solid food? My kids started on cereal when they were 2 weeks old." Which response by the nurse would be appropriate?

"We've found that babies can't digest solid food properly until they're 4 months old." Explanation: Infants younger than 4 months lack the enzymes needed to digest complex carbohydrates. Option 1 doesn't address the grandmother's question directly. Option 2 is a cliché that may block further communication with the grandmother. Option 4 is incorrect because no evidence suggests that introducing solid food early causes eating disorders.

During preoperative teaching for a client who will undergo subtotal thyroidectomy, the nurse should include which statement?

"You must avoid hyperextending your neck after surgery." Explanation: To prevent undue pressure on the surgical incision after subtotal thyroidectomy, the nurse should advise the client to avoid hyperextending the neck. The client may elevate the head of the bed as desired and should perform deep breathing and coughing to help prevent pneumonia. Subtotal thyroidectomy doesn't affect swallowing.

INSIDE THE OPERATING ROOM: Unnecessary personnel and physical movement may be restricted to minimize _____.

- Bacteria in the air

Moderate sedation? - It is used so that patient can still ___by themselves and respond to ___stimuli and ___commands.

- Conscious sedation - Breath Physical Verbal

Exposure to blood and body fluids? - What is common in trauma and other types of surgery?

- Double gloving!

Spinal anesthesia? (Where?)

- Subarachnoid space of the spinal cord.

As a patient advocate, the nurse role is to? (4)

- Support coping strategies - Monitor factors that can cause injury such as patient's position - Equipment malfunction - Environmental hazards.

Laser risk?

-Electrical

A nursing student is reviewing an article about genetic disorders involving the failure of chromosomes to separate completely, resulting in a cell that contains more than one copy or no copy of a particular chromosome. The student would identify which condition as an example of this phenomenon? Select all that apply.

-Turner Syndrome -Down Syndrome

Following a unilateral adrenalectomy, a nurse should assess for hyperkalemia as indicated by:

muscle weakness - Muscle weakness, bradycardia, nausea, diarrhea, and paresthesia of the hands, feet, tongue, and face are findings associated with hyperkalemia, which is transient and results from transient hypoaldosteronism when the adenoma is removed. Tremors, diaphoresis, and constipation aren't seen in hyperkalemia.

The nursing student asks their instructor what the term is for the amount of hydrogen ions in a solution. What should the instructor respond?

pH - The symbol pH refers to the amount of hydrogen ions in a solution; pH can range from 1, which is highly acidic, to 14, which is highly basic. All other options are incorrect.

When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis?

pH 7.48 - Metabolic alkalosis is a clinical disturbance characterized by a high pH and high plasma bicarbonate concentration. The HCO value is below normal. The PaCO value and the oxygen saturation level are within a normal range.

A client with a solar burn of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be:

pain management.

A client with a solar burn of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be:

pain management. Explanation: With a superficial partial thickness burn such as a solar burn (sunburn), the nurse's main concern is pain management. Fluid resuscitation and infection become concerns if the burn extends to the dermal and subcutaneous skin layers. Body image disturbance is a concern that has lower priority than pain management.

Which of the following medications is given to patients diagnosed with angina and is allergic to aspirin?

plavix

The nurse auscultates lung sounds that are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as

pleural friction rub.

The nurse is caring for a client who has suffered a severe stroke. During data collection, the nurse notices Cheyne-Stokes respirations. Cheyne- Stokes respirations are:

progressively deeper breaths followed by shallower breaths with apneic periods. Explanation: Cheyne-Stokes respirations are breaths that become progressively deeper followed by shallower respirations with apneic periods. Biot's respirations are rapid, deep breaths with abrupt pauses between each breath, and equal depth between each breath. Kussmaul's respirations are rapid, deep breaths without pauses. Tachypnea is abnormally rapid respirations.

The nurse is providing home care instructions to a client who has recently had a skin graft. It's most important that the client remember to:

protect the graft from direct sunlight.

Following a full-thickness (third-degree) burn of his left arm, a client is treated with artificial skin. The client understands postoperative care of artificial skin when he states that during the first 7 days after the procedure, he will restrict:

range of motion.

A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is:

subnormal serum glucose and elevated serum ammonia levels.

An example of a curative surgical procedure is

the excision of a tumor.

The amount of air inspired and expired with each breath is called:

tidal volume.

A client with severe angina pectoris and electrocardiogram changes is seen by a physician in the emergency department. In terms of serum testing, it's most important for the physician to order cardiac:

troponin. Explanation: This client exhibits signs of myocardial infarction (MI), and the most accurate serum determinant of an MI is troponin level. Creatine kinase, lactate dehydrogenase and myoglobin tests can show evidence of muscle injury, but they're less specific indicators of myocardial damage than troponin.

A client who has suffered a stroke is too weak to move on his own. To help the client avoid pressure ulcers, the nurse should:

turn him frequently.

A client with viral hepatitis A is being treated in an acute care facility. Because the client requires enteric precautions, the nurse should:

wash her hands after touching the client.

When collecting data on a client who has just been admitted to the medical-surgical unit, the nurse discovers scabies. To prevent scabies infection in other clients, the nurse should:

wear gloves when providing care and isolate the client's bed linens until the client is no longer infectious.

While auscultating the lungs of a client with asthma, the nurse hears a continuous, high-pitched whistling sound on expiration. The nurse will document this sound as which of the following?

wheezes

Initially, which diagnostic should be completed following placement of a NG tube?

x-ray

When caring for a client with cirrhosis, which of the following should a nurse notify immediately? Choose all correct options.

• Change in mental status • Signs of GI bleeding

A client is given a nursing diagnosis of social isolation related to withdrawal of support systems and stigma associated with AIDS. Which outcomes would indicate that the nurse's plan of care was effective? Select all that apply.

• Client demonstrates beginning participation in events and activities. • Client identifies appropriate sources of assistance and support. • Client verbalizes feelings related to the changes imposed by the disease.

Which of the following signs would the nurse recognize as signs of thrombocytopenia? Select all that apply.

• Dark, tarry stools • Bleeding of the gums • Oozing from injection sites

A nursing student has learned about many collaborative interventions to achieve pain relief for clients with acute pancreatitis. Which of the following are appropriate? Choose all that apply.

• Encourage bed rest to decrease the client's metabolic rate. • Teach the client about the correlation between alcohol intake and pain. • Withhold oral feedings to limit the release of secretin.

A client is given a diagnosis of hepatic cirrhosis. The client asks the nurse what findings led to this determination. Which of the following clinical manifestations would the nurse correctly identify? Select all that apply.

• Enlarged liver size • Ascites • Hemorrhoids

A client is scheduled to receive a 25% dextrose solution of parenteral nutrition. The nurse does all of the following. Select all that apply.

• Ensures availability of an infusion pump • Ensures completion of baseline monitoring of the complete blood count (CBC) and chemistry panel • Places a 1.5-micron filter on the tubing

Which of the following reports from the client during the health history would lead the nurse to suspect that the client has a disorder of the hematopoietic or lymphatic system? Select all that apply.

• Experiences prolonged bleeding from an obvious injury. • Has unexplained blood loss, as in rectal bleeding, nosebleeds, bleeding gums, or vomiting blood. • Feels fatigued with normal activities.

After teaching a class about the inheritance patterns of different conditions, the instructor determines that the teaching was successful when the students identify which of the following as resulting from multifactorial inheritance? Select all that apply.

• Familial Alzheimer's disease • Anencephaly • Osteroarthritis • Congenital heart defect

As a nursing instructor, you realize the importance of your students understanding the role of the immune system and its role to protect and defend the body from potential harm. What type of cells are the primary targets of the healthy immune system? Choose all correct options.

• Foreign cells • Cancerous cells • Infectious cells

A nurse is preparing a presentation for a nursing conference about personalized medicine. Which of the following would the nurse include when describing this topic? Select all that apply.

• Genetic predisposition as key to risk reduction • Interaction of genes with the environment • Individualized approach based on person's and disease's genomic profile

A 13-month-old is admitted to the pediatric unit with a diagnosis of gastroenteritis. The toddler has experienced vomiting and diarrhea for the past 3 days, and laboratory tests reveal that he's dehydrated. Which nursing interventions are correct to prevent further dehydration? Select all that apply:

• Give clear liquids in small amounts • Encourage the child to eat nonsalty soups and broths • Monitor the I.V. solution per the physician's order Explanation: A child experiencing nausea and vomiting won't be able to tolerate a regular diet. He should be given sips of clear liquids, and the diet should be advanced as tolerated. Unsalted soups and broths are appropriate clear liquids. I.V. fluids should be monitored to maintain the fluid status and help to rehydrate the child. Milk shouldn't be given because it can worsen the child's diarrhea. Solid foods may be withheld throughout the acute phase, but clear fluids should be encouraged in small amounts (3 to 4 tablespoons every half hour).

In which of the following medical conditions would administering IV normal saline solution be inappropriate? Select all that apply.

• Heart failure • Pulmonary edema • Renal impairment Normal saline is not used for heart failure, pulmonary edema, renal impairment, or sodium retention. It is used with administration of blood transfusions and to replace large sodium losses, as in burn injuries.

A nurse is educating a community group about coronary artery disease. One member asks about how to avoid coronary artery disease. Which of the following items are considered modifiable risk factors for coronary artery disease? Choose all that apply.

• Hyperlipidemia • Tobacco use • Obesity

Phagocytic dysfunction is characterized by the following. Choose all that apply.

• Increased incidence of bacterial infections • Chronic eczematoid dermatitis

A mother brings her teenage son to the clinic, where tests show that he has hepatitis A virus (HAV). They ask the nurse how this could have happened. Which of the following explanations would the nurse correctly identify as possible causes? Select all that apply.

• Infection at school • Suboptimal sanitary habits • Consumption of sewage-contaminated water or shellfish • Sexual activity

As a nursing instructor, you realize the importance of your students understanding the role of the immune system and its role to protect and defend the body from potential harm. What type of cells are the primary targets of the healthy immune system? Choose all correct options

• Infectious cells • Foreign cells • Cancerous cells

Which of the following medications are usually withheld for 48 to 96 hours before skin testing? Select all that apply.

• Over-the-counter (OTC) allergy medications • Corticosteroids • Antihistamines

Which of the following the are early manifestations of liver cancer? Select all that apply.

• Pain • Continuous aching in the back

Not every structure in the upper airway has a purpose in respiration. There are some structures whose role is immunological. Which of the following structures protect against infection? Choose all correct responses.

• Pharyngeal tonsils • Palantine tonsils

A 67-year-old client is returning for a follow-up appointment to the primary care group where you practice nursing. At his last appointment, he received the diagnosis of portal hypertension and the physician instituted interventions to begin treatment of this condition. What is the primary aim of portal hypertension treatment? Choose all correct options.

• Reduce venous pressure • Reduce fluid accumulation

A nursing instructor is preparing a class about gastrointestinal intubation. Which of the following would the instructor include as reason for this procedure? Select all that apply.

• Remove gas and fluids from the stomach • Diagnose gastrointestinal motility disorders • Flush ingested toxins from the stomach • Administer nutritional substances

A nurse is preparing to give a client an infusion of gamma globulin. The nurse knows to stop the infusion if the client experiences which of the following symptoms? Choose all that apply.

• Shaking chills • Flank pain • Tightness in the chest

As a nursing instructor, you realize the importance of your students understanding the role of the immune system and its role to protect and defend the body from potential harm. What type of cells are the primary participants in immune response? Choose all correct options.

• T-cell lymphocytes • B-cell lymphocytes

A nurse is monitoring a client with peptic ulcer disease. Which of the following assessment findings would most likely indicate perforation of the ulcer? Choose all that apply.

• Tachycardia • Hypotension • A rigid, board-like abdomen

When talking with 10- and 11-year-old children about death, the nurse should incorporate which guides? Select all that apply:

• The children will be curious about the physical aspects of death • The children will know that death is inevitable and irreversible • The children will be influenced by the attitudes of the adults in their lives Explanation: School-age children are curious about the physical aspects of death and may wonder what happens to the body. By age 9 or 10, most children know that death is universal, inevitable, and irreversible. Their cognitive abilities are advanced and they respond well to logical explanations. They should be encouraged to ask questions. Because the adults in their environment influence their attitudes towards death, they should be encouraged to include children in the family rituals and be prepared to answer questions that may seem shocking. Teaching about death should begin early in childhood. Comparing death to sleep can be frightening for children and cause them to fear falling asleep.

A nursing instructor is discussing immunodeficiency disorders with students. The instructor tells the class that immunodeficiency disorders are caused by defects or deficiencies in which of the following? Choose all that apply.

• The complement system • B and T lymphocytes • Phagocytic cells

The nurse is completing the physical assessment of a patient suspected of a neurological disorder. The patient reports to the nurse that he has recently suffered a head trauma. In such a case, which of the following precautions should the nurse take for the patient? Select all that apply.

• The nurse should not move or manipulate the patient's head while assessing for bleeding or swelling.

When reviewing the history of a client with pancreatic cancer, the nurse would identify which of the following as a possible risk factor?

History of pancreatitis

When assessing a client with partial thickness burns over 60% of the body, which finding should the nurse report immediately?

Hoarseness of the voice

Which of the following protective responses begin with the B lymphocytes?

Humoral

A newborn has been diagnosed with DiGeorge syndrome. Which of the following would the nurse least likely expect to assess?

Hypercalcemia

Which type of phagocytic disorder (formerly known as Job syndrome) occurs when white blood cells cannot initiate an inflammatory response to infectious organisms?

Hyperimmunoglobulinemia E

Which term means a lack of one or more of the five immunoglobulins?

Hypogammaglobulinemia

A client who is HIV positive is experiencing severe diarrhea. Which laboratory test result would the nurse expect to find?

Hypokalemia

An elderly patient diagnosed with diarrhea is taking digoxin (Lanoxin). Which of the following electrolyte imbalances should the nurse be alert to?

Hypokalemia

The physician prescribes a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance?

Hypokalemia Explanation: A loop diuretic removes water and, along with it, sodium and potassium. This may result in hypokalemia, hypovolemia, and hyponatremia.

A client presents with fatigue, nausea, vomiting, muscle weakness, and leg cramps. Laboratory values are as follows: Na + 147 mEq/L K + 3.0 mEq/L Cl - 112 mEq/L Mg ++ 2.3 mg/dL Ca ++ 1.5 mg/dL Which of the following is consistent with the client's findings?

Hypokalemia - Potassium is the major intracellular electrolyte. Hypocalemia (below 3.5 mEq/L) usually indicates a deficit in total potassium stores. Potassium deficiency can result in derangements in physiology. Clinical signs include fatigue, anorexia, nausea, vomiting, muscles weakness, leg cramps, decreased bowel motility, and paresthesias.

A new surgical patient who has undergone a coronary artery bypass graft (CABG) is receiving opioids for pain control. The nurse must be alert to adverse effects of opioids. Which of the following effects would be important for the nurse to document?

Hypotension

The nurse is teaching a client with a leg ulcer about tissue repair and wound healing. Which of the following statements by the client indicates that the teaching has been effective?

I'll eat plenty of fruits and vegetables

Which stage of surgical anesthesia is also known as excitement?

II

Heart block

Identify which of the following as an age-related change associated with conduction system of the heart?

Radioallergosorbent testing (RAST) measures which of the following immunoglobulins?

IgE

Globulins are proteins contained in plasma. What is their primary function?

Immunologic agents

Which of the following laboratory test results would the nurse associate with obstructive jaundice?

Increased direct bilirubin

Which of the following is a parasympathetic response in the GI tract?

Increased peristalsis

Which of the following is an age-related change associated with the lung?

Increased thickness of the alveolar membranes

The nurse is reviewing the medication record of a client with acute gastritis. Which medication, if noted on the client's record, would the nurse question?

Indocin

A nurse is taking the health history of a newly admitted client and asks for a list of the client's current medications. Which of the following medication classifications would NOT place the client at risk for impaired immune function?

Inotropics

The nursing instructor is talking with her class about spinal anesthesia. What would be the nursing care intervention required when caring for a client recovering from spinal anesthesia?

Instruct the client to remain flat for 6 to 12 hours.

Proteins formed when cells are exposed to viral or foreign agents that are capable of activating other components of the immune system are referred to as

Interferons

A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The physician begins the client on cyanocobalamin (Betalin-12), 100 mcg I.M. daily. Which substance influences vitamin B12 absorption?

Intrinsic factor

When caring for a client with hepatitis B, the nurse should monitor closely for the development of which finding associated with a decrease in hepatic function?

Irritability and drowsiness

A client sees a dermatologist for a skin problem. Later, the nurse reviews the client's chart and notes that the chief complaint was intertrigo. This term refers to which condition?

Irritation of opposing skin surfaces caused by friction

A nurse is assessing a client with syndrome of inappropriate antidiuretic hormone. Which finding requires further action?

Jugular Vein Distension - Jugular vein distention requires further action because this finding signals vascular fluid overload. Tetanic contractions aren't associated with this disorder, but weight gain and fluid retention from oliguria are. Polyuria is associated with diabetes insipidus, which occurs with inadequate production of antidiuretic hormone.

A 44-year-old client has a history of hypertension. As her nurse, you engage her in client education to make her aware of structures that regulate arterial pressure. Which of the following structures are a component of that process?

Kidneys

During a senior citizen health screening, the nurse observes a 75-year-old female with a severely increased thoracic curve, or "humpback". What is this condition called?

Kyphosis Explanation: Kyphosis refers to an increased thoracic curvature of the spine, or "humpback." Lordosis is an increase in the lumbar curve or swayback. Scoliosis is a lateral deformity of the spine. Genus varum is a bow-legged appearance of the legs.

During a pulmonary assessment, the nurse observes the chest for configuration. She identifies the findings as normal. Which of the following would be consistent with normal assessment?

Lateral diameter greater than anteroposterior diameter

A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure?

Lateral recumbent, with chin resting on flexed knees

Which of the following would the nurse expect the physician to order for a client with hypothyroidism?

Levothyroxine sodium: Explanation: Hypothyroidism is treated with thyroid replacement therapy, in the form of dessicated thyroid extract or a synthetic product, such as levothyroxine sodium (Synthroid) or liothyronine sodium (Cytomel). Methimazole and propylthiouracil are antithyroid agents used to treat hyperthyroidism. Propranolol is a beta blocker that can be used to treat hyperthyroidism.

A nurse is providing in-home hospice care to a 75-year-old client with lung cancer. The nurse determines that the client is eligible for Medicare hospice benefits based on which of the following?

Life expectancy of less than 6 months

Which of the following enzymes aids in the digestion of fats?

Lipase

Which of the following options should the nurse encourage to replace fluid and electrolyte losses in a patient with AIDS?

Liquids

A physician has ordered a liver biopsy for a client whose condition is deteriorating. Which of the following places the client at high risk due to her altered liver function during the biopsy?

Low platelet count

A client has a nursing diagnosis of "ineffective airway clearance" as a result of excessive secretions. An appropriate outcome for this client would be which of the following?

Lungs are clear on auscultation.

Which of the following is a center for immune cell proliferation?

Lymph node

In a client who has been burned, which medication should the nurse expect to use to prevent infection?

Mafenide acetate (Sulfamylon)

Which of the following is the most common cause of anaphylaxis?

Medications

Rebleeding may occur from a peptic ulcer and often warrants surgical interventions. Signs of bleeding include which of the following?

Mental confusion

Vomiting results in which of the following acid-base imbalances?

Metabolic alkalosis

Which of the following is considered a bulk-forming laxative?

Metamucil

Which of the following medications, used in the treatment of GERD, accelerate gastric emptying?

Metoclopramide (Reglan)

The nurse documents the presence of a scab on a client's deep wound. The nurse identifies this as which phase of wound healing?

Migratory

A client with cirrhosis is at risk for developing esophageal varices. Which of the following instructions should a nurse provide the client to minimize such risk?

Minimize alcohol use

A mother has brought her child to the clinic for a wellness check. While talking with the nurse, the mother asks the nurse to suggest a diet that will maximize the immune function of her growing children. What dietary pattern should the nurse suggest?

Moderate diet that is balanced and varied

A 73-year-old client has been admitted to the cardiac step-down unit where you practice nursing. After diagnostics, she was brought to your unit with acute pulmonary edema. Which of the following symptoms would you expect to find during your assessment?

Moist, gurgling respirations

Which of the following is the analgesic of choice for acute MI?

Morphine sulfate

Celiac sprue is an example of which category of malabsorption?

Mucosal disorders causing generalized malabsorption

Which type of immunity becomes active as a result of the infection of a specific microorganism?

Naturally acquired active immunity

A 30-year-old client is admitted to the emergency department with a deep partial-thickness burn on his arm after a fire in his workplace. Which signs and symptoms should the nurse expect to see?

Necrotic tissue through most of the dermis Explanation: A deep partial-thickness burn causes necrosis of the epidermal and dermal layers. Redness and pain are characteristics of a superficial injury. Superficial burns cause slight epidermal damage. With deep burns, the nerve fibers are destroyed and the client doesn't feel pain in the affected area. Necrosis through all skin layers is seen with full-thickness injuries.

A client with decreased urine output refractory to fluid challenges is evaluated for renal failure. Which condition may cause the intrinsic (intrarenal) form of acute renal failure?

Nephrotoxic injury secondary to use of contrast media

A client is receiving ganciclovir as part of his treatment for cytomegalovirus retinitis. The nurse would monitor the results of the client's laboratory tests for which of the following?

Neutropenia

A client undergoes total gastrectomy. Several hours after surgery, the nurse notes that the client's nasogastric (NG) tube has stopped draining. How should the nurse respond?

Notify the physician

A client recovering from gastric bypass surgery accidentally removes the nasogastric tube. It is best for the nurse to

Notify the surgeon about the tube's removal

Which type of cells destroys antigens already coated with antibody?

Null Cells

When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?

Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix.

Which of the following cranial nerves is responsible for muscles that move the eye and lid?

Oculomotor

You are presenting an educational workshop for a local community group. You have been asked to speak about older adults and their health. What is the most important piece of information to include in this presentation?

Older adults are more susceptible to infections and malignancies.

A group of students are reviewing the phases of acute renal failure. The students demonstrate understanding of the material when they identify which of the following as occurring during the second phase?

Oliguria

Which of the following is a process in which the antigen-antibody molecule is coated with a sticky substance that facilitates phagocytosis?

Opsonization

Which of the following is a correct route of administration for potassium?

Oral - Potassium may be administered through the oral route. Potassium is never administered by IV push or intramuscularly to avoid replacing potassium too quickly. Potassium is not administered subcutaneously.

Translocation is a term used to describe the general movement of fluid and chemicals within body fluids. In every client's body, fluid-electrolyte balance is maintained through the process of translocation. What specific process allows water to pass through a membrane from a dilute to a more concentrated area?

Osmosis - Osmosis is the movement of water through a semipermeable membrane, one that allows some but not all substances in a solution to pass through, from a dilute area to a more concentrated area.

A client with a severe staphylococcal infection is receiving the aminoglycoside gentamicin sulfate (Garamycin) by the I.V. route. The nurse should monitor the client for which adverse reaction to this drug?

Ototoxicity

The nurse is performing a baseline assessment of a client's skin integrity. Which of the following is a key assessment parameter?

Overall risk of developing pressure ulcers

A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention?

Oxygen saturation (SaO2) of 85%

Which of the following diagnostics is used to identify malignant cells associated with esophageal cancer?

PET

Which diagnostic is more accurate in detecting malignancies than a CT scan?

PET scan

The pre-nursing class is learning about the nervous system in their anatomy class. What part of the nervous system would the students learn is responsible for digesting food and eliminating body waste?

Parasympathetic

Which conduction block produces anesthesia of the nerves supplying the chest, abdominal wall, and extremities?

Paravertebral anesthesia

Which lobe of the brain is responsible for spatial relationships?

Parietal

Which of the following would be the least important issue concerning safety for the perioperative team prior to proceeding to the operating room?

Patient ambulatory aids

A client has a foot ulcer that hasn't shown signs of improvement over the last several months. What medical condition is most likely causing the wound healing delay?

Peripheral vascular disease

A client undergoing a diagnostic examination for gastrointestinal disorder was given polyethylene glycol/electrolyte solution as a part of the test preparation. Which of the following measures should the nurse take once the solution is administered?

Permit the client to drink only clear liquids.

Which finding should a nurse identify as requiring further investigation?

Platelet count of 115,000/mm3

A client is diagnosed with severe combined immunodficiency (SCID). Which of the following would the nurse expect to integrate into the client's plan of care?

Preparation for bone marrow transplantation

A neonate born 18 hours ago with myelomeningocele over the lumbosacral region is scheduled for corrective surgery. Preoperatively, what is the most important nursing goal?

Preventing infection Explanation: Preventing infection is the nurse's primary preoperative goal for a neonate with myelomeningocele. Although the other options are relevant for this neonate, they're secondary to preventing infection.

A group of students is reviewing the medications that may be used to treat esophageal reflux. The students demonstrate understanding of the information when they identify which of the following as an example of a proton-pump inhibitor?

Prilosec

DiGeorge syndrome is an example of which immunodeficiency?

Primary T Cell

The nurse's base knowledge of primary immunodeficiencies includes which of the following statements?

Primary immunodeficiencies develop early in life after protection from maternal antibodies decreases.

What is the function of the thymus gland?

Programs T lymphocytes to become regulator or effector T cells.

During which stage of the immune response does the circulating lymphocyte containing the antigenic message return to the nearest lymph node?

Proliferation

Which of the following medications is an antidote to heparin?

Protamine sulfate

A nurse is preparing to administer saquinavir, which is prescribed for a client who is HIV positive. The nurse integrates knowledge of this drug, identifying it as which of the following?

Protease inhibitor (PI)

A nurse is instructing a client with pressure ulcers about the importance of increasing his protein intake. Why should the nurse encourage protein intake by this client?

Protein is essential for tissue repair

What are antigens?

Protein markers on cells.

A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first?

Pulse - An elevated serum potassium level may lead to a life-threatening cardiac arrhythmia, which the nurse can detect immediately by palpating the pulse. In addition to assessing the client's pulse, the nurse should place the client on a cardiac monitor because an arrythmia can occur suddenly. The client's blood pressure may change, but only as a result of the arrhythmia. Therefore, the nurse should assess blood pressure later. The nurse also may delay assessing respirations and temperature because these aren't affected by the serum potassium level.

Nursing students are reviewing the pathophysiology of human immunodeficiency virus (HIV). They demonstrate understanding of the information when they state which of the following as containing the genetic viral material?

RNA

Which of the following is the greatest risk if the client does not take non-nucleoside reverse transcriptase inhibitors (NNRTI) as prescribed? Choose the correct option.

Rapid onset of drug resistance

The nurse is caring for a client with hepatitis. Which of the following would lead the nurse to suspect that the client is in the prodromal phase?

Rash

A nurse is reviewing the history of a client who is suspected of having glomerulonephritis. Which of the following would the nurse consider significant?

Recent history of streptococcal infection

The nurse obtains a unit of blood for the client, Donald D. Smith. The name on the label on the unit of blood reads Donald A. Smith. All the other identifiers are correct. The nurse

Refuses to administer the blood

RNFA? -responsibilities includes (3)

Registered nurse first assistant! -Handling tissue, suturing & maintaning homeostasis.

A client with a pilonidal sinus undergoes surgery. Which of the following would the nurse include in the client's postoperative plan of care?

Repacking the surgical wound

Which of the following nursing interventions is most appropriate when caring for a client with a nursing diagnosis of risk for injury related to side effects of medication (enoxaparin [Lovenox])?

Report any incident of bloody urine, stools, or both. Explanation: The client who takes an anticoagulant, such as a low-molecular-weight heparin, is routinely screened for bloody urine, stools, or both.

The nurse recognizes that the client who takes hydrochlorothiazide (HydroDIURIL) to manage hypertension is predisposed for which interaction with anesthesia?

Respiratory depression

A nurse is providing postprocedure instructions for a client who had an esophagogastroduodenoscopy. The nurse should perform which action?

Review instructions with the person assisting the client home

A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. Which of the following describes these sounds?

Rhonchi

Which nursing diagnosis is most important for the client who is undergoing a surgical procedure expected to last several hours?

Risk for perioperative positioning injury related to positioning in the OR

A client, newly admitted to the nursing unit, has a primary diagnosis of renal failure. When assessing the client, the nurse notes a blood pressure (BP) of 180/100. The nurse knows that this is what kind of hypertension?

Secondary

Which zone of the surgical area only allows for attire in the form of scrub clothes and caps?

Semirestricted zone

A client with severe hypertension states, "I feel fine; I'm not really sick at all." The nurse will teach the client that the system/organs particularly targeted for damage by severe hypertension include which of the following?

Sensory

The nurse should assess for an important early indicator of acute pancreatitis, which is a prolonged and elevated level of:

Serum lipase

"You sound really discouraged today."

Sharing an observation with the client conveys awareness of the client's feelings and promotes further communication. Spouting clichés, disagreeing with the client, or asking why the client feels a certain way doesn't promote therapeutic communication.

A client with respiratory acidosis is admitted to the intensive care unit for close observation. The nurse should stay alert for which complication associated with respiratory acidosis?

Shock - Complications of respiratory acidosis include shock and cardiac arrest. Stroke and hyperglycemia aren't associated with respiratory acidosis. Seizures may complicate respiratory alkalosis, not respiratory acidosis

Which of the following would indicate to the nurse that a client who has received three cleansing enemas in preparation for a barium enema is experiencing dehydration?

Signs of dizziness and confusion

A nurse is inserting a nasogastric tube for feeding a client. Place in order the steps from 1 to 6 for correctly inserting the tube.

Sit the client in an upright position Apply gloves to the nurse's hands Measure the length of the tube that will be inserted Apply water-soluble lubricant to the tip of the tube Tilt the client's nose upward Instruct the client to lower the head and swallow

The surgical client has been intubated and general anesthesia has been administered. The client exhibits cyanosis, shallow respirations, and a weak, thready pulse. The nurse recognizes that the client is in which stage of general anesthesia?

Stage IV

Which of the following terms refers to a primitive cell, capable of self-replication and differentiation?

Stem Cell

The nurse is aware that the amino acid, arginine,

Stimulates T cell response

A nurse is taking the health history of a newly admitted client. Which of the following conditions would NOT place the client at risk for impaired immune function?

Surgical removal of the appendix

Sudoriferous glands secrete which type of substance?

Sweat

Which of the following is a factor affecting an increase in urine osmolality?

Syndrome of inappropriate antidiuretic hormone release (SIADH) - Factors increasing urine osmolality include SIADH, fluid volume deficit, acidosis, and congestive heart failure. Myocardial infarction typically is not a factor that increases urine osmolality.

Undifferentiated cells that migrate to the thymus gland develop into which of the following?

T lymphocytes

Which of the following clinical manifestations is often the earliest sign of malignant hyperthermia?

Tachycardia (heart rate above 150 beats per minute)

On a routine visit to the physician, a client with chronic arterial occlusive disease reports stopping smoking after 34 years. To relieve symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, the nurse should recommend which additional measure?

Taking daily walks Explanation: Taking daily walks relieves symptoms of intermittent claudication, although the exact mechanism is unclear. Aerobic exercise may make these symptoms worse. Clients with chronic arterial occlusive disease must reduce daily fat intake to 30% or less of total calories. The client should limit dietary cholesterol because hyperlipidemia is associated with atherosclerosis, a known cause of arterial occlusive disease. However, HDLs have the lowest cholesterol concentration, so this client should eat, not avoid, foods that raise HDL levels

Which of the following cerebral lobes contains the auditory receptive areas?

Temporal

A client is admitted to the hospital for diagnostic testing to rule out colorectal cancer. Which intervention should the nurse include on the plan of care?

Test for occult blood

To minimize their dependency on institutionalized care.

The Community Mental Health Centers Act mandates that communities make psychiatric emergency care available to its population. The benefit of this mandate to the chronically mentally ill is..

Subjective family burden that occurs in many families who have a mentally ill loved one.

The Lawson family has been caring for Randy, their 35-year-old son with schizophrenia, for about 15 years. They report that they often are fearful that Randy will become psychotic and hurt someone in public. They are sad because they remember that when Randy was in high school, he was a star student and athlete, and they enjoyed watching him play football. These feelings of the family can best be described as

A client reports an allergy to morphine sulfate, which represents an example of a hypersensitivity reaction. Which of the following statements correctly describes the process of hypersensitivity?

The body produces inappropriate or exaggerated responses to specific antigens.

The brain is a complex structure and is divided into three parts: the cerebrum, the cerebellum, and the brain stem. The cerebrum is divided into two hemispheres and is further divided into four lobes per hemisphere. Which section of the brain controls and coordinates muscle movements?

The cerebellum

A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse and has an elevated serum ammonia level. The nurse should suspect which situation?

The client's hepatic function is decreasing.

A nurse is caring for a client with multiple sclerosis. Client education about the disease process includes which of the following explanations about the cause of the disorder?

The immune system recognizes one's own tissues as "foreign."

The lower the patient's viral load,

The longer the survival time

What is hematopoiesis?

The manufacture and development of blood cells

Use team-building exercises.

The nurse has begun group counseling sessions for several hospitalized patients in the psychiatric facility. Which of the following would be most effective for the nurse to do to promote group cohesiveness?

Both the liver and the spleen have a role in erythrocyte metabolism. How would this role best be described?

The spleen removes erythrocytes after 120 days, and the liver removes severely damaged erythrocytes.

A client with urinary tract infection is prescribed phenazopyridine (Pyridium). Which of the following instructions would the nurse give the client?

This medication will relieve your pain

A major manifestation of Wiskott-Aldrich syndrome includes which of the following?

Thrombocytopenia

T-cell deficiency occurs when which of the following glands fails to develop normally during embryogenesis?

Thymus

A client who is HIV positive has been prescribed antiretroviral drugs. The nurse explains the action of each antiretroviral drug and develops a schedule for the client's self-administration, including strong emphasis about rigidly adhering to the dosage, time and frequency of the administration of the drugs. Why is it important to adhere to the schedule of drug dosing developed for this client?

To avoid resistance to the drugs

A client with a disorder of the erythrocytes asks the nurse to explain what role these cells play. What would the nurse accurately explain to the client?

Transport O2 to and remove CO2 from the tissues

The nursing instructor is teaching their clinical group about laboratory blood tests. What is the major function of erythrocytes?

Transportation of O2 to the tissues and removal of CO2 from the tissues

Hickman and Groshong are examples of which type of central venous access devices?

Tunneled central catheters

Examples are removal of gallbladder, coronary artery bypass, surgical removal of a malignant tumor, colon resection, amputation

Urgent surgery

A client comes to the Emergency Department complaining of a sudden onset of sharp, severe flank pain. During the physical examination, the client indicates that the pain, which comes in waves, travels to the suprapubic region. He states, "I can even feel the pain at the tip of my penis." Which of the following would the nurse suspect?

Urinary caliculi

A nurse assesses a client shortly after living donor kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?

Urinary output of 20mL/hr

A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing?

Use of accessory muscles

What method of communication can be used with a hearing-impaired patient? a) Talking into the more-impaired ear b) Using gestures c) Grimacing d) Talking loudly

Using gestures Correct Explanation: Strategies such as talking into the less-impaired ear and using gestures and facial expressions can help. Therefore options A, C, and D are incorrect

The nurse is assessing a patient for constipation. Which of the following is the first review that the nurse should conduct in order to identify the cause of constipation?

Usual pattern of elimination

Which of the following is the most effective strategy to prevent hepatitis B infection?

Vaccine

A nurse is providing care for a client recovering from gastric bypass surgery. During assessment, the client exhibits pallor, perspiration, palpitations, headache, and feelings of warmth, dizziness, and drowsiness. The client reports eating 90 minutes ago. The nurse suspects:

Vasomotor symptoms associated with dumping syndrome

A client comes to the dermatology clinic with numerous skin lesions. Inspection reveals that the lesions are elevated, sharply defined, less than 1 cm in diameter, and filled with serous fluid. When documenting these findings, the nurse should use which term to describe the client's lesions?

Vesicles

Which diagnostic test measures HIV RNA in the plasma?

Viral Load

The term used to define the balance between the amount of HIV in the body and the immune response is

Viral Set Point

The term used to define the balance between the amount of HIV in the body and the immune response is

Viral set point

Which of the following sets of clinical data would allow the nurse to conclude that the nursing actions taken to prevent postoperative pneumonia have been effective?

Vital signs within normal limits; absence of chills and cough

The nurse is aware that which of the following nutrients promotes normal blood clotting?

Vitamin K

Facilitating the nurse's understanding of how these beliefs affect the client's perception of her disorder.

When the psychiatric nurse is aware of the cultural beliefs of a client diagnosed with bipolar disorder, the therapeutic process is most enhanced by

Covert

Which type of cue is being used when the client states, "Nothing can help me"?

A client with complaints of right lower quadrant pain is admitted to the emergency department. Blood specimens are drawn and sent to the laboratory. Which laboratory finding should be reported to the physician immediately?

White blood cell (WBC) count 22.8/mm3

Which type of graft is utilized when a heart valve replacement is made of tissue from an animal heart valve?

Xenograft

A toddler is brought to the emergency department with sudden onset of abdominal pain, vomiting, and stools that look like red currant jelly. To confirm intussusception, the suspected cause of these findings, the nurse expects the physician to order:

a barium enema. Explanation: A barium enema commonly is used to confirm and correct intussusception. Performing a suprapubic aspiration or inserting an NG tube or an indwelling urinary catheter wouldn't help diagnose or treat this disorder.

A nurse is caring for a client receiving warfarin (Coumadin) therapy following a mechanical valve replacement. The nurse completed the client's prothrombin time and International Normalized Ratio (INR) at 7 a.m., before the morning meal. The client had an INR reading of 4. The nurse's first priority should be to:

assess the client for bleeding around the gums or in the stool and notify the physician of the laboratory results and most recent administration of warfarin.

On auscultation, which finding suggests a right pneumothorax? a) Bilateral inspiratory and expiratory crackles b) Absence of breath sounds in the right thorax c) Inspiratory wheezes in the right thorax d) Bilateral pleural friction rub

b) Absence of breath sounds in the right thorax

A nurse is completing her annual cardiopulmonary resuscitation training. The class instructor tells her that a client has fallen off a ladder and is lying on his back; he is unconscious and isn't breathing. What maneuver should the nurse use to open his airway? a) Head tilt-chin lift b) Jaw-thrust c) Heimlich d) Seldinger

b) Jaw-thrust

A client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery would most likely reverse the manifestations? a) Simple mask b) Nonrebreather mask c) Face tent d) Nasal cannula

b) Nonrebreather mask

Prednisone (Deltasone) is prescribed to control inflammation in a client with interstitial lung disease. During client teaching, the nurse stresses the importance of taking prednisone exactly as prescribed and cautions against discontinuing the drug abruptly. A client who discontinues prednisone abruptly may experience: a) hyperglycemia and glycosuria. b) acute adrenocortical insufficiency. c) GI bleeding. d) restlessness and seizures.

b) acute adrenocortical insufficiency.

The nurse is caring for a client experiencing an acute asthma attack. The client stops wheezing and breath sounds aren't audible. This change occurred because: a) the attack is over. b) the airways are so swollen that no air can get through. c) the swelling has decreased. d) crackles have replaced wheezes.

b) the airways are so swollen that no air can get through.

A client recovering from a pulmonary embolism is receiving warfarin (Coumadin). To counteract a warfarin overdose, the nurse would administer: a) heparin. b) vitamin K1 (phytonadione). c) vitamin C. d) protamine sulfate.

b) vitamin K1 (phytonadione).

A client admitted to the facility for treatment for tuberculosis receives instructions about the disease. Which statement made by the client indicates the need for further instruction? a) "I will have to take the medication for up to a year." b) "This disease may come back later if I am under stress." c) "I will stay in isolation for at least 6 weeks." d) "I will always have a positive test for tuberculosis."

c) "I will stay in isolation for at least 6 weeks."

A client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. He's placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. The nursing goal should be to reduce the FIO2 to no greater than: a) 0.21. b) 0.35. c) 0.5 d) 0.7

c) 0.5

The nurse is caring for a client who has a tracheostomy tube and is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by: a) suctioning the tracheostomy tube frequently. b) using a cuffed tracheostomy tube. c) using the minimal air leak technique with cuff pressure less than 25 cm H2O. d) keeping the tracheostomy tube plugged.

c) using the minimal air leak technique with cuff pressure less than 25 cm H2O.

A female client with genital herpes simplex is being treated in the outpatient department. The nurse teaches her about measures that may prevent herpes recurrences and emphasizes the need for prompt treatment if complications arise. Genital herpes simplex increases the risk of:

cancer of the cervix.

A registered nurse who is responsible for coordinating and documenting patient care in the operating room is a

circulating nurse.

pleural friction rub

creaking or grating sound from roughened, inflamed surfaces of the pleura rubbing together, evident during inspiration, expiration, or both and no change with coughing; usually uncomfortable, especially on deep inspiration.

A nurse on the medical-surgical unit just received report on her client care assignment. Which client should she assess first? a) The client with anorexia, weight loss, and night sweats b) The client with crackles and fever who is complaining of pleuritic pain c) The client who had difficulty sleeping, daytime fatigue, and morning headache d) The client with petechiae over the chest who's complaining of anxiety and shortness of breath

d) The client with petechiae over the chest who's complaining of anxiety and shortness of breath

The nurse observes a new environmental services employee enter the room of a client with severe acute respiratory syndrome (SARS). Which action by the employee requires immediate intervention by the nurse? a) The employee wears a gown, gloves, N95 respirator, and eye protection when entering the room. b) The employee doesn't remove the stethoscope, blood pressure cuff, and thermometer that are kept in the room. c) The employee removes all personal protective equipment and washes her hands before leaving the client's room. d) The employee enters the room wearing a gown, gloves, and a mask.

d) The employee enters the room wearing a gown, gloves, and a mask.

A woman whose husband was recently diagnosed with active pulmonary tuberculosis (TB) is a tuberculin skin test converter. Management of her care would include: a) scheduling her for annual tuberculin skin testing. b) placing her in quarantine until sputum cultures are negative. c) gathering a list of persons with whom she has had recent contact. d) advising her to begin prophylactic therapy with isoniazid (INH).

d) advising her to begin prophylactic therapy with isoniazid (INH).

At 11 p.m., a client is admitted to the emergency department. He has a respiratory rate of 44 breaths/min. He's anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone (Depo-medrol) I.V. At 11:30 p.m., the client's arterial blood oxygen saturation is 86%, and he's still wheezing. The nurse should plan to administer: a) alprazolam (Xanax). b) propranolol (Inderal). c) morphine. d) albuterol (Proventil).

d) albuterol (Proventil).

During the surgical procedure, the client exhibits tachycardia, generalized muscle rigidity, and a temperature of 103°F. The nurse should prepare to administer:

dantrolene sodium (Dantrium)

A 72-year-old client seeks help for chronic constipation. Constipation is a common problem for elderly clients because of several factors related to aging, including:

decreased abdominal strength.

The nurse recognizes older adults require lower doses of anesthetic agents due to:

decreased lean tissue mass

The nurse recognizes that the older adult is at risk for surgical complications due to:

decreased renal function

The nurse's base knowledge of primary immunodeficiencies includes which of the following statements? Primary immunodeficiencies

develop early in life after protection from maternal antibodies decreases.

A client with second- and third-degree burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse knows that this client should avoid arm exercise because it may:

dislodge the autografts.

Age-related changes associated with the cardiac system include

endocardial fibrosis. Explanation: Age-related changes associated with the cardiac system include: endocardial fibrosis, increased size of the left atrium, decreasing number of SA node cells, and myocardial thickening

Halitosis and a sour taste in the mouth are clinical manifestations associated most directly with

esophageal diverticula.

After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway and attends to the client's immediate needs, then prepares to perform an initial neurologic assessment. The nurse should perform an:

evaluation of the corneal reflex response.

Lower motor neuron lesions cause

flaccid muscle paralysis.

Intraosseously

fluid admin - good if cannot obtain IV access (small animals). Also can be given at a relatively fast speed. acceptable for dehydration and shock

A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse should stress the importance of:

increasing fluid intake to prevent dehydration.

When assisting with developing a plan of care for a client recovering from a serious thermal burn, the nurse knows that the most important immediate goal of therapy is:

maintaining the client's fluid, electrolyte, and acid-base balance.

Regarding oral cancer, the nurse provides health teaching to inform the patient that

many oral cancers produce no symptoms in the early stages.

rule of nines

method used to calculate the amount of fluid lost as the result of a burn; divides the body into 11 areas, each accounting for 9% of the total body area

Ibuprofen (Motrin) has which effect on the immune system?

Neutropenia

Clients with Type O blood are at higher risk for which of the following GI disorders?

Duodenal ulcers

Pulmonary Congestion

A client is being assessed for his semiannual examination and you hear crackles bilaterally in his lungs. Which of the following could be a cause of crackles in the bases of his lungs?

When assessing for signs and symptoms related to hematopoietic and lymphatic systems, what details should the nurse ask about further?

A client undergoing cancer treatment

Which category of HIV disease correlates with asymptomatic AIDS?

A

The physician orders digoxin (Lanoxin) 0.1 mg orally every morning for a 6-month-old infant with heart failure. Digoxin is available in a 400 mcg/mL concentration. How many milliliters of digoxin should the nurse give? Record your answer using two decimal places.

0.25 Explanation: To convert mg to mcg: 1,000 mcg/1 mg = X mcg/0.1 mg; X = 100 mcg. To calculate drug dose: Dose on hand/Quantity on hand = Dose desired/X. 400 mcg/mL = 100 mcg/X; X = 0.25 mL.

A client with liver and renal failure has severe ascites. On initial shift rounds, his primary nurse finds his indwelling urinary catheter collection bag too full to store more urine. The nurse empties more than 2,000 ml from the collection bag. One hour later, she finds the collection bag full again. The nurse notifies the physician, who suspects that a bladder rupture is allowing the drainage of peritoneal fluid. The physician orders a urinalysis to be obtained immediately. The presence of which substance is considered abnormal?

Albumin

The instructor in the anatomy and physiology class is discussing the components of the blood. What would the instructor cite as the most abundant protein in plasma?

Albumin

A nursing instructor is lecturing to a class about chronic pancreatitis. Which of the following does the instructor list as major causes?

Alcohol consumption and smokig

Which nursing diagnosis should the nurse plan to address first in the client upon arrival in the intraoperative setting?

Anxiety related to ineffective coping with surgical concerns

High doses of this medication can produce bilateral tinnitus? a) Aspirin b) Dramamine c) Promethazine d) Antivert

Aspirin Correct Explanation: At high doses, aspirin toxicity can produce bilateral tinnitus. Antivert and Dramamine is used for nausea and vomiting related to motion sickness. Antiemetics such as promethazine (Phenergan) suppositories help control the nausea and vomiting and the vertigo because of the antihistamine effect.

Symptoms of progressive gastric cancer include which of the following?

Bloating after meals

To ensure patency of central venous line ports, diluted heparin flushes are used in which of the following situations?

Daily, when not in use

Frequently, what is the earliest symptom of left-sided heart failure?

Dyspnea on exertion

Which factor will most likely decrease drug metabolism during infancy?

Inefficient liver function Explanation: Inefficient liver function will most likely decrease drug metabolism during infancy. As the liver matures during the 1st year of life, drug metabolism improves. Decreased glomerular filtration and increased tubular secretion may affect drug excretion rather than metabolism; reduced protein-binding ability may affect drug distribution but not metabolism.

Which of the following would be an intervention for a patient with a chemical burn to the esophagus?

Insert NG tube

Hypoxemia?

Insufficient oxygenation of arterial blood/

Which of the following is a characteristic of right-sided heart failure?

JVD (Jugular vein distention)

Which of the following is an enzyme secreted by the gastric mucosa?

Pepsin

The nurse is helping a client ambulate for the first time after 3 days of bed rest. Which observation by the nurse suggests that the client tolerated the activity without distress?

The client's pulse and respiratory rates increased moderately during ambulation. Explanation: The pulse and respiratory rates normally increase during and for a short time after ambulation, especially if it's the first ambulation after 3 days of bed rest. A normal walking pace is 70 to 100 steps/minute; a much slower pace may indicate distress. Dizziness, weakness, and profuse perspiration are definite signs of activity intolerance. A client who tolerates ambulation well holds the head erect, gazes straight ahead, and keeps the toes pointed forward; option 3 describes a client with activity intolerance.

A client with suspected renal insufficiency is scheduled for a comprehensive diagnostic workup. After the nurse explains the diagnostic tests, the client asks which part of the kidney "does the work." Which answer is correct?

The nephron Explanation: The nephron, the functioning unit of the kidney, includes the glomerulus, Bowman's capsule, and tubular system, which work together to form urine.

Which of the following statements accurately reflects current stem cell research?

The stem cell is known as a precursor cell that continually replenishes the body's entire supply of both red and white cells.

When developing a care plan for a client who has recently suffered a stroke, a nurse includes the nursing diagnosis Risk for imbalanced body temperature. What is the rationale for this diagnosis?

The stroke may have impacted the body's thermoregulation centers.

A client is chronically short of breath and yet has normal lung ventilation, clear lungs, and an arterial oxygen saturation SaO2 of 96% or better. The client most likely has:

a possible hematologic problem.

Decreased pulse pressure reflects

reduced stroke volume. Explanation: Decreased pulse pressure reflects reduced stroke volume and ejection velocity or obstruction to blood flow during systole. Increased pulse pressure would indicate reduced distensibility of the arteries, along with bradycardia.

An 18-month-old child is brought to the Emergency Department by parents who explain that their child swallowed a watch battery. Radiologic studies show that the battery is in the lungs. Which area of lung is the battery most likely to be in?

right upper lung

In which position should the patient be placed for a thoracentesis?

sitting on the edge of bed

A 67-year-old client is returning for a follow-up appointment to the primary care group where you practice nursing. At his last appointment, he received the diagnosis of portal hypertension and the physician instituted interventions to begin treatment of this condition. What is the primary aim of portal hypertension treatment? Choose all correct options.

• Reduce fluid accumulation • Reduce venous pressure

Which of the following are modes of transmission for HIV? Select all that apply.

• Seminal fluid • Vaginal secretions • Blood • Amniotic fluid

A nurse is teaching a client with gastritis about the need to avoid the intake of caffeinated beverages. The client asks why this is so important. Which of the following explanations from the nurse would be most accurate?

"Caffeine stimulates the central nervous system and thus gastric activity and secretions, which need to be minimized to promote recovery."

A nurse is performing health assessment with a client during an outpatient clinic visit. The most concerning client statement to the nurse is:

"Food seems to be getting stuck in my throat"

A home health nurse who sees a client with diverticulitis is evaluating teaching about dietary modifications necessary to prevent future episodes. Which statement by the client indicates effective teaching?

"I should increase my intake of fresh fruits and vegetables during remissions."

As part of the process of checking the placement of a nasogastric tube, the nurse checks the pH of the aspirate. Which pH finding would indicate to the nurse that the tube is in the stomach?

4

The nurse is assisting in developing a teaching plan for a child with acute poststreptococcal glomerulonephritis. What is the most important point to address in this plan?

Blood pressure monitoring Explanation: Because poststreptococcal glomerulonephritis may cause severe, life- threatening hypertension, the nurse must teach the parents how to monitor the child's blood pressure. Infection control, nutritional planning, and prevention of streptococcal pharyngitis are important but are secondary to blood pressure monitoring.

In which instance may a surgeon operate without informed consent?

Emergency situations

A nurse is instructing a group of nursing assistants about client care. The nurse tells them to turn clients how often to prevent skin breakdown?

Every 2 hours

A patient underwent a continent ileostomy. Within which timeframe should the patient expect to empty the reservoir?

Every 4 to 6 hours

Which signs and symptoms accompany a diagnosis of pericarditis?

Fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR)

Which of the following is an early manifestation of HIV encephalopathy?

Headache

A physician treating a client in the cardiac care unit for atrial arrhythmia orders metoprolol (Lopressor), 25 mg P.O. two times per day. Metoprolol inhibits the action of sympathomimetics at beta1-receptor sites. Where are these sites mainly located?

Heart

A client in labor receives epidural anesthesia. The nurse should assess carefully for which adverse reaction to the anesthetic agent?

Hypotensive crisis Explanation: Hypotensive crisis may occur after epidural anesthesia administration as the anesthetic agent spreads through the spinal canal and blocks sympathetic innervation. Other signs and symptoms of hypotensive crisis associated with epidural anesthesia may include fetal bradycardia (not tachycardia) and decreased (not increased) beat-to-beat variability in the FHR. Urine retention, not renal toxicity, may occur during the postpartum period.

Macrophages attack and destroy foreign substances to the body. Where does this action occur?

In the lymph node

The nursing instructor is talking with senior nursing students about diagnostic procedures used in respiratory diseases. The instructor discusses thoracentesis, defining it as a procedure performed for diagnostic purposes or to aspirate accumulated excess fluid or air from the pleural space. What would the instructor tell the students purulent fluid indicates?

Infection

mantoux test

Intradermal test to determine tuberculin sensitivity based on a positive reaction where the area around the test site becomes red and swollen

A few hours after eating hot and spicy chicken wings, a client presents with lower chest pain. He wonders if he is having a heart attack. How should the nurse proceed first?

Investigate the initial complaint

The nursing students are learning about the immune system in their anatomy and physiology class. What would these students learn is a component of the immune system?

Lymphoid tissues

What chemical is released by cytotoxic T cells?

Lymphokine

Which of the following nursing interventions should a nurse perform to reduce cardiac workload in a patient diagnosed with myocarditis?

Maintain on bedrest

When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider?

Measuring abdominal girth

A day-treatment program

Mrs. Cairns was diagnosed with bipolar I disorder several years ago. After occasional inpatient admissions surrounding manic episodes over the past few years, she has been receiving outpatient psychiatric services for the past 12 months. Her care providers, however, are concerned that these outpatient services are not meeting her needs, though she does not currently meet inpatient admission criteria. Mrs. Cairns may benefit from what?

A client is diagnosed with common variable immunodeficiency (CVID). When assessing the client for possible infection, which of the following would the nurse identify as a least likely cause?

Pneumocystis jiroveci pneumonia

Which of the following adverse effects should the nurse closely monitor in a patient who takes immunosuppressive drugs?

Respiratory or urinary system infections

After undergoing a liver biopsy, a client should be placed in which position?

Right lateral decubitus position

In what location would the nurse palpate for the liver?

Right upper quadrant

To compensate for decreased fluid volume (hypovolemia), the nurse can anticipate which response by the body?

Tachycardia - Fluid volume deficit, or hypovolemia, occurs when the loss of extracellular fluid exceeds the intake...(more) Fluid volume deficit, or hypovolemia, occurs when the loss of extracellular fluid exceeds the intake of fluid. Clinical signs include oliguia, rapid heart rate, vasoconstriction, cool and clammy skin, and muscle weakness. The nurse monitors for rapid, weak pulse and orthostatic hypotension.

Which of the following is a true statement regarding regional enteritis (Crohn's disease)?

The clusters of ulcers take on a cobblestone appearance.

Chest pain, weight gain, fatigue.

The nurse is taking a health history from a client admitted with the medical diagnosis of cardiovascular disease (CVD). Identify which of the following symptoms indicate CVD.

Sinoatrial (SA) node, atrioventricular (AV) node, bundle of His, right and left bundle branches, and the Purkinje fibers

The nurse is teaching a beginning EKG class to staff nurses. As the nurse begins to discuss the the parts of the EKG complex, one of the students asks what the normal order of conduction through the heart is. The correct response would be which of the following?

When assessing a client who reports recent chest pain, the nurse obtains a thorough history. Which client statement most strongly suggests angina pectoris?

The pain occurred while I was mowing the lawn

Abcesses?

a localized collection of pus in the tissues of the body, often accompanied by swelling and inflammation and frequently caused by bacteria.

The nurse is caring for a client with chest trauma. Which nursing diagnosis takes highest priority? a) Impaired gas exchange b) Anxiety c) Decreased cardiac output d) Ineffective cardiopulmonary tissue perfusion

a) Impaired gas exchange

A client suffers adult respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm? a) Kinking of the ventilator tubing b) A disconnected ventilator tube c) An ET cuff leak d) A change in the oxygen concentration without resetting the oxygen level alarm

a) Kinking of the ventilator tubing

A client has a sucking stab wound to the chest. Which action should the nurse take first? a) Draw blood for a hematocrit and hemoglobin level. b) Apply a dressing over the wound and tape it on three sides. c) Prepare a chest tube insertion tray. d) Prepare to start an I.V. line.

b) Apply a dressing over the wound and tape it on three sides.

The nurse is planning to administer a sodium polystyrene sulfonate (Kayexalate) enema to a client with a potassium level of 5.9 mEq/L. Correct administration and the effects of this enema would include having the client:

retain the enema for 30 minutes to allow for sodium exchange; afterward, the client should have diarrhea. Explanation: Kayexalate is a sodium exchange resin. Thus the client will gain sodium as potassium is lost in the bowel. For the exchange to occur, Kayexalate must be in contact with the bowel for at least 30 minutes. Sorbitol in the Kayexalate enema causes diarrhea, which increases potassium loss and decreases the potential for Kayexalate retention.

An 84-year-old woman is to receive 2 units of packed red blood cells. During the transfusion of the first unit at 125 mL/hour, the client reports shortness of breath 30 minutes into the process. The client exhibits the vital signs shown in the accompanying table. The best nursing intervention is to:

slow the rate of the transfusion and obtain an order for furosemide (Lasix)

Nursing assessment findings reveal that the client is afraid of dying during the surgical procedure. Which surgical team member would be most helpful in addressing the client's concern?

surgeon

A client has hypercholesterolemia. The nurse understands that which of the following reflects the phenotype of the disease? Select all that apply.

• Early onset of cardiovascular disease • Skin xanthoma • Family history of heart disease

A 3-year-old client is admitted to the pediatric unit with pneumonia. He has a productive cough and appears to have difficulty breathing. The parents tell the nurse that the toddler hasn't been eating or drinking much and has been very inactive. Which interventions to improve airway clearance should be included by the nurse in the care plan? Select all that apply:

• Perform chest physiotherapy as ordered. • Encourage coughing and deep breathing. • Perform postural drainage. • Maintain humidification with a cool mist humidifier. Explanation: Chest physiotherapy and postural drainage work together to break up congestion and then drain secretions. Coughing and deep breathing are also effective to remove congestion. A cool mist humidifier helps loosen thick mucous and relax airway passages. Fluids should be encouraged, not restricted. The child should be placed in semi-Fowler's to high Fowler's position to facilitate breathing and promote optimal lung expansion.

A nurse is assisting with newborn screening. For which condition would the nurse expect to screen? Select all that apply.

• Phenylketonuria • Galactosemia

A nurse is developing a teaching plan for a client with an immunodeficiency. Which of the following would the nurse need to emphasize? Select all that apply.

• Prophylactic medication regimens • Maintenance of a well-balanced diet • Ways to manage stress

Which of the following are antidepressants used in the treatment of AIDS? Select all that apply

• Prozac • Tofranil • Norpramin

In the interest of public health, the CDC has developed HIV Transmission Prevention strategies. The strategies address the routes that HIV can be transmitted and steps that can be taken to reduce or eliminate transmission. Which categories of risk are addressed by these strategies? Choose all correct options.

• Sexual activity • Illegal drugs

The nurse is caring for a patient who is Arabic. The nurse remembers learning that three elements are frequently used to identify diversity. Choose the three from the following list.

• Skin color • Age • Geographic area

Which of the following will the nurse observe as symptoms of perforation in a client with intestinal obstruction? Choose all that apply.

• Sudden, sustained abdominal pain • Abdominal distention

A B-cell deficiency, such as CVID, is a disorder characterized by the following. Choose all that apply.

• There is a disappearance of germinal centers from lymphatic tissue. • There is complete lack of antibody production. • Disease onset occurs most often in the second decade of life.

Choice Multiple question - Select all answer choices that apply. Instructing a class of six graders on the importance of protecting their hearing by avoiding excessive noise, you list the activities that can destroy hearing. On your list is loud concerts, loud mP3 player volume, loud headphones, etc. You also indicate the signs of hearing impairment so they can help protect their friends. Which of the following are signs of diminished hearing? Choose all correct responses. a) Turning the head b) Leaning back during conversation c) Clear speech d) Asking for words to be repeated

• Turning the head • Asking for words to be repeated Correct Explanation: The nurse observes for signs of hearing impairment such as frequently asking that words be repeated.

Choice Multiple question - Select all answer choices that apply. Instructing a class of six graders on the importance of protecting their hearing by avoiding excessive noise, you list the activities that can destroy hearing. On your list is loud concerts, loud mP3 player volume, loud headphones, etc. You also indicate the signs of hearing impairment so they can help protect their friends. Which of the following are signs of diminished hearing? Choose all correct responses. a) Clear speech b) Leaning back during conversation c) Turning the head d) Asking for words to be repeated

• Turning the head • Asking for words to be repeated Explanation: The nurse observes for signs of hearing impairment such as frequently asking that words be repeated.

A client with a nasogastric tube set to low intermittent suction is receiving D51/2NS at 100 mL/hr. The nurse has identified a nursing diagnosis of deficient fluid volume. Which of the following are data that support this diagnosis? Select all that apply.

• Urine output that decreased from 60 to 40 mL/hr • Heart rate that increased from 82 to 98 beats/min within 2 hours • Fluid output of 2150 mL and total fluid intake of 2000 mL for the past 24 hours

(SELECT ALL THAT APPLY) Which instructions should be included in the teaching plan of a 19-year-old client with acne vulgaris who's prescribed tretinoin (Retin-A), benzoyl peroxide, and tetracycline (Achromycin)?

"(2) Take tetracycline on an empty stomach. (4) Maintain the prescribed treatment because it is more likely to improve acne than a strict diet and fanatic scrubbing with soap and water.

An adolescent is started on valproic acid to treat seizures. Which statement should be included when educating the adolescent?

"A common adverse effect is weight gain." Explanation: Weight gain is a common adverse effect of valproic acid. Drowsiness and irritability are adverse effects more commonly associated with phenobarbital. Felbamate (Felbatol) more commonly causes insomnia.

A child has just been diagnosed with a primary immune deficiency. The parents state, "Oh, no. Our child has AIDS." Which response by the nurse would be most appropriate?

"Although AIDS is an immune deficiency, your child's condition is different from AIDS."

An adult client reports that it is taking longer than usual for minor cuts and injuries to clot. Which of the following questions would the nurse most likely ask the client?

"Are you regularly taking aspirin?"

A nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. Which statement describes a healthy stoma?

"At first, the stoma may bleed slightly when touched."

A client is prescribed tetracycline to treat peptic ulcer disease. Which of the following instructions would the nurse give the client?

"Be sure to wear sunscreen when taking this medication"

A client understands what resources are available to help him perform wound care at home when he states the following:

"Before I go home, I'll speak to the home health care nurse to make sure I have the supplies I need." Explanation: The client's acknowledgement that he will need to speak to the home care nurse about supplies demonstrates that he is able to perform self-care, and is familiar with the resources available. The social worker can help with financial issues, not wound care issues. The home health care nurse is available for consultation, but she won't provide all of the client's health care needs. Dressing changes don't need to be performed in the physician's office.

An adolescent, age 16, is brought to the clinic for evaluation for a suspected eating disorder. To best evaluate the effects of role and relationship patterns on the child's nutritional intake, the nurse should ask:

"Do you like yourself physically?" Explanation: Role and relationship patterns focus on body image and the client's relationship with others, which commonly interrelate with food intake. Questions about activities and food preferences elicit information about health promotion and health protection behaviors. Questions about food allergies elicit information about health and illness patterns.

A client with extreme weakness, pallor, weak peripheral pulses, and disorientation is admitted to the emergency department. His wife reports that he has been "spitting up blood." A Mallory-Weiss tear is suspected, and the nurse begins taking a client history from the client's wife. The question by the nurse that demonstrates her understanding of Mallory-Weiss tearing is:

"Has he had any recent forceful vomiting?"

A school-age child has a fever, joint inflammation, and a nonpruritic rash. Knowing that these are signs of rheumatic fever, the nurse should ask the parents:

"Has your child had strep throat recently?" Explanation: Group A beta-hemolytic streptococcal infection typically precedes rheumatic fever. An inflammatory disease, rheumatic fever affects the heart, joints, and central nervous system. It isn't infectious and can't be transmitted from one person to another. Congenital heart defects don't play a role in the development of rheumatic fever. H. influenzae vaccine doesn't prevent streptococcal infection or rheumatic fever.

A client with extreme weakness, pallor, weak peripheral pulses, and disorientation is admitted to the emergency department. His wife reports that he has been "spitting up blood." A Mallory-Weiss tear is suspected, and the nurse begins taking a client history from the client's wife. The question by the nurse that demonstrates her understanding of Mallory-Weiss tearing is:

"Has your partner had recent forceful vomiting?"

A nurse is providing discharge teaching to a client who is immunosuppressed. Which statement by the client indicates the need for additional teaching?

"I can eat whatever I want as long as it's low in fat."

A nurse enters a client's room and observes a container with sputum. Upon questioning about the specimen, which of the following items of information from the client would necessitate the nurse to obtain a new specimen?

"I coughed that up about 8 hours ago."

The nurse determines that teaching for the client with peptic ulcer disease has been effective when the client states:

"I have learned some relaxation strategies that decrease my stress."

(see full question) A nurse is teaching a client with adrenal insufficiency about corticosteroids. Which statement by the client indicates a need for additional teaching

"I may stop taking this medication when I feel better." Explanation: The client requires additional teaching because he states that he may stop taking corticosteroids when he feels better. Corticosteroids should be gradually tapered by the physician. Tapering the corticosteroid allows the adrenal gland to gradually resume functioning. Corticosteroids increase the risk of infection and may mask the early signs of infection, so the client should avoid people who are sick. Corticosteroids cause muscle wasting in the extremities, so the client should increase his protein intake by eating foods such as chicken and dairy products. Corticosteroids have been linked to glaucoma and corneal lesions, so the client should visit his ophthalmologist regularly.

When preparing a client for magnetic resonance imaging (MRI) of the abdomen, which statement would indicate the need to notify the physician?

"I really don't like to be in small, enclosed spaces."

After teaching a client with immunodeficiency about ways to prevent infection, the nurse determines that teaching was successful when the client states which of the following?

"I should avoid being around other people who have an infection."

A client approaches the nurse and points at the sky, showing her where the men would be coming from to get him. Which response is most therapeutic?

"It seems like the world is pretty scary for you, but you're safe here." Explanation: Explaining that the world is scary but the client is safe acknowledges the client's fears and feelings, and offers a sense of security as the nurse tries to understand the symbolism. She reflects these concerns to the client, along with reassurance of safety. The first response validates the delusion, not the feelings and fears, and doesn't orient the client to reality. The second response gives false reassurance; because the nurse isn't sure of the symbolism, she can't make this promise. The last response rejects the client's feelings and doesn't address his fears.

The charge nurse overhears a nurse complaining that she has been assigned to a toddler diagnosed with tetralogy of Fallot for the past 3 days and the mother is very demanding. Which response by the charge nurse is best?

"It's important for the child to have someone assigned to him who's familiar with his care." Explanation: A toddler with tetralogy of Fallot requires the care of someone who's familiar with the toddler's condition. Providing continuity of care enhances safety and promotes well- being for this toddler and his parents. Options 2 and 3 are condescending to the nurse and don't help enhance the nurse's understanding of the situation. Both responses would further increase the nurse's anger. Changing the assignment isn't in the best interest of the toddler.

A nurse is providing dietary instructions to a client with a history of pancreatitis. Which instruction is correct?

"Maintain a high-carbohydrate, low-fat diet."

A nurse is teaching a client who has experienced an episode of acute gastritis and knows further education is necessary when the client makes the following statement:

"My appetite should come back tomorrow"

The cardinal signs of diabetes insipidus are polyuria and polydipsia. Hypernatremia, not hyponatremia, occurs with diabetes insipidus. Jaundice occurs because of abnormal bilirubin metabolism, not diabetes insipidus. Hyperchloremia, not hypochloremia, occurs with diabetes insipidus.

"My infant's fluid intake will be restricted." Explanation: The simplest test used to diagnose diabetes insipidus is restriction of oral fluids and observation of consequent changes in urine volume and concentration. A weight loss of 3% to 5% indicates severe dehydration, and the test should be terminated at this point. This test is done in the hospital, and the infant is watched closely.

A nurse is preparing a client for lumbar puncture. The client has heard about post-lumbar puncture headaches and asks how to avoid having one. The nurse tells the client that these headches can be avoided by doing which of the following after the procedure?

"Remain prone for 2 to 3 hours."

A student nurse is caring for a client who is severely anemic. The instructor asks the student how anemia affects the transport of oxygen to the cells. What would be the student's best answer?

"The cells are denied adequate oxygen because most of the oxygen in the body is transported by the hemoglobin in red blood cells."

The nurse is assessing a client following laparoscopy. The client states that his stomach looks bloated and asks if this is normal. How will the nurse respond?

"Yes, your abdomen may appear larger as a result of the injection of carbon dioxide for visualization."

A nursing student is assigned to a patient with a mechanical valve replacement. The patient asks the student, "Why do I have to take antibiotics before getting my teeth cleaned?" Which response by the nursing student is most appropriate?

"You are at risk of developing an infection in your heart."

Five days after running out of medication, a client taking clonazepam (Klonopin) says to the nurse, "I know I shouldn't have just stopped the drug like that, but I'm okay." Which response would be best?

"You could go through withdrawal symptoms for up to 2 weeks." Explanation: Withdrawal symptoms can appear after 1 or 2 weeks because this benzodiazepine has a long half-life. Looking for another problem unrelated to withdrawal isn't the nurse's best strategy. The act of discontinuing an antianxiety medication doesn't indicate that a client has learned to cope with stress. Every client taking medication needs to be monitored for withdrawal symptoms when the medication is stopped abruptly.

A nurse is discussing nutrition with a primigravida. The client states that she knows that calcium is important during pregnancy but that she and her family don't consume many milk or dairy products. What advice should the nurse give?

"You should consume other non-dairy foods that are high in calcium." Explanation: Food is considered the ideal source of nutrients. However, milk and dairy aren't the only food sources of calcium. While prenatal vitamins are generally recommended, they don't satisfy all requirements. The calcium requirement for pregnancy is 1,300 mg/day. Over-the-counter supplements aren't always safe and should be specifically recommended by the health care practitioner. While it's true that all fetal organs are formed by the end of the first trimester, development continues throughout pregnancy.

A client who has just been diagnosed with myocardial infarction (MI) begins to cry and tells the nurse that his brother died of a heart attack last year. Which response by the nurse is most appropriate?

"You sound as though you think you're going to die." Explanation: The client's questions and concerns should be acknowledged and addressed by the nurse after an MI. The nurse shouldn't give false reassurance or ignore the client's immediate concern.

A client presented with gastrointestinal bleeding 2 days ago and continues to have problems. The physician has ordered a visualization of the small intestine via a capsule endoscopy. Which of the following will the nurse include in the client education about this procedure?

"You will need to swallow a capsule."

During the admission assessment, a client with a panic disorder begins to hyperventilate and says, "I'm going to die if I don't get out of here right now!" What's the nurse's best response?

"You're having a panic attack. I'll stay here with you." Explanation: During a panic attack, the nurse's best approach is to orient the client to what's happening and provide reassurance that the client won't be left alone. The client's anxiety level is likely to increase—and the panic attack is likely to continue—if the client is told to calm down, asked the reasons for the attack, or is left alone.

A client presented with gastrointestinal bleeding 2 days ago and continues to have problems. The physician has ordered a visualization of the small intestine via a capsule endoscopy. Which of the following will the nurse include in the client education about this procedure?

"you will need to swallow a capsule"

(SELECT ALL THAT APPLY) Which nursing interventions are effective in preventing pressure ulcers?

(1) Clean the skin with warm water and a mild cleaning agent; then apply a moisturizer. (4) Turn and reposition the client every 1 to 2 hours unless contraindicated. (6) Use pillows to position the client and increase his comfort.

(SELECT ALL THAT APPLY) A client who was transferred from a long-term care facility is admitted with dehydration and pneumonia. Which nursing interventions can help prevent pressure ulcer formation in this client?

(1) Reposition the client every 2 hours. (2) Perform range-of-motion exercises. Encourage the client to eat a well-balanced diet.

(SELECT ALL THAT APPLY) A 42-year-old client comes to the clinic and is diagnosed with shingles. Which findings confirm this diagnosis?

(1) Severe, deep pain around the thorax (2) Red, nodular skin lesions around the thorax (3) Fever (4) Malaise

Immunoglobulins (also known as antibodies) promote the destruction of invading cells in various ways, using different mechanisms. Which of the following mechanisms is used by immunoglobulins to destroy pathogenic antigens?

(1) neutralizing their toxins; (2) linking them together in a process called agglutination and (3) causing them to precipitate, or become solid. Second, antibodies can facilitate the destruction of antigens with other mechanisms

(SELECT ALL THAT APPLY) A 35-year-old client is brought to the emergency department with second- and third-degree burns over 15% of his body. His admission vital signs are: blood pressure 100/50 mm Hg, heart rate 130 beats/minute, and respiratory rate 26 breaths/minute. Which nursing interventions are appropriate for this client?

(3) Begin an I.V. infusion of lactated Ringer's solution.Administer 6 mg of morphine I.V. (6) Administer tetanus prophylaxis, as ordered.

Potential adverse effects of surgery and anesthesia? Temperature? Skin? Burns? Drug?

- Hyperthermia (effect of anesthesia) - Skin and nerve damage from prolong inappropriate positioning. - Electrical shock, laser and burns - Drug toxicity, faulty equipment and human error.

Potential adverse effects of surgery and anesthesia? Intubation?

- Laryngeal trauma, oral trauma, broken teeth!

- Liver and kidney in elderly patients also can't ____.

- Metabolized medication and anesthetic agents well.

Monitored anesthesia care?

- Moderate sedation

Elderly patients also have a decreased plasma proteins, therefore the anesthetic agent remains free or unbound. What does this causes?

- Potent action!

Role of the circulating nurse? (5)

- Provide appropriate environment - Veryfying consent - Coordinating the team - Monitors aseptic practices - Monitor patients and documents specific activities throughout the operation to ensure patient's safety.

Gerontologic considerations: Elderly are at higher risk from anesthesia and cardiovascular & ____changes. - The aging heart have ___ability to ____to stress. - Excessive or rapid administration of IV can cause __. - What happens next? BP will drop and may lead to ___ ischemia, ___, ___, infarction and anoxia.

- Pulmonary - Respond to stress - Pulmonary Edema -cerebral ischemia -thrombosis -embolism

Anesthesiologist and anesthetist roles? - Monitor? Vital signs? (6)

- Re assess patient's physical condition immediately prior to initiating anesthesia & make sure patient is breathing well! - Monitor 1) Blood pressure, pulse, respiration , electrocardiagram (ECG) 2) Blood oxygen saturation 3) tidal volume 4) Blood and gas level 5) Alveolar gas concentrations 6) Body temperature.

General anesthesia?

- State of narcosis (entire body reflexes is loss)

Epidural anesthesia?

- State of narcosis achieved by injecting an anesthetic agent into the epidural space of the spinal cord.

Potential adverse effects of surgery and anesthesia? (8) (Immune? Cardiovascular? electrolyte, anesthesia, CNS, respiratory?)

- allergic reaction - Cardiac dysrythmia -Electrolyte imbalance - myocardial depression, bradycardia and circulatory collapse - CNS agitation, seizures & respiratory arrest - Oversedation or undersedation -Agitation or disorientation - Hypoxemia or hypercarbia

Malignant hyperthermia? - What happens? - Can eventually cause? - How/ why does this happens?

- rare life threatening condition triggered by exposure of most anesthetic agents. - Increase in skeletal muscle oxidative metabolism that can overwhelm the body's capacity to supply oxygen, remove carbon dioxide and regulate body temperature. - DEATH - It is believed to be inherited as an autosomal dominant disorder!

The surgical area is divided into 3

1) Unrestricted zone 2) Semirestricted zone 3) Restricted zone

165. A nurse is explaining the Joint Commission's universal protocol for preventing wrong-site, wrong-procedure, and wrong-person surgery to a group of nursing students. The nurse explains that site marking involves:

1. The surgeon marking the area of the operative procedure. The surgeon is responsible for verifying the operative site, and he or she must mark the operative site before the client is brought into the operating suite. The client will be asked to verify the site that requires surgery. The client may refuse to have the site marked and is asked about marking the site.

Despite conventional treatment, a client's psoriasis has worsened. His physician prescribes methotrexate (Trexall), 25 mg by mouth as a single weekly dose. The pharmacy dispenses 2.5 mg scored tablets. How many tablets should the nurse instruct the client to consume to achieve the prescribed dose?

10

A client with peptic ulcer disease must begin triple medication therapy. For how long will the client follow this regimen?

10-14 days

Morbid obesity is defined as being how many pounds over the person's ideal body weight?

100 lbs

During a prenatal visit, the nurse measures a client's fundal height at 19 cm. This measurement indicates that the fetus has reached approximately which gestational age?

19 weeks Explanation: The fundal height measurement in centimeters equals the approximate gestational age in weeks, until week 32. Thus, fundal height at 12 weeks is 12 cm; at 24 weeks, 24 cm; and at 28 weeks, 28 cm.

A child diagnosed with insulin-dependent diabetes mellitus is attending a camp for diabetic children. He gives himself regular insulin and insulin zinc suspension (Humulin L) at 8 a.m. The nurse should plan to observe him for signs and symptoms of hypoglycemia resulting from the effects of the Humulin L insulin between which of the following times?

2 p.m. and 5 p.m. Explanation: The action of an intermediate-acting insulin such as insulin zinc suspension (Humulin L) begins 1 to 3 hours after injection and peaks 6 to 12 hours after injection. The child is most at risk for hypoglycemia at the times when the insulin would peak, in this case beginning between 2 p.m. and 5 p.m.

A client with atopic dermatitis is prescribed medication for photochemotherapy. The nurse teaches the client about the importance of protecting the skin from ultraviolet light before drug administration and stresses the need to protect the eyes. After administering medication for photochemotherapy, the client must protect the eyes for:

24 hours.

154. A nurse is caring for a client who is scheduled for surgery. The client is concerned about the surgical procedure. To alleviate the client's fears and misconceptions about surgery, the nurse should:

3. Ask the cliet to discuss information known about the planned surgery.

A 57-year-old homeless female with a history of alcohol abuse has been admitted to your hospital unit. She was admitted with signs and symptoms of hypovolemia - minus the weight loss. She exhibits a localized enlargement of her abdomen. What condition could she be presenting?

3rd Spacing - Third-spacing describes the translocation of fluid from the intravascular or intercellular space to ...(more) Third-spacing describes the translocation of fluid from the intravascular or intercellular space to tissue compartments, where it becomes trapped and useless. The client manifests signs and symptoms of hypovolemia with the exception of weight loss. There may be signs of localized enlargement of organ cavities (such as the abdomen) if they fill with fluid, a condition referred to as ascites.

The nurse is explaining the DASH diet to a patient diagnosed with hypertension. The patients inquires about how many servings of fruit per day can be consumed on the diet. The nurse would be correct in stating which of the following?

4 to 5

The development of a positive HIV antibody test following initial infection generally occurs in which timeframe?

4 weeks

The nurse is preparing to administer intravenous immunoglobulin to a client with a primary immunodeficiency. This is the client's first dose. The nurse would anticipate administering another dose in approximately which time?

4 weeks

160. A nurse is caring for a postoperative client who has a drain inserted into the surgical wound. Which of the following nursing actions w/be inappropriate for the care of the drain?

4. Secure the drain by curling or folding it and taping it firmly to the body. Aseptic technique must be used when emptying the drainage container or changing the dressing to avoid contamination of the wound. Usualy drainage from the wound is pale, red, and watery, whereas active bleeding will be bright red in color. The drain s/be checked for patency to provide an exit for the fluid or blood to promote healing. The nurse needs to ensure that drainage flows freely and that there are no kinks in the drains. Curling or folding the drain prevents the flow of the drainage.

164. A nurse is explaining the concept of time-out in the perioperative area. The purpose of time out is:

4. To allow the surgical team a chance to verbally verify their agreement about the client's name, surgical procedure, and the site. The time-out occurs in the perioperative area after the client has been prepped and draped. The entire team must verbally verify their agreement regarding the client's name, the procedure to be performed, and the surgical site.

A client newly diagnosed with acute lymphocytic leukemia has a right subclavian central venous catheter in place. The nurse who's caring for the client is teaching a graduate nurse about central venous catheter care. The nurse should instruct the graduate nurse to change the central venous catheter dressing every:

48 hours

Sevelamer hydrochloride (Renagel) has been prescribed for a client with chronic renal failure. The physician has prescribed Renagel 800 mg orally three times per day with meals to treat the client's hyperphosphatemia. The medication is available in 400 mg tablets. How many tablets per day will the nurse administer to the client?

6

A client is beginning highly active antiretroviral therapy (HAART). The client demonstrates an understanding of the need for follow up when he schedules a return visit for viral load testing at which time?

6 weeks

Which of the following Glasgow Coma Scale scores indicates coma?

7

An instructor asks students approximately how long platelets last? What would the students correctly identify?

7.5 days

This example of cholesterol gallstones (left side of picture) is the result of decreased bile acid synthesis and increased cholesterol synthesis in the liver, which in turn, form stones. Cholesterol stones account for what percentage of cases of gallbladder disease in the United States?

75%

A client is recovering from a neck dissection. What volume of serosanguineous secretions would the nurse expect to drain over the first 24 hours?

80-120 mL

old-old

85 years of age and older

The majority of patient with primary immunodeficiency are in which age group?

< 20 YO

Hyperreflexia

A 36-year-old patient has been receiving a selective serotonin reuptake inhibitor for treatment of depression. She is exhibiting manifestations of serotonin syndrome. The nurse should be aware of which of the following symptoms of this syndrome?

Gradual, unexplained weight gain.

A 63-year-old accountant was admitted to the cardiac ICU with full-blown pulmonary edema. After he was revived, the nurse discusses his symptoms with the client and his wife. What is a typical, subtle symptom that communicates right-sided heart failure?

young-old to old-old and frail elderly explaination

A 76-year-old client with no debilitating conditions belongs to the middle-old geriatric population. The young-old geriatric population ranges in age from 65 to 74; the middle-old from 75 to 84; and the old-old from 85 and older. Within each of these three subgroups is another group, the frail elderly, which includes all individuals older than age 65 who have one or more debilitating conditions.

A nurse is preparing a presentation for a local community group of older adults about colon cancer. Which of the following would the nurse include as the primary characteristic associated with this disorder?

A change in bowel habits

• Carry a card identifying yourself as a pacemaker recipient. • Avoid large magnetic fields.

A client has had a pacemaker inserted and is ready for discharge. The nurse is providing education about pacemaker safety. Which of the following are items that the nurse will be sure to address? Choose all that apply.

Failure to capture

A client receives a pacemaker to treat a recurring arrhythmia. When monitoring the cardiac rhythm strip, the nurse observes extra pacemaker spikes that don't precede a beat. Which condition should the nurse suspect?

A nurse is assessing a client with a family history of cancer. Which finding requires immediate follow-up?

A client states he feels a lump in his throat

Impassive

A client who is schizophrenic is catatonic and has a masklike face. Which of the following facial expressions is being exhibited?

Muscular rigidity, tremors, and difficulty swallowing.

A comprehensive nursing assessment for NMS would necessarily include what?

Which of the following diagnostic tests are done to determine suspected pituitary tumor?

A computed tomography scan Explanation: A computed tomography or magnetic resonance imaging scan is done to detect a suspected pituitary tumor

dividing the body into sections

A frontal or coronal plane runs longitudinally at a right angle to a sagittal plane, dividing the body into anterior and posterior regions. A sagittal plane runs longitudinally, dividing the body into right and left regions; if exactly midline, it is called a midsagittal plane. A transverse plane runs horizontally at a right angle to the vertical axis, dividing the structure into superior and inferior regions.

Ego

A group of nursing students are reviewing information about Freud's personality structure. The students demonstrate understanding of this information when they identify the ability to form mutually satisfying relationships as a function of which of the following?

The dynamics of the entire family have and will continue to shift to accommodate a change.

A mother completes treatment for an addiction to prescription pain medications. As part of the mother's therapy, the family participates in a family therapy program. According to family systems theory, this is because of what?

10 Minutes

A nurse has come upon an unresponsive, pulseless victim. She has placed a 911 call and begins CPR. The nurse understands that if the patient has not been defibrillated within which time frame, the chance of survival is close to zero?

Place the client in high Fowler's position.

A nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, the nurse should:

• Responding indirectly to statements • Using open-ended statements • Concentrating on what patient says

A nurse is engaged in active listening. Which of the following would the nurse use?

"Mental health is marked by productivity, fulfilling relationships, and adaptability."

A nurse is giving a presentation about preventing mental illness to college freshmen. A student asks, "What does it mean to be mentally healthy?" Which of the following potential responses by the nurse is best?

"Mental health care services are inadequate and fragmented."

A nurse is preparing a presentation about the current status of mental health services in the United States. Which statement would the nurse include as the most reflective of this status?

"Theory provides the focus for my nursing care of depressed clients."

A nurse shows an understanding of the impact of nursing theory on nursing practice when stating

Countertransference

A nurse therapist finds herself feeling sad after sessions with a client. The client's passiveness reminds her of a family member who led a very unhappy life. What is the term for this emotional dynamic

"The only difference is the rate, which will be below 60 bpm in sinus bradycardia."

A nursing student is caring for one of the nurse's assigned cardiac clients. The student asks, "How can I tell the difference between sinus rhythm and sinus bradycardia when I look at the EKG strip" The best reply by the nurse is which of the following?

Decrease myocardial contractility.

A patient has a high magnesium level. Identify how hypermagnesemia affects cardiac function.

Low blood pressure

A patient is receiving anticoagulant therapy. The nurse should be alert to potential signs and symptoms of external or internal bleeding, as evidenced by which of the following?

Services that promote the patient's reintegration into the community

A patient is referred to a psychosocial rehabilitation program. When explaining this type of care to the patient, the nurse would emphasize which of the following?

Services that promote the patient's reintegration into the community.

A patient is referred to a psychosocial rehabilitation program. When explaining this type of care to the patient, the nurse would emphasize which of the following?

An increased risk of falls is dangerous for any patient. What patient would be at an increased risk of falls?

A patient with vertigo Explanation: Vertigo is defined as the misperception or illusion of motion either of the person or the surroundings. A patient suffering from vertigo will be at an increased risk of falls. This makes options A, B, and D incorrect.

• Welfare of the patient • Legal welfare of the nurse • Legal welfare of the institution

A psychiatric nurse working in an inpatient facility understands the importance of accurate documentation and explains to a new graduate that documentation is done for which reasons?

"When you exercise, try to avoid doing so at the hottest times of the day."

A young client with a new diagnosis of bipolar I disorder is scheduled to begin therapy with lithium. Which of the following instructions should the nurse provide to this client?

Semirestricted zone?

ATTIRE CONSISTS OF SCRUB, CLOTHES AND CAPS - Area where scrub attire etc is required, may include areas where surgical instruments are processed.

Restricted zone?

ATTIRE CONSISTS OF SCRUB, CLOTHES, CAPS AND MASK Area in the operating room where scrub attire and surgical masks are required! Includes operating room and sterile core areas!

The human body is an intricate mechanism which maintains homeostasis through a multitude of chemical reactions. The measureable chemical levels disclose how well the body is (or is not) functioning. Which of these chemical substances release hydrogen into fluid?

Acids - Acids are substances that release hydrogen into fluid. The delicate balance of fluid, electrolytes, acids, and bases is ensured by an adequate intake of water and nutrients, physiologic mechanisms that regulate fluid volume, and chemical processes that buffer the blood to keep its pH nearly neutral.

While visiting the pediatric clinic with her 2 year old, a mother picks up a brochure about immunizations and asks about active and passive acquired immunity to childhood diseases. The nurse explains that immunizations are which of the following and why?

Active acquired immunity, because the person's own body develops defenses

A nurse is working in a pediatric clinic. After giving a hepatitis B immunization to an infant, the mother asks what kind of protection this provides for her child. The correct response is which of the following?

Active acquired immunity, which lasts many years or a lifetime

A client comes to the emergency department complaining of severe pain in the right flank, nausea, and vomiting. The physician tentatively diagnoses right ureterolithiasis (renal calculi). When planning this client's care, the nurse should assign the highest priority to which nursing diagnosis?

Acute pain

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority?

Acute pain r/t biliary spasms

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority?

Acute pain related to biliary spasms

A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these findings as signs and symptoms of:

Acute pulmonary edema

You are making rounds on your clients. You find one of your clients struggling to breathe, appears confused, has tachycardia, and the skin appears dusky. What should you do to restore normal pH if ventilation efforts are not very successful?

Administer Sodium Bicarbonate IV - When the client makes frantic efforts to breathe, breathes slowly, or stops breathing, and has tachycardia, and the skin appears dusky (cyanosis), the condition is likely to be acute respiratory acidosis. The accumulation of CO2 leads to behavioral changes, including confusion. Excess carbonic acid pulls pH below 7.35. The nurse should administer sodium bicarbonate IV to balance the acid and bring the pH to a normal level. Bronchodilators may be useful in chronic respiratory acidosis but not in the acute version. Potassium (needed in hypokalemia) and magnesium sulfate (needed in hypomagnesemia) have no role in acute respiratory acidosis

A client in the emergency department complains of squeezing substernal pain that radiates to the left shoulder and jaw. He also complains of nausea, diaphoresis, and shortness of breath. What should the nurse do?

Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin. Explanation: Cardiac chest pain is caused by myocardial ischemia. Therefore the nurse should administer supplemental oxygen to increase the myocardial oxygen supply, attach a cardiac monitor to help detect life-threatening arrhythmias, and take vital signs to ensure that the client isn't hypotensive before giving sublingual nitroglycerin for chest pain. Registration information may be delayed until the client is stabilized. Alerting the cardiac catheterization team or the physician before completing the initial assessment is premature.

The nurse caring for a client with small-bowel obstruction would plan to implement which nursing intervention first?

Administering I.V. fluids Explanation: I.V. infusions containing normal saline solution and potassium should be given first to maintain fluid and electrolyte balance. For the client's comfort and to assist in bowel decompression, the nurse should prepare to insert an NG tube next. A blood sample is then obtained for laboratory studies to aid in the diagnosis of bowel obstruction and guide treatment. Blood studies usually include a complete blood count, serum electrolyte levels, and blood urea nitrogen level. Pain medication often is withheld until obstruction is diagnosed because analgesics can decrease intestinal motility.

Patients who have received corticosteroids preoperatively are at risk for which type of insufficiency?

Adrenal

Which of the following is the most common cause of symptomatic hypomagnesemia in the United States?

Alcoholism - Alcoholism is currently the most common cause of symptomatic hypomagnesemia in the United States. Any disruption in small bowel function, as in intestinal resection or inflammatory bowel disease, can lead to hypomagnesemia.

Which of the following is the most common cause of symptomatic hypomagnesemia?

Alcoholism - Alcoholism is currently the most common cause of symptomatic hypomagnesemia. IV drug use, sedentary lifestyle, and burns are not the most common causes of hypomagnesemia.

Which principle of the psychoanalytic model is particularly useful to psychiatric nurses?

All behavior has meaning. Explanation: The principle that all behavior has meaning is of particular importance to the psychiatric nurse. It serves as the basis for the nurse's assessment and analysis of the client's behavior, which reflects the client's needs. Psychoanalytic theory also proposes that the first 6 years of a person's life determine personality; these early influences are difficult, if not impossible, to counteract. However, this assumption is less useful to the nurse in planning interventions that meet the client's current needs. Reinforcement as a means of perpetuating behavior is associated with behavioral theory, not the psychoanalytic model. Incongruence between verbal and nonverbal communications is a part of communications theory.

Dennis Morgan, a 49-year-old chef, is a client of the primary care group where you practice nursing. Dennis has been studying up on blood cell production since the development of his blood disorder. At each appointment, he tries to fool you, his nurse, with blood cell trivia. His latest question: "Which of the following cell types are produced from pluripotential stem cells?" Your response is:

All options are correct.

A patient has an order for arterial blood gases (ABG) to be drawn? Which of the following tests must be done prior to the procedure?

Allen Test

A longitudinal tear or ulceration in the lining of the anal canal is termed a (an)

Anal fissure

Which of the following is the most severe form of hypersensitivity reaction?

Anaphylaxis

Which of the following is a change that occurs in chronic glomerulonephritis?

Anemia

A client who had abdominal surgery 4 days ago reports that "something gave way" when he sneezed. The nurse observes a wound evisceration. Which nursing action is the first priority?

Applying a sterile, moist dressing

In the client with burns on the legs, which nursing intervention helps prevent contractures?

Applying knee splints

In the client with burns on the legs, which nursing intervention helps prevent contractures?

Applying knee splints Explanation: Applying knee splints prevents leg contractures by holding the joints in a position of function. Elevating the foot of the bed can't prevent contractures because this action doesn't hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs.

Notify the nursing supervisor and approach the individual.

Approaching the person and requesting the client's medical record isn't sufficient considering the confidential health care information. Notifying the nursing supervisor, then approaching the individual before informing the client provides the most appropriate approach to this breech of client confidentiality. Contacting security might not be warranted unless the nurse learns the reason the unauthorized individual was reading the client's chart. The nurse should also document the incident according to facility policy.

When an attenuated toxin is administered to a client, the B lymphocytes create memory cells that recognize the antigen if it invades the body at a future time. What kind of immunity is this?

Artificially acquired active immunity

A nurse notices that a client who came to the clinic for treatment of anxiety disorder has a strong body odor. What can the nurse do or say to help this client?

Ask the client basic hygiene questions to determine how frequently he bathes. Explanation: The nurse should inquire about the client's basic hygiene to help determine the cause of his strong body odor. The nurse can then devise a plan of care based on the information she obtains. Offering the client an opportunity to freshen up doesn't address the problem and might offend him. Preparing the client for his examination and then leaving the room doesn't address the hygiene issues. Providing the client with personal care items also might offend him.

While assessing a patient with pericarditis, the nurse cannot auscultate a friction rub. Which action should the nurse implement?

Ask the patient to lean forward and listen again.

A patient complains about chest pain and heavy breathing when exercising or when stressed. Which of the following is a priority nursing intervention for the patient diagnosed with coronary artery disease?

Assess chest pain and administer prescribed drugs and oxygen

A nonverbal client has just finished undergoing a bronchoscopy procedure and writes that he want to eat lunch now. Which intervention is necessary for the nurse to complete at this time?

Assess for a cough reflex.

A client with achalasia recently underwent pneumatic dilation. The nurse intervenes after the procedure by

Assess lung sounds

A client in the emergency department reports that a piece of meat became stuck in the throat while eating. The nurse notes the client is anxious with respirations at 30 breaths/min, frequent swallowing, and little saliva in the mouth. An esophagogastroscopy with removal of foreign body is scheduled for today. The first activity of the nurse is to:

Assess lung sounds bilaterally

A client who underwent abdominal surgery and has a nasogastric (NG) tube in place begins to complain of abdominal pain that he describes as "feeling full and uncomfortable." Which assessment should the nurse perform first?

Assess patency of the NG tube

A 33-year-old female client tells the nurse she has never had an orgasm. She tells the nurse that her partner is upset that he can't meet her needs. Which nursing intervention is most appropriate?

Assess the couple's perception of the problem Explanation: Assessing the couple's perception of the problem will define it and assist the couple and the nurse in understanding it. A nurse can't make a medical diagnosis such as sexual aversion disorder. Most women can be taught to reach orgasm if there's no underlying medical condition. When assessing the client, the nurse should be professional and matter-of-fact; she shouldn't make the client feel inadequate or defensive

A client in end-stage renal disease is prescribed epoetin alfa (Epogen) and oral iron supplements. Before administering the next dose of epoetin alfa and oral iron supplement, the nurse

Assesses the hemoglobin level

A client with anorexia complains of constipation. Which of the following nursing measures would be most effective in helping the client reduce constipation?

Assist client to increase dietary fiber.

A client with catatonic schizophrenia is mute, can't perform activities of daily living, and stares out the window for hours. What is the nurse's first priority?

Assist the client with feeding. Explanation: According to Maslow's hierarchy of needs, the need for food is among the most important. Other needs, in order of decreasing importance, include hygiene, safety, and a sense of belonging.

Which condition most commonly results in coronary artery disease (CAD)?

Atherosclerosis Explanation: Atherosclerosis, or plaque formation, is the leading cause of CAD. Diabetes mellitus is a risk factor for CAD but isn't the most common cause. Renal failure doesn't cause CAD, but the two conditions are related. MI is commonly a result of CAD.

A patient has undergone a cardiac catheterization. He is to be discharged today. What information should the nurse emphasize during discharge teaching?

Avoid heavy lifting for the next 24 hours. Explanation: For the next 24 hours, the patient should not bend at the waist, strain, or life heavy objects. The patient should avoid tub baths, but shower as desired. The patient should call her the health care provider if she has any bleeding, swelling, new bruising, or pain from her procedure puncture site, or a temperature of 101.5 degrees Fahrenheit or more

When preparing a client with acquired immunodeficiency syndrome (AIDS) for discharge to home, the nurse should be sure to include which instruction?

Avoid sharing things such as toothbrushes and razors

The nurse is providing discharge education for the client going home after a cardiac catheterization. Which of the following would be important information to give this client?

Avoid tub baths, but shower as desired. Explanation: Guidelines for self-care after hospital discharge following a cardiac catheterization include shower as desired (no tub baths), avoid bending at the waist and lifting heavy objects, the physician will indicate when it is okay to return to work, and notify the physician right away if you have bleeding, new bruising, swelling, or pain at the puncture site.

A family meeting is held with a client who abuses alcohol. While listening to the family, which unhealthy communication pattern might be identified?

Avoidance of issues that cause conflict Explanation: The interaction pattern of a family with a member who abuses alcohol commonly revolves around denying the problem, avoiding conflict, or rationalizing the addiction. Health care providers are more likely to use jargon. The family might have problems setting limits and expressing disapproval of the client's behavior. Nonverbal communication usually gives the nurse insight into family dynamics

A nurse is checking laboratory values on a client who has crackles in the lower lobes, 2+ pitting edema, and dyspnea with minimal exertion. Which laboratory value does the nurse expect to be abnormal?

B-type natriuretic peptide (BNP) Explanation: The client's symptoms suggest heart failure. BNP is a neurohormone that's released from the ventricles when the ventricles experience increased pressure and stretch, such as in heart failure. A BNP level greater than 51 pg/ml is commonly associated with mild heart failure. As the BNP level increases, the severity of heart failure increases. Potassium levels aren't affected by heart failure. CRP is an indicator of inflammation. It's used to help predict the risk of coronary artery disease. There is no indication that the client has an increased CRP. There is no indication that the client is experiencing bleeding abnormalities, such as those seen with an abnormal platelet count.

When caring for a client who is a Mormon, the nurse notices something on the lunch tray that should be removed or substituted out of respect for the client's religion. Which of the following would be an item to remove?

Beer

A client understands what resources are available to help him perform wound care at home when he states the following:

Before I go home, I'll speak to the home health care nurse to make sure I have the supplies I need.

In a typical spinal cord, it functions as a "highway" for sensory and descending motor neurons - to provide conduction of impulses to and from the brain. The spinal cord is surrounded and protected by bony vertebrae. Where does the spinal cord end?

Between the first and second lumbar vertebrae

A client is returning from the operating room after inguinal hernia repair. The nurse notes that he has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-sided heart failure?

Bibasilar crackles

A group of nursing students are studying for a test over acid-base imbalance. One student asks another what the major chemical regulator of plasma pH is. What should the second student respond?

Bicarbonate-carbonic acid buffer system - The major chemical regulator of plasma pH is the bicarbonate-carbonic acid buffer system. Therefore options A and C are incorrect. Option D does not exist, it is only a distractor for this question.

If concern exists about fluid accumulation in a client's lungs, what area of the lungs will the nurse focus on during assessment?

Bilateral lower lobes

While taking the health history of a newly admitted client, the nurse reviews general lifestyle behaviors. Which of the following would have a positive effect on the immune system?

Biofeedback, relaxation, hypnosis.

A client is receiving nitroglycerin ointment (Nitro-Dur) to treat angina pectoris. The nurse evaluates the therapeutic effectiveness of this drug by assessing the client's response and checking for adverse effects. Which vital sign is most likely to reflect an adverse effect of nitroglycerin?

Blood pressure 84/52 mm Hg

A client with chronic renal failure (CRF) is admitted to the urology unit. Which diagnostic test results are consistent with CRF?

Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/dl

The nurse is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication of this condition?

Bone fracture Explanation: Bone fracture is a major complication of osteoporosis that results when loss of calcium and phosphate increases the fragility of bones. Estrogen deficiencies result from menopause — not osteoporosis. Calcium and vitamin D supplements may be used to support normal bone metabolism, but a negative calcium balance isn't a complication of osteoporosis. Dowager's hump results from bone fractures. It develops when repeated vertebral fractures increase spinal curvature.

Which of the following are the insensible mechanisms of fluid loss?

Breathing - Loss of fluid from sweat or diaphoresis is referred to as insensible loss because it is unnoticeable and immeasurable. Losses from urination and bowel elimination are measurable.

A 45-year-old waitress with a history of IV drug use also is HIV-positive. She has been following her antiretroviral medication regimen faithfully and is doing well. She's attending college to get a social work degree and is focused on a bright future. In her regular CD counts, what factor will indicate she has progressed from HIV to AIDS?

CD4 count < 200/mm indicates a diagnosis of AIDs to be made.

Which stage of HIV infection is indicated when the results are more than 500 CD4+ lymphocytes/mm?

CDC category A: HIV asymptomatic

The nurse accompanies a client to an exercise stress test. The client can achieve the "target heart rate," but the ECG leads show an ST-segment elevation. The nurse recognizes this as a "positive" stress test, and will begin to prepare the client for which of the following procedures?

Cardiac catheterization Explanation: An elevated ST-segment means an evolving myocardial infarction. A cardiac catheterization would be the logical next step

A client with chest pain arrives in the emergency department and receives nitroglycerin, morphine (Duramorph), oxygen, and aspirin. The physician diagnoses acute coronary syndrome. When the client arrives on the unit, his vital signs are stable and he has no complaints of pain. The nurse reviews the physician's orders. In addition to the medications already given, which medication does the nurse expect the physician to order?

Carvedilol (Coreg)

The primary source of microorganisms for catheter-related infections are the skin and which of the following?

Catheter hub

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will order diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client doesn't comply with the recommended treatment, which complication may arise?

Cerebral Edema - Noncompliance with treatment for SIADH may lead to water intoxication from fluid retention caused by excessive antidiuretic hormone. This, in turn, limits water excretion and increases the risk for cerebral edema. Hypovolemic shock results from, severe deficient fluid volume; in contrast, SIADH causes excess fluid volume. The major electrolyte disturbance in SIADH is dilutional hyponatremia, not hyperkalemia. Because SIADH doesn't alter renal function, potassium excretion remains normal; therefore, severe hyperkalemia doesn't occur. Tetany results from hypocalcemia, an electrolyte disturbance not associated with SIADH.

When assessing a client during a routine checkup, the nurse reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. Aphthous stomatitis is best described as:

Chancre sore of the oral soft tissues

A Community Health Nurse is giving an informational talk on hearing loss to the local PTO. What would the nurse tell the attendees that hearing impairment can trigger? a) Disturbed image b) Problems reading c) Overprotectiveness d) Changes in attitude

Changes in attitude Correct Explanation: Hearing impairment can trigger changes in attitude, the ability to communicate, the awareness of surroundings, and even the ability to protect oneself, affecting a person's quality of life. The scenario does not specify anyone for the hearing impaired to be overprotective of, nor does it specify an image to become disturbed. Hearing impairment would not cause problems reading.

A client had transurethral prostatectomy for benign prostatic hypertrophy. He's currently being treated with a continuous bladder irrigation and is complaining of an increase in severity of bladder spasms. What should the nurse do first for this client?

Check for the presence of clots, and make sure the catheter is draining properly Explanation: Blood clots and blocked outflow of the urine can increase spasms. The irrigation shouldn't be stopped as long as the catheter is draining because clots will form. A belladonna and opium suppository should be given to relieve spasms but only after assessment of the drainage. Oral analgesics should be given if the spasms are unrelieved by the belladonna and opium suppository.

When preparing a client for hemodialysis, which of the following would be most important for the nurse to do?

Check for thrill or bruit over the access site.

Which method is most reliable for confirming a preschooler's identity before administering a medication?

Check the hospital identification bracelet. Explanation: The only safe method for identifying the child is to check the identification band for the client's name and medical record number and then compare that information with the medication record. Children sometimes exchange beds during play, so checking the name on the bed isn't reliable. Infants are unable to give their names, toddlers or preschoolers may admit to any name, and school-age children may deny their identities in an attempt to avoid the medication. Parents aren't always at the bedside, so they shouldn't be relied on for identification

When checking a client's I.V. insertion site, the nurse notes normal color and temperature at the site and no swelling. However, the I.V. solutions haven't infused at the ordered rate; the flow rate is slow even with the roller clamp wide open. When the nurse lowers the I.V. fluid bag, no blood returns to the tubing. What should the nurse do first?

Check the tubing for kinks and reposition the client's wrist and elbow. Explanation: The nurse should first check for common causes of a decreased I.V. flow rate, such as kinks in the tubing and poor positioning of the affected arm. The nurse should discontinue the I.V. infusion only if other measures fail to solve the problem. Irrigating I.V. tubing may dislodge clots, if present. Elevating the I.V. fluid bag may help if no kinks are found and if repositioning doesn't resolve the problem.

If a client's central venous catheter accidentally becomes disconnected, what should a nurse do first?

Clamp the catheter

You are caring for three clients who have the following blood count values: Client A has 24,500 white blood cells (WBCs), client B has 13.4 g/dL hemoglobin, and client C has a 250,000/mm3 platelet count. Which statement correctly describes the condition of each client?

Client A has a higher WBC count than normal, client B has a normal hemoglobin count, and client C has a normal platelet count.

The nurse has just admitted a 12-year-old client who is going to have an above-the-knee amputation of their left leg due to osteosarcoma. The nurse knows that adequate preoperative teaching and learning is important for what reason? The nurse has just admitted a 12-year-old client who is going to have an above-the-knee amputation of their left leg due to osteosarcoma. The nurse knows that adequate preoperative teaching and learning is important for what reason?

Client will have a shorter recovery period.

The nurse recognizes that the client most at risk for mortality associated with surgery is the:

Client with chronic alcoholism

Deficient fluid volume

Clients with acute pancreatitis commonly experience deficient fluid volume, which can lead to hypovolemic shock. The volume deficit may be caused by vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma leaking into the peritoneal cavity. Hypovolemic shock will cause a decrease in cardiac output. Tissue perfusion will be ineffective if hypovolemic shock occurs, but this wouldn't be the primary nursing diagnosis.

Which of the following is a clinical manifestation of fluid volume excess (FVE)? Select all that apply.

Clinical manifestations of FVE include distended neck veins, crackles in the lung fields, shortness of breath, increased blood pressure, and tachycardia.

A client diagnosed with acute myelocytic leukemia (AML) has been receiving chemotherapy. During the last two cycles of chemotherapy, the client developed severe thrombocytopenia requiring multiple platelet transfusions. The client is now scheduled to receive a third cycle. How can the nurse best detect early signs and symptoms of thrombocytopenia?

Closely observe the client's skin for petechiae and bruising. Explanation: The nurse should closely observe the client's skin for petechiae and bruising, early signs of thrombocytopenia. Daily platelet counts may not reflect the client's condition as quickly as subtle changes in the client's skin. Performing frequent cardiovascular assessments and checking the client's history won't help detect early signs and symptoms of thrombocytopenia.

A nurse is caring for a client with a low platelet count. The nurse understands that a low platelet count affects which of the following?

Clotting of blood

hypoxia.

Clubbing is a sign of prolonged hypoxia. Causes of clubbing include emphysema, chronic bronchitis, lung cancer, and heart failure. Beau's lines (transverse depressions in the nail that extend beyond the nail bed) occur with acute illness, malnutrition, and anemia. Koilonychia (thin, spoon-shaped nails with lateral edges that tilt upward) is associated with Raynaud's disease, malnutrition, chronic infections, and hypochromic anemia. Onycholysis (loosening of the nail plate with separation from the nail bed) is associated with hyperthyroidism, psoriasis, contact dermatitis, and Pseudomonas infections.

More than 50% of individuals with this disease develop pernicious anemia:

Common variable immunodeficiency (CVID)

A client tells a nurse that her ileoconduit appliance won't adhere to her skin. The nurse inspects the site and notes that the area around the stoma is red, moist, and tender to touch. How should the nurse intervene?

Consult the wound-ostomy nurse. Explanation: The skin is most likely excoriated from urine leaking from the appliance. The nurse should consult the wound-ostomy nurse, who can suggest care interventions. Some facilities require a physician's order to obtain a wound culture. Patting the skin dry and applying a new appliance won't address the problem with the appliance. Applying skin adhesive spray to excoriated skin will further irritate the skin and increase the client's discomfort.

The nurse is caring for a 10-year-old child with cystic fibrosis. The child's parents tell the nurse that they're having difficulty coping with their child's disease. Which action would be most appropriate for the nurse to take?

Consulting with the social worker to help the family find appropriate resources Explanation: The nurse can help this family by assisting them with finding appropriate financial, psychological, and social support and by providing referrals to the local community agencies and the Cystic Fibrosis Foundation. The child should be treated as much like a normal child as possible, and he should be encouraged to make friends with other children regardless of their physical condition. The nurse shouldn't encourage the parents not to visit because the child might feel abandoned.

A client with a sacral pressure ulcer is limited to 2 hours of sitting in a chair twice per day. She is scheduled for physical therapy three times per day and dressing changes twice per day. How can a nurse best coordinate this client's care?

Coordinate physical therapy with getting the client out of bed for breakfast and dinner; then request bedside physical therapy for the third session.

The nurse is teaching a group of adolescents about automobile safety. Which is the most effective teaching method for this age-group?

Coordinating a panel of peers who were involved in motor vehicle accidents Explanation: Coordinating a panel of peers to discuss motor vehicle accidents and their prevention is more effective for this age-group. Adolescents are more likely to listen to others their age who have experienced similar circumstances. Lecturing about the effects of drugs and alcohol on driving will most likely be ineffective for this age-group. Adolescents won't be motivated to read the written materials. Animated videos aren't age-appropriate and may minimize the importance of the material.

The nurse is assessing the lungs of a patient diagnosed with pulmonary edema. Which of the following would be expected upon auscultation?

Crackles at lung bases

Which ventilation-perfusion ratio is exhibited by a pulmonary emboli?

Dead Space

A client seeks medical attention for dyspnea, chest pain, syncope, fatigue, and palpitations. A thorough physical examination reveals an apical systolic thrill and heave, along with a fourth heart sound (S4) and a systolic murmur. Diagnostic tests reveal that the client has hypertrophic cardiomyopathy (HCM). Which nursing diagnosis may be appropriate?

Decreased CO

During assessment of a client admitted for cardiomyopathy, the nurse notes the following symptoms: dyspnea on exertion, fatigue, fluid retention, and nausea. The initial appropriate nursing diagnosis is which of the following?

Decreased CO

Which of the following is associated with impaired immunity in the aging patient?

Decreased renal function

Which of the following is an age-related change associated with the respiratory system?

Decreased size of the airway

A patient has a high magnesium level. Identify how hypermagnesemia affects cardiac function.

Decreases myocardial contractility Explanation: Hypermagnesemia can cause depression of myocardial contractility and excitability heart block and asystole. Hypomagnesemia predisposes patient to atrial or ventricular tachycardias

A patient has a high magnesium level. Identify how hypermagnesemia affects cardiac function.

Decreases myocardial contractility Explanation: Hypermagnesemia can cause depression of myocardial contractility and excitability heart block and asystole. Hypomagnesemia predisposes patient to atrial or ventricular tachycardias.

A client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem?

Decreasing the rate of feedings and the concentration of the formula Explanation: Complaints of abdominal discomfort and nausea are common in clients receiving tube feedings. Decreasing the rate of the feeding and the concentration of the formula should decrease the client's discomfort. Feedings are normally given at room temperature to minimize abdominal cramping, so this intervention should have already been performed. To prevent aspiration during feeding, the head of the client's bed should be elevated at least 30 degrees. Changing tube feeding administration sets every 24 hours prevents bacterial growth; it doesn't decrease the client's discomfort.

Assisting the client with deep-breathing exercises

Deep-breathing exercises are beneficial to promoting rest as they help the client to relax. The client's door should be closed to reduce noise and distractions. Tea contains caffeine, which acts as a stimulant. While sedatives may be used occasionally for assistance with rest, regular use isn't advised because dependence may develop.

What is the most appropriate nursing diagnosis for the client with acute pancreatitis?

Deficient fluid volume

The nurse is changing the dressing of a client who is 4 days postoperative with an abdominal wound. The nurse has changed this dressing daily since surgery. Today, the nurse notes increased serosanguinous drainage, wound edges not approximated, and a ¼-inch gap at the lower end of the incision. The nurse concludes which of the following conditions exists?

Dehiscence

You are caring for a 72-year-old client who has been admitted to your unit for a fluid volume imbalance. You know which of the following is the most common fluid imbalance in older adults?

Dehydration - The most common fluid imbalance in older adults is dehydration. Because of reduced thirst sensation that often accompanies aging, older adults tend to drink less water. Use of diuretic medications, laxatives, or enemas may also deplete fluid volume in older adults. Chronic fluid volume deficit can lead to other problems such as electrolyte imbalances.

Which of the following is the primary symptom of achalasia?

Difficulty swallowing

A nurse is caring for a 17-year-old girl who's receiving parenteral nutrition in 25% dextrose solution. How should this solution be administered?

Directly into the superior vena cava Explanation: Solutions that contain more than 12.5% dextrose are administered through a central venous access device directly into the superior vena cava by way of the jugular or subclavian vein. Special tubing is used that contains an in-line filter to remove bacteria and particulate material. A superficial vein, gastrostomy tube, and the oral route are never used for this type of solution.

There are many ethical issues in the care of clients with HIV or HIV/AIDS. What is an ethical issue healthcare providers deal with when caring for clients with HIV/AIDS?

Disclosure of the patient's condition

A client with cirrhosis has been referred to hospice care. Assessment data reveal a need to discuss nutrition with the client. What is the nurse's priority intervention?

Discuss meals that include low-fat high-carbohydrate content.

A client who is HIV positive is receiving highly active antiretroviral therapy (HAART) that includes a protease inhibitor (PI). The client comes to the clinic for a follow-up visit. Assessment reveals lipoatrophy of the face and arms. The client states, "I'm thinking the side effects of the drug are worse than the disease. Look what's happening to me." The nurse would most likely identify which nursing diagnosis as the priority?

Disturbed body image related to loss of fat in the face and arms

The nurse is reviewing a client's laboratory results and notes that her hemoglobin level is 15 g/dL. What action should the nurse take next?

Document the finding as normal.

While assessing a client, a nurse notes a stage I pressure ulcer on the client's left hip. How should the nurse report this finding?

Document the size, extent, and location of the wound in the client's medical record

The physician prescribes an emollient for a client with pruritus of recent onset. The client asks why the emollient should be applied immediately after a bath or shower. How should the nurse respond?

Doing so prevents evaporation of water from the hydrated epidermis.

Which drug is most commonly used to treat cardiogenic shock?

Dopamine (Intropin)

To implant an intracranial pressure monitor, what membranes will the surgeon need to penetrate? Choose all correct responses.

Dura mater • Arachnoid • Pia mater

Which of the following is also known as a proxy directive?

Durable power of attorney for healthcare

When counseling parents of a neonate with congenital hypothyroidism, the nurse understands that the severity of the intellectual deficit is related to which parameter?

Duration of the condition before treatment Explanation: The severity of the intellectual deficit is related to the degree of hypothyroidism and the duration of the condition before treatment. Cranial malformations don't affect the severity of the intellectual deficit, nor does the degree of hypothermia as it relates to hypothyroidism. It isn't the specific T4 level at diagnosis that affects the intellect but how long the child has been hospitalized.

A client is diagnosed with herpes simplex. Which statement about herpes simplex infection is true?

During early pregnancy, herpes simplex infection may cause spontaneous abortion or premature delivery.

The nurse is revising a client's plan of care. During which step of the nursing process does such revision take place?

During the evaluation step of the nursing process, the nurse determines whether the goals established in the plan of care have been achieved and evaluates the success of the plan. If a goal is unmet or partially met, the nurse reexamines the data and revises the plan. Data collection involves gathering relevant information about the patient. Planning involves setting priorities, establishing goals, and selecting appropriate interventions. Implementation involves providing actual nursing care.

Increased appetite and thirst may indicate that a client with chronic pancreatitis has developed diabetes melitus. Which of the following explains the cause of this secondary diabetes?

Dysfunction of the pancreatic islet cells

Which nursing objective is most important when working with neonates who are suspected of having congenital hypothyroidism?

Early identification Explanation: The most important nursing objective is early identification of the disorder. Nurses caring for neonates must be certain that screening is performed, especially in neonates who are preterm, discharged early, or born at home. Promoting bonding, allowing rooming in, and encouraging fluid intake are all important but are less important than early identification.

A nurse has admitted a client suspected of having acute pancreatitis. The nurse knows that mild acute pancreatitis is characterized by:

Edema and inflammation

Examples are control of hemorrhage; repair of trauma, perforated ulcer, intestinal obstruction; tracheostomy

Emergency surgery

High or increased compliance occurs in which disease process?

Emphysema

While assessing for tactile fremitus, the nurse palpates almost no vibration. Which of the following conditions in this client's history will account for this finding?

Emphysema

A female patient has undergone a lumbar puncture for a neurological assessment. The patient is put under the postprocedure care of a nurse. Which of the following important postprocedure nursing interventions should be performed to ensure maximum comfort to the patient?

Encourage a liberal fluid intake for the patient

A nurse is preparing a client with Crohn's disease for a barium enema. What should the nurse do the day before the test?

Encourage fluid intake

A 15-year-old client who sustained a spinal cord injury is on bedrest. Which intervention by the nurse might best help the adolescent cope with the prolonged bedrest?

Encouraging visitation by his friends Explanation: Encouraging visitation by friends might best help the adolescent cope with prolonged bedrest. Friends are much more important than family to this age-group. Providing reading material and video games might be somewhat helpful, but not as helpful as encouraging visits from friends.

The nursing priority of care for a client exhibiting signs and symptoms of coronary artery disease should be to:

Enhance myocardial oxygenation

A nurse is assisting with a percutaneous liver biopsy. Place the steps involved in care in the correct sequence from first to last.

Ensure that the biopsy equipment is assembled and in order. Help the client assume a supine position. Place a rolled towel beneath the client's right lower ribs. While the physician inserts the needle, instruct the client to take a deep breath and hold it to keep the liver as near to the abdominal wall as possible. Make sure that the specimen container is labeled and delivered to the laboratory.

A physician has arrived on the floor to perform a bone marrow aspiration. The nurse first

Ensures that the client has signed the informed consent form

Which action by the nurse displays client advocacy during a skin assessment?

Ensuring client privacy by pulling the curtain closed

ELISA stands for:

Enzyme-linked immunoabsorbent assay

A client is suspected of having an immune system disorder. The physician wants to perform a diagnostic test to confirm the diagnosis. What test might the physician order?

Enzyme-linked immunosorbent assay

Which cells have the major function of transporting O2 to and removing CO2 from tissues?

Erythrocytes

Cancer of the esophagus is most often diagnosed by which of the following?

Esophagogastroduodenoscopy (EGD) with biopsy and brushings

Austin Holbritter, a six-month-old male, and his elder brother Matthew, a three-year-old male, are being seen in the pediatric clinic where you practice nursing. They are being seen by the physician for their third middle ear infection of this winter season. The mother reports they develop an upper respiratory infection and an ear infection seems quick to follow. What contributes to this event?

Eustachian tubes

A nurse places a client in full leather restraints. How often must the nurse check the client's circulation?

Every 15 minutes Explanation: Circulatory as well as skin and nerve damage can occur quickly. Therefore, circulation should be assessed at least every 15 minutes. Checking every hour, 2 hours, or 8 hours isn't often enough and could result in permanent damage to the client's extremities.

An elderly client tells the nurse that he doesn't want to take a bath. Which action by the nurse is most appropriate?

Explaining why a bath is important to overall health, and telling the client that she'll return in 30 minutes to help him bathe Explanation: It's important for the client to understand why a bath is important to overall health. Communicating with the client shows respect and aids compliance. Giving the client a specific time for the bath allows him time to prepare for the care. Documenting bath refusal, calling the physician, and contacting family members are inappropriate before discussing the importance of the bath with the client and reattempting to provide care.

A nurse is caring for an adult client with numerous draining wounds from gunshots. The client's pulse rate has increased from 100 to 130 beats per minute over the last hour. The nurse should further assess the client for which of the following?

Extracellular Fluid Volume Deficit - Fluid volume deficit (FVD) occurs when the loss extracellular fluid (ECF) volume exceeds the intake of fluid. FVD results from loss of body fluids and occurs more rapidly when coupled with decreaesd fluid intake. A cause of this loss is hemorrhage.

A client has a new order for metoclorpramide (Reglan). The nurse identifies that this medication should not be used long term and only in cases where all other options have been exhausted. This is because this medication has what type of potential side effect?

Extrapyramidal

A client with chronic renal failure (CRF) has developed faulty red blood cell (RBC) production. The nurse should monitor this client for:

Fatigue and weakness

At a previous visit, the parents of an infant with cystic fibrosis received instruction in the administration of pancrelipase (Pancrease). At a follow-up visit, which finding suggests the need for further teaching?

Fatty stools Explanation: Pancreatic enzymes normally aid in food digestion in the intestine. In a child with cystic fibrosis, however, these natural enzymes can't reach the intestine because mucus blocks the pancreatic duct. Without these enzymes, undigested fats and proteins produce fatty stools. Treatment with pancreatic enzymes should result in stools of normal consistency; noncompliance with the treatment produces fatty stools. Noncompliance doesn't cause bloody urine, bloody stools, or glucose in urine.

The nurse is assigned to an adolescent. Which nursing diagnosis is most appropriate for a hospitalized adolescent?

Fear related to disturbed body image Explanation: Fear related to disturbed body image is the most appropriate nursing diagnosis for a hospitalized adolescent because of the adolescent's developmental level and concern for physical appearance. An adolescent may fear disfigurement resulting from procedures and treatments. Separation is rarely a major stressor for the adolescent, eliminating a diagnosis of Anxiety related to separation from parents. Adolescents may have Fear related to the unknown but typically ask questions if they want information. A diagnosis of Ineffective coping related to activity restrictions may be appropriate for a toddler who has difficulty tolerating activity restrictions but is an unlikely nursing diagnosis for an adolescent.

The mode of transmission of hepatitis A virus (HAV) includes which of the following?

Fecal-oral

Rebound hypoglycemia is a complication of parental nutrition caused by which of the following?

Feedings stopped too abruptly

Which of the following is the first barrier method that can be controlled by the woman?

Female condom

Because uteroplacental circulation is compromised in clients with preeclampsia, a nonstress test (NST) is performed to detect which condition?

Fetal well-being Explanation: An NST is based on the theory that a healthy fetus has transient fetal heart rate accelerations with fetal movement. A fetus with compromised uteroplacental circulation usually won't have these accelerations, which indicate a nonreactive NST. An NST can't detect anemia in a fetus. Serial ultrasounds will detect IUGR and oligohydramnios in a fetus.

A client is diagnosed with pericarditis. The nurse anticipates that the client may exhibit which signs and symptoms?

Fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR) Explanation: The classic signs and symptoms of pericarditis include fever, positional chest discomfort, nonspecific ST-segment elevation, elevated ESR, and pericardial friction rub. All other symptoms may result from acute renal failure.

An 8-year-old client has tested positive for West Nile virus infection. The nurse suspects the client has the severe form of the disease when she recognizes which signs and symptoms?

Fever, muscle weakness, and change in mental status Correct Explanation: Severe West Nile virus infection (also called West Nile encephalitis or West Nile meningitis) affects the central nervous system and may cause headache, neck stiffness, fever, muscle weakness or paralysis, changes in mental status, and seizures. Such signs and symptoms as fever, rash, malaise,anorexia, nausea and vomiting, and lymphadenopathy suggest the mild form of West Nile virus infection.

A nurse is completing a head to toe assessment on a patient diagnosed with right-sided heart failure. To assess peripheral edema, which of the following areas should be examined?

Fingers, hands Explanation: When right-sided heart failure occurs, blood accumulates in the vessels and backs up in peripheral veins, and the extra fluid enters the tissues. Particular areas for examination are the dependent parts of the body, such as the feet and ankles. Other prominent areas prone to edema are the fingers, hands, and over the sacrum. Cyanosis can be detected by noting color changes in the lips and earlobes.

A client with end-stage acquired immunodeficiency syndrome (AIDS) has profound manifestations of Cryptosporidium infection caused by the protozoa. In planning the client's care, the nurse should focus on his need for:

Fluid replacement

The Emergency Department (ED) nurse is caring for a client who is known to make excessive use of laxatives who is showing signs of bradycardia. The client is admitted for hemodialysis. The ED nurse knows that a major goal of managing this client is what?

Flush out Excess magnesium - The main objective is to flush out excess magnesium. Laxatives contain magnesium, and their excessive use may cause hypermagnesemia. Bradycardia or slow heart rate is one of the signs of this imbalance. In severe cases, hemodialysis may be necessary. Magnesium sulfate is administered in hypomagnesemia and not hypermagnesemia. Mechanical ventilation is necessary only if there is a change in respiratory rate, rhythm, or depth. The physician may permit the use of magnesium-free laxatives and the client should follow the recommended frequency of their use.

The nurse is to discontinue a nasogastric tube that had been used for decompression. The first thing the nurse does is

Flush with 10 mL of water

Which type of deficiency results in macrocytic anemia?

Folic Acid

The mother of a 3-year-old with a myelomeningocele is thinking about having another baby. The nurse should inform the woman that she should increase her intake of which acid?

Folic acid to 4 mg/day Explanation: The American Academy of Pediatrics recommends that a woman who has had a child with a neural tube defect increase her intake of folic acid to 4 mg per day 1 month before becoming pregnant and continue this regimen through the first trimester. A woman who has no family history of neural tube defects should take 0.4 mg/day. All women of childbearing age should be encouraged to take a folic acid supplement because the majority of pregnancies in the United States are unplanned. Ascorbic acid hasn't been shown to have any effect on preventing neural tube defects.

A nurse is working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress?

Following safer-sex practices

Postoperatively, a patient with a radical neck dissection should be placed in which position?

Fowler's

Which of the following is a factor affecting an increase in serum osmolality?

Free Water Loss - Free water loss is a factor increasing serum osmolality. Diuretic use, overhydration, and hyponatremia are factors decreasing serum osmolality.

Which lobe of the brain is responsible for concentration and abstract thought?

Frontal

Which of the following cerebral lobes is the largest and controls abstract thought?

Frontal

A few hours after eating hot and spicy chicken wings, a client presents with lower chest pain. He wonders if he is having a heart attack. How should the nurse proceed first?

Further investigate the initial complaint

A client has a new order for metoclorpramide (Reglan). The nurse identifies that this medication can be safely administered for which conditon?

GERD

Which of the following is a factor that increases blood urea nitrogen (BUN)?

GI Bleeding - Factors that increase BUN include GI bleeding, dehydration, increased protein intake, and fever.

A nurse is preparing a client for surgery. During preoperative teaching, the client asks where is bile stored. The nurse knows that bile is stored in the:

Gallbladder

Which of the following surgical procedures for obesity utilizes a prosthetic device to restrict oral intake?

Gastric banding

A client has a gastrointestinal tube that enters the stomach through a surgically created opening in the abdominal wall. The nurse documents this as which of the following?

Gastrostomy tube

Which of the following is a nonmodifiable risk factor for coronary artery disease (CAD)?

Gender

The nurse is aware that loss of consciousness occurs with which type of anesthesia?

General

You are caring for a new client on your unit who is third-spacing fluid. You know to assess for what type of edema?

Generalized - There may be generalized edema in all the interstitial spaces, which sometimes is called brawny edema or anasarca. Options B and D are not part of the process of third-spacing fluid. Option C is a distractor for this question.

Which of the following would a nurse be least likely to identify as a cause of secondary immunodeficiency?

Genetics

A 2-month-old infant arrives in the emergency department with a heart rate of 180 beats/minute and a temperature of 103.1° F (39.5° C) rectally. Which intervention is most appropriate?

Give acetaminophen (Tylenol). Explanation: Acetaminophen should be given first to decrease the infant's temperature. A heart rate of 180 beats/minute is normal in an infant with a fever. Fluid intake is encouraged after the acetaminophen is given to help replace insensible fluid losses. Carotid massage is an attempt to decrease the heart rate as a vagal maneuver; it won't work in this infant because the source of the increased heart rate is fever. A tepid sponge bath may be given to help decrease the temperature and calm the infant.

A client with esophageal cancer has difficulty in swallowing. Which of the following would be appropriate to help the client achieve improved nutrition?

Give high-protein, semiliquid foods

A client undergoing a complete blood cell (CBC) count for the detection of anemia wants to know more about hemoglobin. Which of the following should the nurse explain to the client as being the main function of hemoglobin?

Gives its oxygen to cells of the body and picks up carbon dioxide

Which of the following causes should the nurse suspect in a client is diagnosed with intrarenal failure?

Glomerulonephritis

Cranial nerve IX is also known as which of the following?

Glossopharyngeal

The following appears on the medical record of a male patient receiving parenteral nutrition: WBC: 6500/cu mm Potassium 4.3 mEq/L Magnesium 2.0 mg/dL Calcium 8.8 mg/dL Glucose 190 mg/dL Which finding would alert the nurse to a problem?

Glucose level

Which statement best describes an expected outcome?

Goals that the client should reach as a result of planned nursing interventions Explanation: Expected outcomes are realistic, measurable goals that include target dates for when the goals will be achieved. They're devised by the nursing staff with input from the client. The goals are attained by following planned nursing interventions.

When collecting data on a child with juvenile hypothyroidism, the nurse expects which finding?

Goiter Explanation: Juvenile hypothyroidism results in goiter, weight gain, sleepiness, and a slow heart rate. It doesn't cause weight loss, insomnia, or tachycardia.

Which of the following precautions should the nurse take when a client is at risk of injury secondary to the vertigo and probable imbalance? a) Recommend that the client keep his/her eyes close b) Restrict the client from looking at one place c) Allow the client to move the head slowly d) Have the client sit in a wheelchair when moving

Have the client sit in a wheelchair when moving Correct Explanation: The nurse should have the client sit in a wheelchair when moving him or her.

A nurse is trying to determine if a client who abuses heroin has any drug-related legal problems. Which assessment question is the best to ask the client?

Have you received any legal violations related to your drug use? Explanation: Asking about legal violations related to drug use provides direct information about drug-related legal problems. When a spouse becomes aware of a partner's substance abuse, the first action isn't necessarily to institute legal action. Even if the client reports to a probation officer, the offense isn't necessarily a drug-related problem. Asking if the client has a history of frequent visits with the employee assistance program manager isn't useful; it assumes any such visit is related to drug issues.

In which of the following medical conditions would administering IV normal saline solution be inappropriate? Select all that apply. • Severe hemorrhage • Pulmonary edema • Heart failure • Burns • Renal Impairment

Heart Failure, Pulmonary Edema, Renal Impairment - Normal saline is not used for heart failure, pulmonary edema, renal impairment, or sodium retention. It is used with administration of blood transfusions and to replace large sodium losses, as in burn injuries.

Which of the following complications is most common after an abdominal aortic aneurysm resection?

Hemorrhage and shock Explanation: Hemorrhage and shock are the most common complications after abdominal aortic aneurysm resection. Renal failure can occur as a result of shock or from injury to the renal arteries during surgery. Graft occlusion and enteric fistula formation are rare complications of abdominal aortic aneurysm repair.

In presenting a workshop on parameters of cardiac function, which conditions should a nurse list as those most likely to lead to a decrease in preload?

Hemorrhage, sepsis, and anaphylaxis Explanation: Preload is the volume in the left ventricle at the end of diastole. It's also referred to as end-diastolic volume. Preload is reduced by any condition that reduces circulating volume, such as hemorrhage, sepsis, and anaphylaxis. Hemorrhage reduces circulating volume by loss of volume from the intravascular space. Sepsis and anaphylaxis reduce circulating volume by increased capillary permeability. Diuresis, vasodilation, and third spacing also reduce preload. Preload increases with fluid overload and heart failure.

A client and spouse are visiting the clinic. The client recently experienced a seizure and says she has been having difficulty writing. Before the seizure, the client says that for several weeks she was sleeping late into the day but having restlessness and insomnia at night. The client's husband says that he has noticed the client has been moody and slightly confused. Which of the following problems is most consistent with the client's clinical manifestations?

Hepatic encephalopathy

When reviewing the history of a client with Crohn disease, which factor would the nurse associate with this disorder?

Heredity Explanation: Although the definitive cause of Crohn disease is unknown, it's thought to be associated with infectious, immune or psychological, factors. Because it has a higher incidence in siblings, it may have a genetic cause. Constipation isn't linked to Crohn disease. On the contrary, Crohn disease causes bouts of diarrhea. Diet may contribute to exacerbations of Crohn disease but isn't considered a cause. A lack of exercise isn't considered a cause of Crohn disease.

After teaching nursing students about autosomal-dominant and autosomal-recessive inherited disorders, the instructor determines that the teaching was successful when the class identifies which of the following as true about autosomal-dominant inherited conditions?

Horizontal transmission is more commonly seen in families.

After teaching nursing students about autosomal-dominant and autosomal-recessive inherited disorders, the instructor determines that the teaching was successful when the class identifies which of the following as true about autosomal-dominant inherited conditions?

Horizontal transmission is typically seen in families

Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray?

Hot roast beef sandwich with gravy

Which of the following should be incorporated into the patient teaching plan to prevent deep vein thrombosis?

Hourly leg exercises

A client presents with anorexia, nausea and vomiting, deep bone pain, and constipation. The following are the client's laboratory values. Na + 130 mEq/L K + 4.6 mEq/L Cl - 94 mEq/L Mg ++ 2.8 mg/dL Ca ++ 13 mg/dL Which of the following alterations is consistent with the client's findings?

Hypercalcemia - More than 99% of the body's calcium is found in the skeletal system. Hypercalcemia (greater than 10.2 mg/dL) can be a dangerous imbalance. The client presents with anorexia, nausea and vomiting, constipation, abdominal pain, bone pain, and confusion.

A client with a history of chronic renal failure is admitted with pulmonary edema following a missed dialysis treatment yesterday. His laboratory results are serum potassium 6.0 mEg/L, serum sodium 130 mEg/L, and serum bicarbonate 18 mEg/L. The nurse interprets that the client has which of the following conditions?

Hyperkalemia Explanation: The kidneys are responsible for excreting potassium. In renal failure, the kidneys can no longer excrete potassium, resulting in hyperkalemia. The kidneys are responsible for regulating the acid-base balance; in renal failure, acidemia, not alkalemia, would be likely. Generally, hyponatremia, not hypernatremia, would occur because of the dilutional effect of water retention. Hypokalemia is generally seen in clients undergoing diuresis.

A physician orders regular insulin 10 units I.V. along with 50 ml of dextrose 50% for a client with acute renal failure. What electrolyte imbalance is this client most likely experiencing?

Hyperkalemia - Administering regular insulin I.V. concomitantly with 50 ml of dextrose 50% helps shift potassium from the extracellular fluid into the cell, which normalizes serum potassium levels in the client with hyperkalemia. This combination doesn't help reverse the effects of hypercalcemia, hypernatremia, or hyperglycemia.

A nurse is caring for a client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat:

Hyperkalemia - Hyperkalemia is a common complication of acute renal failure. It's life-threatening if immediate action isn't taken to reverse it. Administering glucose and regular insulin, with sodium bicarbonate if necessary, can temporarily prevent cardiac arrest by moving potassium into the cells and temporarily reducing serum potassium levels. Hypernatremia, hypokalemia, and hypercalcemia don't usually occur with acute renal failure and aren't treated with glucose, insulin, or sodium bicarbonate.

During the auscultation of heart, what is revealed by an atrial gallop?

Hypertensive heart disease Explanation: Auscultation of the heart requires familiarization with normal and abnormal heart sounds. An extra sound just before S1 is an S4 heart sound, or atrial gallop. An S4 sound often is associated with hypertensive heart disease. A sound that follows S1 and S2 is called an S3 heart sound or a ventricular gallop. An S3 heart sound is often an indication of heart failure in an adult. In addition to heart sounds, auscultation may reveal other abnormal sounds, such as murmurs and clicks, caused by turbulent blood flow through diseased heart valves.

You are caring for a client that has been admitted with a possible clotting disorder. The client is complaining of excessive bleeding and bruising without cause. You know that you should take extra care to check for signs of bruising or bleeding in what condition?

Hypocalcemia - Hypocalcemia or low serum calcium levels can affect clotting. Therefore, in this condition the nurse should take extra care to check for bruising or bleeding. There is no such risk in dehydration, hypokalemia, or hypomagnesemia

A client presents with fatigue, nausea, vomiting, muscle weakness, and leg cramps. Laboratory values are as follows: Na + 147 mEq/L K + 3.0 mEq/L Cl - 112 mEq/L Mg ++ 2.3 mg/dL Ca ++ 1.5 mg/dL Which of the following is consistent with the client's findings?

Hypokalemia - Potassium is the major intracellular electrolyte. Hypocalemia (below 3.5 mEq/L) usually indicates a d...(more) Potassium is the major intracellular electrolyte. Hypocalemia (below 3.5 mEq/L) usually indicates a deficit in total potassium stores. Potassium deficiency can result in derangements in physiology. Clinical signs include fatigue, anorexia, nausea, vomiting, muscles weakness, leg cramps, decreased bowel motility, and paresthesias.

Which of the following conditions does the nurse need to confirm when he or she taps the facial nerve of a client who has dysphagia?

Hypomagnesemia - If there is a unilateral spasm of facial muscles when the nurse taps over the facial muscle, it is known as Chvostek's sign, which is a sign of hypocalcemia and hypomagnesemia. The additional symptom of dysphagia reinforces the possibility of hypomagnesemia rather than hypocalcemia. A positive Chvostek's sign does not apply to hypercalcemia, hypervolemia, or hypermagnesemia.

A client presents with muscle weakness, tremors, slow muscle movements, and vertigo. The following are the client's laboratory values: Na+ 134 mEq/L K+ 3.2 mEq/L Cl- 111 mEq/L Mg++ 1.1 mg/dL Ca++ 8.4 mg/dL Identify which of the following alterations is consistent with the client's findings.

Hypomagnesemia - Magnesium, the second most abundant intracellular cation, plays a role in both carbohydrate and protein metabolism. The most common cause of this imbalance is loss in the gastrointestinal tract. Hypomagnesemia is a value less than 1.3 mg/dL. Signs and symptoms include muscle weakness, tremors, irregular movements, tetany, vertigo, focal seizures, and positive Chvostek's and Trousseau's signs.

Infants with DiGeorge syndrome have which type of endocrine disorder?

Hypoparathyroidism

Patients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which of the following is a sign of potential hypovolemia?

Hypotension

The nurse is caring for a patient diagnosed with abdominal perforation. Which of the following is a clinical manifestation of this disease process?

Hypotension

Which of the following is inconsistent as a condition related to metabolic syndrome?

Hypotension

Oral intake is controlled by the thirst center, located in which of the following cerebral areas?

Hypothalamus

A nurse is assessing a client and obtains the following findings: abdominal discomfort, mild diarrhea, blood pressure of 100/80 mm Hg, pulse rate of 88 beats/minute, respiratory rate of 20 breaths/minute, temperature 100° F (37.8° C). The nurse suspects the client will be diagnosed with:

IBD

Which stage of anesthesia is termed surgical anesthesia?

III

Which New York Heart Association classification of heart failure has a poor prognosis and includes symptoms of cardiac insufficiency at rest?

IV

A client with ataxia-telangiectasia is admitted to the unit. The nurse caring for the client would expect to see what included in the treatment regimen?

IV Gamma Globulin Administration

A 14-year-old female client in skeletal traction for treatment of a fractured femur is expected to be hospitalized for several weeks. When planning care, the nurse should take into account the client's need to achieve what developmental milestone?

Identity Explanation: According to Erikson's theory of personal development, the adolescent is in the stage of identity versus role confusion. During this stage, the body is changing as secondary sex characteristics emerge. The adolescent is trying to develop a sense of identity, and peer groups take on more importance. When an adolescent is hospitalized, she is separated from her peer group and body image may be altered. Toddlers are in the developmental stage of autonomy versus shame and doubt. Preschool children are in the stage of initiative versus guilt. School-age children are in the stage of industry versus inferiority.

Nursing students are reviewing information about the various types of primary immunodeficiencies. The students demonstrate understanding of the material when they identify which of the following as an example of a primary immunodeficiency involving B-lymphocyte dysfunction?

IgA deficiency

Which of the following immunoglobulins assumes a major role in blood-borne and tissue infections?

IgG

After teaching a group of students about irritable bowel syndrome and antidiarrheal agents, the instructor determines that the teaching was effective when the students identify which of the following as an example of an opiate-related antidiarrheal agent?

Immodium

Bence Jones protein

Immunoglobulin (protein) fragment found in the urine of patients with multiple myeloma Presence of Bence Jones protein in the urine almost always confirms multiple myeloma, but absence doesn't rule it out.

A client with severe combined immunodeficiency is to receive a hematopoietic stem cell transplant. Which of the following would the nurse expect to be started?

Immunosuppressive agents

The nurse is caring for an elderly client with a respiratory infection. While reviewing age-related changes in the immune system, the nurse identifies which of the following as having contributed to this client's infection?

Impaired ciliary action as a result of exposure to environmental toxins

A student nurse is preparing a plan of care for a client with chronic pancreatitis. What nursing diagnosis related to the care of a client with chronic pancreatitis is the priority?

Impaired nutrition: less than body requirements

A fluid volume deficit can be caused by either dehydration or hypovolemia. What is the distinction between the two? a) In hypovolemia all fluid compartments have decreased volumes. b) In dehydration intracellular fluid volume is depleted. c) In hypovolemia only blood volume is low. d) In dehydration only blood volume is low.

In hypovolemia only blood volume is low - Dehydration results when the volume of body fluid is significantly reduced in both extracellular and...(more) Dehydration results when the volume of body fluid is significantly reduced in both extracellular and intracellular compartments. In dehydration, all fluid compartments have decreased volumes; in hypovolemia, only blood volume is low. This makes options A, B, and D incorrect.

The nurse plans to administer dexamethasone cream to a client who has dermatitis over the anterior chest. How should the nurse apply this topical agent?

In long, even, outward, and downward strokes in the direction of hair growth

The tongue

In many cases, the muscles controlling the tongue relax, causing the tongue to obstruct the airway. When this occurs, the nurse should use the head-tilt, chin-lift maneuver to cause the tongue to fall back in place. If a neck injury is suspected, the jaw- thrust maneuver must be performed. A foreign object, saliva or mucus, and edema are less common sources of airway obstruction in an unconscious adult.

You are performing pulmonary function studies on clients in the clinic. What position do you know a client should be in to have maximum lung capacities and volumes?

In the standing position

Which of the following would be inconsistent as criterion of extubation in the patient who has undergone a coronary artery bypass graft (CABG)?

Inability to speak

When the nurse notes that the post cardiac surgery patient demonstrates low urine output (< 25 mL/hr) with high specific gravity (> 1.025), the nurse suspects:

Inadequate fluid volume

Which of the following is the most important postoperative assessment parameter for patients undergoing cardiac surgery?

Inadequate tissue perfusion

The nurse is deciding whether to report a suspected case of child abuse. Which criterion is the most important for the nurse to consider?

Incompatibility between the history and the injury Explanation: Incompatibility between the history and the injury is the most important criterion on which to base the decision to report suspected child abuse. The other criteria also may suggest child abuse but are less reliable indicators.

Which diet plan is recommended for an infant with heart failure?

Increase caloric content per ounce Explanation: Formulas with increased caloric content are given to meet the greater caloric requirements from the overworked heart and labored breathing. Fluid restriction and low-sodium formulas aren't recommended. An infant's nutritional needs depend on fluid. Daily weights at the same time of the day on the same scale before feedings are recommended to follow trends in nutritional stability and diuresis. Low-sodium formulas may cause hyponatremia.

Which of the following is a gerontological consideration associated with the pancreas?

Increase in fibrous material

Which of the following is a characteristic of the intrarenal category of acute renal failure?

Increased BUN

Which of the following may occur with respiratory acidosis?

Increased Intracranial Pressure (ICP) - If respiratory acidosis is severe, intracranial pressure may increase, resulting in papilledema and dilated conjunctival blood vessels. Increased blood pressure, increased pulse, and decreased mental alertness occur with respiratory acidosis.

A client has a respiratory rate of 38 breaths/min. What effect does breathing faster have on arterial pH level?

Increased arterial pH - Respiratory alkalosis is always caused by hyperventilation, which is a decrease in plasma carbonic acid concentration. The pH is elevated above normal as a result of a low PaCO2.

Early signs of hypervolemia include

Increased breathing effort and weight gain - Early signs of hypervolemia are weight gain, elevated blood pressure, and increased breathing effort. Eventually, fluid congestion in the lungs leads to moist breath sounds. An earliest symptom of hypovolemia is thirst

When obtaining the vital signs of a client with multiple traumatic injuries, the nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication?

Increased intracranial pressure (ICP) Explanation: Decreased heart and respiratory rates and increased systolic blood pressure reflect Cushing's triad, which may develop when ICP increases. Shock typically causes tachycardia, tachypnea, and hypotension. In encephalitis, the temperature rises and the heart and respiratory rates may increase from the effects of fever on the metabolic rate. If the client doesn't maintain adequate hydration, hypotension may occur. Status epilepticus causes unceasing seizures, not changes in vital signs.

A client is receiving an I.V. infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant?

Increased urine output

A nurse who works in the OR is required to assess the patient continuously and protect the patient from potential complications. Which of the following would not be included as a symptom of malignant hyperthermia?

Increased urine output

The nurse is caring for a client with acute pyelonephritis. Which nursing intervention is most important?

Increasing fluid intake to 3 L/day Explanation: Acute pyelonephritis is a sudden inflammation of the interstitial tissue and renal pelvis of one or both kidneys. Infecting bacteria are normal intestinal and fecal flora that grow readily in urine. Pyelonephritis may result from procedures that involve the use of instruments (such as catheterization, cystoscopy, and urologic surgery) or from hematogenic infection. The most important nursing intervention is to increase fluid intake to 3 L/day. This helps empty the bladder of contaminated urine and prevents calculus formation. Administering a sitz bath would increase the likelihood of fecal contamination. Using an indwelling urinary catheter could cause further contamination. Encouraging the client to drink cranberry juice to acidify urine is helpful but isn't the most important intervention.

The nurse is caring for a client with acute pyelonephritis. Which nursing intervention is most important?

Increasing fluid intake to 3 L/day Explanation: Acute pyelonephritis is a sudden inflammation of the interstitial tissue and renal pelvis of one or both kidneys. Infecting bacteria are normal intestinal and fecal flora that grow readily in urine. Pyelonephritis may result from procedures that involve the use of instruments (such as catheterization, cystoscopy, and urologic surgery) or from hematogenic infection. The most important nursing intervention is to increase fluid intake to 3 L/day. This helps empty the bladder of contaminated urine and prevents calculus formation. Administering a sitz bath would increase the likelihood of fecal contamination. Using an indwelling urinary catheter could cause further contamination. Encouraging the client to drink cranberry juice to acidify urine is helpful but isn't the most important intervention.

Which symptom, when observed in laboring clients with gestational hypertension, would most likely indicate a worsening condition?

Increasing oliguria Explanation: Renal plasma flow and glomerular filtration are decreased in gestational hypertension, so increasing oliguria indicates a worsening condition. Blood pressure increases as a result of increased peripheral resistance. Increasing (not decreasing) edema would suggest a worsening condition. Trace levels to +1 proteinuria are acceptable; higher levels would indicate a worsening condition.

A client is diagnosed with deep vein thrombosis. Which nursing diagnosis should receive highest priority at this time?

Ineffective peripheral tissue perfusion related to venous congestion Explanation: Ineffective peripheral tissue perfusion related to venous congestion takes highest priority because venous inflammation and clot formation impede blood flow in a client with deep vein thrombosis. Option 1 is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Option 2 is inappropriate because no evidence suggests that this client has a excessive fluid volume. Option 3 may be warranted but is secondary to ineffective tissue perfusion.

Ineffective peripheral tissue perfusion related to venous congestion

Ineffective peripheral tissue perfusion related to venous congestion takes highest priority because venous inflammation and clot formation impede blood flow in a client with deep vein thrombosis. Option 1 is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Option 2 is inappropriate because no evidence suggests that this client has a excessive fluid volume. Option 3 may be warranted but is secondary to ineffective tissue perfusion.

A male client is scheduled for an electroencephalogram (EEG). When the nurse caring for the client is preparing him for the test, the client states that during childhood he was mildly electrocuted but miraculously lived. Therefore, he is quite afraid of going through an EEG. In what ways can the nurse help dispel the client's fear regarding the test?

Inform the client that he will not experience any electrical shock.

Which of the following is a true statement regarding the role of baroreceptors?

Initiates the parasympathetic response Explanation: During elevations of blood pressure, the baroreceptors increase their rate of discharge. This initiates parasympathetic activity and inhibits sympathetic response, lowering the heart rate and blood pressure.

A nurse is inserting a nasogastric tube in an alert client. During the procedure, the client begins to cough constantly and has difficulty breathing. The nurse suspects the nasogastric tube is

Inserted into the lungs

Which of the following would be an intervention for a patient with a chemical burn to the esophagus?

Insertion of nasogastric tube

When examining the abdomen of a client with complaints of nausea and vomiting, which of the following would the nurse do first?

Inspection

Which action should a nurse take first when admitting a client with herpes zoster infection?

Institute isolation precautions according to facility policy.

Which action should a nurse take first when admitting a client with herpes zoster infection?

Institute isolation precautions according to facility policy. Explanation: The nurse should first institute isolation precautions to prevent the spread of the herpes zoster infection. After isolation precautions are in effect, the nurse can instruct the client to wear light clothing and provide a tepid bath to promote client comfort. The nurse should also caution the client against scratching the lesions because that might cause infection and scarring.

A client has a cheesy white plaque in the mouth. The plaque looks like milk curds and can be rubbed off. The best nursing intervention is to

Instruct the client to swish prescribed nystatin (Mycostatin) solution for 1 minute.

A new nurse auscultates adventitious breath sounds but is not sure what to document and confers with an experienced nurse. This experienced nurse documents a pleural friction rub. Which of the following did the experienced nurse do during her assessment to identify the rub?

Instructed the client to hold the breath

Which nursing intervention takes highest priority when caring for a client who's receiving a blood transfusion?

Instructing the client to report any itching, swelling, or dyspnea Explanation: Because administration of blood or blood products may cause serious adverse effects such as allergic reactions, the nurse must monitor the client for these effects. Signs and symptoms of life-threatening allergic reactions include itching, swelling, and dyspnea. Although the nurse should inform the client of the duration of the transfusion and should document its administration, these actions are less critical to the client's immediate health. The nurse should monitor vital signs 5 minutes after the transfusion is started, again in 15 minutes, and then at least hourly depending on the client's condition.

Which medication is considered safe during pregnancy?

Insulin Explanation: Insulin is a required hormone for any client with diabetes mellitus, including the pregnant client. Aspirin, magnesium hydroxide, and oral antidiabetic agents aren't recommended for use during pregnancy because these agents may cause fetal harm.

A 2-year-old child is brought to the emergency department with suspected croup. Which data collection finding reflects increasing respiratory distress?

Intercostal retractions Explanation: Clinical manifestations of respiratory distress include tachypnea, tachycardia, restlessness, dyspnea, and intercostal retractions. Fever is a sign of infection. Bradycardia is a late sign of impending respiratory arrest. Cyanosis, not pallor, is a sign of increasing respiratory distress.

The body has several mechanisms to fight disease, one of which is sending chemical messengers. Specifically, the messengers released by lymphocytes, monocytes, and macrophages have differing roles in the immune response. Which messenger enables cells to resist viral replication and slow viral replication?

Interferons

A toddler is brought to the emergency department in cardiac arrest. The physician tries three times to insert an I.V. catheter but is unsuccessful. By which alternate route can the physician administer emergency medications?

Intraosseously Explanation: The physician can safely administer emergency medications, such as sodium bicarbonate, calcium, glucose, crystalloids, colloids, blood, dopamine, epinephrine, and dobutamine by the intraosseous route if the I.V. route is inaccessible. Emergency medications shouldn't be administered by the sublingual, topical, or subcutaneous routes.

Milieu Therapy

Involved clients' interactions with one another, including practicing interpersonal relationship skills, giving one another feedback about behavior, and working cooperatively as a group to solve day-to-day problems.

The nurse is caring for a client who underwent a subtotal gastrectomy 36 hours ago. The client has a nasogastric (NG) tube. The nurse knows to do the following with the NG:

Irrigate the NG tube with NS if ordered

Patients diagnosed with hypervolemia should avoid sweet or dry food because:

It increases the client's desire to consume fluid. - The management goal in hypervolemia is to reduce fluid volume. For this reason, fluid is rationed, and the client is advised to take limited amount of fluid when thirsty. Sweet or dry food can increase the client's desire to consume fluid. Sweet or dry food does not obstruct water elimination nor does it cause dehydration. Weight regulation is not part of hypervolemia management except to the extent that it is achieved on account of fluid reduction.

Your six-year-old son, Austin, was riding his bike outside and fell - resulting in an impressive case of road rash on his left lateral thigh. Since you're studying hematopoiesis in nursing school, you begin to explain the wound-healing process to him to distract him from his painful wound management. Which of the following best describes the function of fibrinogen?

It plays a key role in forming blood clots

Ada Zontor, a 60-year-old bookkeeper, is a client with the neurological group where you practice nursing. Mrs. Zontor has been exhibiting neurological symptoms for several weeks and the neurologist is admitting her to hospital for extensive testing. Since diagnostics have not yet revealed the cause of her difficulties, which of her following comments would indicate the need for further client education?

It's good to know the continual tingling in my fingers and toes is not connected with my nervous system!

A 4-year-old child had a subungual hemorrhage of the toe after a jar fell on his foot. Electrocautery is performed. Which teaching statement regarding the rationale for using electrocautery to treat the injury is most accurate?

It's used to relieve pain and reduce the risk of infection Explanation: The hematoma is treated with electrocautery to relieve pain and reduce the risk of infection. Electrocautery doesn't prevent the loss of the nail. The discoloration seen with subungual hemorrhage is from the collection of blood under the nail bed. It isn't permanent and doesn't affect nail growth.

High LDL Levels

Jack Donohue, a 62-year-old stock broker, attends his annual physical appointment and indicates physical changes since his last examination. He reports chest pain and palpitation during and after his morning jogs. Jack's family history reveals includes coronary artery disease. His lipid profile reveals his LDL level to be 122 mg/dl. Which of the following correctly states the Jack's condition?

A new client has been admitted with right-sided heart failure. The nurse knows to look for which of the following assessment findings when assessing this client?

Jugular vein distention

Nursing students are reviewing information about the different manifestations associated with AIDS. The students demonstrate understanding of these manifestations when they identify which of the following as the most common HIV-related malignancy?

Kaposi's Sarcoma

Which of the following mouth conditions are associated with HIV infection?

Karposi's Sarcoma

The nurse is helping a patient to correctly perform peritoneal dialysis at home. The nurse must educate the patient about the procedure. Which educational information should the nurse provide to the patient?

Keep the dialysis supplies in a clean area, away from children and pets

The nurse wants to help a client maintain healthy skin. Which nursing intervention will help achieve this goal?

Keeping the client well-hydrated

Which intervention has the highest priority when providing skin care to a bedridden client?

Keeping the skin clean and dry without using harsh soaps

An 83-year-old client is undergoing lipid profile studies in an effort to determine a proper nutritional balance for his CAD. In his lipid profile, his LDL is greater than his HDL. Why is this a risk factor for this client?

LDL sticks to the arteries

A 68-year-old resident at a long-term care facility lost the ability to swallow following a stroke 4 years ago. She receives nutrition via a PEG tube. The client remains physically and socially active and has adapted well to the tube feedings. Occasionally, the client develops constipation that requires administration of a laxative to restore regular bowel function. Which of the following is the most likely cause of this client's constipation?

Lack of free water intake

An unemployed woman, age 24, seeks help because she feels depressed and abandoned and doesn't know what to do with her life. Last week, her boyfriend broke up with her after she drove his car into a tree after an argument. The client's initial diagnosis is borderline personality disorder. Which nursing observations support this diagnosis?

Lack of self-esteem, strong dependency needs, and impulsive behavior Explanation: Borderline personality disorder is characterized by lack of self-esteem, strong dependency needs, and impulsive behavior. Instability in interpersonal relationships, mood, and poor self-image also are common. The client typically can't tolerate being alone and expresses feelings of emptiness or boredom. Flat affect, social withdrawal, and unusual dress are characteristic of schizoid personality disorder. Suspiciousness, hypervigilance, and emotional coldness are seen in paranoid personality disorders. In antisocial personality disorder, clients are usually insensitive to others and act out sexually; they may also be violent.

Which of the following nutritional deficiencies may delay wound healing?

Lack of vitamin C

What's the best way for a nurse to position a 3-year-old child with right lower lobe pneumonia?

Left side-lying Explanation: The child with right lower lobe pneumonia should be placed on his left side. This places the unaffected left lung in a position that allows gravity to promote blood flow though the healthy lung tissue and improve gas exchange. Placing the child on his right side, back, or stomach doesn't promote circulation to the unaffected lung.

After an anterior wall myocardial infarction (MI), which problem is indicated by auscultation of crackles in the lungs?

Left-sided heart failure Explanation: The left ventricle is responsible for most of the cardiac output. An anterior wall MI may result in a decrease in left ventricular function. When the left ventricle doesn't function properly, resulting in left-sided heart failure, fluid accumulates in the interstitial and alveolar spaces in the lungs and causes crackles. Pulmonic and tricuspid valve malfunction causes right-sided heart failure.

After an anterior wall myocardial infarction (MI), which problem is indicated by auscultation of crackles in the lungs?

Left-sided heart failure Explanation: The left ventricle is responsible for most of the cardiac output. An anterior wall MI may result in a decrease in left ventricular function. When the left ventricle doesn't function properly, resulting in left-sided heart failure, fluid accumulates in the interstitial and alveolar spaces in the lungs and causes crackles. Pulmonic and tricuspid valve malfunction causes right-sided heart failure.

Which of the following should not be allowed with regards to the wearing of masks in the operating room?

Let masks hang around the neck

A client has a leukocyte count of 3,000/mm3. How would the nurse document the client's condition?

Leukopenia

A nurse is teaching a client who receives nitrates for the relief of chest pain. Which instruction should the nurse emphasize?

Lie down or sit in a chair for 5 to 10 minutes after taking the drug.

Antimanic

Lithium was one of the first psychotropic drugs developed. Lithium is in which of the following medication classifications?

For a patient with salivary calculi, which of the following procedures uses shock waves to disintegrate the stone?

Lithotripsy

Albumin is important for the maintenance of fluid balance within the vascular system. Albumin is produced by which of the following?

Liver

A client with cancer is being evaluated for possible metastasis. Which of the following is a common metastasis site for cancer cells?

Liver Explanation: The liver is one of the five most common cancer metastasis sites. The others are the lymph nodes, lung, bone, and brain. The colon, reproductive tract, and WBCs are occasional metastasis sites.

A client is being prepared to undergo laboratory and diagnostic testing to confirm the diagnosis of cirrhosis. Which test would the nurse expect to be used to provide definitive confirmation of the disorder?

Liver biopsy

Which characteristics would the nurse expect to see in the client with schizophrenia?

Loose associations, grandiose delusions, and auditory hallucinations Explanation: Loose associations, grandiose delusions, and auditory hallucinations are all characteristic of the classic schizophrenic client. These clients aren't able to care for their physical appearance. They frequently hear voices telling them to do something either to themselves or to others. Additionally, they verbally ramble from one topic to the next. Periods of hyperactivity and irritability alternating with depression are characteristic of bipolar disorder. Delusions of jealousy and persecution, paranoia, and mistrust are characteristics of paranoid disorders. Sadness, apathy, feelings of worthlessness, anorexia, and weight loss are characteristics of depression.

A physician orders spironolactone (Aldactone), 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect?

Loss of 1 kg in 24 hours

The nurse is caring for an 82-year-old male client who has come to the clinic for a yearly physical. When assessing the client, the nurse notes the blood pressure (BP) is 140/93. The nurse knows that in older clients what happens that may elevate the systolic BP?

Loss of arterial elasticity

A patient is receiving anticoagulant therapy. The nurse should be alert to potential signs and symptoms of external or internal bleeding, as evidenced by which of the following?

Low BP

A client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system, the nurse states that humoral immunity is provided by which type of white blood cell?

Lymphocyte

Which cells are white blood cells with immune functions?

Lymphocytes

The nursing students are learning about the immune system in their anatomy and physiology class. What would these students learn is a component of the immune system?

Lymphoid Tissues

A physician has ordered that a client with suspected lung cancer undergo magnetic resonance imaging (MRI). The nurse explains the benefits of this study to the client. Included in teaching would be which of the following regarding the MRI?

MRI can view soft tissues and can help stage cancers.

A critical care nurse is caring for a client with acute pancreatitis. One potentially severe complication involves the respiratory system. Which of the following would be an appropriate intervention to prevent complications associated with the respiratory system?

Maintain patient in Semi-Fowlers position

Ralph Wilson, is a 52-year-old client in the hospital unit where you practice nursing. He is being treated for myocarditis. Which of the following nursing interventions should you perform to reduce cardiac workload in a client with myocarditis?

Maintain pt on bed rest

A critical care nurse is caring for a client with pancreatitis. One potentially severe complication involves the respiratory system. Which of the following would be an appropriate intervention to prevent complications associated with the respiratory system?

Maintain the client in a semi-Fowler's position.

Ralph Wilson, is a 52-year-old client in the hospital unit where you practice nursing. He is being treated for myocarditis. Which of the following nursing interventions should you perform to reduce cardiac workload in a client with myocarditis?

Maintain the client on bed rest

A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, the nurse should assign highest priority to:

Maintaining patent airway

A client with cancer has a neck dissection and laryngectomy. An intervention that the nurse will do is:

Make a notation in the call light system that the patient cannot speak

The nurse is teaching parents about accident prevention for a toddler. Which of the following guidelines is most appropriate?

Make sure all medications are kept in containers with childproof safety caps. Explanation: All over-the-counter and prescription medications should have childproof safety caps. Poisoning accidents are common in toddlers, due to the toddler's curiosity and his increasing mobility and ability to climb. When riding in a car, a toddler should be strapped into a car seat. Wearing a seat belt is an appropriate guideline for a school-age child. Never leaving a child alone on a bed is an appropriate guideline for parents of infants. Toddlers already have the ability to climb on and off of beds and other furniture by themselves. Note, however, that toddlers should never be left unattended on high surfaces, such as an examining table in a physician's office. Toddlers should be in a rear-facing convertible car seat; those who weigh 20 to 40 lb can be placed facing forward.

The nurse is aware that the most prevalent cause of immunodeficiency worldwide is

Malnutrition

Why is it important for a nurse to provide required information and appropriate explanations of diagnostic procedures to patients with respiratory disorders?

Manage decreased energy levels

Denial.

Many families take years to understand that a member is mentally ill and to identify the warning signs of relapse. During this period, they try to normalize puzzling behaviors. This is called

From the following profiles of clients, which client would be most likely to undergo the diagnostic test of cholecystography?

Mark, suspected of having stones in the gallbladder

When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider?

Measure abdominal girth according to a set routine.

A nurse is caring for a client who is at risk for skin breakdown. To decrease the risk, the nurse must help ensure that the client remains adequately hydrated. Which action can the nurse take to help determine the client's fluid needs?

Measure intake and output.

The mother of a preschooler recently diagnosed with type 1 diabetes mellitus makes an urgent call to the pediatrician's office. She says her child had an uncontrollable temper tantrum while playing and now is lethargic and hard to arouse. The nurse should instruct the mother to take which action first?

Measure the child's blood glucose level. Explanation: In a child with type 1 diabetes mellitus, behavioral changes may signal either hypoglycemia or hyperglycemia; measuring the blood glucose level is the only way to determine which condition is present. Urine glucose measurement doesn't accurately reflect the current blood glucose level. Forcing a lethargic child to drink fluids could cause aspiration. After measuring the child's blood glucose level, the mother may need to take additional emergency measures such as administering insulin or a simple glucose source. If the child doesn't respond to these measures, the mother may need to call for emergency help.

Your client's lab values are sodium 166 mEq/L, potassium 5.0 mEq/L, chloride 115 mEq/L, and bicarbonate 35 mEq/L. What condition is this client likely to have, judging by anion gap?

Metabolic Acidsosis - The anion gap is the difference between sodium and potassium cations and the sum of chloride and bicarbonate anions. An anion gap that exceeds 16 mEq/L indicates metabolic acidosis. In this case, the anion gap is (166 + 5) minus (115 + 35), yielding 21 mEq/L, which suggests metabolic acidosis. Anion gap is not used to check for respiratory alkalosis, metabolic alkalosis, or respiratory acidosis

A client has been diagnosed with an intestinal obstruction and has a nasogastric tube set to low continuous suction. Which acid-base disturbance is this client at risk for developing?

Metabolic Alkalosis - Metabolic alkalosis is a clinical disturbance characterized by a high pH and a high plasma biacarbonate concentration. The most common cuase of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and choloride ions. Gastric fluid has an acid pH, and loss of this acidic fluid increases the alkalinity of body fluids.

The nurse is caring for a client who has bulimia. What is a common metabolic complication associated with bulimia?

Metabolic alkalosis Explanation: With repeated emesis, the client with bulimia loses stomach acids, thus becoming alkalotic. Respiratory pH disturbances aren't directly related to bulimia.

A client presents to the emergency department, reporting that he has been vomiting every 30 to 40 minutes for the past 8 hours. Frequent vomiting puts this client at risk for which imbalances?

Metabolic alkalosis and hypokalemia

A nurse is preparing an in-service presentation about primary immunodeficiencies. When describing these conditions, which of the following would the nurse need to integrate into the presentation?

Most cases are typically diagnosed in infancy

Which of the following is a term that refers to individual, family, group, and cultural expressions of grief and associated behaviors?

Mourning

The Family Nurse Practitioner is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly?

Moving the head and chin toward the chest

Following a unilateral adrenalectomy, a nurse should assess for hyperkalemia as indicated by:

Muscle Weakness - Muscle weakness, bradycardia, nausea, diarrhea, and paresthesia of the hands, feet, tongue, and face are findings associated with hyperkalemia, which is transient and results from transient hypoaldosteronism when the adenoma is removed. Tremors, diaphoresis, and constipation aren't seen in hyperkalemia.

The nurse is talking with a client who is scheduled for a computed tomography (CT) colonography. Which client statement would indicate to the nurse that the client needs additional teaching about this procedure?

My doctor will be able to remove any polyps he finds

A nurse is caring for a client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission?

NPO

Which of the following is the most common symptom of gastrointestinal (GI) problems in general?

Nausea

A client with chronic schizophrenia who takes neuroleptic medication is admitted to the psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, tachycardia, altered consciousness, and diaphoresis. These findings suggest which life-threatening reaction?

Neuroleptic malignant syndrome Explanation: The client's signs and symptoms suggest neuroleptic malignant syndrome, a life-threatening reaction to neuroleptic medication that requires immediate treatment. Tardive dyskinesia causes involuntary movements of the tongue, mouth, facial muscles, and arm and leg muscles. Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles. Akathisia causes restlessness, anxiety, and jitteriness.

Which type of white blood cell (WBC) is the most numerous?

Neutrophil

When teaching a client with intertrigo about prescribed skin care measures, the nurse should include which important instruction to prevent Candida albicans overgrowth?

Never apply cornstarch to the affected areas.

A client is receiving parenteral nutrition (PN) through a peripherally inserted central catheter (PICC) and will be discharged home with PN. The home health nurse evaluates the home setting and makes a recommendation when noting the following:

No land line; cell phone available and taken by family member during working hours

Which of the following venous access devices can be used for less than 6 weeks in patients requiring parenteral nutrition?

Non-tunneled catheter

Students are reviewing information from the Centers for Disease Control and Prevention (CDC) for a class presentation about preventing the transmission of HIV transmission. Which of the following would the students be least likely to include in their presentation?

Nonlatex lambskin condoms are highly effective in preventing HIV infection

Which of the following venous access devices can be used for less than 6 weeks in patients requiring parenteral nutrition?

Nontunneled catheter

When bowel sounds are heard about every 15 seconds, the nurse would record that the bowel sounds are

Normal

A nurse discovers that a stat dose of potassium chloride that was prescribed by the physician was never administered. Which action should the nurse take?

Notify the charge nurse so she can notify the physician of the missed dose. Explanation: An error was made that needs to be addressed by notifying the charge nurse. The charge nurse should then notify the physician to determine if the medication is still appropriate for the client, and then request the medication from the pharmacy if it's still needed. The physician might order a potassium level to see if the dose is sufficient for the client. It isn't appropriate to ask the client if the medication is still needed. After the charge nurse and physician have been notified, the nurse should document the incident according to facility policy.

The nurse sees an unauthorized person reading a client's medical record outside a client's room. Which action should the nurse take?

Notify the nursing supervisor and approach the individual. Explanation: Approaching the person and requesting the client's medical record isn't sufficient considering the confidential health care information. Notifying the nursing supervisor, then approaching the individual before informing the client provides the most appropriate approach to this breech of client confidentiality. Contacting security might not be warranted unless the nurse learns the reason the unauthorized individual was reading the client's chart. The nurse should also document the incident according to facility policy.

A patient comes in to get an EIA test done because her physician suspects AIDS. Which of the following nursing actions is essential before an EIA test is performed?

Obtaining consent from patient

Which of the following medications is classified as a proton pump inhibitor (PPI)?

Omeprazole

A patient has undergone a liver biopsy. Which of the following postprocedure positions is appropriate?

On the right side

Establishment or enlargement of state hospitals.

One of the primary reforms accomplished by Dorothea Lynde Dix was the:

A client is scheduled for the following tests: barium enema, small bowel series, enteroclysis enema, and an oral cholecystogram. Which test would the nurse expect the client to undergo first?

Oral cholecystogram

Which adverse effect can be expected by the parents of a 2-year-old child who has been started on rifampin after testing positive for tuberculosis?

Orange body secretions Explanation: Rifampin and its metabolites will turn urine, feces, sputum, tears, and sweat an orange color. This isn't a serious adverse effect. Rifampin may also cause GI upset, headache, drowsiness, dizziness, vision disturbances, and fever. Liver enzyme and bilirubin levels increase because of hepatic metabolism of the drug. Parents should be taught the signs and symptoms of hepatitis and hyperbilirubinemia such as jaundice of the sclera or skin.

When assessing a client, which adaptation indicates the presence of respiratory distress?

Orthopnea

Which of the following terms is used to describe the inability to breathe easily except in an upright position?

Orthopnea

Oncotic pressure refers to the

Osmotic pressure exerted by proteins - Oncotic pressure is a pulling pressure exerted by proteins, such as albumin. Osmolality refers to the number of dissolved particles contained in a unit of fluid. Osmotic diuresis occurs when the urine output increases due to excretion of substances such as glucose. Osmotic pressure is the amount of pressure needed to stop the flow of water by osmosis.

Which diagnostic produces images of the body by detecting the radiation emitted from radioactive substances?

PET Scan

A client with carcinoma of the head of the pancreas is scheduled for surgery. Which of the following should the nurse administer to the client before surgery?

Packed RBCs

A client is scheduled for an esophagogastroduodenoscopy (EGD) to detect lesions in the gastrointestinal tract. The nurse would observe for which of the following while assessing the client during the procedure?

Pain and discomfort tolerance

Which finding is an early indicator of bladder cancer?

Painless, intermittent hematuria Explanation: As cancer cells destroy normal bladder tissue, bleeding occurs and causes painless, intermittent hematuria. (Pain is a late symptom of bladder cancer.) The other options aren't associated with bladder cancer. Occasional polyuria may occur with diabetes or increased alcohol or caffeine intake. Nocturia commonly accompanies benign prostatic hypertrophy. Dysuria may indicate a urinary tract infection (UTI).

Which of the following is the major cause of morbidity and mortality in patients with acute pancreatitis?

Pancreatic necrosis

The surgical team: Consist of?

Patient, anesthesiologist or anesthetist, surgeon, nurses &surgical technologist/ assistants!

Acetylcholine

Patients diagnosed with myasthenia gravis have a decrease in which of the following receptors?

Tyramine

Patients taking monoamine oxidase inhibitors (MAOIs) for depression must be placed on a diet that is low in which of the following?

The term that describes the percentage of individuals known to carry the gene for a trait and who actually manifest the condition is

Penetrance

Postpericardiotomy syndrome may occur in patients who undergo cardiac surgery. The nurse should be alert to which of the following clinical manifestations associated with this syndrome?

Pericardial friction rub

A client undergoing a diagnostic examination for gastrointestinal disorder was given polyethylene glycol/electrolyte solution as a part of the test preparation. Which of the following measures should the nurse take once the solution is administered?

Permit to drink only clear liquids

A majority of patients with CVID develop which type of anemia?

Pernicious

A client is examined and found to have pinpoint, pink-to-purple, nonblanching macular lesions 1 to 3 mm in diameter. Which term best describes these lesions?

Petechiae Explanation: Petechiae are small macular lesions 1 to 3 mm in diameter. Ecchymosis is a purple-to-brown bruise, macular or papular, that varies in size. A hematoma is a collection of blood from ruptured blood vessels that's more than 1 cm in diameter. Purpura are purple macular lesions larger than 1 cm.

Which of the following is a term used to describe the process of ingestion and digestion of bacteria by cells?

Phagocytosis

The nurse is caring for a pregnant woman who is undergoing prenatal screening for genetic conditions. When developing the client's teaching plan about the conditions associated with this screening, which condition would the nurse least likely include?

Phenylketonuria

A 2-year-old child is admitted to the pediatric unit with the diagnosis of bacterial meningitis. Which diagnostic measure would be appropriate for the nurse to perform first?

Place the toddler in respiratory isolation Explanation: Nurses should take necessary precautions to protect themselves and others from possible infection from the bacterial organism causing meningitis. The affected child should immediately be placed in respiratory isolation; then the parents can be informed about the treatment plan. This should be done before laboratory tests are performed.

Which intervention by a nurse might help prevent pressure ulcers?

Placing an alternating-current mattress on the client's bed

A recent abduction of a 2-month-old infant has raised awareness of the need for security plans for hospitals. Which security measure helps ensure the hospitalized infant's security?

Placing an identification bracelet on the infant and the parent immediately on admission Explanation: The safest way to ensure that the parents or legal guardians are who they say they are is to place a bracelet on both the infant and the parents or guardians at the time of admission. Limiting visitors isn't necessary. Locking the door and having visitors call the nurses' station for admission increases the workload of the nursing staff. It isn't feasible to place security guards at the entrances.

Which cells have the lifespan of approximately 7.5 days and one-third of their population remains in the spleen (unless needed to fight significant bleeding)?

Platelets

While hospitalized, a client accidentally injures his finger and begins to bleed. What substance does the nurse recognize as naturally rushing to the site of injury before any other action takes place?

Platelets

A client is admitted to a healthcare facility with minor lacerations on the leg. The nurse caring for this client observes swelling in the tissues surrounding the affected area. A blood clot is suspected. The nurse should know that which of the following is the first step when the formation of a blood clot begins?

Platelets break down and migrate to the injured area

Which of the following medications is given to patients diagnosed with angina and is allergic to aspirin?

Plavix

A client with AIDS is exhibiting shortness of breath, cough, and fever. The nurse most likely would suspect infection with which of the following?

Pneumocystis jiroveci

Which of the following is caused by improper catheter placement and inadvertent puncture of the pleura?

Pneumothorax

A nurse is assisting with screening of specific ethnic groups to identify possible cancer-predisposing genes. The nurse is engaged in which of the following?

Population screening

A client is weak and drowsy after a lumbar puncture. The nurse caring for the client knows that what priority nursing intervention should be provided after a lumbar puncture?

Position the client flat for at least 3 hours.

The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action?

Position the client to maintain a patent airway.

The nurse is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the plan of care?

Post a turning schedule at the client's bedside.

A physician orders digoxin (Lanoxin) for a client with heart failure. During digoxin therapy, which laboratory value may predispose the client to digoxin toxicity?

Potassium level of 2.8 mEq/L

The nurse is performing wound care. Which of the following practices violates surgical asepsis?

Pouring solution onto a sterile field cloth

The nurse is performing wound care on a client. Which task indicates surgical asepsis?

Preparing sterile surgical instruments for the physician to debride the wound

Which of the following represents a responsibility of the scrub nurse?

Preparing sutures

Which terms refers to the progressive hearing loss associated with aging? a) Otalgia b) Sensorineural hearing loss c) Presbycusis d) Exostoses

Presbycusis Correct Explanation: Both middle and inner ear age-related changes result in hearing loss. Exostoses refer to small, hard, bony protrusions in the lower posterior bony portion of the ear canal. Otalgia refers to a sensation of fullness or pain in the ear. Sensorineural hearing loss is loss of hearing related to damage of the end organ for hearing and/or cranial nerve VIII.

When assisting in developing a plan of care for a hospitalized child, the nurse knows that children in which age-group are most likely to view illness as a punishment for misdeeds?

Preschool age Explanation: School-age children are most likely to view illness as a punishment for misdeeds. Separation anxiety, although seen in all age-groups, is most common in older infants. Fear of death is typical of older children and adolescents.

What is the major purpose of withholding food and fluid before surgery?

Prevent aspiration

What are antigens?

Protein markers on cells

A 44-year-old client is in the hospital unit where you practice nursing. From the results of a series of diagnostic tests, she has been diagnosed with acute glomerulonephritis. What would you expect to find as a result of this condition?

Proteinuria

The nurse observes dry mucous membranes in a client who is receiving tube feedings after an oral surgery. The client also complains of unpleasant tastes and odors. Which of the following measures should be included in the client's plan of care?

Provide frequent mouth care

Which of the following would be the highest priority, immediate nursing intervention for a client just diagnosed with acute gastritis?

Provide physical and emotional support

A client with a disorder of the oral cavity cannot tolerate tooth brushing or flossing. Which of the following strategies can the nurse employ to assist this client?

Provide the client with an irrigating solution of baking soda and warm water.

A child, age 14, is hospitalized for nutritional management and drug therapy after experiencing an acute episode of ulcerative colitis. Which nursing intervention would be appropriate?

Providing small, frequent meals Explanation: Clients with ulcerative colitis, also known as inflammatory bowel syndrome, tolerate small, frequent meals better than a few large meals daily. Eating large amounts of food may exacerbate the abdominal distention, cramps, and nausea typically caused by ulcerative colitis. Frequent meals also provide the additional calories needed to restore nutritional balance. This client doesn't lack digestive enzymes and therefore doesn't need enzyme supplementation. Antibiotics are contraindicated because they may interfere with the actions of other prescribed drugs and because ulcerative colitis isn't caused by bacteria. High-fiber foods may irritate the bowel further.

Which of the following is an enzyme that begins the digestion of starches?

Ptyalin

A client is admitted to the hospital with systolic left-sided heart failure. The nurse knows to look for which of the following assessment findings for this client?

Pulmonary congestion

Which of the following is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SaO2)?

Pulse Oximetry

The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease?

Purpura and petechiae

Which of the following would be inconsistent as a lifestyle change directive for the patient diagnosed with heart failure?

Push fluids

The nurse is reviewing the results of a urinalysis on a client with acute pyelonephritis. Which of the following would the nurse most likely expect to find?

Pyuria

Your client, a 2-year-old male, is scheduled to have surgery related to his cleft palate. You will be preparing this client for which type of surgery?

Reconstructive

When interviewing a client with internal hemorrhoids, which of the following would the nurse expect the client to report?

Rectal Bleeding

When interviewing a client with internal hemorrhoids, which of the following would the nurse expect the client to report?

Rectal bleeding

Which of the following is the most common symptom of a polyp?

Rectal bleeding

Following ingestion of carrots or beets, the nurse would expect which alteration in stool color?

Red

A client with an intravenous infusion is rubbing his arm. The nurse assesses the site and decides to discontinue the current infusion because of concern that the client has developed phlebitis. Which of the following clinical manifestations would the nurse assess with phlebitis? Select all that apply. • Reddended area along the path of the vein • Tender area around the insertion site • Ecchymosis at the insertion site • Rapid, shallow respirations • Cool area around the insertion site

Reddended area along the path of the vein & Tender area around the insertion site -Phlebitis is inflammation of a vein and is characterized by a reddened, warm area around an insertion site or along the path of a vein. The involved area is also tender and swollen. The nurse assesses infusion sites and determines the proper action to take. If indications lead to suspected phlebitis, the nurse will discontinue the intravenous line and restart with a different vessel.

Which of the following is a function of calcitonin? Select all that apply.

Reduces bone resorption, Increases urinary excretion of calcium, Increases deposition of calcium in bones - Calcitonin reduces bones resorption, increasing deposition of calcium and phosphorous in the bones, and increases urinary excretion of calcium and phosphate.

Circulating nurse (circulator)

Registered nurse who coordinates and documents patient care in the operating room.

Which of the following medications, used in the treatment of GERD, accelerate gastric emptying?

Reglan

A student nurse is working with a client who is diagnosed with head trauma. The nurse has documented Cheyne-Stokes respirations. The student would expect to see which of the following?

Regular breathing where the rate and depth increase, then decrease

A client with atopic dermatitis is prescribed a potent topical corticosteroid. To address a potential client problem associated with this treatment, the nurse helps formulate the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement, which ""related-to"" phrase should be added?

Related to percutaneous absorption of the topical corticosteroid

A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client?

Relieving abdominal pain

Which of the following is the most successful treatment for gastric cancer?

Removal of the tumor

When a central venous catheter dressing becomes moist or loose, what should a nurse do first?

Remove the dressing, clean the site, and apply a new dressing.

The nurse is screening donors for blood donation. The client who is an acceptable donor for blood is the client who

Reports having a cold 1 month ago that resolved quickly

A client being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk?

Reposition q 2hrs

A client with pancreatitis is admitted to the medical intensive care unit. Which nursing intervention is most appropriate?

Reserving an antecubital site for a peripherally inserted central catheter (PICC)

A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance?

Respiratory Acidosis - Respiratory acidosis is always from inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2 concentrations. Respiratory acidosis can occur in diseases that impair respiratory muscles such as myasthenia gravis.

A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate?

Respiratory Alkalosis - A client with pneumonia may hyperventilate in an effort to increase oxygen intake. Hyperventilation leads to excess carbon dioxide (CO2) loss, which causes alkalosis — indicated by this client's elevated pH value. With respiratory alkalosis, the kidneys' bicarbonate (HCO3-) response is delayed, so the client's HCO3- level remains normal. The below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2 loss and signals a respiratory component. Because the HCO3- level is normal, this imbalance has no metabolic component. Therefore, the client is experiencing respiratory alkalosis.

A client comes to the emergency department with status asthmaticus. His respiratory rate is 48 breaths/minute, and he is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 of 70 mm Hg, and bicarbonate (HCO3??') of 26 mEq/L. What disorder is indicated by these findings?

Respiratory Alkalosis - Respiratory alkalosis results from alveolar hyperventilation. It's marked by a decrease in PaCO2 to less than 35 mm Hg and an increase in blood pH over 7.45. Metabolic acidosis is marked by a decrease in HCO3? to less than 22 mEq/L, and a decrease in blood pH to less than 7.35. In respiratory acidosis, the pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg. In metabolic alkalosis, the HCO3? is greater than 26 mEq/L and the pH is greater than 7.45.

A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects:

Respiratory Alkalosis - This client's above-normal pH value indicates alkalosis. The below-normal PaCO2 value indicates acid loss via hyperventilation; this type of acid loss occurs only in respiratory alkalosis. These ABG values wouldn't occur in metabolic acidosis, respiratory acidosis, or metabolic alkalosis.

A client comes to the emergency department with status asthmaticus. His respiratory rate is 48 breaths/minute, and he is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 of 70 mm Hg, and bicarbonate (HCO3??') of 26 mEq/L. What disorder is indicated by these findings?

Respiratory alkalosis - Respiratory alkalosis results from alveolar hyperventilation. It's marked by a decrease in PaCO2 to less than 35 mm Hg and an increase in blood pH over 7.45. Metabolic acidosis is marked by a decrease in HCO3? to less than 22 mEq/L, and a decrease in blood pH to less than 7.35. In respiratory acidosis, the pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg. In metabolic alkalosis, the HCO3? is greater than 26 mEq/L and the pH is greater than 7.45.

A 12-year-old child diagnosed with muscular dystrophy is hospitalized secondary to a fall. Surgery is necessary as well as skeletal traction. Which complication would be of greatest concern to the nursing staff?

Respiratory infection Explanation: Respiratory infection can be fatal for children with muscular dystrophy due to poor chest expansion and decreased ability to mobilize secretions. Skin integrity, infection of pin sites, and nonunion healing are all causes for concern, but not as important as prevention of respiratory infection.

A nurse is caring for a client after a lung biopsy. Which assessment finding requires immediate intervention?

Respiratory rate of 44 breaths/minute

A teenager is brought to the facility by friends after accidentally ingesting gasoline while siphoning it from a car. Based on the nurse's knowledge of petroleum distillates, which system would be most affected?

Respiratory system Explanation: The primary concern with petroleum distillate ingestion is its effect on the respiratory system. Aspiration or absorption of petroleum distillates can cause severe chemical pneumonitis and impaired gas exchange. The GI, neurologic, and cardiovascular systems may be affected if the petroleum contains additives such as pesticides.

Which stage of the immune response occurs when the differentiated lymphocytes function in either a humoral or a cellular capacity?

Response stage

The nurse is assessing a client for constipation. Which of the following is the first review that the nurse should conduct in order to identify the cause of constipation? Choose the correct option.

Review the client's usual pattern of elimination

A nurse is obtaining a history from a new client in the cardiovascular clinic. When investigating for childhood diseases and disorders associated with structural heart disease, which finding should the nurse consider significant?

Rheumatic fever

Central venous pressure is measured in which of the following heart chambers?

Right atrium Explanation: The pressure in the right atrium is used to assess right ventricular function and venous blood return to the heart. The left atrium receives oxygenated blood from the pulmonary circulation. The left ventricle receives oxygenated blood from the left atrium. The right ventricle is not the central collecting chamber of venous circulation.

Within the physiology of the heart, each chamber has a particular role in maintaining cellular oxygenation. Which chamber of the heart is responsible for receiving deoxygenated blood from the venous system?

Right atrium Explanation: The right atrium receives deoxygenated blood from the venous system.

Within the physiology of the heart, each chamber has a particular role in maintaining cellular oxygenation. Which chamber of the heart is responsible for receiving deoxygenated blood from the venous system?

Right atrium Explanation: The right atrium receives deoxygenated blood from the venous system.

A patient in the ICU has a central venous pressure (CVP) line placed. The CVP reading is 10 mm Hg. The nurse would interpret this reading as being related to which of the following?

Right-sided heart failure Explanation: Normal CVP is 2 to 8 mm Hg. A CVP greater that 8 mm Hg indicates hypervolemia or right-sided heart failure. A CVP less than 2 mm Hg indicates a reduction in preload or hypovolemia.

The nurse is caring for a wheelchair-bound client. Which piece of equipment impedes circulation to the area it's meant to protect?

Ring or donut

A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client?

Risk for infection

Which nursing diagnosis is most relevant in the first 12 hours of life for a neonate born with a myelomeningocele?

Risk for infection Explanation: All of these nursing diagnoses are important for a child with a myelomeningocele. However, during the first 12 hours of life, the most life-threatening event would be an infection. The other diagnoses will be addressed as the child develops

A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?

Risk for injury

roll the vial gently between the palms.

Rolling the vial gently between the palms produces heat, which helps dissolve the medication. Doing nothing or inverting the vial wouldn't help dissolve the medication. Shaking the vial vigorously could cause the medication to break down, altering its action.

The Family Nurse Practitioner is assessing a 55-year-old who came to the clinic complaining of being "unsteady" on their feet. What would be a test for equilibrium?

Romberg test

Unrestricted zone?

STREET CLOTHES ARE ALLOWED in the operating room that interfaces with other departments, including patien't reception and holding area!

A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?

Scale

Patients with chronic liver dysfunction have problems with insufficient vitamin intake. Which of the following may occur as a result of vitamin C deficiency?

Scurvy

Which of the following arterial blood gas results would be consistent with metabolic alkalosis?

Serum bicarbonate of 28 mEq/L - Evaluation of arterial blood gases reveals a pH greater than 7.45 and a serum bicarbonate concentration greater than 26 mEq/L.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result?

Serum sodium level of 124 mEq/L - In SIADH, the posterior pituitary gland produces excess antidiuretic hormone (vasopressin), which decreases water excretion by the kidneys. This, in turn, reduces the serum sodium level, causing hyponatremia, as indicated by a serum sodium level of 124 mEq/L. In SIADH, the serum creatinine level isn't affected by the client's fluid status and remains within normal limits. A hematocrit of 52% and a BUN level of 8.6 mg/dl are elevated. Typically, the hematocrit and BUN level decrease.

The nurse is caring for a client recovering from a major burn. Burns affect the immune system by causing a loss of large amounts of which of the following?

Serum, which depletes the body's store of immunoglobulins

Assertive Community Model

Service delivery model that provides comprehensive, locally based treatment to people with SPMI.

A client has been admitted to the hospital with signs of dehydration. Which action would be least beneficial in increasing the client's fluid intake?

Serving fluids in large amounts Explanation: Fluids should be served in small amounts at frequent intervals. It's overwhelming to the client to have large amounts of fluids to drink. Teaching the client about the need for fluid increase and including him in the selection of beverages will enhance compliance. Fluids should be served at the appropriate temperatures to increase enjoyment and palatability.

The nursing student has just reviewed material in the course textbook regarding pancreatitis. The student knows that a major symptom of pancreatitis that causes the client to seek medical care is:

Severe abdominal pain

The patient is on a continuous tube feeding. The tube placement should be checked every

Shift

A client with respiratory acidosis is admitted to the intensive care unit for close observation. The nurse should stay alert for which complication associated with respiratory acidosis?

Shock - Complications of respiratory acidosis include shock and cardiac arrest. Stroke and hyperglycemia aren't associated with respiratory acidosis. Seizures may complicate respiratory alkalosis, not respiratory acidosis.

Which of the following terms is used to describe stone formation in a salivary gland, usually the submandibular gland?

Sialolithiasis

You are caring for a client who has a diagnosis of HIV. Part of this client's teaching plan is educating the client about his or her medications. What is essential for the nurse to include in the teaching of this client regarding medications?

Side effects of drugs

Your client is taking medications that depress the hematopoietic system. What signs should you closely monitor in this client?

Signs of leukopenia and thrombocytopenia

Which ventilation-perfusion ratio is exhibited by acute respiratory distress syndrome (ARDS)?

Silent Unit

A patient is to undergo surgery on his kidney. The patient would be placed in which position for the surgery?

Sims (lateral position)

An infant, age 8 months, has a tentative diagnosis of congenital heart disease. During data collection, the nurse measures a heart rate of 170 beats/minute and a respiratory rate of 70 breaths/minute. How should the nurse position the infant?

Sitting in an infant seat Explanation: Because the infant's data collection findings suggest that respiratory distress is developing, the nurse should position the infant with the head elevated at a 45-degree angle to promote maximum chest expansion; an infant seat maintains this position. Placing an infant flat on his back or abdomen or in high Fowler's position could increase respiratory distress by preventing maximal chest expansion.

A client is recovering from gastric surgery. Toward what goal should the nurse progress the client's enteral intake?

Six small meals daily with 120 mL fluid between meals

Which of the following would the nurse expect of an elderly client's skin?

Slowed healing

Which of the following electrolytes is the primary determinant of extracellular fluid (ECF) osmolality?

Sodium - Sodium is the primary determinant of ECF osmolality. Sodium plays a major role in controlling water distribution throughout the body because it does not easily cross the intracellular wall membrane and because of its abundance and high concentration in the body. Potassium, calcium, and magnesium are not primary determinants of ECF osmolality.

Gynecomastia is a common side effect of which of the following diuretics?

Spironolactone (Aldactone)

What organ is considered lymphoid tissue?

Spleen

Which of the following in a client's health history would the nurse recognize as potentially compromising the client's blood cell volume?

Splenoectomy

A nurse is developing a teaching plan for a terminally ill client and his family about about the stages of dying and emotional reactions experienced. The nurse integrates knowledge of which of the following in the teaching plan?

Stages are applicable to any loss

A client is admitted with nausea, vomiting, and diarrhea. His blood pressure on admission is 74/30 mm Hg. The client is oliguric and his blood urea nitrogen (BUN) and creatinine levels are elevated. The physician will most likely write an order for which treatment?

Start I.V. fluids with a normal saline solution bolus followed by a maintenance dose.

You notify the physician that your client is third-spacing fluid. What orders would you expect the physician to give you?

Start IV fluids and blood products - This is done by administering IV solutions—sometimes at rapid rates—and blood products, such as albumin, to restore colloidal osmotic pressure. The restriction of fluids; the administration of diuretics and the increase of sodium in the diet are not orders the physician would be expected to give for a client is third-spacing fluids.

A treatment option for SCID includes

Stem cell transplant

After teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders, the instructor determines that the teaching was successful when the students identify which of the following structures as possibly being affected?

Stomach

Which of the following nursing actions is most important in caring for the client following lithotripsy?

Strain the urine carefully for stone fragments.

Which of the following would the nurse identify as the deepest layer of the epidermis?

Stratum germinativum

Which type of incontinence refers to involuntary loss of urine through an intact urethra as a result of a sudden increase in intra-abdominal pressure?

Stress

Within our brains, cerebrospinal fluid (CSF) is manufactured in the ventricles and constantly circulates around the brain and spinal cord. The CSF functions as a cushion to protect structures and maintain relatively consistent intracranial pressure. Where does CSF circulate?

Subarachnoid space

The client vomits during the surgical procedure. The best action by the nurse is:

Suction the client to remove saliva and gastric secretions.

Which of the following will the nurse observe as symptoms of perforation in a patient with intestinal obstruction?

Sudden, sustained abdominal pain

The nurse is preparing to examine the abdomen of a client complaining of a change in his bowel pattern. The nurse would place the client in which position?

Supine with knees flexed

You are caring for a client who is undergoing bone marrow aspiration to determine their blood cell formation status. What nursing intervention should you provide to your client after the test?

Support the client during a bone marrow aspiration and monitor the status.

A client with appendicitis is experiencing excruciating abdominal pain. An abdominal X-ray film reveals intraperitoneal air. The nurse should prepare the client for:

Surgery

Which of the following is the treatment of choice for acoustic neuromas? a) Surgery b) Chemotherapy c) Palliation d) Radiation

Surgery Correct Explanation: Surgical removal of acoustic tumors is the treatment of choice because these tumors do not respond well to radiation or chemotherapy. There would be no need for palliation.

Hippocampus

Susan cannot remember anything before her accident yesterday. Which brain structure might be injured?

Hippocampus part of the limbic system, controls emotions, memory, and learning. It is also thought to mediate feelings of aggression, sexual impulses, and submissive behavior.

Susan cannot remember anything before her accident yesterday. Which brain structure might be injured?

The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority?

Swallow reflex

T-cell and B-cell lymphocytes are the primary participants in the immune response. What do they do?

T-cell and B-cell lymphocytes distinguish harmful substances and ignore those natural and unique to a person.

The anatomy and physiology instructor is explaining a cell-mediated response to the pre-nursing students. What actions would the instructor explain occur in a cell-mediated response?

T-cell lymphocytes survey proteins in the body and attack the invading antigens.

A client who has sustained a head injury to the parietal lobe cannot identify a familiar object by touch. The nurse knows that this deficit is which of the following?

Tactile agnosia

An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make?

Take a stool softener such as docusate sodium (Colace) daily.

A client with an esophageal stricture is about to undergo esophageal dilatation. As the bougies are passed down the esophagus, the nurse should instruct the client to do which action to minimize the vomiting urge?

Take long, slow breaths

The client has a chancre on his lips. The nurse instructs the client to

Take measures to prevent spreading to others

A client with an esophageal stricture is about to undergo esophageal dilatation. As the bougies are passed down the esophagus, the nurse should instruct the client to do which action to minimize the vomiting urge?

Take slow, deep breaths

A client has a circular rash on her leg, accompanied by malaise, fever, headache, and joint aches. Laboratory studies and physical examination findings confirm that she has Lyme disease. Her physician prescribes tetracycline hydrochloride (Achromycin), 500 mg by mouth four times per day. Which instruction should the nurse give the client about self-administration of tetracycline?

Take the drug on an empty stomach.

The parents of a school-age child with asthma express concern about letting the child participate in sports. What should the nurse tell the parents about the relationship between exercise and asthma?

Taking prophylactic drugs before the activity can prevent asthma attacks and enable the child to engage in most sports. Explanation: Although exercise may trigger asthma attacks, taking prophylactic asthma drugs before beginning the activity can prevent attacks, enabling the child to engage in most sports. Asthma attacks may be triggered by various factors, including allergens, exercise, medications, upper respiratory infections, and psychological stress. Provided the asthma is under control, most children can participate in sports and other physical activities; in fact, they benefit from exercise. Activity restrictions hamper peer interaction, which is essential to the development of the school-age child. A child with asthma may tolerate intermittent activities better than continuous ones.

When caring for the patient with acute glomerulonephritis, which of the following assessment findings should the nurse anticipate?

Tea-colored urine

A nurse is caring for a patient experiencing a panic attack. Which intervention by the nurse would be most appropriate?

Tell the client to take deep breaths Explanation: During a panic attack a client may experience symptoms of dizziness, shortness of breath, and feelings of suffocation. The nurse should remain with the client and direct what's said toward changing the physiological response, such as taking deep breaths. During an attack, the client is unable to talk about anxious situations and isn't able to address feelings, especially uncomfortable feelings and frustrations. While having a panic attack, the client is also unable to focus on anything other than the symptoms, so the client won't be able to discuss the cause of the attack

A mother brings her young child to the clinic for an evaluation of an infection. The mother states, "He's been taking antibiotics now for more than 2 months and still doesn't seem any better. It's like he's always sick." During the history and physical examination, which of the following would alert the nurse to suspect a primary immunodeficiency?

Ten ear infections in the past year

Which of the following results in decreased gas exchange in older adults?

The alveolar walls contain fewer capillaries.

The nurse is administering nitroglycerin, which he knows decreases preload as well as afterload. Preload refers to which of the following?

The amount of blood presented to the ventricles just before systole

The nurse teaches a mother how to provide adequate nutrition for her toddler, who has cerebral palsy. Which of the following observations indicates that teaching has been effective?

The child eats finger foods by himself. Explanation: The child with cerebral palsy should be encouraged to be as independent as possible. Finger foods allow the toddler to feed himself. Because spasticity affects coordinated chewing and swallowing as well as the ability to bring food to the mouth, it's difficult for the child with cerebral palsy to eat neatly. Independence in eating should take precedence over neatness. The child with cerebral palsy may require more time to bring food to the mouth; thus, chewing and swallowing shouldn't be rushed to finish a meal by a specified time. The child with cerebral palsy may vomit after eating due to a hyperactive gag reflex. Therefore, the child should remain in an upright position after eating to prevent aspiration and choking.

One day after an appendectomy, a 9-year-old client rates his pain at 4 out of 5 on the pain scale but is playing video games and laughing with his friend. Which of the following would the nurse document on the child's chart?

The child rates pain at 4 out of 5. Pain medication administered as prescribed. Explanation: Pain is what the child says it is, and the nurse must document what the child reports. If a child's behavior appears to differ from the child's rating of pain, believe the pain rating. A child who uses a passive coping behavior (such as distraction) may rate pain as more intense than children who use active coping behavior (such as crying). Making judgments about pain based on behavior can result in children being inadequately medicated for pain.

A client states that he has 20/40 vision. Which statement about this client's vision is true?

The client can read from 20' (6 m) what a person with normal vision can read from 40'. Explanation: The numerator, which is always 20, is the distance in feet between the vision chart and the client. The denominator indicates from what distance an eye with normal vision can read the chart. Normal vision is defined as 20/20. The other options are inaccurate.

A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis?

The client had a liver transplant 2 years ago. - A history of immunocompromised status, such as that which occurs with liver transplantation, places the client at a higher risk for contracting tuberculosis. Other risk factors include inadequate health care, traveling to countries with high rates of tuberculosis (such as southeastern Asia, Africa, and Latin America), being a health care worker who performs procedures in which exposure to respiratory secretions is likely, and being institutionalized.

A nurse is caring for a client who's ordered continuous ambulatory peritoneal dialysis (CAPD). Which finding should lead the nurse to question the client's suitability for CAPD?

The client has a history of diverticulitis.

A client with dysphagia is being prepared for discharge. Which outcome indicates that the client is ready for discharge?

The client is free from esophagitis and achalasia.

A client with human immunodeficiency virus undergoes intradermal anergy testing using Candida and mumps antigen. During the 3 days following the tests, there is no induration or evidence of reaction at the intradermal injection sites. The most accurate conclusion the nurse can make is:

The client is immunodeficient and will not have a skin response

A nurse enters the room of a client who has returned to the unit after having a radical neck dissection. Which assessment finding requires immediate intervention?

The client lying in a lateral position, with the head of bed flat

Which outcome indicates effective client teaching to prevent constipation?

The client reports engaging in a regular exercise regimen.

A client, 2 months pregnant, has hyperemesis gravidarum. Which expected outcome is most appropriate for her?

The client will exhibit uterine growth within the expected norms for gestational age. Explanation: For a client with hyperemesis gravidarum, the goal of nursing care is to achieve optimal fetal growth, which can be evaluated by monitoring uterine growth through fundal height assessment. The nurse shouldn't assume that excessive vomiting signifies that the client doesn't accept the pregnancy. Clients with hyperemesis gravidarum rarely gain weight according to the expected pattern. They may be hospitalized briefly to regulate fluid and electrolyte status, but they don't require hospitalization for the duration of pregnancy. In fact, hospitalization may add to the stress of pregnancy by causing family separation and financial concerns.

Which outcome is most appropriate for a teenager who's irritable, hasn't slept well in 6 months, and has dropped out of social activities?

The client will obtain appropriate mental health services Explanation: Mental health services can protect the client and offer the best means of regaining mental health. The client could reestablish a healthy sleeping pattern without addressing underlying issues. The parents' worrying is unrelated to the child's immediate need for help. The child's behavior suggests the need for professional service, not disciplinary measures.

A client with a recent history of a stroke has been discharged from the rehabilitation facility with a walker. During the client's return visit to the physician's office, the nurse assesses his gait. Which finding indicates the need for further teaching about walker use?

The client's arms are fully extended when using the walker. Explanation: When using a walker, the client's arms should be slightly bent at the elbow, allowing maximum support from the arms while ambulating. The weak leg is always moved forward first with the walker to provide the maximum support. When sitting, the client should always back up to the chair and feel the chair with his legs before sitting. The client should use the armrests of the chair for support because the armrests are more stable than the walker.

A client has been diagnosed with AIDS and tuberculosis (TB). A nursing student asks the nurse why the client's skin test for TB is negative if the client's physician has diagnosed TB. The nurse's correct reply is which of the following?

The client's immune system cannot mount a response to the test.

A client realizes that regular use of laxatives has greatly improved his bowel pattern. However, the nurse cautions this client against the prolonged use of laxatives for which reason?

The client's natural bowel function may become sluggish.

stethescope; diaphragm; bell and palpation

The diaphragm of a stethoscope detects high-pitched sounds best; the bell detects low-pitched sounds best. Palpation detects thrills best.

Atypical antipsychotics work on dopamine-receptor and serotonin-receptor blockade, whereas traditional antipsychotics work on dopamine-receptor blockade.

The difference between traditional and atypical antipsychotics is that:

Publication of the first psychiatric nursing text, Nursing Mental Disease, by Harriet Bailey

The following events are important in the development of psychiatric-mental health nursing practice. Which event occurred first?

A nurse is administering lanoxin, which she knows increases contractility as well as cardiac output. Contractility refers to which of the following?

The force of the contraction related to the status of the myocardium

A nurse is caring for a 30-year-old client diagnosed with atrial fibrillation who has just had a mitral valve replacement. The client is being discharged with prescribed warfarin (Comaudin). She mentions to you that she relies on the rhythm method for birth control. What education would be a priority for the nurse to provide to this client?

The high risk for complications if she becomes pregnant while taking warfarin

The nurse is performing a neurological assessment of a client who has sustained damage to the frontal cortex. Which of the following deficits will the nurse look for during assessment?

The inability to tell how a mouse and a cat are alike

Which of the following would be inaccurate information pertaining to SCID?

The inheritance of SCID can be autosomal dominant.

A 64-year-old male client, who leads a sedentary life-style, and a 31-year-old female client, who has a very stressful and active life-style, require a vaccine against a particular viral disorder. As the nurse, you would know that in one of this client's the vaccine will be less effective. In which client is the vaccine more likely to be less effective and why?

The male client because of his age

A client at 33 weeks' gestation is admitted in preterm labor. She is given betamethasone (Celestone) 12 mg I.M. q 24 hours × 2. What is the expected outcome of this drug therapy?

The neonate will be delivered with mature lungs. Explanation: Betamethasone is a corticosteroid that induces the production of surfactant. The pulmonary maturation that results causes the fetal lungs to mature more rapidly than normal. Because the lungs are mature, the risk of respiratory distress in the neonate is lowered but not eliminated. Betamethasone also decreases the surface tension within the alveoli. Betamethasone has no influence on contractions or carrying the fetus to full term. It also does not prevent infection.

Troponin T and I

The nurse is awaiting results of cardiac biomarkers for a patient with severe chest pain. The nurse would identify which cardiac biomarker as remaining elevated the longest when myocardial damage has occurred?

The nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first?

The nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first?

Avoid tub baths, but shower as desired.

The nurse is providing discharge education for the client going home after a cardiac catheterization. Which of the following would be important information to give this client?

Lactic acidosis

The nurse should monitor the client for signs of lactic acidosis, a life- threatening adverse reaction associated with metformin. Nausea, vomiting, and megaloblastic anemia are adverse reactions associated with metformin, but they aren't considered life-threatening.

Reinforce the dressing and contact the physician.

The nurse should reinforce the dressing and notify the physician. A saturated dressing might signal postoperative hemorrhage. Continuing to monitor the client without notifying the physician delays treatment. The nurse should also monitor the client's vital signs. The first postoperative dressing should be changed by the physician, not the nurse.

"Remember to hold the cane with the hand on the opposite side of your weak leg."

The nurse should remind the client to hold the cane with the hand on the opposite side of the weak leg. Telling the client that the cane is temporary offers false reassurance. Safe cane walking requires the client to hold the cane on the side opposite the disability.

A client with diabetes begins to have digestive problems and is told by the physician that they are a complication of the diabetes. Which of the following explanations from the nurse is most accurate?

The pancreas secretes digestive enzymes

Respite residential care

The parents of a young adult diagnosed with schizophrenia are providing care for the patient in their home. During a home visit, the parents state, "It's been so difficult taking care of our son. We need a break. But he needs constant supervision." Which of the following would be appropriate for the nurse to suggest?

Which statement is correct about conversion disorders?

The psychological conflict is repressed Explanation: In conversion disorders, the client isn't conscious of intentionally producing symptoms that can't be self-controlled. The symptoms are characterized by one or more neurologic symptoms. Understanding the principles and conflicts behind the symptoms can prove helpful during a client's therapy.

Perfusion refers to blood supply to the lungs, through which the lungs receive nutrients and oxygen. What are the two methods of perfusion?

The two methods of perfusion are the bronchial and pulmonary circulation.

A client is to have an upper GI procedure with barium ingestion and abdominal ultrasonography. While scheduling these diagnostic tests, the nurse must consider which factor?

The ultrasonography should be scheduled before the GI procedure.

The nurse should include which fact when teaching an adolescent group about the human immunodeficiency virus (HIV)?

The virus can be spread through many routes, including sexual contact Explanation: HIV can be spread through many routes, including sexual contact and contact with infected blood or other body fluids. The incidence of HIV in the adolescent population has increased since 1995, even though more information about the virus is targeted to reach the adolescent population. Only about 25% of all new HIV infections in the United States occurs in people younger than age 22.

The nurse is providing care for a client who has a sacral pressure ulcer with a wet-to-dry dressing. Which guideline is appropriate for a wet-to-dry dressing?

The wound should remain moist from the dressing.

Nursing students are reviewing information about attitudes related to death and dying. The students demonstrate understanding of the information when they identify which of the following as most accurate?

There remains a conspiracy of silence about dying despite progress in the area.

The nurse is caring for a client diagnosed with asthma. While performing the shift assessment, the nurse auscultates breath sounds including sibilant wheezes, which are continuous musical sounds. What characteristics describe sibilant wheezes?

They can be heard during inspiration and expiration.

You are studying for a physiology test about the respiratory system. What should you know about central chemoreceptors in the medulla?

They respond to changes in CO2 levels and hydrogen ion concentrations (pH) in the cerebrospinal fluid.

A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects:

This client's above-normal pH value indicates alkalosis. The below-normal PaCO2 value indicates acid...(more) This client's above-normal pH value indicates alkalosis. The below-normal PaCO2 value indicates acid loss via hyperventilation; this type of acid loss occurs only in respiratory alkalosis. These ABG values wouldn't occur in metabolic acidosis, respiratory acidosis, or metabolic alkalosis.

A patient is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in which of the following?

Thought content

A client with a suspected pulmonary disorder undergoes pulmonary function tests. To interpret test results accurately, the nurse must be familiar with the terminology used to describe pulmonary functions. Which term refers to the volume of air inhaled or exhaled during each respiratory cycle?

Tidal Volume

A patient diagnosed with arthritis has been taking aspirin and now reports experiencing adverse effects. What adverse effect indicates that a decrease in dose may be necessary? a) Vertigo b) Otalgia c) Tinnitus d) Nystagmus

Tinnitus Correct Explanation: Tinnitus is a sign of ototoxicity, which can occur when a patient's dose is too high.

A client with dissociative identity disorder (DID) is admitted to an inpatient psychiatric unit. A nurse-manager asks all staff to attend a meeting. Which is the most likely reason for the meeting?

To allow staff members to discuss concerns about working with a client with DID Explanation: Allowing all staff members to meet together may prevent them from splitting into groups who believe the diagnosis is valid and those who don't. Unless this client shows behaviors harmful to himself or others, restraints aren't needed. Telling the staff that no one should refuse to work with the client or that this client will probably be difficult sets a negative tone as the staff develops a plan of care for the client and implements it.

The instructor of the pre-nursing physiology class is explaining respiration to the class. What does the instructor explain is the main function of respiration?

To exchange oxygen and CO2 between the atmospheric air and the blood and between the blood and the cells

Why are antacids administered regularly, rather than as needed, in peptic ulcer disease?

To maintain gastric pH at 3.0-3.5

A client is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthesiologist's instructions. Why does the client require special positioning for this type of anesthesia?

To prevent cerebrospinal fluid (CSF) leakage

A client in a clinic setting has just been diagnosed with hypertension. She asks what the end goal is for treatment. The correct reply from the nurse is which of the following?

To prevent complications/death by achieving and maintaining a blood pressure of 140/90 or less

The nurse is caring for a client with an immune system disorder. Why should the nurse consult drug references when assessing a client with an immune system disorder?

To verify that the client is not hypersensitive to substances in the prescribed medications

Knowing respiratory physiology is important to understand how the disease process can work within that system. Which hollow tube transports air from the laryngeal pharnyx to the bronchi?

Trachea

To treat a client with acne vulgaris, the physician is most likely to prescribe which topical agent for nightly application?

Tretinoin (retinoic acid [Retin-A])

When describing the role of the pancreas to a client with a pancreatic dysfunction, the nurse would identify which substance as being acted on by pancreatic lipase?

Triglycerides

A client with severe angina pectoris and electrocardiogram changes is seen by a physician in the emergency department. In terms of serum testing, it's most important for the physician to order cardiac:

Troponin

The patient has had biomarkers drawn after complaining of chest pain. Which diagnostic of myocardial infarction remains elevated for as long as 3 weeks?

Troponin

The nurse is awaiting results of cardiac biomarkers for a patient with severe chest pain. The nurse would identify which cardiac biomarker as remaining elevated the longest when myocardial damage has occurred?

Troponin T and I Explanation: After myocardial injury, these biomarkers rise early (within 3 to 4 hours), peak in 4 to 24 hours, and remain elevated for 1 to 3 weeks. These early and prolonged elevations may make very early diagnosis of acute myocardial infarction (MI) possible and allow for late diagnosis in patients who have delayed seeking care for several days after the onset of acute MI symptoms. CK-MB returns to normal within 3 to 4 days. Myoglobin returns to normal within 24 hours. BNP is not considered a cardiac biomarker. It is a neurohormone that responds to volume overload in the heart by acting as a diuretic and vasodilator.

A nurse is caring for a client in the emergency department who is complaining of severe abdominal pain. The client is diagnosed with acute pancreatitis. Which laboratory value requires immediate intervention?

Troponin of 2.3 mcg/L

Which task can a licensed practical nurse (LPN) safely delegate to a nursing assistant?

Turning a client every 2 hours

The nurse-client relationship

Two major clinical characteristics affect client compliance: the nurse-client relationship and the therapeutic regimen. The client's drug knowledge, psychosocial factors, and disease duration and severity are client characteristics, not clinical ones.

Mr. Sam Wallace, a 53-year-old male, is a regular client in the respiratory group where you practice nursing. As with all adults, millions of alveoli form most of the pulmonary mass. The squamous epithelial cells lining each alveolus consist of different types of cells. Which type of the alveoli cells produce surfactant?

Type II Cells

Parents of a 6-year-old child tell a physician that the child has been having periods of unawareness with short periods of staring. Based on his history, the child is probably having which type of seizure?

Typical absence Explanation: A typical absence seizure has an onset between ages 4 and 8. It's exhibited by an abrupt loss of consciousness, amnesia, or unawareness characterized by staring and a 3-cycle/second spike and waveform on an EEG. The attack lasts from 10 to 30 seconds and may occur as frequently as 50 to 100 times a day. No postictal or confused state follows the attack. A complex partial seizure most commonly occurs in older children and adults, causing a brief impairment of consciousness. A myoclonic seizure occurs in older children and is exhibited by lightning jerks without loss of consciousness. An abrupt increase in muscle tone, loss of consciousness, and marked autonomic signs and symptoms characterize the tonic seizure.

A client is to have an upper GI procedure with barium ingestion and abdominal ultrasonography. While scheduling these diagnostic tests, the nurse must consider which factor?

Ultrasound before GI procedure

A client has a new order for metoclorpramide (Reglan). The nurse knows that this medication should not be used long term and only in cases where all other options have been exhausted. This is because this medication has the potential for extrapyramidal side effects. Extrapyramidal side effects include which of the following?

Uncontrollable movement of the face and limbs

Ataxia is the term that refers to

Uncoordinated muscle movement

The nurse is caring for an infant with hypospadias. Which anomaly would the nurse assess the infant for that commonly accompanies this condition?

Undescended testes Explanation: Because undescended testes may also be present in hypospadias, the small penis may appear to be an enlarged clitoris. This shouldn't be mistaken for ambiguous genitalia. If there's any doubt, more tests should be performed. Hernias don't generally accompany hypospadias.

In which zone of the surgical area are street clothes allowed?

Unrestricted

Which of the following is also termed preinfarction angina?

Unstable angina

A client with GERD develops espophagitis. Which diagnostic test would the nurse expect the physician to order to confirm the diagnosis?

Upper endoscopy with biopsy

Which type of positioning should be utilized for a patient undergoing a paracentesis?

Upright at the edge of the bed

Which clinical finding should a nurse look for in a client with chronic renal failure?

Uremia

After sustaining a stroke, a client is transferred to the rehabilitation unit. A medical-surgical nurse reviews the client's residual neurological deficits with a rehabilitation nurse. Which neurological deficit places the client at risk for skin breakdown?

Urinary incontinence and right-sided hemiparesis

A nurse is implementing appropriate infection control precautions for a client who is positive for human immunodeficiency virus (HIV). The nurse demonstrates a need for a review of transmission routes by identifying which body fluid as a means of transmission?

Urine

A client admitted with a gunshot wound to the abdomen is transferred to the intensive care unit after an exploratory laparotomy. I.V. fluid is being infused at 150 ml/hour. Which assessment finding suggests that the client is experiencing acute renal failure (ARF)?

Urine output of 250 ml/24 hours

The nurse would expect to observe which of the following when assessing a client with cholelithiasis?

Urine that appears dark brown

A nurse is teaching a client about maintaining a healthy heart. The nurse should include which point in her teaching?

Use alcohol in moderation

A client being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk?

Use incentive spirometry every hour.

Which factor in a client's history indicates she's at risk for candidiasis?

Use of corticosteroids Explanation: Small numbers of the fungus Candida albicans commonly inhabit the vagina. Because corticosteroids decrease host defense, they increase the risk of candidiasis. Pregnancy, not nulliparity, increases the risk of candidiasis. Candidiasis is rare before menarche and after menopause. The use of hormonal contraceptives, not spermicidal jelly, increases the risk of candidiasis.

A female patient who is 38 years of age has begun to suffer from rheumatoid arthritis. She is also being assessed for disorders of the immune system. She works as an aide at a facility that cares for children infected with AIDS. Which of the following is the most important factor related to the patient's assessment?

Use of other drugs.

Cardiac complications, which may occur following resection of an esophageal tumor, are associated with irritation of which nerve at the time of surgery?

Vagus

Which assessment finding would the nurse expect to document for a client with ataxia-telangiectasis?

Vascular Lesions

The nurse is admitting a client to the unit with a diagnosis of ataxia-telangiectasia. A clinical manifestation is telangiectasia. The nurse would recognize that the client is exhibiting telangiectasia when assessing the presence of what?

Vascular lesions caused by dilated blood vessels

A client is actively bleeding from esophageal varices. Which of the following medications would the nurse most expect to be administered to this client?

Vasopressin

Which of the following medications are used to decrease portal pressure, halting bleeding of esophageal varices?

Vasopressin

A client is actively bleeding from esophageal varices. Which of the following medications would the nurse most expect to be administered to this client?

Vasopressin (Pitressin)

What is the difference between respiration and ventilation?

Ventilation is the movement of air in and out of the respiratory tract.

The client is to receive a unit of packed red blood cells. The first intervention of the nurse is to

Verify that the client has signed a written consent form.

A client with severe and chronic liver disease is showing manifestations related to inadequate vitamin intake and metabolism. He reports difficulty driving at night because he cannot see well. Which of the following vitamins is most likely deficient for this client?

Vitamin A

The nurse knows that the client with cholelithiasis can have a nutritional deficiency. The obstruction of bile flow due to cholelitiasis can interfere with the absorption of

Vitamin A

Patients diagnosed with malabsorption syndrome may have vitamin and mineral deficiency. Patient who easily bleed have which of the following deficiencies?

Vitamin K

Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's uremia. Which finding during this procedure signals a significant problem?

WBC count

The nurse is changing a dressing and providing wound care. Which activity should she perform first?

Wash her hands thoroughly.

A client is diagnosed with gonorrhea. When teaching the client about this disease, the nurse should include which instruction?

Wash your hands thoroughly to avoid transferring the infection to your eyes.

A nurse is providing discharge instructions for a client who fell from a bicycle, resulting in a fractured jaw. The client underwent surgical intervention with rigid fixation. The nurse includes in the instruction

Ways to obtain supplemental nutrition

Which of the following is an age-related change of the gastrointestinal system?

Weakened gag reflex

A male client has doubts about performing peritoneal dialysis at home. He informs the nurse about his existing upper respiratory infection. Which of the following suggestions can the nurse offer to the client while performing an at-home peritoneal dialysis?

Wear a mask when performing exchanges

As Americans live longer, relatively rare conditions are becoming more commonplace - one of which is hypervolemia. What are early signs of hypervolemia? Choose all correct options.

Weight Gain & Increased breathing effort - Early signs of hypervolemia are elevated BP, increased breathing effort, etc. Eventually, fluid congestion in the lungs leads to moist breath sounds. An earliest symptom of hypovolemia is thirst.

A client with suspected HIV has had two positive enzyme-linked immunosorbent assay tests. What diagnostic test would be run next?

Western Blot

Coordinate internal and external responses

What is the function of the thalamus and the hypothalamus?

To give a comprehensive picture of client functioning

What is the purpose of the five-axis system used in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, text revision (DSM-IV-TR)?

"Asking for help from those who care about us isn't a sign of weakness."

When a client shares that "I will solve my own problems without asking my family for help," the nurse reacts most therapeutically when responding.

Facilitating the nurse's understanding of how these beliefs affect the client's perception of her disorder

When the psychiatric nurse is aware of the cultural beliefs of a client diagnosed with bipolar disorder, the therapeutic process is most enhanced by...

They require rephrasing of unclear questions.

Which of the following is an inaccurate depiction of a concrete question?

It involves changing one's values or beliefs.

Which of the following is an inaccurate depiction of self-awareness?

Olanzapine (Zyprexa)

Which of the following is considered an atypical antipsychotic?

Instruct the patient to restrict food and oral intake.

Which of the following nursing interventions is required to prepare a patient with cardiac dysrhythmia for an elective electrical cardioversion?

Avoid sources of electrical interference.

Which of the following postimplantation instructions must a nurse provide a patient with a permanent pacemaker?

PR interval

Which of the following tends to be prolonged on the electrocardiogram (ECG) during a first-degree atrioventricular (AV) block?

Potency

Which of the following terms is used to describe the amount of the drug needed to achieve the maximum effect?

Primary

Which of the following types of prevention strategies would aim to stop mental disorders from ever occurring and to reduce identified cases of psychiatric disorders and disabilities within a population?

Covert; Covert cues are vague or hidden messages that need interpretation and exploration.

Which type of cue is being used when the client states, "Nothing can help me"?

Foster homes

Which type of residential setting may care for one to three clients in a family-like atmosphere, including meals and social activities with the family?

A client who's diagnosed with a right subarachnoid hemorrhage should be placed in which position?

With the head of the bed elevated Explanation: Elevating the head of the bed enhances cerebral venous return and thereby decreases intracranial pressure (ICP). The other positions wouldn't decrease ICP.

When the parents of an infant diagnosed with hypothyroidism have been taught to count the pulse, which intervention should the nurse teach them in case they obtain a high pulse rate?

Withhold the medication and call the primary health care provider Explanation: If parents have been taught to count the pulse of an infant diagnosed with hypothyroidism, they should be instructed to withhold the dose and consult their primary health care provider if the pulse rate is above a certain value.

A client with chest pain doesn't respond to nitroglycerin. When he's admitted to the emergency department, the health care team obtains an electrocardiogram and administers I.V. morphine. The physician also considers administering alteplase (Activase). This thrombolytic agent must be administered how soon after onset of myocardial infarction (MI) symptoms?

Within 6 hours

Right Ventricle

Within the physiology of the heart, each chamber has a particular role in maintaining cellular oxygenation. Which chamber of the heart is responsible for pumping blood to the lungs to be oxygenated?

Left atrium

Within the physiology of the heart, each chamber has a particular role in maintaining cellular oxygenation. Which chamber of the heart is responsible for receiving oxygenated blood from the lungs?

A client transferred to a long-term care facility has a stage II pressure ulcer on her coccyx. Who should the nurse consult about the care of this client?

Wound care nurse

Unintentional retention of object will cause ___ ___. What can form? What may develop?

Wound infection - abcesses - Fistula between organs

A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note:

Yellow sclerae

Clients with recurrent life-threatening tachydysrhythmias.

You are caring for a client who has been admitted to have a cardioverter defibrillator implanted. You would know that implanted cardioverter defibrillators are used in what clients?

Elective electrical cardioversion

Your client has been diagnosed with an atrial dysrhythmia. The client has come to the clinic for a follow-up appointment and to talk with the physician about options to stop this dysrhythmia. What would be a procedure used to treat this client?

Thallium-201

Your client is going to have a stress test. What radionuclide would most likely be used to diagnose ischemic heart disease during this test?

A client is admitted to the psychiatric unit with a tentative diagnosis of psychosis. Her physician prescribes the phenothiazine thioridazine (Mellaril), 50 mg by mouth three times per day. Phenothiazines differ from central nervous system (CNS) depressants in their sedative effects by producing:

a calming effect from which the client is easily aroused. Explanation: Shortly after phenothiazine administration, a quieting and calming effect occurs, but the client is easily aroused, alert, and responsive and has good motor coordination.

A teenager with heart failure prescribed digoxin (Lanoxin) asks the nurse, "What's the drug supposed to do?" The nurse responds to the teenager based on the understanding that this drug is classified as:

a cardiac glycoside Explanation: Digoxin is a cardiac glycoside. It decreases the workload of the heart and improves myocardial function. ACE inhibitors cause vasodilation and increase sodium excretion. Diuretics help remove excess fluid. Vasodilators enhance cardiac output by decreasing afterload.

The nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess a client for pneumothorax resolution after the procedure, the nurse can anticipate that he'll require:

a chest X-ray. Explanation: Chest X-ray confirms whether the chest tube has resolved the pneumothorax. If the chest tube hasn't resolved the pneumothorax, the chest X-ray will reveal air or fluid in the pleural space. SaO2 values may initially decrease with a pneumothorax but typically return to normal in 24 hours. ABG levels may show hypoxemia, possibly with respiratory acidosis and hypercapnia not related to a pneumothorax. Chest auscultation will determine overall lung status, but it's difficult to determine if the chest is reexpanded sufficiently.

The following statement appears on a client's plan of care: "Client will ambulate in the hall without assistance within 4 days." This statement is an example of:

a client outcome. Explanation: A client outcome is a short- or long-term goal based on projected nursing interventions. A nursing diagnosis is a statement about a client's actual or potential problem. Subjective data are information relayed to the nurse by the client. A nursing intervention is an action the nurse takes in response to a client's problem.

When evaluating a severely depressed adolescent, the nurse knows that one indicator of a high risk for suicide is:

a preoccupation with death. Explanation: An adolescent who demonstrates a preoccupation with death (such as by talking about death frequently) should be considered at high risk for suicide. Although depression, excessive sleepiness, and a history of cocaine use may occur in suicidal adolescents, they also occur in adolescents who aren't suicidal.

A client with chronic obstructive pulmonary disease is admitted to an acute care facility because of an acute respiratory infection. When assessing the client's respiratory rate, the nurse notes an abnormal inspiratory-expiratory (I:E) ratio of 1:4. What is a normal I:E ratio? a) 1:2 b) 2:1 c) 1:1 d) 2:2

a) 1:2

For a client with an endotracheal (ET) tube, which nursing action is most essential? a) Auscultating the lungs for bilateral breath sounds b) Turning the client from side to side every 2 hours c) Monitoring serial blood gas values every 4 hours d) Providing frequent oral hygiene

a) Auscultating the lungs for bilateral breath sounds

A nurse is performing a respiratory assessment on a client with pneumonia. She asks the client to say "ninety-nine" several times. Through her stethoscope, she hears the words clearly over his left lower lobe. What term should the nurse use to document this finding? a) Bronchophony b) Tactile fremitus c) Crepitation d) Egophony

a) Bronchophony

A trauma victim in the intensive care unit has a tension pneumothorax. Which signs or symptoms are associated with a tension pneumothorax? a) Decreased cardiac output b) Flattened neck veins c) Tracheal deviation to the affected side d) Hypotension e) Tracheal deviation to the opposite side f) Bradypnea

a) Decreased cardiac output d) Hypotension e) Tracheal deviation to the opposite side

The home health nurse sees a client with end-stage chronic obstructive pulmonary disease. An outcome identified for this client is preventing infection. Which finding indicates that this outcome has been met? a) Decreased oxygen requirements b) Increased sputum production c) Decreased activity tolerance d) Normothermia

a) Decreased oxygen requirements

A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? a) Endotracheal suctioning b) Encouragement of coughing c) Use of cooling blanket d) Incentive spirometry

a) Endotracheal suctioning

A client comes to the emergency department complaining of sudden onset of diarrhea, anorexia, malaise, cough, headache, and recurrent chills. Based on the client's history and physical findings, the physician suspects Legionnaires' disease. While awaiting diagnostic test results, the client is admitted to the facility and started on antibiotic therapy. What is the drug of choice for treating Legionnaires' disease? a) Erythromycin (Erythrocin) b) Rifampin (Rifadin) c) Amantadine (Symmetrel) d) Amphotericin B (Fungizone)

a) Erythromycin (Erythrocin)

A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/min. These signs are associated with which condition? a) Hypoxia b) Delirium c) Hyperventilation d) Semiconsciousness

a) Hypoxia

After receiving an oral dose of codeine for an intractable cough, the client asks the nurse, "How long will it take for this drug to work?" How should the nurse respond? a) In 30 minutes b) In 1 hour c) In 2.5 hours d) In 4 hours

a) In 30 minutes

A client with pneumococcal pneumonia is admitted to an acute care facility. The client in the next room is being treated for mycoplasmal pneumonia. Despite the different causes of the various types of pneumonia, all of them share which feature? a) Inflamed lung tissue b) Sudden onset c) Responsiveness to penicillin d) Elevated white blood cell (WBC) count

a) Inflamed lung tissue

The nurse is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide? a) It helps prevent early airway collapse. b) It increases inspiratory muscle strength. c) It decreases use of accessory breathing muscles. d) It prolongs the inspiratory phase of respiration.

a) It helps prevent early airway collapse.

A client with suspected inhalation anthrax is admitted to the emergency department. Which action by the nurse takes the highest priority? a) Monitor vital signs and oxygen saturation every 15 to 30 minutes. b) Suction the client as needed to obtain a sputum specimen for culture and sensitivity. c) Assess intake and output and maintain adequate hydration. d) Reassure the client that intubation and mechanical ventilation will be temporary.

a) Monitor vital signs and oxygen saturation every 15 to 30 minutes.

A client with chronic obstructive pulmonary disease presents with respiratory acidosis and hypoxemia. He tells the nurse that he doesn't want to be placed on a ventilator. What action should the nurse take? a) Notify the physician immediately so he can determine client competency. b) Have the client sign a do-not-resuscitate (DNR) form. c) Determine whether the client's family was consulted about his decision. d) Consult the palliative care group to direct care for the client.

a) Notify the physician immediately so he can determine client competency.

A 33-year-old woman with primary pulmonary hypertension is being evaluated for a heart-lung transplant. The nurse asks her what treatments she is currently receiving for her disease. She is likely to mention which treatments? a) Oxygen b) Aminoglycosides c) Diuretics d) Vasodilators e) Antihistamines f) Sulfonamides

a) Oxygen c) Diuretics d) Vasodilators

A client has hypoxemia of pulmonary origin. What portion of arterial blood gas results is most useful in distinguishing between acute respiratory distress syndrome and acute respiratory failure? a) Partial pressure of arterial oxygen (PaO2) b) Partial pressure of arterial carbon dioxide (PaCO2) c) pH d) Bicarbonate (HCO3-)

a) Partial pressure of arterial oxygen (PaO2)

A client is admitted to the emergency department with an acute asthma attack. The physician prescribes ephedrine sulfate, 25 mg subcutaneously (S.C.). How soon should the ephedrine take effect? a) Rapidly b) In 3 minutes c) In 1 hour d) In 2 hours

a) Rapidly

The nurse administers albuterol (Proventil), as prescribed, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect? a) Respiratory rate of 22 breaths/minute b) Dilated and reactive pupils c) Urine output of 40 ml/hour d) Heart rate of 100 beats/minute

a) Respiratory rate of 22 breaths/minute

A client with respiratory acidosis is admitted to the intensive care unit for close observation. The nurse should stay alert for which complication associated with respiratory acidosis? a) Shock b) Stroke c) Seizures d) Hyperglycemia

a) Shock

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition? a) The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. b) The client has a partial pressure of arterial carbon dioxide (PaCO2) value of 65 mm Hg or higher. c) The client exhibits restlessness and confusion. d) The client exhibits bronchial breath sounds over the affected area.

a) The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher.

A client with chronic obstructive pulmonary disease (COPD) is admitted to the medical-surgical unit. To help this client maintain a patent airway and achieve maximal gas exchange, the nurse should: a) instruct the client to drink 2 L of fluid daily. b) maintain the client on bed rest. c) administer anxiolytics, as prescribed, to control anxiety. d) administer pain medication as prescribed.

a) instruct the client to drink 2 L of fluid daily.

A client who weighs 175 lb (79.4 kg) is receiving aminophylline (Aminophyllin) (400 mg in 500 ml) at 50 ml/hour. The theophylline level is reported as 6 mcg/ml. The nurse calls the physician who instructs the nurse to change the dosage to 0.45 mg/kg/hour. The nurse should: a) question the order because the dosage is too low. b) question the order because the dosage is too high. c) set the pump at 45 ml/hour. d) stop the infusion and have the laboratory repeat the theophylline measurement.

a) question the order because the dosage is too low.

A slightly obese client with a history of allergy-induced asthma, hypertension, and mitral valve prolapse is admitted to an acute care facility for elective surgery. The nurse obtains a complete history and performs a thorough physical examination, paying special attention to the cardiovascular and respiratory systems. When percussing the client's chest wall, the nurse expects to elicit: a) resonant sounds. b) hyperresonant sounds. c) dull sounds. d) flat sounds.

a) resonant sounds.

A woman whose husband was recently diagnosed with active pulmonary tuberculosis (TB) is a tuberculin skin test converter but doesn't show signs of active tuberculosis. Management of her care would include:

advising her to begin prophylactic therapy with isoniazid (INH). Explanation: Individuals who are tuberculin skin test converters should begin a 6-month regimen of an antitubercular drug such as INH, and they should never have another skin test. After an individual has a positive tuberculin skin test, subsequent skin tests will cause severe skin reactions but won't provide new information about the client's TB status. The client doesn't have active TB, so she can't transmit, or spread, the bacteria. Therefore, she shouldn't be quarantined or asked for information about recent contacts.

For an infant who's about to undergo a lumbar puncture, the nurse should place the infant in:

an arched, side-lying position, avoiding flexion of the neck onto the chest. Explanation: For a lumbar puncture, the nurse should place the infant in an arched, side- lying position to maximize the space between the third and fifth lumbar vertebrae. The nurse's hands should rest on the back of the infant's shoulders to prevent neck flexion, which could block the airway and cause respiratory arrest. The infant should be placed at the edge of the bed or table during the procedure, and the nurse should speak quietly to calm the child. A mummy restraint would limit access to the lumbar area because it involves wrapping the child's trunk and extremities snugly in a blanket or towel. A prone position wouldn't cause separation of the vertebral spaces.

The nurse assesses a client for evidence of postpartum hemorrhage during the third stage of labor. Early signs of this postpartum complication include:

an increased pulse rate, increased respiratory rate, and decreased blood pressure. Explanation: An increased pulse rate followed by an increased respiratory rate and decreased blood pressure may be the first signs of postpartum hemorrhage and hypovolemic shock.

A client, 11 weeks pregnant, is admitted to the facility with hyperemesis gravidarum. She tells the nurse she has never known anyone who had such severe morning sickness. The nurse understands that hyperemesis gravidarum results from:

an unknown cause. Explanation: The cause of hyperemesis gravidarum isn't known. However, etiologic theories implicate hormonal alterations and allergic or psychosomatic conditions. No evidence suggests that hyperemesis gravidarum results from a neurologic disorder, inadequate nutrition, or hemolysis of fetal RBCs.

A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family? a) "Clean the tracheostomy tube with alcohol and water." b) "Family members should continue to talk to the client." c) "Oral intake of fluids should be limited for 1 week only." d) "Limit the amount of protein in the diet."

b) "Family members should continue to talk to the client."

A home care nurse visits a client with chronic obstructive pulmonary disease who requires oxygen. Which statement by the client indicates the need for additional teaching about home oxygen use? a) "I lubricate my lips and nose with K-Y jelly." b) "I make sure my oxygen mask is on tightly so it won't fall off while I nap." c) "I have a 'no smoking' sign posted at my front entry-way to remind guests not to smoke." d) "I clean my mask with water after every meal."

b) "I make sure my oxygen mask is on tightly so it won't fall off while I nap."

For a client with an acute pulmonary embolism, the physician prescribes heparin (Liquaemin), 25,000 U in 500 ml of dextrose 5% in water (D5W) at 1,100 U/hour. The nurse should administer how many milliliters per hour? a) 8 b) 22 c) 30 d) 50

b) 22

A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first? a) Instruct the client to breathe into a paper bag. b) Administer oxygen by nasal cannula as prescribed. c) Auscultate breath sounds bilaterally every 4 hours. d) Encourage the client to deep-breathe and cough every 2 hours.

b) Administer oxygen by nasal cannula as prescribed.

A 29-year-old client with severe shortness of breath comes to the emergency department. He tells the emergency department staff that he recently traveled to China for business. Based on his travel history and presentation, the staff suspects severe acute respiratory syndrome (SARS). Which isolation precautions should the staff institute? a) Droplet precautions b) Airborne and contact precautions c) Contact and droplet precautions d) Contact precautions

b) Airborne and contact precautions

A client, confused and short of breath, is brought to the emergency department by a family member. The medical history reveals chronic bronchitis and hypertension. To learn more about the client's current respiratory problem, the physician orders a chest X-ray and arterial blood gas (ABG) analysis. When reviewing the ABG report, the nurse sees many abbreviations. What does a lowercase "a" in an ABG value represent? a) Acid-base balance b) Arterial blood c) Arterial oxygen saturation d) Alveoli

b) Arterial blood

An adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. Prescribed respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure? a) Immediately before a meal b) At least 2 hours after a meal c) When bronchospasms occur d) When secretions have mobilized

b) At least 2 hours after a meal

Before weaning a client from a ventilator, which assessment parameter is most important for the nurse to review? a) Fluid intake for the past 24 hours b) Baseline arterial blood gas (ABG) levels c) Prior outcomes of weaning d) Electrocardiogram (ECG) results

b) Baseline arterial blood gas (ABG) levels

During inspiration, which of the following occurs? a) Lungs recoil. b) Diaphragm descends. c) Alveolar pressure is positive. d) Inspiratory muscles relax.

b) Diaphragm descends.

After receiving the wrong medication, the client's breathing stops. The nurse initiates the code protocol, and the client is emergently intubated. As soon as the client's condition stabilizes, the nurse completes an incident report. What should the nurse do next? a) Place the incident report on the client's chart. b) Document the incident in the nurses' notes. c) Document in the nurses' notes that an incident report was completed. d) Make a copy of the incident report for the client.

b) Document the incident in the nurses' notes.

A client with chronic obstructive pulmonary disease (COPD) is being evaluated for a lung transplant. The nurse performs the initial physical assessment. Which signs and symptoms should the nurse expect to find? a) Decreased respiratory rate b) Dyspnea on exertion c) Barrel chest d) Shortened expiratory phase e) Clubbed fingers and toes f) Fever

b) Dyspnea on exertion c) Barrel chest e) Clubbed fingers and toes

The nurse is planning care for a client after a tracheostomy. One of the client's goals is to overcome verbal communication impairment. Which of the following interventions should the nurse include in the care plan? a) Make an effort to read the client's lips to foster communication. b) Encourage the client's communication attempts by allowing him time to select or write words. c) Answer questions for the client to reduce his frustration. d) Avoid using a tracheostomy plug because it blocks the airway.

b) Encourage the client's communication attempts by allowing him time to select or write words.

An elderly client with influenza is admitted to an acute care facility. The nurse monitors the client closely for complications. What is the most common complication of influenza? a) Septicemia b) Pneumonia c) Meningitis d) Pulmonary edema

b) Pneumonia

A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do? a) Check for an apical pulse. b) Suction the client's artificial airway. c) Increase the oxygen percentage. d) Ventilate the client with a handheld mechanical ventilator.

b) Suction the client's artificial airway.

A client with end-stage chronic obstructive pulmonary disease requires bi-level positive airway pressure (BiPAP). While caring for the client, the nurse determines that bilateral wrist restraints are required to prevent compromised care. Which client care outcome is associated with restraint use in the client who requires BiPAP? a) The client will remain infection-free. b) The client will maintain adequate oxygenation. c) The client will maintain adequate urine output. d) The client will remain pain-free.

b) The client will maintain adequate oxygenation.

A client with acute bronchitis is admitted to the health care facility and is receiving supplemental oxygen via nasal cannula. When monitoring this client, the nurse suddenly hears a high-pitched whistling sound. What is the most likely cause of this sound? a) The water level in the humidifier reservoir is too low. b) The oxygen tubing is pinched. c) The client has a nasal obstruction. d) The oxygen concentration is above 44%.

b) The oxygen tubing is pinched.

A client with a pneumothorax receives a chest tube attached to a Pleur-evac. The nurse notices that the fluid of the second chamber of the Pleur-evac isn't bubbling. Which nursing assumption would be most invalid? a) The tubing from the client to the chamber is blocked. b) There is a leak somewhere in the tubing system. c) The client's affected lung has reexpanded. d) The tubing needs to be cleared of fluid.

b) There is a leak somewhere in the tubing system.

A nurse detects bilateral crackles when auscultating a client's lungs. Which statement about crackles is true? a) They're usually heard on expiration and may clear with a cough. b) They're usually heard on inspiration and sometimes clear with a cough. c) They're hissing or musical and are usually heard on inspiration and expiration; if severe, they may be heard without a stethoscope. d) They're creaking and grating and are usually heard over the problem area on both inspiration and expiration.

b) They're usually heard on inspiration and sometimes clear with a cough.

A 47-year-old male client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is: a) lobar pneumonia. b) empyema. c) Pneumocystis carinii pneumonia. d) infected chest tube wound site.

b) empyema.

The nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is: a) helping him communicate. b) keeping his airway patent. c) encouraging him to perform activities of daily living. d) preventing him from developing an infection.

b) keeping his airway patent.

Which task can be safely delegated to a licensed practical nurse (LPN)? a) Teaching a newly diagnosed diabetic about insulin administration. b) Admitting a client who underwent a thoracotomy to the nursing unit from the postanesthesia care unit. c) Changing the dressing of a client who underwent surgery two days ago. d) Administering an I.V. bolus of morphine sulfate to a client experiencing incisional pain

c) Changing the dressing of a client who underwent surgery two days ago.

A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client? a) Administering oxygen, coughing, breathing deeply, and maintaining bed rest b) Coughing, breathing deeply, maintaining bed rest, and using an incentive spirometer c) Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer d) Administering pain medications, frequent repositioning, and limiting fluid intake

c) Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer

A recent immigrant from Vietnam is diagnosed with pulmonary tuberculosis (TB). Which intervention is most important for the nurse to implement with this client? a) Client teaching about the cause of TB b) Reviewing the risk factors for TB c) Developing a list of people with whom the client has had contact d) Client teaching about the importance of TB testing

c) Developing a list of people with whom the client has had contact

The physician orders a palliative care consult for a client with end-stage chronic obstructive pulmonary disease who wishes no further medical intervention. Which step should the nurse anticipate based on her knowledge of palliative care? a) Decreasing administration of pain medications b) Reducing oxygen requirements c) Increasing the need for antianxiety agents d) Decreasing the use of bronchodilators

c) Increasing the need for antianxiety agents

A client who sustained a pulmonary contusion in a motor vehicle accident develops a pulmonary embolism. Which nursing diagnosis takes priority with this client? a) Excess fluid volume related to excess sodium intake b) Acute pain related to tissue trauma c) Ineffective breathing pattern related to tissue trauma d) Activity intolerance related to insufficient energy to carry out activities of daily living

c) Ineffective breathing pattern related to tissue trauma

A client in the emergency department is diagnosed with a communicable disease. When complications of the disease are discovered, the client is admitted to the hospital and placed in respiratory isolation. Which infection warrants respiratory isolation? a) Chickenpox b) Impetigo c) Measles d) Cholera

c) Measles

A client is receiving conscious sedation while undergoing bronchoscopy. Which assessment finding should receive the nurse's immediate attention? a) Absent cough and gag reflexes b) Blood-tinged secretions c) Oxygen saturation of 90% d) Respiratory rate of 13 breaths/min

c) Oxygen saturation of 90%

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? a) pH b) Bicarbonate (HCO3-) c) Partial pressure of arterial oxygen (PaO2) d) Partial pressure of arterial carbon dioxide (PaCO2)

c) Partial pressure of arterial oxygen (PaO2)

The nurse is developing a teaching plan for a client with asthma. Which teaching point has the highest priority? a) Avoid contact with fur-bearing animals. b) Change filters on heating and air conditioning units frequently. c) Take prescribed medications as scheduled. d) Avoid goose down pillows.

c) Take prescribed medications as scheduled.

A client with a history of type 1 diabetes is admitted to the hospital with community-acquired pneumonia. The client's blood glucose level in the emergency care unit was 576 mg/dl. The physician prescribes an I.V. containing normal saline solution, an insulin infusion, and I.V. levofloxacin (Levaquin). The nurse piggybacks the insulin infusion into the normal saline solution. She questions whether she can also piggyback the levofloxacin into the same I.V. line. Which health team member should she collaborate with to check the compatibility of these solutions? a) The physician who prescribed the medications b) The coworker with 20 years nursing experience c) The pharmacist covering the floor d) The infectious disease nurse

c) The pharmacist covering the floor

The nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? a) The system is functioning normally. b) The client has a pneumothorax. c) The system has an air leak. d) The chest tube is obstructed.

c) The system has an air leak.

A client in acute respiratory distress is brought to the emergency department. After endotracheal (ET) intubation and initiation of mechanical ventilation, the client is transferred to the intensive care unit. Before suctioning the ET tube, the nurse hyperventilates and hyperoxygenates the client. What is the rationale for these interventions? a) They help prevent subcutaneous emphysema. b) They help prevent pneumothorax. c) They help prevent cardiac arrhythmias. d) They help prevent pulmonary edema.

c) They help prevent cardiac arrhythmias.

A client with a suspected pulmonary disorder undergoes pulmonary function tests. To interpret test results accurately, the nurse must be familiar with the terminology used to describe pulmonary functions. Which term refers to the volume of air inhaled or exhaled during each respiratory cycle? a) Vital capacity b) Functional residual capacity c) Tidal volume d) Maximal voluntary ventilation

c) Tidal volume

or a client with advanced chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange? a) Encouraging the client to drink three glasses of fluid daily b) Keeping the client in semi-Fowler's position c) Using a high-flow Venturi mask to deliver oxygen as prescribed d) Administering a sedative as prescribed

c) Using a high-flow Venturi mask to deliver oxygen as prescribed

A client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for: a) pleural effusion. b) pulmonary edema. c) atelectasis. d) oxygen toxicity.

c) atelectasis.

After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must: a) report fluctuations in the water-seal chamber. b) clamp the chest tube once every shift. c) encourage coughing and deep breathing. d) milk the chest tube every 2 hours.

c) encourage coughing and deep breathing.

A client with chronic sinusitis comes to the outpatient department complaining of headache, malaise, and a nonproductive cough. When examining the client's paranasal sinuses, the nurse detects tenderness. To evaluate this finding further, the nurse should transilluminate the: a) frontal sinuses only. b) sphenoidal sinuses only. c) frontal and maxillary sinuses. d) sphenoidal and ethmoidal sinuses.

c) frontal and maxillary sinuses.

Inspiratory and expiratory stridor may be heard in a client who: a) is experiencing an exacerbation of goiter. b) is experiencing an acute asthmatic attack. c) has aspirated a piece of meat. d) has severe laryngotracheitis.

c) has aspirated a piece of meat.

A client's chest X-ray reveals bilateral white-outs, indicating adult respiratory distress syndrome (ARDS). This syndrome results from: a) cardiogenic pulmonary edema. b) respiratory alkalosis. c) increased pulmonary capillary permeability. d) renal failure.

c) increased pulmonary capillary permeability.

A client with advanced acquired immunodeficiency syndrome (AIDS) is diagnosed with active tuberculosis. Which of the following regimens would the nurse expect the physician to prescribe? a) isoniazid (Laniazid) and rifampin (Rifadin) b) ethambutol (Myambutol), pyrazinamide, and isoniazid c) isoniazid, rifampin, ethambutol, and pyrazinamide d) ethambutol, ciprofloxacin (Cipro), pyrazinamide, and streptomycin

c) isoniazid, rifampin, ethambutol, and pyrazinamide

A 21-year-old client with cystic fibrosis develops pneumonia. To decrease the viscosity of respiratory secretions, the physician prescribes acetylcysteine (Mucomyst). Before administering the first dose, the nurse checks the client's history for asthma. Acetylcysteine must be used cautiously in a client with asthma because: a) it's a respiratory depressant. b) it's a respiratory stimulant. c) it may induce bronchospasm. d) it inhibits the cough reflex.

c) it may induce bronchospasm.

A client with severe acute respiratory syndrome (SARS) privately informs the nurse that he doesn't want to be placed on a ventilator if his condition worsens. The client's wife and children have repeatedly expressed their desire that everything be done for the client. The most appropriate action by the nurse would be to: a) inform the family of the client's wishes. b) assure the family that everything possible will be done. c) support the client's decision. d) assure the client that everything possible will be done.

c) support the client's decision.

The nurse is caring for a teenage client involved in a motor vehicle accident. The client has a chest tube in place. If the chest tube is accidentally removed, the nurse should immediately:

cover the opening with sterile petroleum gauze. Explanation: If a chest tube is accidentally removed, the nurse should cover the insertion site with sterile petroleum gauze. The nurse should then observe the client for respiratory distress, as tension pneumothorax may develop. If so, the nurse should remove the gauze to allow air to escape. The nurse shouldn't reintroduce the tube. Rather, the nurse should have another staff member call a physician so another tube can be introduced by the physician under sterile conditions.

During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates:

cranial nerves IX and X.

After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's teenage daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy? a) 3 to 5 days b) 1 to 3 weeks c) 2 to 4 months d) 6 to 12 months

d) 6 to 12 months

A nurse caring for a client with deep vein thrombosis must be especially alert for complications such as pulmonary embolism. Which findings suggest pulmonary embolism? a) Nonproductive cough and abdominal pain b) Hypertension and lack of fever c) Bradypnea and bradycardia d) Chest pain and dyspnea

d) Chest pain and dyspnea

The physician determines that a client has been exposed to someone with tuberculosis. The nurse expects the physician to order which of the following? a) Daily oral doses of isoniazid (Nydrazid) and rifampin (Rifadin) for 6 months to 2 years b) Isolation until 24 hours after antitubercular therapy begins c) Nothing, until signs of active disease arise d) Daily doses of isoniazid, 300 mg for 6 months to 1 year

d) Daily doses of isoniazid, 300 mg for 6 months to 1 year

The nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? a) Nonproductive cough and normal temperature b) Sore throat and abdominal pain c) Hemoptysis and dysuria d) Dyspnea and wheezing

d) Dyspnea and wheezing

The nurse is caring for a client with pneumonia. As part of prescribed therapy, the client must use a bedside incentive spirometer to promote maximal deep breathing. The nurse checks to make sure the client is using the spirometer properly. During each waking hour, the client should perform a minimum of how many sustained, voluntary inflation maneuvers? a) One to two b) Three to four c) Five to seven d) Eight to ten

d) Eight to ten

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? a) Hypotension, hyperoxemia, and hypercapnia b) Hyperventilation, hypertension, and hypocapnia c) Hyperoxemia, hypocapnia, and hyperventilation d) Hypercapnia, hypoventilation, and hypoxemia

d) Hypercapnia, hypoventilation, and hypoxemia

On arrival at the intensive care unit, a critically ill client suffers respiratory arrest and is placed on mechanical ventilation. The physician orders pulse oximetry to monitor the client's arterial oxygen saturation (SaO2) noninvasively. Which vital sign abnormality may alter pulse oximetry values? a) Fever b) Tachypnea c) Tachycardia d) Hypotension

d) Hypotension

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? a) Nausea or vomiting b) Abdominal pain or diarrhea c) Hallucinations or tinnitus d) Light-headedness or paresthesia

d) Light-headedness or paresthesia

A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder? a) Respiratory alkalosis b) Respiratory acidosis c) Metabolic alkalosis d) Metabolic acidosis

d) Metabolic acidosis

A client undergoes a tracheostomy after many failed attempts at weaning him from a mechanical ventilator. Two days after tracheostomy, while the client is being weaned, the nurse detects a mild air leak in the tracheostomy tube cuff. What should the nurse do first? a) Call the physician. b) Remove the malfunctioning cuff. c) Add more air to the cuff. d) Suction the client, withdraw residual air from the cuff, and reinflate it.

d) Suction the client, withdraw residual air from the cuff, and reinflate it.

A client is undergoing a complete physical examination as a requirement for college. When checking the client's respiratory status, the nurse observes respiratory excursion to help assess: a) lung vibrations b) vocal sounds c) breath sounds d) chest movements

d) chest movements

The nurse assessing a client for tracheal displacement should know that the trachea will deviate toward the: a) contralateral side in a simple pneumothorax. b) affected side in a hemothorax. c) affected side in a tension pneumothorax. d) contralateral side in a hemothorax.

d) contralateral side in a hemothorax.

Before administering ephedrine, the nurse assesses the client's history. Because of ephedrine's central nervous system (CNS) effects, it is not recommended for: a) clients with an acute asthma attack. b) clients with narcolepsy. c) clients under age 6. d) elderly clients.

d) elderly clients.

A client with chronic obstructive pulmonary disease tells the nurse that he feels short of breath. The client's respiratory rate is 36 breaths/min and the nurse auscultates diffuse wheezes. His arterial oxygen saturation is 84%. The nurse calls the assigned respiratory therapist to administer a prescribed nebulizer treatment. The therapist says, "I have several more nebulizer treatments to do on the unit where I am now. As soon as I'm done, I'll come assess the client." The nurse's most appropriate action is to: a) notify the primary physician immediately. b) stay with the client until the therapist arrives. c) administer the treatment by metered-dose inhaler. d) give the nebulizer treatment herself.

d) give the nebulizer treatment herself.

A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis? a) pH, 7.5; PaCO2 30 mm Hg b) pH, 7.40; PaCO2 35 mm Hg c) pH, 7.35; PaCO2 40 mm Hg d) pH, 7.25; PaCO2 50 mm Hg

d) pH, 7.25; PaCO2 50 mm Hg

A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects: a) metabolic acidosis. b) metabolic alkalosis. c) respiratory acidosis. d) respiratory alkalosis.

d) respiratory alkalosis.

A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, the nurse must remain alert for:

diaphoresis, vomiting, and diarrhea.

For a client with cirrhosis, deterioration of hepatic function is best indicated by:

difficulty in arousal. Explanation: Hepatic encephalopathy, a major complication of advanced cirrhosis, occurs when the liver no longer can convert ammonia (a by-product of protein breakdown) into glutamine. This leads to an increased blood level of ammonia — a central nervous system toxin — which causes a decrease in the level of consciousness. Fatigue, muscle weakness, nausea, anorexia, and weight gain occur during the early stages of cirrhosis.

A patient develops diarrhea secondary to antibiotic therapy. He is to receive two tablets of diphenoxylate HCl with atropine sulfate (Lomotil) orally as needed for each loose stool. The nurse should inform him that he may experience

dizziness. Explanation: The most common adverse effects of diphenoxylate HCl with atropine sulfate are drowsiness and dizziness related to the drug's chemical similarity to meperidine, an opioid. Tachycardia is an adverse effect, not bradycardia. Muscle aches and an increase in appetite are not adverse effects of the drug.

When assisting the patient to interpret a negative HIV test result, the nurse informs the patient that the results mean that

his body has not produced antibodies to the AIDS virus.

Early signs of hypervolemia include

increased breathing effort and weight gain - Early signs of hypervolemia are weight gain, elevated blood pressure, and increased breathing effort...(more) Early signs of hypervolemia are weight gain, elevated blood pressure, and increased breathing effort. Eventually, fluid congestion in the lungs leads to moist breath sounds. An earliest symptom of hypovolemia is thirst

To avoid recording an erroneously low systolic blood pressure because of failure to recognize an auscultatory gap, the nurse should:

inflate the cuff at least another 30 mm Hg after the radial pulse becomes impalpable. Explanation: The nurse should wrap an appropriately sized cuff around the client's upper arm and then place the diaphragm of the stethoscope over the brachial artery. The nurse should then rapidly inflate the cuff until she can no longer palpate or auscultate the pulse and continue inflating until the pressure rises another 30 mm Hg. The other options aren't appropriate measures.

Bladder retraining following removal of an indwelling catheter begins with

instructing the patient to follow a 2 to 3 hour timed voiding schedule.

The nurse caring for the client with acute renal failure would question which of the following for the treatment of hyperkalemia?

lanthanum carbonate (Fosrenol)

Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain, and venography reveals deep vein thrombosis (DVT). When checking this client, the nurse is most likely to detect:

left calf circumference 1" (2.5 cm) larger than the right. Explanation: Signs of DVT include inflammation and edema in the affected extremity, causing its circumference to exceed that of the opposite extremity. Pallor, coolness, decreased pulse, and hair loss in an extremity signal interrupted arterial blood flow, which doesn't occur in DVT.

The primary objective in the immediate postoperative period is

maintaining pulmonary ventilation.

The nurse is providing discharge instructions for a slightly overweight client seen in the Emergency Department for chest pain. The client was diagnosed as having gastroesophageal reflux disease. The nurse notes in the client's record that the client is taking carbidopa/levodopa (Sinemet). The nurse questions the physician's order for

metoclopramide

A black client with asthma seeks emergency care for acute respiratory distress. Because of this client's dark skin, the nurse should assess for cyanosis by inspecting the:

mucous membranes.

The nurse is caring for a 16-year-old female client who isn't sexually active. The client asks if she needs a Papanicolaou (Pap) test. The nurse should reply:

no because she isn't sexually active. Explanation: A 16-year-old client who isn't sexually active doesn't need a Pap test. When a client is sexually active or reaches age 18, a Pap test should be performed.

A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis?

pH, 7.25; PaCO2 50 mm Hg - In respiratory acidosis, ABG analysis reveals an arterial pH below 7.35 and partial pressure of arterial carbon dioxide (PaCO2) above 45 mm Hg. Therefore, the combination of a pH value of 7.25 and a PaCO2 value of 50 mm Hg confirms respiratory acidosis. A pH value of 7.5 with a PaCO2 value of 30 mm Hg indicates respiratory alkalosis. A ph value of 7.40 with a PaCO2 value of 35 mm Hg and a pH value of 7.35 with a PaCO2 value of 40 mm Hg represent normal ABG values, reflecting normal gas exchange in the lungs.

The nurse is assessing a client with multiple myeloma. The nurse should keep in mind that clients with multiple myeloma are at risk for:

pathologic bone fractures. Explanation: Clients with multiple myeloma are at risk for pathologic bone fractures secondary to diffuse osteoporosis and osteolytic lesions. Also, clients are at risk for renal failure secondary to myeloma proteins by causing renal tubular obstruction. Liver failure and heart failure aren't usually sequelae of multiple myeloma. Hypoxemia isn't usually related to multiple myeloma.

Which of the following would be the least important issue concerning safety for the perioperative team prior to proceeding to the operating room?

patient ambulatory aids

If an indwelling catheter is necessary, the nursing interventions that should be implemented to prevent infection include

performing meticulous perineal care daily with soap and water.

A nurse is assessing a client with heart failure. To assess hepatojugular reflux, the nurse should:

press the right upper abdomen. Explanation: As the right upper abdomen (the area over the liver) is compressed for 30 to 40 seconds, the nurse observes the internal jugular vein. If the internal jugular vein becomes distended, a client has positive hepatojugular reflux. Hepatojugular reflux, a sign of right-sided heart failure, is assessed with the head of the bed at a 45-degree, not 90-degree, angle.

Following a small-bowel resection, a client develops fever and anemia. The surface surrounding the surgical wound is warm to the touch and necrotizing fasciitis is suspected. Another manifestation that would most suggest necrotizing fasciitis is:

pressurelike pain.

A 53-year-old client is seeing the physician today because he has had laryngitis for 2 weeks. After a thorough examination, the doctor orders medications and instructs the client to follow up in 1 week if his voice has not improved. What is the primary function of the larynx?

producing sound

When the balloon on the distal tip of a pulmonary artery catheter is inflated and a pressure is measured, the measurement obtained is referred to as the

pulmonary artery wedge pressure. Explanation: When the balloon is inflated, the tip of the catheter floats into smaller branches of the pulmonary artery until it can no longer be passed and the pressure is recorded, reflecting left atrial pressure and left ventricular end-diastolic pressure. Central venous pressure is measured in the right atrium. Pulmonary artery pressure is measured when the balloon tip is not inflated. Cardiac output is determined through thermodilution involving injection of fluid into the pulmonary artery catheter.

Pink frothy sputum may be an indication of

pulmonary edema.

circadian rhythm

the biological clock; regular bodily rhythms that occur on a 24-hour cycle

In developing the plan of care for the intraoperative client, the nurse recognizes that it is essential to consider:

the client's cultural beliefs

A nurse is helping a physician insert a subclavian central line. After the physician has gained access to the subclavian vein, he connects a 10-ml syringe to the catheter and withdraws a sample of blood. He then disconnects the syringe from the port. Suddenly, the client becomes confused, disoriented, and pale. The nurse suspects an air embolus. She should:

turn the client on his left side and place the bed in Trendelenburg's position.

A client is admitted to the psychiatric unit with a diagnosis of borderline personality disorder. The nurse expects data collection to reveal:

unpredictable behavior and intense interpersonal relationships. Explanation: A client with borderline personality disorder displays a pervasive pattern of unpredictable behavior, mood, and self-image. Interpersonal relationships may be intense and unstable, and behavior may be inappropriate and impulsive. Although the client's impaired ability to form relationships may affect parenting skills, inability to function as a responsible parent is more typical of antisocial personality disorder. Somatic symptoms characterize avoidant personality disorder. Coldness, detachment, and lack of tender feelings typify schizoid and schizotypal personality disorders.

A client is admitted for treatment of chronic renal failure (CRF). The nurse knows that this disorder increases the client's risk of:

water and sodium retention secondary to a severe decrease in the glomerular filtration rate. Explanation: A client with CRF is at risk for fluid imbalance — dehydration if the kidneys fail to concentrate urine, or fluid retention if the kidneys fail to produce urine. Electrolyte imbalances associated with this disorder result from the kidneys' inability to excrete phosphorus; such imbalances may lead to hyperphosphatemia with reciprocal hypocalcemia. CRF may cause metabolic acidosis, not metabolic alkalosis, secondary to the inability of the kidneys to excrete hydrogen ions.

During data collection, a client with schizophrenia leaves his arm in the air after the nurse has taken his blood pressure. His action shows evidence of:

waxy flexibility. Explanation: Waxy flexibility is defined as retaining any position that the body has been placed in. Somatic delusions involve a false belief about the functioning of the body. Neologisms are invented meaningless words. Nihilistic delusions are false ideas about self, others, or the world.

Before a transesophageal echocardiogram, a nurse gives a client an oral topical anesthetic spray. When the client returns from the procedure, the nurse observes that he has no active gag reflex. In response, the nurse should:

withhold food and fluids. Explanation: Following a transesophageal echocardiogram in which the client's throat has been anesthetized, the nurse should withhold food and fluid until the client's gag reflex returns. There's no indication that oral airway placement would be appropriate. The client should be in the upright position, and the nurse needn't insert an NG tube.

The nurse is caring for a client with skin grafts covering third-degree burns on the arms and legs. During dressing changes, the nurse should be sure to:

wrap elastic bandages distally to proximally on dependent areas.

candidiasis

yeast infection; infections occurring on the skin or mucous membranes in the warm, moist areas such as the vagina or the mouth

A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note:

yellow sclerae. Explanation: Yellow sclerae may be the first sign of jaundice, which occurs when the common bile duct is obstructed. Urine normally is light amber. Circumoral pallor and black, tarry stools are signs of hypoxia and GI bleeding, respectively.

A nurse is taking health history data from a client. Use of which of the following medications would especially alert the nurse to an increased risk of hepatic dysfunction and disease in this client? Select all that apply.

• Acetaminophen • Ketoconazole • Valproic acid

A client has an increased number of eosinophils. Which of the following disorders would the nurse expect the client to have? Select all that apply.

• Allergy • Parasitic infection

After reviewing the various primary immunodeficiencies, nursing students demonstrate understanding of the information when they identify which of the following as complement system deficiencies? Select all that apply.

• Angioneurotic edema • Paroxysmal nocturnal hemoglobinuria

A mother reports that her 6-year-old girl recently started wetting the bed and running a low-grade fever. A urinalysis is positive for bacteria and protein. A diagnosis of a urinary tract infection (UTI) is made, and the child is prescribed antibiotics. Which interven-tions are appropriate? Select all that apply:

• Assess the mother's understanding of UTI and its causes • Instruct the mother to administer the antibiotic as prescribed—even if the symptoms diminish • Discourage taking bubble baths Explanation: Assessing the mother's understanding of UTI and its causes provides the nurse with a baseline for teaching. The full course of antibiotics must be given to eradicate the organism and prevent recurrence, even if the child's signs and symptoms de-crease. Bubble baths can irritate the vulva and urethra and contribute to the development of a UTI. Fluids should be encouraged, not limited, in order to prevent urinary stasis and help flush the organism out of the urinary tract. Instructions should be given to the child at her level of understanding to help her better understand the treatment and promote compliance. The child should wipe from the front to the back, not back to front, to minimize the risk of contamination after elimination.

A nursing student is preparing a teaching plan for a client with an immunodeficiency disorder. The student is going to include the cardinal symptoms in teaching. Which of the following would the student include? Choose all that apply.

• Chronic diarrhea • Chronic or recurrent severe infections • Poor response to treatment of infections

A client is being treated for diverticulosis. Which of the following points should the nurse include in this client's teaching plan? Choose all correct options.

• Drink at least 8 to 10 large glasses of fluid every day. • Do not suppress the urge to defecate.

While conducting a physical examination of a client, which of the following skin findings would alert the nurse to the possibility of liver problems? Select all that apply.

• Ecchymoses • Jaundice • Petechiae

A female client has undergone a lumbar puncture for a neurological assessment. The client is put under the post-procedure care of a nurse. Which of the following important post-procedure nursing interventions should be performed to ensure maximum comfort to the client? Choose all that apply.

• Encourage a liberal fluid intake for the client. • Position the client flat for at least three hours or as directed by the physician.

A nurse is working with the family of a client who has Alzheimer's disease. The nurse notes that the client's spouse is too exhausted to continue providing care all alone. The adult children live too far away to provide relief on a weekly basis. Which nursing interventions would be most helpful? Select all that apply. Recommending community resources for adult day care and respite care

• Encouraging the spouse to talk about the difficulties involved in caring for a loved one • Asking whether friends or church members can help with errands or provide short periods of relief Explanation: Many community services exist for Alzheimer's clients and their families. Encouraging use of these resources may make it possible to keep the client at home and to alleviate the spouse's exhaustion. The nurse can also support the caregiver by urging her to talk about the difficulties she's facing in caring for her spouse. Friends and church members may be able to help provide care to the client, allowing the caregiver time for rest, exercise, or an enjoyable activity. Arranging a family meeting to tell the children to participate more would probably be ineffective and might evoke anger or guilt. Counseling might be helpful, but it wouldn't alleviate the caregiver's physical exhaustion or address the client's immediate needs. A long-term care facility isn't an option until the family is ready to make that decision.

When assessing whether a patient is a candidate for home parenteral nutrition, which of the following would be important to address? Select all that apply.

• Health status • Family support • Motivation for learning • Telephone access

Susan Hopkins, a 32-year-old administrative assistant, is being seen by a physician with the urology practice where you practice nursing. She has a history of neurogenic bladder and uses a permanent, indwelling catheter to facilitate urine elimination. What contributes to the likelihood of developing urinary tract or bladder infections? Choose all correct options.

• Indwelling catheter • Decreased fluid intake

A secondary immunodeficiency is characterized by the following. Choose all that apply.

• It usually occurs as a result of underlying disease processes. • It frequently is caused by certain autoimmune disorders. • It may be caused by certain viruses.

When reviewing the laboratory test results of a client with X-linked agammaglobulinemia, which of the following would be most likely? Select all that apply.

• Low levels of IgM • Absent B cells

Which of the following are functions of saliva? Select all that apply.

• Lubrication • Digestion • Protection against harmful bacteria

The two types of inherited B-cell deficiencies result from lack of differentiation of B cells. These types result from which two of the following deficiencies? Choose the two that apply.

• Mature B-cells • Plasma cells

Students are reviewing the concepts of phenotype and genotype as they apply to hypercholesterolemia. The students demonstrate an understanding by identifying which of the following as characteristic of the genotype of this disease? Select all that apply.

• Mutations in low-density lipoprotein (LDL) receptors • Disruption in an apolipoprotein gene

A client is diagnosed with common variable immunodeficiency (CVID). Which of the following would the nurse identify as potential infections for this client? Choose all that apply.

• Staphylococcus aureus • Streptococcus pneumoniae • Haemophilus influenzae

A client with chronic bronchitis is admitted with an exacerbation of symptoms. During the nursing assessment, the nurse will expect which of the following findings? Select all that apply.

• Use of accessory muscles to breathe • Purulent sputum with frequent coughing

A 13-year-old client at the pulmonary clinic where you practice nursing has an extensive history of asthma and is seeing the pulmonologist for her monthly appointment. What are the primary functions of the lungs? Choose all correct options.

• Ventilation • Gas exchange

The nurse is preparing to administer chloramphenicol (Chloromycetin Otic) to a 2-year-old client with an infection of the external auditory canal. The order reads, "2 drops in the right ear three times per day." Which steps should the nurse take to administer this medication? Select all that apply:

• Wash her hands and arrange supplies at the bedside. • Warm the medication to body temperature. • Examine the ear canal for drainage. Explanation: The nurse should prepare to instill the eardrops by washing her hands, gathering the supplies, and arranging the supplies at the bedside. To avoid adverse effects resulting from eardrops that are too cold (such as vertigo, nausea, and pain), the medication should be warmed to body temperature in a bowl of warm water. Temperature of the drops should be tested by placing a drop on the wrist. Before instilling the drops, the ear canal should be examined for drainage that may reduce the medication's effectiveness. Because the dose is to be given in the right ear, the child should be placed on his left side with his right ear facing up. For an infant or a child younger than age 3, gently pull the auricle down and back because the ear canal is straighter in children of this age-group.

A client in the cardiac unit is undergoing procedures to determine the extent of his left-sided heart failure. As his nurse, what adventitious lung sounds would you expect to hear during your auscultation of his lungs to support his diagnosis? Choose all correct options.

• Wheezes • Wet lung sounds Explanation: If the left side of the heart fails to pump efficiently, blood backs up into the pulmonary veins and lung tissue. With left-sided congestive heart failure, auscultation reveals a crackling sound and gurgles.

A client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction? a) "Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days." b) "Lie in bed with your head elevated, and refrain from blowing your nose for 24 hours." c) "Shampoo your hair every day for 10 days to help prevent ear infection." d) "Try to ambulate independently after about 24 hours."

"Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days." Explanation: The nurse should instruct the client to avoid air travel, sudden movements that may cause trauma, and exposure to loud sounds and pressure changes (such as from high altitudes) for 30 days after a stapedectomy. Immediately after surgery, the client should lie flat with the surgical ear facing upward; nose blowing is permitted but should be done gently and on one side at a time. The client's first attempt at postoperative ambulation should be supervised to prevent falls caused by vertigo and light-headedness. The client must avoid shampooing and swimming to keep the dressing and the ear dry.

Which of the following solutions is hypotonic?

0.45% NaCl - Half-strength saline is hypotonic. Lactated Ringer's solution is isotonic. Normal saline (0.9% NaCl) is isotonic. A solution that is 5% NaCl is hypertonic.

Below which serum sodium level may convulsions or coma can occur?

135 mEq/L - Normal serum concentration level ranges from 135 to 145 mEq/L. When the level dips below 135 mEq/L, there is hyponatremia. Manifestations of hyponatremia include mental confusion, muscular weakness, anorexia, restlessness, elevated body temperature, tachycardia, nausea, vomiting, and personality changes. Convulsions or coma can occur if the deficit is severe. Values of 140, 142, and 145 mEq/L are within the normal range.

A 2-year-old girl is scheduled to have a myringotomy. How long would the nurse tell the parents that it will take for the incision to heal?

24 to 72 hours Explanation: Myringotomy also allows the drainage to be analyzed (by culture and sensitivity testing) so that the infecting organism can be identified and appropriate antibiotic therapy prescribed. The incision heals within 24 to 72 hours. This makes options A, B, and C incorrect.

A 57-year-old homeless female with a history of alcohol abuse has been admitted to your hospital unit. She was admitted with signs and symptoms of hypovolemia - minus the weight loss. She exhibits a localized enlargement of her abdomen. What condition could she be presenting?

3rd Spacing - Third-spacing describes the translocation of fluid from the intravascular or intercellular space to tissue compartments, where it becomes trapped and useless. The client manifests signs and symptoms of hypovolemia with the exception of weight loss. There may be signs of localized enlargement of organ cavities (such as the abdomen) if they fill with fluid, a condition referred to as ascites.

The nurse is reviewing the results of a client's audiometric testing. The nurse determines that the client has a mild hearing loss based on the result signifying which loss of decibels? a) 20 b) 80 c) 40 d) 60

60 Explanation: A mild hearing loss is identified by a loss of greater than 40 decibels. A loss of up to 15 decibels would be classified as normal hearing. A loss greater than 15 to 25 decibels would be classified as slight hearing loss. A loss of greater than 40 to 55 decibels would be classified as a moderate hearing loss.

Air embolism is a potential complication of IV therapy. The nurse should be alert to which clinical manifestation associated with air embolism?

Chest Pain - Manifestations of air embolism include dyspnea and cyanosis; hypotension; weak, rapid pulse; loss of consciousness; and chest, shoulder, and low back pain. Jaundice is not associated with air embolism.

Why should the nurse encourage a client with otitis externa to eat soft foods? Choose the correct option. a) Chewing may lead to further complications, such as otitis media b) Chewing may cause discomfort c) Chewy foods, such as red meat, may react with the prescribed analgesics and antibiotics d) Chewing may cause excessive drainage

Chewing may cause discomfort Correct Explanation: The nurse encourages a client with otitis externa to eat soft foods or consume nourishing liquids because chewing may cause discomfort.

A nurse is planning care for a client in acute addisonian crisis. Which nursing diagnosis should receive the highest priority?

Decreased cardiac output: Explanation: An acute addisonian crisis is a life-threatening event, caused by deficiencies of cortisol and aldosterone. Glucocorticoid insufficiency causes a decrease in cardiac output and vascular tone, leading to hypovolemia. The client becomes tachycardic and hypotensive and may develop shock and circulatory collapse. The client with Addison's disease is at risk for infection; however, reducing infection isn't a priority during an addisonian crisis. Impaired physical mobility and Imbalanced nutrition: Less than body requirements are appropriate nursing diagnoses for the client with Addison's disease, but they aren't priorities in a crisis.

You are caring for a 72-year-old client who has been admitted to your unit for a fluid volume imbalance. You know which of the following is the most common fluid imbalance in older adults?

Dehydration - The most common fluid imbalance in older adults is dehydration. Because of reduced thirst sensation that often accompanies aging, older adults tend to drink less water. Use of diuretic medications, laxatives, or enemas may also deplete fluid volume in older adults. Chronic fluid volume deficit can lead to other problems such as electrolyte imbalances. Therefore, options A, C, and D are incorrect.

The nurse in the emergency department is caring for a 4 year-old brought in by his parents with complaints that the child will not stop crying and pulling at his ear. Based upon information collected by the nurse, which of the following statements applies to a diagnosis of external otitis? a) External otitis is usually related to an upper respiratory infection. b) External otitis is characterized by pain when the pinna of the ear is pulled. c) External otitis is usually accompanied by a high fever in children. d) External otitis can be prevented by using cotton-tipped applicators to clean the ear.

External otitis is characterized by pain when the pinna of the ear is pulled. Explanation: External otitis is an infection of the external ear. Pain can be elicited when the pinna of the ear is pulled. Fever and accompanying upper respiratory infection occur more commonly in conjunction with otitis media (infection of the middle ear). Cotton-tipped applicators can actually cause external otitis so their use should be avoided.

Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis?

Extreme Anxiety - Extreme anxiety may lead to respiratory alkalosis by causing hyperventilation, which results in excessive carbon dioxide (CO2) loss. Other conditions that may set the stage for respiratory alkalosis include fever, heart failure, injury to the brain's respiratory center, overventilation with a mechanical ventilator, pulmonary embolism, and early salicylate intoxication. Type 1 diabetes may lead to diabetic ketoacidosis; the deep, rapid respirations occurring in this disorder (Kussmaul's respirations) don't cause excessive CO2 loss. Myasthenia gravis and opioid overdose suppress the respiratory drive, causing CO2 retention, not CO2 loss; this may lead to respiratory acidosis, not alkalosis.

A group of 16-and 17-year-old girls are attending a concert. The music at the concert will be 80 to 90 dB. What should the girls be aware of? a) Hearing loss may occur with a decibel level in this range. b) Sounds in this decibel level are not perceived to be harsh to the ear. c) Hearing will not be affected by a decibel level in this range. d) Ear plugs will have no affect on decibel levels.

Hearing loss may occur with a decibel level in this range. Correct Explanation: Sound louder than 80 dB is perceived by the human ear to be harsh and can be damaging to the inner ear. Ear protection or plugs do help to minimize the effects of high decibel levels.

A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to stimuli. The laboratory report indicates a serum calcium level of 12.0 mg/dl, a serum potassium level of 3.9 mEq/L, a serum chloride level of 101 mEq/L, and a serum sodium level of 140 mEq/L. Based on this information, the nurse determines that the client's symptoms are most likely associated with which electrolyte imbalance?

Hypercalcemia - The normal reference range for serum calcium is 9 to 11 mg/dl. A serum calcium level of 12 mg/dl clearly indicates hypercalcemia. The client's other laboratory findings are within their normal ranges, so the client doesn't have hypernatremia, hypochloremia, or hypokalemia.

Wallace Guterman, a 36-year-old construction manager, is being seen by a physician in the primary care group where you practice nursing. He presents with a huge lower jaw, bulging forehead, large hands and feet and frequent headaches. What could be causing his symptoms?

Hyperpituitarism: Explanation: Acromegaly is a condition in which GH is oversecreted after the epiphyses of the long bones have sealed. A client with acromegaly has coarse features, a huge lower jaw, thick lips, a thickened tongue, a bulging forehead, a bulbous nose, and large hands and feet. When the overgrowth is from a tumor, headaches caused by pressure on the sella turcica are common.

An elderly client takes 40 mg of Lasix twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use?

Hypokalemia - Hypokalemia (potassium level below 3.5 mEq/L) usually indicates a defict in total potassium stores. Potassium-losing diuretics, such as loop diuretics, can induce hypokalemia.

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the physician in the emergency department. After completing ordered diagnostic tests, the physician indicates to the client what caused the symptoms that brought him to the hospital. What is the origin of the client's symptoms?

Impaired cerebral circulation

Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg?

Instruct the client to breathe into a paper bag. - The ABG results reveal respiratory alkalosis. The best intervention to raise the PaCO2 level would be to have the client breathe into a paper bag. Administering a decongestant, offering fluids frequently, and administering supplemental oxygen wouldn't raise the lowered PaCO2 level.

A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer?

Lactated Ringer's solution - Lactated Ringer's solution, with an osmolality of approximately 273 mOsm/L, is isotonic. The nurse shouldn't give half-normal saline solution because it's hypotonic, with an osmolality of 154 mOsm/L. Giving 5% dextrose and normal saline solution (with an osmolality of 559 mOsm/L) or 10% dextrose in water (with an osmolality of 505 mOsm/L) also would be incorrect because these solutions are hypertonic.

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

Light-headedness or paresthesia - The client with respiratory alkalosis may complain of light-headedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rarely are associated with respiratory alkalosis or any other acid-base imbalance.

The nurse is developing a plan of care for a client with Meniere's disease and identifies a nursing diagnosis of excess fluid volume related to fluid retention in the inner ear. Which intervention would be most appropriate to include in the plan of care? a) Restrict high-potassium foods. b) Limit foods that are high in sodium. c) Administer prescribed antihistamine. d) Encourage intake of caffeinated fluids.

Limit foods that are high in sodium. Correct Explanation: Sodium and fluid retention disrupts the delicate balance between the endolymph and perilymph in the inner ear. Therefore, many clients can control their symptoms by adhering to a low-sodium diet. Caffeinated fluids are to be avoided because of their diuretic effect. Diuretics, not antihistamines, would be prescribed to lower the pressure in the endolymphatic system. Foods high in potassium would be encouraged if the client is prescribed a diuretic that causes potassium loss.

Hearing aids help with which of the following problems? a) Improves discrimination of words b) Makes sounds louder c) Improves understanding of speech d) Improves communication skills

Makes sounds louder Explanation: A hearing aid makes sounds louder, but it does not improve a patient's ability to discriminate words or understand speech. Hearing aids amplify all sounds, including background noise, which may be disturbing to the wearer. It does not improve communication skills.

A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder?

Metabolic Acidosis - This client's pH value is below normal, indicating acidosis. The HCO3- value also is below normal, reflecting an overwhelming accumulation of acids or excessive loss of base, which suggests metabolic acidosis. The PaCO2 value is normal, indicating absence of respiratory compensation. These ABG values eliminate respiratory alkalosis, respiratory acidosis, and metabolic alkalosis.

A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance?

Metabolic Alkalosis - A pH over 7.45 with a HCO3- level over 26 mEq/L indicates metabolic alkalosis. Metabolic alkalosis is always secondary to an underlying cause and is marked by decreased amounts of acid or increased amounts of base HCO3-. The client isn't experiencing respiratory alkalosis because the PaCO2 is normal. The client isn't experiencing respiratory or metabolic acidosis because the pH is greater than 7.35.

A nurse is teaching about ischemic stroke prevention to a community group and emphasizes that control of hypertension, which is the major risk factor for stroke, is key to prevention. Ways to control hypertension include the Dietary Approaches to Stop Hypertension (DASH) diet. This diet includes which of the following?

Moderate amounts of low-fat dairy products

A priority nursing intervention for a client with hypervolemia involves which of the following?

Monitoring respiratory status for signs and symptoms of pulmonary complications. - Hypervolemia, or fluid volume excess (FVE), refers to an isotonic expansion of the extracellular fluid. Nursing interventions for FVE include measuring intake and output, monitoring weight, assessing breath sounds, monitoring edema, and promoting rest. The most important intervention in the list involves monitoring the respiratory status for any signs of pulmonary congestion. Breath sounds are assessed at regular intervals.

A nurse is planning preoperative teaching for a client with conductive hearing loss due to otosclerosis. The client is scheduled for a stapedectomy with insertion of a prosthesis. What information is most crucial to include in the client's preoperative teaching?

Noticeable improvement in hearing may not be experienced for up to 6 weeks after surgery. Correct Explanation: Stapedectomy is a very successful procedure; approximately 95% of clients experience restoration of hearing. However, hearing returns gradually and can continue to improve for several weeks after surgery. It is important that the client understand this in order to prevent disappointment, anxiety, or depression after surgery. While it is important that a member of the nursing staff assist all postoperative clients who are getting out of bed for the first time after surgery, this information is routinely provided and is not specific to the client undergoing stapedectomy. Availabilty of close-captioned TV programs is very advantageous; however, it is not crucial information related to surgical outcomes.

Which of the following is an involuntary rhythmic movement of the eyes that is also associated with vestibular dysfunction? a) Tinnitus b) Vertigo c) Presbycusis d) Nystagmus

Nystagmus Correct Explanation: Nystagmus is an involuntary rhythmic movement of the eyes; pathologically it is an ocular disorder but is also associated with vestibular dysfunction. Nystagmus can be horizontal, vertical, or rotary, and can be caused by a disorder in the central or peripheral nervous system. Vertigo is defined as the misperception or illusion of motion of the person or their surroundings. Tinnitus is ringing in the ears. Presbycusis is a progressive hearing loss.

Which of the following describes a condition characterized by abnormal spongy bone formation around the stapes? a) Otitis externa b) Otosclerosis c) Middle ear effusion d) Chronic otitis media

Otosclerosis Explanation: Otosclerosis is more common in females than males and is frequently hereditary. A middle ear effusion is denoted by fluid in the middle ear without evidence of infection. Chronic otitis media is defined as repeated episodes of acute otitis media causing irreversible tissue damage and persistent tympanic membrane perforation. Otitis externa refers to inflammation of the external auditory canal.

The calcium level of the blood is regulated by which mechanism?

Parathyroid hormone (PTH) - The serum calcium level is controlled by PTH and calcitonin. The thyroid hormone, adrenal gland, or androgens do not regulate the calcium level in the blood.

Which of the following electrolytes is a major cation in body fluid?

Potassium - Potassium is a major cation that affects cardiac muscle functioning. Chloride is an anion. Bicarbonate is an anion. Phosphate is an anion.

A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?

Prepare to assist with ventilation. - Respiratory acidosis is associated with hypoventilation; in this client, hypoventilation suggests intake of a drug that has suppressed the brain's respiratory center. Therefore, the nurse should assume the client has respiratory depression and should prepare to assist with ventilation. After the client's respiratory function has been stabilized, the nurse can safely monitor the heart rhythm, prepare for gastric lavage, and obtain a urine specimen for drug screening.

As a nurse practicing within a pediatric medicine group, you take your role quite seriously in preserving children's hearing and preventing hearing loss in your clients. What can you do to maintain hearing within your client base? a) Prevent fevers b) Increase antibiotic therapy use c) Reduce frequency and severity of ear infections d) Distribute earplugs to all clients

Reduce frequency and severity of ear infections Correct Explanation: Nurses play a pivotal role in preventing hearing loss by reducing the severity and frequency of ear infections among children and advocating for measures that reduce exposure to loud noise.

A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate?

Respiratory alkalosis - A client with pneumonia may hyperventilate in an effort to increase oxygen intake. Hyperventilation leads to excess carbon dioxide (CO2) loss, which causes alkalosis — indicated by this client's elevated pH value. With respiratory alkalosis, the kidneys' bicarbonate (HCO3-) response is delayed, so the client's HCO3- level remains normal. The below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2 loss and signals a respiratory component. Because the HCO3- level is normal, this imbalance has no metabolic component. Therefore, the client is experiencing respiratory alkalosis.

Which nursing diagnosis takes highest priority for a client admitted for evaluation for Ménière's disease? a) Risk for deficient fluid volume related to vomiting b) Imbalanced nutrition: Less than body requirements related to nausea and vomiting c) Acute pain related to vertigo d) Risk for injury related to vertigo

Risk for injury related to vertigo Correct Explanation: Vertigo, the chief finding in Ménière's disease, is a severe, rotational whirling sensation that typically causes the client to fall when attempting to stand or walk. Because client safety is paramount, the nursing diagnosis of Risk for injury related to vertigo takes priority. Vertigo doesn't cause pain. Although nausea and vomiting may lead to inadequate nutrition and fluid loss, these problems are secondary to client safety.

While reviewing the health history of a 72-year-old client experiencing hearing loss the nurse notes the patient has had no trauma or loss of balance. What data is likely to be linked to the client's hearing deficit? a) Previous perforation of the eardrum as a result of a high dive b) Routine use of quinine for management of leg cramps c) Recent completion of radiation therapy for treatment of thyroid cancer d) Allergy to hair coloring and hair spray

Routine use of quinine for management of leg cramps Correct Explanation: Long-term, regular use of quinine for management of leg cramps is associated with loss of hearing acuity. Radiation therapy for cancer should not affect hearing; however, hearing can be significantly compromised by chemotherapy. Allergy to hair products may be associated with otitis externa; however, it is not linked to hearing loss. An ear drum that perforates spontaneously due to the sudden drop in altitude associated with a high dive usually heals well and is not likely to become infected. Recurrent otitis media with perforation can affect hearing as a result of chronic inflammation of the ossicles in the middle ear.

Your patient has been diagnosed with a loss of hearing related to damage of the end organ for hearing or cranial nerve VIII. What term is used to describe this condition? a) Sensorineural hearing loss b) Presbycusis c) Exostoses d) Otalgia

Sensorineural hearing loss Correct Explanation: Exostoses refer to small, hard, bony protrusions in the lower posterior bony portion of the ear canal. Otalgia refers to a sensation of fullness or pain in the ear. Sensorineural hearing loss is loss of hearing related to damage of the end organ for hearing or cranial nerve VIII. Presbycusis is the term used to refer to the progressive hearing loss associated with aging. Both middle and inner ear age-related changes result in hearing loss.

A nurse explains to a client with thyroid disease that the thyroid gland normally produces:

T3, thyroxine (T4), and calcitonin. Explanation: The thyroid gland normally produces thyroid hormone (T3 and T4) and calcitonin. The pituitary gland produces TSH to regulate the thyroid gland. The hypothalamus gland produces TRH to regulate the pituitary gland.

To compensate for decreased fluid volume (hypovolemia), the nurse can anticipate which response by the body?

Tachycardia - Fluid volume deficit, or hypovolemia, occurs when the loss of extracellular fluid exceeds the intake of fluid. Clinical signs include oliguia, rapid heart rate, vasoconstriction, cool and clammy skin, and muscle weakness. The nurse monitors for rapid, weak pulse and orthostatic hypotension.

Which of the following terms refers to surgical repair of the tympanic membrane? a) Myringotomy b) Tympanoplasty c) Tympanotomy d) Ossiculoplasty

Tympanoplasty Correct Explanation: Tympanoplasty may be necessary to repair a scarred eardrum. A tympanotomy is an incision into the tympanic membrane. A myringotomy is an incision into the tympanic membrane. An ossiculoplasty is a surgical reconstruction of the middle ear bones to restore hearing.

Which of the following terms refers to surgical repair of the tympanic membrane? a) Tympanoplasty b) Ossiculoplasty c) Myringotomy d) Tympanotomy

Tympanoplasty Explanation: Tympanoplasty may be necessary to repair a scarred eardrum. A tympanotomy is an incision into the tympanic membrane. A myringotomy is an incision into the tympanic membrane. An ossiculoplasty is a surgical reconstruction of the middle ear bones to restore hearing.

A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation?

Urine pH of 3.0 - Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal and requires further investigation. Urine specific gravity normally ranges from 1.010 to 1.025, making this client's value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals. Red blood cells should measure 0 to 3 per high-power field; white blood cells, 0 to 4 per high-power field. Urine should be clear, with color ranging from pale yellow to deep amber.

Which of the following instructions, regarding swimming, should the nurse give to the client who is recovering from otitis externa? Choose the correct option. a) Avoid cold water. b) Insert a loose cotton pledget in the external ear. c) Wear soft plastic ear plugs. d) Wear a scarf.

Wear soft plastic ear plugs. Correct Explanation: The nurse should advise the client to wear soft plastic ear plugs to prevent trapping water in the ear while swimming.

A client is diagnosed as having serous otitis media. When describing this condition to the client, which of the following would be most accurate? a) "You have a common infection in one of the bones of your face." b) "You have some fluid that has collected in your middle ear but no infection." c) "Your eardrum has ruptured because of the extreme pressure in your middle ear from the infection." d) "It has resulted from the several recurrent episodes of acute otitis media you've had."

You have some fluid that has collected in your middle ear but no infection." Correct Explanation: Serous otitis media invovles fluid, without evidence of active infection, in the middle ear. Recurrent episodes of acute otitis media leads to chronic otitis media. An infection of the temporal bone (temporal bone osteomyelitis) is a serious but rare external ear infection called malignant external otitis. Rupturing of the eardrum refers to tympanic membrane perforation.

During a follow-up visit to the physician, a client with hyperparathyroidism asks the nurse to explain the physiology of the parathyroid glands. The nurse states that these glands produce parathyroid hormone (PTH). PTH maintains the balance between calcium and:

phosphorus Explanation: PTH increases the serum calcium level and decreases the serum phosphate level. PTH doesn't affect sodium, potassium, or magnesium regulation.

A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects:

respiratory alkalosis. - This client's above-normal pH value indicates alkalosis. The below-normal PaCO2 value indicates acid loss via hyperventilation; this type of acid loss occurs only in respiratory alkalosis. These ABG values wouldn't occur in metabolic acidosis, respiratory acidosis, or metabolic alkalosis.