NCLEX/EXIT EXAM Study

A nurse is reading the medical record of a client admitted to the hospital with a diagnosis of diabetes insipidus. Which of these signs/symptoms should the nurse expect to see documented in the client's record? Select all that apply. a. Anuria b. Tachycardia c. Complaints of thirst d. Moist mucous membranes e. Complaints of muscle weakness f. Blood pressure of 168/98 mm Hg

B, C, E Diabetes insipidus is a disorder of water metabolism caused by hyposecretion of ADH and a deficiency of vasopressin. Signs/symptoms include polyuria (5 to 20 L/day), polydipsia, signs of dehydration, inability to concentrate urine and a low urinary specific gravity of 1.006 or less, fatigue, muscle pain and weakness, postural hypotension and tachycardia.

A nurse discontinues an infusion of packed RBC because the client is experiencing a transfusion reaction. After discontinuing the transfusion, which action is taken next? a. Remove the IV catheter b. Contact the HCP c. Change the solution to 5% dextrose in water d. Obtain a culture of the tip of the catheter device once removed

B. If the nurse suspected a transfusion reaction, the transfusion is stopped and NS infused at a KVO rate pending further HCP orders. The nurse then contacts the HCP. Dextrose in water is not used; it may cause clotting or hemolysis of blood cells. NS is the only type of IV fluid that is compatible with blood.

A client is found to have ulcerative colitis, and the nurse provides instructions to the client about the diet that should be followed while the disease is in remission. Which option is best? a. Milk b. Cabbage c. Boiled potatoes d. Coffee with cream

Boiled potatoes During remission, the client must avoid intestinal stimulants such as alcohol, caffeinated beverages, high-fat foods, gas-forming foods, milk products, and raw fruits and veggies that are very high in fiber. Vitamins and iron supplements may be prescribed.

A regular diet has been prescribed for a client with a leg fracture who has been placed in skeletal traction. Which foods will promote wound healing? a. Spare ribs, rice, gelatin, tea b. Pasta, garlic bread, ginger ale c. Chicken breast, broccoli, strawberries, milk d. Peanutbutter and jelly sandwich, chocolate cake, tea

Chicken breast, broccoli, strawberries, milk Protein and vitamin C are needed for wound healing. Poultry and milk are good sources of protein; broccoli and strawberries are good sources of vitamin C. Peanutbutter is a source if niacin. Gelatin, jelly, tea, and ginger ale have no nutritional value. Pasta, rice and bread delivery complex carbs. Spare ribs may contain some protein but are high in fat.

While making initial rounds, the charge nurse should see which client first? a. A postoperative client with a tracheostomy who has signs of a tracheoesophageal fistula b. A postoperative client with CBI that is draining pale pink urine c. A preoperative client with a history of syncope who is scheduled for a carotid endarterectomy d. A preoperative client with a prolonged PTT who has receiving anticoagulants

A

How does Donepezil (Aricept) reduce the symptoms for clients with mild to moderate Alzheimer's disease? A. Enhancing Acetylcholine function. B. Inhibiting Serotonin Uptake. C. Anti-oxidating free radical. D. Reducing GABA action.

A. Donepezil prevents an enzyme known as acetylcholinesterase from breaking down acetylcholine in the brain. Increased concentrations of acetylcholine lead to increased communication between the nerve cells that use acetylcholine as a chemical messenger, which may temporarily improve or stabilize the symptoms of Alzheimer's disease.

What is the goal for the care of a client with mild-to-moderate Alzheimer's disease who takes donepezil? a. The client will maintain the highest level of cognitive ability b. The client will demonstrate improved cognitive ability within one month c. The client will engage in abstract thinking within one month d. The client will communicate clearly within one month

A. Donepezil slows cell destruction. The medication will not improve the client's disease process; due to cell destruction of executive functioning, abstract thinking is not possible.

A client is brought to the emergency department by a neighbor. The client is lethargic and has a fruity odor on the breath. The client's arterial blood gas (ABG) results are pH 7.25, PaCO234 mm Hg (4.52 kPa), PaO2 86 mm Hg (11.3 kPa), HCO3 14 mEq/L (14 mmol/L). Which acid-base disturbance does the nurse recognize in these results? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

A. The normal pH is 7.35 to 7.45. The normal PaCO2 is 35-45 mm Hg (4.66-5.98 kPa). The normal HCO3 (bicarbonate) is 22-26 mEq/L (22-26 mmol/L). The normal PaO2 is 80-100 mm Hg (10.6-13.33 kPa). Acidosis is defined as a pH of less than 7.35; alkalosis is defined as a pH greater than 7.45. Metabolic acidosis is present when the HCO3 is less than 22 mEq/L (22 mmol/L); metabolic alkalosis is present when the HCO3 is greater than 26 mEq/L (26 mmol/L). This client's ABG values are consistent with metabolic acidosis.

Buspirone, a nonbenzodiazepine anxiolytic, is prescribed to treat anxiety and the nurse provides information to the client. Which information is true? a. The medication is addictive b. The medication does not usually cause sedation c. The medication relieves anxiety immediately with first dose d. The medication can intensify the effects of other CNS depressants

B. Buspirone is an anxiolytic used to reduce anxiety. Common side effects include headache, nausea, dizziness, lightheadedness, and excitement. It does not usually cause sedation, has no abuse potential, and does not intensify the effects of CNS depressants. Antianxiety effects take at least a week to develop.

A client with Hodgkin's disease will be receiving chemotherapy with doxorubicin. Which actions should the nurse plan to take as a means of monitoring the client for toxicity specific to this medication? a. Checking the temperature b. Attaching a cardiac monitor c. Assessing client for peripheral edema .d Drawing a blood specimen to check platelet count

B. Doxorubicin can cause both acute and delayed injury to the heart. Acute effects, such as EKG changes, may develop within minutes of administration. Delayed cardiotoxicity, which appears as HF resulting from diffuse cardiomyopathy, is often unresponsive to treatment.

A physician prescribes the administration of parenteral nutrition (PN), to be started at a rate of 50 mL/hr by way of infusion pump through an established subclavian central line. After the first 2 hours of the PN infusion, the client suddenly complains of difficulty breathing and chest pain. The nurse immediately: a. Obtains blood for culture b. Clamps the TPN infusion line c. Obtains an ECG d. Obtains a sample for blood glucose testing

B. One complications of a subclavian central line is embolism, caused by air or thrombus. Sudden onset of chest pain shortly after initiation of TPN may mean that this complication has developed. The infusion is clamped, the client turned on the left side with head down, and the HCP notified immediately.

A nurse is explaining coughing exercises and the procedure for splinting an incision to a client who is scheduled for abdominal surgery. Which instruction should the nurse provide to the client? a. Sit upright and lean as far forward as possible. b. Fold the arms over a pillow placed over the abdominal incision and press gently. c. Use the fingertips of both hands and press as deeply as possible over each side of the incision. d. Stand and lean over a bedside table, then hold a pillow over the abdominal incision with one hand while providing support for standing with the other hand.

B. Splinting an abdominal incision with the use of a pillow or rolled blanket provides support to the incision and aids in coughing and expectoration of secretions. The client may assume a supine, side-lying, or semi-Fowler's to Fowler's position. The client folds the arms over a pillow or rolled towel placed over the abdominal incision and presses gently during breathing and coughing exercises. Leaning forward as far as possible, pressing as deeply as possible at the sides of the abdominal incision, and leaning over a bedside table holding the incision with one hand will all be uncomfortable and will not provide support to the incision; these actions are also unsafe for the client.

A client who has just undergone a skin biopsy is listening to discharge instructions from the nurse. The nurse determines that the client needs further teaching if the client indicates planning to do what as part of aftercare? a. Use the antibiotic ointment as prescribed b. Return in 7 days to have the sutures removed c. Apply cool compresses to the site twice a day for 20 minutes d. Call the primary health care provider if excessive drainage from the wound occurs

C. Cool compresses are not used on biopsy sites. After a skin biopsy, the nurse instructs the client to keep the dressing dry and in place for a minimum of 8 hours. After dressing removal, the site is kept clean and dry but may be cleansed daily with tap water or saline solution. The primary health care provider may prescribe an antibiotic ointment to minimize local bacterial colonization, and the ointment should be used as directed. The nurse instructs the client to report any redness or excessive drainage at the site. Sutures are usually removed 7 to 10 days after biopsy.

A nurse is providing information to a client who has just learned that he has type 1 diabetes mellitus. The nurse tells the client that the blood level of HbA1c will need to be checked periodically. How does the nurse explain the purpose of the test to the client? a. It is performed to determine how well the insulin is working. b. It is performed to determine whether a larger dose of insulin is required. c. It is used to measure the degree of glucose control in the preceding 3 months. d. It is used to measure the hemoglobin level to ensure that the prescribed diet is adequate for the client's needs.

C. The HbA1c blood test is a measure of the degree of glucose control during the previous 3 months, the lifespan of the hemoglobin molecule. How well the client's insulin is working, determining whether a larger dose of insulin is required, and determining the adequacy of the prescribed diet are not the purposes of this blood test.

What is the goal of nursing care for a client with a neurocognitive disorder due to Alzheimer's disease? a. Individualizing care b. Improving cognition c. Maintaining optimum function d. Promoting self-confidence and self-esteem

C. There is not a cure for Alzheimer's, but support can help the client and the client's family live at a maximum level. A and D are approaches, not the desired outcome.

The nurse has provided instructions to a client about the use of an incentive spirometer and is watching the client use the device. Which observation indicates that the client is using the spirometer correctly? a. The client lies supine to use the device. b. The client places the lips loosely over the mouthpiece. c. The client holds the breath for 3-4 seconds on reaching maximal inspiration. d. The client exhales slowly through the mouthpiece, maintains a constant flow, and holds the breath.

C. To use an incentive spirometry, the client assumes an upright position. After exhaling completely, the client uses the lips to form a seal around the mouthpiece; inhales slowly, maintaining a constant flow through the unit; holds the inspiration for 3-4 seconds; and then exhales slowly.

The nurse assists a primary health care provider in performing a liver biopsy. In what position should the nurse place the client after the procedure? a. Prone b. Left Sims c. On the left side d. On the right side

D. After a liver biopsy, the client is positioned on the right side for at least 2 hours to splint the puncture site and help prevent bleeding. Prone, left Sims, and left side-lying positions are all incorrect options.

Which child requires the most immediate follow-up by a nurse? a. A 10-month-old with yellow nasal mucous and a fever of 101, who is fussy and crying loudly b. A 5-year-old who has started wetting the bed and constantly requests extra snacks and drinks c. A 13-year-old who was injured while playing football the previous day and now cannot bear weight on his foot due to severe pain d. A 9-year-old who got hit on the head with a baseball bat and has a bruise behind his ear and clear nasal discharge

D. Bruising behind the ear following a head injury is referred to as a Battle sign, which is an indication of a basilar skull fracture. Because the clear nasal drainage may be CSF, this child needs the most immediate assessment to determine severity of the head injury.

The nurse is working with a newly licensed nurse who is undergoing education prior to inserting an IV and is gathering the equipment needed to start an IV line in an older client who will be receiving an IV solution of 0.9% NS. The nurse realizes that teaching has been effective if the new nurse selects which gauge of catheter for this client? a. 14 b. 16 c. 19 d. 21

D. For an older client, the smallest gauge IV catheter possible should be used. A gauge of 21 or smaller is preferred.

The HCP prescribes premedication of IV diphenhydramine hydrochloride to a patient who has previously had a transfusion reaction and is to receive a current transfusion. When does the nurse plan to administer the premedication? a. 1 hour before the transfusion b. 15 minutes after the transfusion c. 30 minutes before the transfusion d. Immediately before the transfusion

D. History of an allergic reaction may warrant the administration of an antihistamine. IV medication should be given immediately before the transfusion is started. If an oral medication is prescribed, it should be administered 30 minutes before.

Which statement or question best illustrates the nurse's understanding of the role of nursing assistive personnel (NAP) in the instillation of ear medications? A. "Did you let the ear medication warm to room temperature?" B. "Do you think the patient is capable of instilling her own eardrops?" C. "Please tell the patient that the medication may make him dizzy when he stands up." D. "Be sure to keep the patient on her side for a few minutes, because I just administered her eardrops."

D. NAP may provide supportive care to a patient receiving ear medication. Responsibility for patient assessment and patient education can not be delegated to NAP.

1. The nurse is placing supplies on a sterile field that is being prepared for a dressing change. Which action is likely to contaminate the field? A. Placing a role of sterile tape on the field B. Holding a prepackaged sterile item in the non-dominant hand while opening it C. Adding supplies that will expire in 2 days D. Placing the needed supplies near the back of the sterile field

D. Placing the needed supplies near the back of the sterile field could cause the nurse to reach across the sterile field, which would be a breach in sterile technique. Placing a sterile item on the sterile field will not contaminate the field. All other options will not contaminate the field.

Which groups may be activated by state and federal government authorities to assist during a flooding situation that results from a hurricane? Select all that apply. One, some, or all responses may be correct. 1 National Guard 2 American Red Cross 3 Medical Reserve Corps 4 Public health departments 5 Local emergency departments

1, 2, 3, 4 During catastrophic mass casualty events, such as flooding, the National Guard, ARC, public health department, various military units, a MRC, or DMAT can be activated.

A health care provider prescribes digoxin for a client. The nurse teaches the client to be alert for which common early indication of acute digoxin toxicity? 1 Vomiting 2 Urticaria 3 Photophobia 4 Respiratory distress

1. Nausea, vomiting, anorexia, and abdominal pain are early indications of acute toxicity in approximately 50% of clients who take a cardiac glycoside, such as digoxin. Urticaria is a rare, not common, manifestation of digoxin toxicity. Photophobia is a later, not early, manifestation of digoxin toxicity. Respiratory distress is not directly associated with digoxin toxicity.

A client abruptly stops taking a barbiturate. Which withdrawal complication would the nurse anticipate that the client may experience? 1 Ataxia 2 Seizures 3 Diarrhea 4 Urticaria

2. Seizures are a serious side effect that may occur with abrupt withdrawal from barbiturates.

A nurse is performing nasotracheal suctioning on a client. Which observations should be cause for concern to the nurse? Select all that apply. a. The client becomes cyanotic. b. Secretions are becoming bloody. c. The client gags during the procedure. d. Clear to opaque secretions are removed. e. The heart rate varies from 80 to 82 beats/min.

A, B The nurse monitors the client for adverse effects of suctioning, which include cyanosis, an excessively rapid or slow heart rate, and the sudden appearance of bloody secretions. If any of these findings is noted, the nurse stops suctioning and contacts the primary health care provider immediately. The descriptions in the other options are expected findings and not a reason for concern.

A communication technique where the listener gives the speaker her full attention in order to understand, respond, and remember what was said is called: a. Active listening b. Listening c. Reflective listening d. Nonverbal communication

A. Active listening is a communication technique where the listener gives the speak her full attention in order to understand, respond, and remember what was said. Listening is the passive process of hearing someone speak. Reflective listening is a communication technique where the listener repeats back what the speaker says to verify understanding.

The nurse is using a standard framework and professional norms when preparing a change-of-shift report. What are some other ethical strategies the nurse needs to employ when preparing this report? SATA a. Respect assumptions b. Monitor language and tone c. Adopt a "need-to-know policy" d. Be alert to presence of gossip e. Try to limit use of obscene language f. Hold yourself and one another accountable

B, C, D, F Some ethical strategies to use when preparing a change-of-shift report include: monitoring language and tone, adopting a need-to-know policy, being alert to the presence of gossip, and holding oneself accountable. A change-of-shift report is given from 1 caregiver to another who is taking on responsibility for the client's care to ensure continuity of care.

Which of the following memory issues/deficits are related to Mild Neurocognitive disorder due to Alzheimers disease? SATA a. Temporarily misplaces keys and purse b. Forgets purpose or use of an item c. Cooks a meal and forgets to serve it d. Momentarily forgets an acquaintance's name e. Becomes lost on the client's own street

B, C, E All of these options are associated with Alzheimer's disease. A and D are typically associated with "normal forgetfulness".

A client has sustained superficial partial-thickness burns of the anterior surfaces of the thighs. On assessment, which of these characteristics would the nurse expect to see? Select all that apply. a. Mild erythema b. Blistering and edema c. Blackening without edema d. Wet, shiny, weeping surface e. Red base and broken epidermis f. Yellow discoloration with severe edema

B, D, E A mottled red base and broken epidermis with a wet, shiny, weeping surface are characteristic of a superficial partial-thickness burn. This type of burn injury is also characterized by blistering, edema, and pain. A superficial burn is characterized by mild to severe erythema (pink to red) and the absence of blisters. A full-thickness burn is characterized by a deep red, black, white, yellow, or brown coloration. The injured surface appears dry, is edematous, and may or may not be painful. In a deep full-thickness burn the injured area is black; edema and pain are usually absent.

A nurse is monitoring a client who has returned from colostomy surgery with an ostomy pouch system in place. On checking the stoma, the nurse notes that it is purple and firm. Which initial action by the nurse is appropriate? a. Documenting the findings b. Contacting the health care provider c. Placing warm packs over the stoma d. Changing the ostomy pouch system

B. A healthy stoma should be reddish pink and moist and will protrude about ¾ inch from the abdominal wall. A small amount of bleeding at the site of the stoma is normal. If the nurse checks the stoma and notes that it shows signs of ischemia (a dark-red, purplish, or black stoma or a stoma that is dry, firm, or flaccid), the health care provider must be notified immediately. Although the nurse would document the findings, this is not the initial appropriate action. Placing warm packs over the stoma or changing the ostomy pouch system are incorrect actions that are not helpful and delay necessary intervention.

The nurse is performing an assessment on a client with a diagnosis of pernicious anemia. Which finding would the nurse expect to note? a. Dyspnea b. Dusky mucous membranse c. SOB on exertion d. Red tongue that is smooth and sore

D. Classic signs of pernicious anemia include weakness, mild diarrhea, and a smooth red tongue that is sore. The client also may have nervous system signs such as paresthesias, balance difficulty, and occasional confusion.

A client has been given instructions regarding the recently prescribed levothyroxine. The nurse determines the teaching was effective if the client states the medication should be taken in which manner? a. With food b. At bedtime c. With a snack at 3 PM d. In the morning, on an empty stomach

D. Levothyroxine should be taken on an empty stomach to enhance its absorption. The daily dose is taken in the morning an hour before breakfast.

A pediatric clinic has only one pulse oximeter available for continuous monitoring of oxygen saturation. Which client should it be used on? a. A 6-month-old with a hemoglobin of 10 who is receiving an iron supplement b. An 8-month-old who is vomiting and passing stools with a currant jelly appearance c. A 2-year-old who has a fever and enlarged tonsils covered with purulent discharge d. A 3-year-old with a sore throat who is drooling and sitting in a tripod position

D. This child is manifesting signs of epiglottitis, an acute condition that can rapidly lead to severe respiratory distress. This child needs the pulse oximeter. The other options do not require continuous pulse oximetry.

A client with cirrhosis has an increased ammonia level. Which diet does the nurse anticipate will be of benefit to the client? a. One low in protein b. One high in fluids c. One high in carbs d. One with a moderate amount of fat

Low protein A low-protein diet would be prescribed for the client with cirrhosis who has an increased ammonia level. Protein in the diet is transported to the liver by the portal vein after digestion and absorption. The liver breaks down protein, forming ammonia.

Which identifies accurate nursing documentation notations? SATA a. The client slept through the night. b. Abdominal wound dressing is dry and intact without drainage. c. The client seemed angry when awakened for vital sign measurement. d. The client appears to become anxious when it is time for respiratory treatments e. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

1, 2, 5 Factual documentation contains descriptive, objective information about what the nurse sees, hears, feels, or smells. The use of inferences without supporting factual data is not acceptable, because it can be misunderstood. The use of vague terms, such as seemed or appears, is not acceptable because these words suggest that the nurse is stating an opinion.

Which assessment findings indicate a client is experiencing an allergic reaction to antibiotic therapy? Select all that apply. One, some, or all responses may be correct. 1 Pruritus 2 Confusion 3 Wheezing 4 Muscle aches 5 Bronchospasm

1, 3, 5 Manifestations of an allergic reaction to antibiotic therapy include pruritus, wheezing, and bronchospasm. Confusion and muscle aches are not specifically identified as being manifestations of an allergic reaction to antibiotic therapy.

A client has returned to the hospital with heart failure after being dismissed three days prior. The client mentions eating some of the following items. The nurse determines which foods likely contributed to the re-admission? Select all that apply. a. Ketchup b. Broccoli c. Baked ham d. Cantaloupe e. Watermelon f. American cheese

A, C, F Processed foods are generally high in sodium. Some commonly eaten foods that are high in sodium are bacon, butter, canned foods, cheeses, hot dogs, ham, ketchup, lunchmeats, milk, mustard, snack foods, soy sauce, table salt, and white and whole-wheat bread. Broccoli, cantaloupe, and watermelon are low-sodium foods.

A client has just been scheduled for endoscopic retrograde cholangiopancreatography (ERCP). What should the nurse tell the client about the procedure? Select all that apply. a. That informed consent is required b. That the test takes about 4 hours to complete c. That no premedication for sedation will be necessary d. That food and fluids will be withheld before the procedure e. That multiple position changes may be necessary to pass the tube

A, D, E The client must sign informed consent before the procedure, which takes about an hour to perform. IV sedation is given to relax the client, and an anesthetic spray is used to help keep the client from gagging as the endoscope is passed. Foods and fluids are withheld before the procedure to prevent aspiration. Multiple position changes may be needed to facilitate the passage of the tube.

The practitioner orders the nurse to remove a patient's Penrose drain. The nurse has never done this procedure before. Which action should the nurse take next? A. Ask a colleague who is competent in the procedure to remove the drain. B. Inform the practitioner that he or she will have to do it himself or herself. C. Proceed with removal as removing a Penrose drain is a simple and straightforward procedure. D. Pass along the order to remove the drain to the next shift in the hopes that the next nurse will be familiar with the procedure.

A. Although removal of these drains is a straightforward procedure, nurses should demonstrate competency before performing it themselves. Improper removal may result in significant tissue injury. If there were no nurses available who were competent to remove the drain, the nurse may have to inform the practitioner that he would have to do it, but this would not be a first step.

Which teaching method is most effective when providing instruction to members of special populations? 1.Teach-back 2.Video instruction 3.Written materials 4.Verbal explanation

1, When providing education to members of special populations, return explanation and demonstration (teach-back) are of particular importance to ensure safety and mutual understanding. This method is the most reliable in confirming client understanding of the instructions. Video instruction, written materials, and verbal explanation are helpful and may be incorporated with the teach-back method.

When providing care for a client with paraplegia secondary to a spinal cord injury, which potential complication may occur early during the recovery period? 1 Bladder control 2 Nutritional intake 3 Quadriceps setting 4 Use of aids for ambulation

1. Because of the location of the micturition reflex center (in the sacral region of the spinal cord), bladder function may be impaired with lower spinal cord injuries. This client's ability to ingest, digest, or metabolize food is not affected; nutrition is less of a problem than bladder control. Quadriceps settings require motor control, which the client does not have. Because there is no voluntary control over the lower extremities, accomplishing mobility usually occurs with a wheelchair rather than ambulation.

Which strategy would the nurse use to meet a preschooler's developmental needs just before a physical exam? a. Allowing the child to handle the exam equipment b. Explaining what will happen to the child c. Arranging for a peer who has had the same exam to talk to the child d. Requesting that one of the parents stay with the child during the exam

1. Handling the equipment permits the child to investigate and become familiar with the instruments to be used. An explanation is beyond the comprehension of the average 4 year old and will do little to reduce anxiety. Having a parent present is supportive, but the child should be given an opportunity to handle the equipment whether the parent is present or not.

When a client who has thrombophlebitis tells the nurse, "I am worried about getting a clot in my lungs that will kill me," which action will the nurse take next? 1 Ask what the client already knows about complications of thrombophlebitis. 2 Tell the client that most people with thrombophlebitis do not develop pulmonary emboli. 3 Teach the client that anticoagulant use helps decrease the risk for a pulmonary embolism. 4 Instruct the client to tell the nursing staff about any chest pain of shortness of breath.

1. The nurse's first action would be to determine the client's understanding of thrombophlebitis and PE risk. It is true that most people with thrombophlebitis do not develop pulmonary embolism and this may be reassuring to the client, but more assessment of the client is needed first. The client's anxiety may be decreased by knowing the anticooagulant will help decrease risk of PE, but assessment of knowledge is needed first.

A client with a history of depression presents with multiple physical complaints and reports taking very high doses of vitamin D to "naturally" treat depression. Which symptoms might be explained by this vitamin toxicity? Select all that apply. One, some, or all responses may be correct. 1 Hunger 2 Confusion 3 Bone pain 4 Frequent urination 5 Malaise and fatigue

2, 3, 4, 5. Vitamin D toxicity can result in confusion, bone pain, frequent urination, malaise, and fatigue. It does not result in hunger but can cause loss of appetite.

A client is admitted to the hospital with a diagnosis of intestinal obstruction and has an intestinal tube inserted. As prescribed, the nurse instills 30 mL of normal saline into the tube to maintain patency. Which action would the nurse take next? 1 Add 30 mL to the gastric output on the intake and output record. 2 Record 30 mL as intake in the intake and output record. 3 Recognize that the amount instilled equals insensible losses. 4 Identify that the amount is insignificant and does not need to be documented.

2. All fluid taken in by the client regardless of route should be recorded on the intake and output record; documentation indicates that the action was implemented. Fluid instilled must be added to intake. The amount of gastric output needs to be accurate. No amount of fluid is considered insignificant; insensible losses through the skin and lungs equal approximately 800 mL daily. The HCP prescription indicates that the instillation is to be done as needed.

Which intervention would the nurse implement first when providing care for an older adult male client who is immobile and incontinent of urine? 1 Restrict the client's fluid intake. 2 Regularly offer the client a urinal. 3 Apply incontinence pants. 4 Insert an indwelling urinary catheter.

2. Regularly offering the urinal is the first step. Retraining the bladder includes a routine pattern of attempts to void, which may increase bladder muscle tone and produce a conditioned response. Restricting fluid intake can result in dehydration and a urinary tract infection in an older client. Applying incontinence pants does not address the cause of the incontinence, promotes skin breakdown, and may lower the client's self-esteem. Inserting an indwelling urinary catheter increases the risk of a urinary tract infection. Insertion of an indwelling urinary catheter requires a primary health care provider's prescription.

Which statements made by the student nurse indicate the need for further teaching about preparedness when responding to a fire in the health care facility? Select all that apply. One, some, or all responses may be correct. 1 "I will direct the stable clients to walk to a safe location on their own." 2 "I will ask ambulatory clients to help push wheelchair clients out of danger." 3 "I will endanger myself while moving and protecting the clients from the fire." 4 "I will continue to provide oxygen to the clients that can breathe on their own." 5 "I will move immobile clients from the fire area in a bed, stretcher, or wheelchair."

3, 4 It is the responsibility of the nurse to protect clients from danger if any fire occurs. The nurse would not risk personal injury, and also should not risk injury to other staff members. It is hazardous to provide oxygen in an environment with a fire. The nurse would direct stable clients to help push the wheelchairs of the clients who are unable to move on their own. The nurse would take care of immobile clients by ambulating them.

The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse? 1.Call security. 2.Call the police. 3.Call the nursing supervisor. 4.Lock the coworker in the medication room until help is obtained.

3.

Acetaminophen 15 mg/kg is prescribed for a child with a temperature of 102°F (38.9°C). How much would the nurse tell the parent to administer if the child weighs 9.6 kg and the acetaminophen strength was 160 mg/5 mL? Record your answer using one decimal place. ___ mL

4.5 mg; To determine the dose, multiply 15 mg × 9.6 kg = 144 mg. Use the "desire over have" formula of ratio and proportion to solve this problem.

Spironolactone, a potassium-retaining diuretic, is prescribed for a client with HF, and the nurse provides medication instructions to the client. Which statement by the client indicates understanding? a. I need to avoid foods that contain potassium b. I should take the medication on an empty stomach c. I need to eat a banana or drink a glass of orange juice every day d. I need to drink at least 10-12 glasses of water per day while taking this.

A. Spironolactone is a potassium retaining diuretic. Therefore the client should avoid foods with potassium. The client should take the medication with food to enhance absorption. The client with HF should limit fluid intake as prescribed.

Managing fluid volume

- Weigh the patient daily (same time, same scale, same amount of clothing) -Observe weight graph for trends (1 L = 1 KG) -Accurately measure all fluid intake and output -Monitor for symptoms of fluid overload at least every 4 hours during critical illnesses -Ask about presence of headache or blurred vision -Assess LOC and degree of cognition

Which type(s) of hepatitis most commonly spread by consuming contaminated food and water, or by fecal contamination? Select all that apply. One, some, or all responses may be correct. 1 Hepatitis A 2 Hepatitis B 3 Hepatitis C 4 Hepatitis D 5 Hepatitis E

1, 5 Hepatitis A and E most commonly are spread through the fecal-oral route. Hepatitis B most commonly is spread through the sharing of needles and through unprotected sex. Hepatitis C and D most commonly are spread through intravenous (IV) drug needle sharing.

The nurse receives the report on four clients whose vital signs need to be assessed. Checking the vital signs of which client would be most safe for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1 The client with an ankle sprain 2 The client with possible pneumonia 3 The client with substernal chest pain 4 The client with unstable vital signs since admission

1. Checking the vital signs of the client with an ankle sprain, who is a nonurgent case, is safe to delegate to UAP. The nurse would not delegate checking vital signs for the client with possible pneumonia because that client would be an urgent status with possible respiratory compromise. The nurse would not delegate checking vital signs of the client with substernal chest pain because that client is an emergent case with possible hemodynamic compromise. The nurse would not delegate checking vital signs of the client with unstable vital signs because that is an emergent case that needs continuous assessment by the nurse.

While assessing a postpartum client who is suspected of having a thyroid disorder, the nurse suspects that the client has autoimmune thyroiditis. Which diagnostic studies are most suitable for confirming this diagnosis? 1 Radioactive iodine uptake 2 Computed tomography scan 3 Magnetic resonance imaging 4 Thyroid-stimulating hormone

1. The postpartum client may have silent, painless thyroiditis. Radioactive iodine uptake is suppressed in silent thyroiditis, so this test would be beneficial in diagnosing the thyroiditis. A computed tomography scan is used to detect thyroid nodules. Magnetic resonance imaging is also used in evaluating thyroid nodules. A blood test for thyroid-stimulating hormone is used to evaluate thyroid function.

The nurse has made an error in documentation of the dose administered of an opioid pain medication in the client's record. The nurse draws 1 mg from the vial and another registered nurse (RN) witnesses wasting of the remaining 1 mg. When scanning the medication, the nurse entered into the medication administration record (MAR) that 2 mg of hydromorphone was administered instead of the actual dose administered, which was 1 mg. The nurse should take which action(s) to correct the error in the MAR? Select all that apply. 1.Complete and file an occurrence report. 2.Right-click on the entry and modify it to reflect the correct information. 3.Document the correct information and end with the nurse's signature and title. 4.Obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg. 5.Document in a nurse's note in the client's record detailing the corrected information.

2, 3, 4, 5 EHR will have a time date stamp that indicates an amendment has been entered. If the nurse makes an error in the MAR, the nurse should follow agency policies to correct the error. In the AMR, the nurse can click on the entry and modify it to reflect the corrected information. With it being an opioid, the nurse should obtain a cosignature from the RN who witnessed the wasting. A nurse's note should be used to detail the event and the corrections made, and the nurse's name and title will be stamped on the entry in the EHR. An occurrence report is not necessary.

A client reports to a health clinic because a sexual partner recently was diagnosed as having gonorrhea. The health history reveals that the client has engaged in receptive anal intercourse. Which finding would the nurse assess for in this client? 1 Melena 2 Anal itching 3 Constipation 4 Ribbon-shaped stools

2, Anal itching and irritation can occur from having anal intercourse with a person infected with gonorrhea. Frank rectal bleeding, not upper gastrointestinal bleeding (melena), occurs. Painful defecation, not constipation, occurs. The shape of formed stool does not change; however, defection can be painful.

The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which best action? 1.Refuse to float to the ICU based on lack of unit orientation. 2.Clarify the ICU client assignment with the team leader to ensure that it is a safe assignment. 3.Ask the nursing supervisor to review the hospital policy on floating. 4.Submit a written protest to nursing administration, and then call the hospital lawyer.

2. Floating is an acceptable practice used by hospitals to solve understaffing problems. Legally, the nurse cannot refuse to float unless a union contract guarantees that nurses can work only in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountering this situation, the nurse should set priorities and identify potential areas of harm to the client. That is why clarifying the client assignment with the team leader to ensure that it is a safe one is the best option. The nursing supervisor is called if the nurse is expected to perform tasks that he or she cannot safely perform. Submitting a written protest and calling the hospital lawyer is a premature action.

What is the focus of medical surgical nursing? a. To meet the immediate needs of the patient b. To promote health and prevent illness in pediatric patients c. Promote health and prevent illness or injury in infants d. To safely meet the biologic, psychosocial, cultural, and spiritual needs of the patient e. None of the above

D.

A client asks if the nurse agrees with the other group members that the client is intellectualizing to avoid discussing feelings. Which response is the best? 1 "Sometimes it seems that way to me, too." 2 "What's your perception of the other members?" 3 "Are you uncomfortable with what you were told?" 4 "I'd rather not give my personal opinion at this time."

3. "Are you uncomfortable?" helps the client identify behaviors and feelings in a nonthreatening manner. Agreeing with the other group members indicates a lack of acceptance of the client. The perception of the others is not the issue; the focus should be turned back to the client. The nurse's refusal to answer will psychologically remove the nurse from the group.

A client is being evaluated as a potential kidney donor for a family member. The client asks the nurse why separate teams are evaluating the donor and recipient. What is the most appropriate response by the nurse? 1. Helps reduce the cost of the preoperative workup 2. Saves the client and the recipient valuable preoperative time 3. Avoids a conflict of interest between the team evaluating the recipient and the team evaluating the donor 4. Provides for a sufficient number of persons reviewing the case so that no information is overlooked

3. Both the kidney donor and the kidney recipient need thorough medical and psychological evaluation before transplant surgery. Separate teams evaluate the donor and the recipient to avoid a conflict of interest in providing care for the 2 clients. Options 1, 2, and 4 are not related to the purpose of this approach.

A client who is going to be discharged has been receiving 3 mg of risperidone 3 times a day. Which information will the nurse give the client about the medication? 1 May be reduced if the client feels better at home 2 May be discontinued after the client is discharged 3 May cause sedation if taken concurrently with alcohol 4 Should be taken early in the day to be sure that it is not forgotten

3. Risperidone potentiates the action of alcohol and can cause oversedation if the medication and alcohol are taken together. This medication should be taken consistently to maintain a therapeutic blood medication level and prevent recurrence of symptoms. Medications should be taken as prescribed; taking them all at once may interrupt the maintenance of a constant therapeutic blood level.

Which intervention would the nurse implement to prevent cross-contamination of herpes genitalis from one client to another? 1 Institute droplet precautions with this client. 2 Arrange transfer of the client to a private room. 3 Wear a gown and gloves when providing direct care. 4 Close the door and wear a mask when in the room.

3. The exudate from herpes virus type 2 is highly contagious; gown and gloves should be worn. A face shield should be worn if there is a potential for splashing of body fluids.

Which action of the nurse leader is appropriate when preparing to share information with followers? 1 Giving complete information at one time 2 Avoiding sharing information through e-mail 3 Determining which information is to be shared 4 Sending text messages instead of face-to-face communication

3. The nurse leader would determine the information that has to be shared with followers but should not give all information at once. The nurse leader would give only limited information; giving too much at once can create disinterest in the listeners. The nurse leader can share information through e-mail, because it is a primary communication method. The nurse leader would use face-to-face communication rather than text messages.

Which would the nurse include in the plan of care for a toddler who follows a vegetarian or vegan diet? 1 Monitoring an arterial blood gas analysis 2 Monitoring serum sodium concentrations 3 Monitoring for hemoglobin and hematocrit 4 Monitoring serum potassium concentrations

3. The toddler on a vegetarian diet is at risk for iron deficiency anemia, therefore the Hgb and Hct levels are monitored.

Which site would be monitored for a pulse to assess the status of circulation to the foot? Select all that apply. One, some, or all responses may be correct. 1 Carotid artery 2 Femoral artery 3 Popliteal artery 4 Dorsalis pedis artery 5 Posterior tibial artery

4, 5 The dorsalis pedis pulse and posterior tibial pulse are sites of assessments of circulation to the foot. The carotid, located along the medial edge of the sternocmeidomastoid muscle in the neck, is an easily accessible site to assess physiologic shock or cardiac arrest. The femoral artery pulse and popliteal pulse assess the circulation to the lower leg.

Which nursing action is appropriate when assessing a pediatric client's arm circumference? 1 Using specialized calipers for the measurements 2 Having cloth tape available to measure the midpoint 3 Recording the average of 1 measurement using 2 sites 4 Measuring vertically along the posterior aspect of the upper arm

4. Arm circumference is an indirect measurement of muscle mass. The appropriate nursing action is to measure vertically along the posterior aspect of the upper arm to the acromial process and to the olecrnaon process. Specialized calipers are used for skinfold measurements. The nurse would record the average of at least 2 measurements at the same site.

A client is prescribed imipramine 75 mg three times per day. Which nursing action is appropriate when administering this medication? 1 Telling the client steroids will not be prescribed 2 Warning the client not to eat cheese 3 Monitoring the client for increased tolerance 4 Having the client checked for increased intraocular pressure

4. Glaucoma is one of the side effects of imipramine, and the client should be taught about the symptoms. The prescribing of steroids and avoiding cheese are true of monoamine oxidase inhibitors (MAOIs); imipramine is not an MAOI. Tolerance is not an issue with tricyclic antidepressants such as imipramine.

A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that which scenario is characteristic of the team-based model of nursing practice? 1. Each staff member is assigned a specific task for a group of clients 2. A staff member is assigned to determine the client's needs at home and begin discharge planning 3. A single RN is responsible for providing care to 6 clients with the aid of an AP 4. An RN leads 2 LPNs and 3 APs in providing care to a group of 12 clients

4. In team nursing, nursing personnel are led by a registered nurse leader in providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 3 identifies primary nursing (relationship-based practice).

A nurse is preparing to administer enteric-coated acetylsalicylic acid tablets orally to a client. When the nurse brings the medication to the client, the client tells the nurse that she has difficulty swallowing and will not be able to swallow the pills. Which action is most appropraite? a. Contacting the HCP b. Administering an elixir of the medication c. Crushing the pills and mixing into applesauce d. Administering the suppository form of the medication

A Enteric-coated tablets, which are absorbed in the small intestine, should not be crushed, because the mediation could irritate the stomach. For these reasons, an elixir form of a medication should not be given in place of enteric-coated tablets. Also, aspirin is not available in elixir form. The nurse would not administer a medication by a different route.

A nurse notes that the site of a client's peripheral IV catheter is reddened, warm, painful, and slightly edematous near the insertion point of the catheter. The nurse should take which action first? a. Remove the IV catheter b. Slow the rate of infusion c. Notify the HCP d. Check for loose catheter connections

A Phlebitis is an inflammatory process in the vein. Phlebitis at an IV site may be indicated by client discomfort at the site or by redness, warmth, and swelling in the area of the catheter. The IV catheter should be removed and a new IV line inserted at a different site; slowing the rate and checking for loose connections are not correct.

8. The nurse is teaching a nursing student how to change a drainage pouch. Which statement by the student demonstrates understanding of this process? A. "I need to make sure there are no wrinkles in the pouch barrier because wrinkles lead to leaking." B. "It's ok if there are small wrinkles in the pouch barrier, as I can just add extra barrier cream to the outside." C. "I need to make sure there are no wrinkles in the pouch barrier because wrinkles put extra pressure on the skin and can lead to skin breakdown." D. "Small wrinkles are often unavoidable due to a patient's body shape and the location of the pouch."

A. Wrinkles will interfere with the pouch's ability to make a good seal and will lead to leaking. Verbalization of this statement indicates the nursing student understood that part of changing a wound pouch. Extra barrier cream applied on the outside will not sufficiently make up for the leak. Wrinkles in the pouch barrier do not present a sufficient cause for skin breakdown. Although it may be difficult to ensure the absence of wrinkles depending on the patients body shape, it is still best practice to avoid them.

A client with a breast mass who is scheduled for an excisional breast biopsy asks the nurse about the procedure. What information should the nurse provide the client? a. The mass is removed entirely. b. Fluid is removed from the mass. c. Tissue is removed from the mass. d. Tissue is aspirated from the mass through a large-bore needle.

A.In an excisional biopsy, the mass itself is removed for histologic (cellular) evaluation. An incisional biopsy involves the surgical removal of tissue from a mass. Aspiration biopsy is the removal of fluid or tissue from a mass through a large-bore needle.

A client with a genitourinary tract infection has been prescribed metronidazole and fluid therapy. The nurse concludes that the client understands the dietary regimen to be followed when the client states to eliminate what from the diet? a. Alcohol b. Diet cola c. Bran flakes d. Chicken livers

Alcohol A disulfiram-type reaction may result when someone taking metronidazole ingests alcohol. This syndrome includes palpitations, SOB, severe headache, flushing, and nausea.

A clear liquid diet has been prescribed for a client who has just undergone surgery. Which foods should the nurse offer? SATA a. Custard b. Apple juice c. Orange juice d. Chicken broth e. Orange gelatin f. Vanilla ice cream

Apple Juice, Chicken Broth, and Orange gelatin A clear liquid diet consists of foods, such as apple juice, chicken broth, and gelatin. Which are relatively transparent. Custard, orange juice, and vanilla ice cream are components of a full liquid diet.

Triamterene has been prescribed for a client with history of HTN. Which fruits should the nurse tell the client are acceptable to eat while on this medication? a. Prunes b. Apples c. Peaches d. Avocados e. Nectarines f. Cranberries

Apples, Peaches, Cranberries Triamterene is a potassium-retaining diuretic, so the client must omit foods high in potassium. Fruits that are naturally high in potassium include prunes, avocados, bananas, fresh oranges, and mangoes, nectarines, and papayas.

While reviewing a 79 year old female patients lab studies, the nurse notes that the Hgb is 6.8 and the Hct is 24%. The nurse reports this to the HCP, who prescribes a transfusion of 1 unit of packed RBC. Which are part of the correct procedures for administering the blood? a. Using a 22-gauge needle to infuse the blood b. Monitoring patient for circulatory overload during the infusion c. Planning to ensure that the infusion will be complete in 4 hours d. Monitoring the patient closely for a transfusion reaction, especially during the first 50 mL e. Ensuring that the transfusion is started within 1 hour of the blood bag's delivery to the unit.

B C D The normal Hgb reading in a female is approximately 12-15, and the normal hematocrit is 35-47. To avoid septicemia, the transfusion time should not exceed 4 hours. If the client's size or condition does not allow the infusion within 4 hours, the blood bank may split the unit into smaller portions. The patient will be monitored for circulatory overload due to her age; older client is one population at risk for overload. Although a transfusion reaction can occur at any time, it is most likely going to occur with the first 15 minutes or the first 50 mL of infused solution. Blood bank regulations prevent the return of components to the blood bank if the product has been warmed to more than 50 degrees, so 30 minutes is considered to be the maximum time out of monitored storage in most hospitals. The gauge of the needle used for transfusion varies with the product being infused. Generally a 19-gauge or larger is required to achieve maximal flow rate. The lumen of a 22-gauge would be too small to infuse blood.

A nurse manager is planning care for a teen with a possible fracture of the foot. Which tasks can be assigned to the UAP assisting the nurse? SATA a. Palpate for presence of pedal pulses b. Apply a cold pack to the teenager's foot c. Explain to the client the difference between a fracture and a sprain d. Use a numeric pain scale to assess the teen's pain level e. Take the teen's vital signs

B, E Applying a cold pack may be delegated to the UAP with sufficient instruction and supervision. Taking VS is a common task delegated to a UAP as long as a life-threatening complication has not occurred. Client teaching and assessment is done by the nurse.

A nurse is teaching a client with heart disease about a low-fat diet. Which foods should the client include in the diet? SATA a. Avocados b. Baked tuna c. Green olives d. Baked potato e. Fresh cherries f. Cream cheese

Baked tuna, baked potato, fresh cherries Fruits and veggies tend to be lower in fat because they do not come from animal sources, although olives, though technically a fruit, are high in fat along with avocados . Fish is naturally lower in fat. Meats and dairy products such as cream cheese are higher in fat, although modifications can be made to these foods to reduce fat content.

A client who is mouth breathing is receiving oxygen by face mask. The assistive personnel (AP) asks the nurse why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The nurse responds that the primary purpose of the water is to promote which goal? a. Prevent the client from getting a nosebleed b. Give the client added fluid by way of the respiratory tree c. Humidify the oxygen that is bypassing the client's nose d. Prevent fluid loss from the lungs during mouth breathing

C. The purpose of the water bottle is to humidify the oxygen that is bypassing the nose during mouth breathing. The remaining options are incorrect; additionally, a client who is breathing through the mouth is not at risk for nosebleeds.

Which situation requires the most immediate action at a skilled care unit? a. A resident with a colostomy tells the nurse manager that his colostomy bag is very full and is about to pop b. A resident who is hard of hearing turns her head away when the nurse manager inquires about how she is feeling c. A resident with incontinence has urinated on the floor while ambulating from his room toward the dining room d. A resident sitting in a wheelchair outside the shower room is wrapped in a blanket and states she is cold

C; this situation is a safety hazard and requires immediate intervention because it increases the risk of falls. Persons who are hard of hearing often turn their head in an effort to hear better. The nurse should determine if that is the situation or if the resident has a problem, but it is not priority.

A patient is having diagnostic tests to confirm the diagnosis of scoliosis. Which test is most conclusive of the diagnosis? a. A CBC b. An IVP c. An x-ray d. A biopsy

C; x-ray confirms a diagnosis of scoliosis.

After demonstrating the correct procedure for CPR in an infant during a CPR recertification course, the nurse asks a student to perform the procedure on a mannequin. Which ratio of chest compressions to ventilations performed by the student indicates to the nurse that the student is performing the procedure correctly? 5:1 15:1 15:2 30:2

CPR in an infant or child is performed at a ratio of 30 chest compressions to two ventilations. Therefore the other options are incorrect.

A client with atrial fibrillation has been placed on warfarin sodium. As part of the instructions for the medication, which foods does the nurse tell the client are acceptable to eat? SATA a. Kale b. Cherries c. Broccoli d. Cabbage e. Potatoes f. Spaghetti

Cherries, potatoes, spaghetti Anticoagulant medications work by antagonizing the action of vitamin K, which is needed for clotting. When a client is taking an anticoagulant, foods high in vitamin K are often omitted from the diet. Vitamin K is found in large amounts in green, leafy veggies such as kale, broccoli, spinach, brussels sprouts, cabbage, and turnip greens. Cherries, potatoes, and spaghetti are low in vitamin K.

The nurse provides instructions to a client two is beginning therapy with oral theophylline. The nurse recognizes that the client understands the instructions when she states she should limit what in the diet? a. Coffee, chocolate, cola b. Oysters, lobster, shrimp c. Apples, oranges, pineapple d. Cottage cheese, cream cheese, dairy creamers

Coffee, cola, chocolate Theophylline is a bronchodilator, and the nurse teaches the client to limit intake of xanthine-containing foods while taking this medication.

Which food should the nurse offer to a client who has been prescribed a full liquid diet? a. Toast b. Plain bagel c. Cooked custard d. Scrambled eggs

Cooked custard A full liquid diet consists of liquid foods that are clear or opaque liquid foods, including those that are liquid at room temperature. Cooked custard is allowed. Toast and a bagel are allowed on a regular diet; scrambled eggs are allowed on a soft diet.

A client being seen in the clinic for the first time tells the nurse that his last physical examination was 10 years ago. A physical examination is performed, several laboratory tests are prescribed, and a follow-up appointment is scheduled for the client. The laboratory results are sent to the clinic, where the nurse reviews the results. Which values are abnormal? Select all that apply. a. BUN, 10 mg/dL (3.57 mmol/L) b. Magnesium, 2.0 mg/dL (0.82 mmol/L) c. WBCs, 5,000 cells/mm3 (5 x 109/L) d. Phosphorus, 9.6 mg/dL (3.1 mmol/L) e. Neutrophils, 900 cells/mm3 (0.09 x 109 f. Serum creatinine, 1.0 mg/dL (88.4 mcmol/L)

D, E Normal values are phosphorus, 2.7 to 4.5 mg/dL; neutrophils, 56% or 1800 to 7800 cells/mm3; BUN, 8 to 25 mg/dL; magnesium, 1.6 to 2.6 mg/dL; WBCs, 4500 to 11,000 cells/mm3; and serum creatinine, 0.6 to 1.3 mg/dL.

A nurse performs an assessment of a client with a serum calcium level of 8.0 mg/dL (2.0 mmol/L). Which clinical manifestations of this electrolyte imbalance would the nurse expect to note? Select all that apply. a. Tachycardia b. Hypertension c. Bounding peripheral pulses d. Presence of the Trousseau sign e. Hyperactive deep tendon reflexes

D, E The normal calcium level is 8.6 mg/dL to 10 mg/dL (2.15 to 2.5 mmol/L). A serum calcium level of 8.0 mg/dL (2.0 mmol/L) indicates hypocalcemia. Clinical manifestations associated with hypocalcemia include a decreased heart rate, hypotension, the Trousseau and Chvostek sign, and hyperactive deep tendon reflexes. Other clinical manifestations include diminished peripheral pulses, abdominal cramping and diarrhea, muscle twitching, paresthesias, tetany, and seizures. ECG findings include prolonged ST and QT intervals.

The nurse is assisting to defibrillate a client in ventricular fibrillation. After placing the pad on the client's chest and before discharge, which intervention is a priority? a. Ensure that the client has been intubated b. Set the defibrillator to the synchronize mode c. Administer an amiodarone bolus IV d. Confirm that the rhythm is actually ventricular fibrillation

D. Until the defibrillator is attached and charged, the client is resuscitated by using cardiopulmonary resuscitation. Once the defibrillator has been attached, the electrocardiogram is checked to verify that the rhythm is ventricular fibrillation or pulseless ventricular tachycardia. Leads also are checked for any loose connections. A nitroglycerin patch, if present, is removed. The client does not have to be intubated to be defibrillated. The machine is not set to the synchronous mode because there is no underlying rhythm with which to synchronize. Amiodarone may be given subsequently but is not required before defibrillation.

The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? a. A client who is ambulatory demonstrating steady gait b. A postop client who has just received an opioid pain medication c. A client scheduled for physical therapy for the first crutch-walking session d. A client with a WBC count of 14,000 and a temperature of 38.4

D. he nurse should plan to care for the client who has an elevated white blood cell count and a fever first, because this client's needs are the priority. The client who is ambulatory with steady gait and the client scheduled for physical therapy for a crutch-walking session do not have priority needs. Waiting for pain medication to take effect before providing care to the postoperative client is best.

A nurse is reviewing the results of laboratory tests performed on a female client. Which of the following findings are abnormal and warrant primary health care provider notification? Select all that apply. a.Albumin, 4 g/dL (40 g/L) b. Protein, 6.0 g/dL (60 g/L) c. Ammonia, 40 mcg/dL (28.6 mcmol/L) d. Triglycerides, 150 mg/dL (1.69 mmol/L) e. Direct bilirubin, 1.2 mg/dL (20.5 mcmol/L) f. Total cholesterol, 250 mg/dL (6.47 mmol/L)

E, F Normal values for these parameters are: albumin, 3.4 to 5 g/dL; protein, 6.0 to 8.0 g/dL; ammonia, 10 to 80 mcg/dL; triglycerides, less than 200 mg/dL; direct bilirubin, 0 to 0.3 mg/dL; and total cholesterol, 140 to 199 mg/dL.

Diverticulitis is diagnosed in a client who has been experiencing episodes of GI cramping. The nurse should tell the client to maintain which type of diet, during the asymptomatic period? a. Low in fat b. High in fiber c. Low in residue d. High in carbs

High-fiber When a client's diverticulitis is asymptomatic, a soft high-fiber diet containing fruits, veggies, and whole grains is recommended. The client is also instructed to consume a small amount of bran daily and to take bulk-forming laxatives, if prescribed, to increase stool mass and softness. Increasing fluids to 2500-3000 mL daily is also important.

Rectally administered lactulose is prescribed for a client with hepatic encephalopathy. Which parameter should the nurse monitor to evaluate effectiveness of the medication? a. BP b. Ammonia level c. Electrolyte levels d. Looseness of stools

Lactulose is a hyperosmotic laxative and ammonia detoxicant. It can enhance intestinal excretion of ammonia and decrease the blood ammonia level in a client with portal HTN and hepatic encephalopathy. Diarrhea is an indicator of overdose. Used correctly, the medication should result in the production of 2-3 soft stools per day. BP is not associated with the effectiveness of this medication. Electrolyte levels are monitored for clients who take this medication frequently, in large doses, or for prolonged periods.

A client is resuming eating after undergoing partial gastrectomy. What measures should the nurse tell the client to take to minimize the risk of complications? SATA a. Lying down after eating b. Eating high-protein foods c. Drinking liquids with meals d. Eating 6 small meals per day e. Eating concentrated sweets during the day

Lying down after meals, eating high-protein foods, eating 6 small meals a day The client who has undergone partial gastrectomy is at risk for dumping syndrome. This client should be prescribed a diet that is high in protein, moderate in fat, and low in carbs. The client should lie down after meals and avoid drinking liquids with meals. Frequent small meals are encouraged. The client should also avoid concentrated sweets.

A client who experienced a stroke is experiencing residual dysphagia. Which food should be removed from his meal tray? a. Peas b. Scrambled eggs c. Cheese casserole d. Mashed potatoes

Peas In general, flavorful, warm, or well-chilled foods with texture stimulate swallow reflex. Moist pastas, casseroles, egg dishes, and potatoes are usually well tolerated. Raw veggies, chunky veggies such as diced beets, stringy veggies, and those with skin such as corn and peas are foods commonly excluded from a diet of a client with dysphagia.

The nurse teaches a client who has begun taking phenelzine, a MAOI, about the medication. Which foods when selected indicate the need for further teaching? a. Peas b. Broccoli c. Potatoes d. Red wine e. Avocados f. Cereal with raisins

Red wine, avocados, raisins Because phenelzine is an MAOI, the client should avoid foods that are high in tyramine, which could trigger a potentially fatal hypertensive crisis. Foods to avoid include aged cheeses, smoked or processed meats, raisins, avocados, figs, beer. Veggies with the exception of broad-bean pods are generally acceptable.

A client with a UTI has been started on nitrofurantoin, a urinary antiseptic. The client is taught about foods that will keep the urine acidic. Which food should the nurse tell the client to eliminate? a. Prunes b. Oranges c. Rhubarb d. Cranberries

Rhubarb When a client is taking nitrofurantoin, the urinary pH must be acidic. The client will be on an acid ash diet. Rhubarb reduces acidity of urine and should be avoided.

A client who has sustained multiple fracture of the left leg is in skeletal traction. The nurse has obtained an overhead trapeze to improve the client's bed mobility. To which high-risk area must the nurse pay particular attention during assessment for indications of pressure and skin breakdown? a. Left heel b. Scapulae c. Right heel d. Back of the head

Right heel Certain areas are under pressure and at risk for breakdown in the client who is in skeletal traction. These areas include the elbows (if they are used for repositioning) and the heel of the unaffected leg, which is used as a brace when the client pushes up from the bed. Other such pressure points include popliteal space, achilles tendon, and the ischial tuberosity.

A nurse provides dietary instructions to a client with cholecystitis. Which menu selection by the client indicates understanding? a. Roast turkey, baked potato b. Fruit plate with whipped cream c. Fried chicken, mac and cheese d. BBQ ribs, buttered noodles

Roast turkey, baked potato The client with cholecystitis should reduce intake of fat. Foods that should generally be avoided to achieve this end include sauces and gravies, fatty meats, fried foods, products made with cream, and heavy desserts.

A nurse has provided dietary instructions to a client with a new diagnosis of gout. Which menu suggestions by the client indicate the need for further instruction? SATA a. Carrots b. Tapioca c. Scallops d. Broccoli e. Chicken liver

Scallops, Chicken liver Rationale: Organ meats such as liver, as well as certain seafoods, including scallops, sardines, and herring, should be omitted from the diet of a client with gout due to high purine content. The foods identified in other options can be consumed freely by this client.

The nurse is instructing a client with hypertension about foods that are low in sodium. Which menu items indicate that the client understands what has been taught? a. Spaghetti with fresh tomatoes b. Boiled lobster, baked potato c. Grilled chicken with turnip greens d. Instant hot cereal with bacon e. Tomato soup with a ham sandwich

Spaghetti/fresh tomatoes Grilled chicken, turnip greens Rationale: Foods that are lower in sodium include fruits and vegetables, which do not contain physiologic saline. Fresh poultry and pastas are also low in sodium. Highly processed and refined foods such as lunch meats are high in sodium unless specifically labeled "low sodium". Saltwater fish and shellfish are higher in sodium.

A client with renal calculi is instructed to follow an alkaline ash diet. Which menu choice by the client indicates understanding? a. Chicken, potatoes, cranberries b. Spinach salad, milk, banana c. Peanut butter sandwich, milk, prunes d. Linguini with shrimp, salad, a plum

Spinach salad, milk, banana In an alkaline ash diet, all fruits are allowed except cranberries, prunes, and plums. The other options are of an acid ash diet.

A nurse is monitoring a client with hyperparathyroidism for signs of hypocalcemia and prepares to test the client for the Trousseau sign. Which item should the nurse obtain to perform this test? a. Cotton b. Tongue blade c. Reflex hammer d. Blood pressure cuff

The presence of the Trousseau sign is an indication of hypocalcemia. To test for the Trousseau sign, the nurse places a blood pressure cuff around the client's upper arm, inflates the cuff to a pressure greater than the client's systolic pressure, and keeps the cuff inflated for 1 to 4 minutes. In a positive result, the client's hands and fingers go into spasm in palmar flexion under these hypoxic conditions. Cotton, a tongue blade, and a reflex hammer are not needed to perform this test.

An adult client who recently underwent surgery suddenly experiences sharp chest pain and dyspnea and lapses into unconsciousness. The client is not breathing and does not have a pulse. The nurse calls a code and begins CPR. How many chest compressions per minute does the nurse deliver? 40 50 70 100

The proper number of chest compressions per minute should be delivered to ensure adequate cardiac output. In an adult client, the correct number of chest compressions is at least 100 per minute. Forty, 50, and 70 are all incorrect.

For which vitamin deficiency should the nurse monitor the client who is on a vegan diet? a. Vitamin A b. Vitamin B12 c. Vitamin C d. Vitamin E

Vitamin B12 The client on a vegan diet does not consume animal products and is therefore at risk for B12 deficiency. Fruits and veggies, which are acceptable to a vegan, contains vitamins A, C and E.

A nurse has taught a client with a new colostomy about measure to control odor in the ostomy drainage bag. Which foods listed indicate that the client has understood? SATA a. eggs b. yogurt c. parsley d. broccoli e. cucumbers f. cranberry juice

Yogurt, parsley, cranberry juice Deodorizing foods for the client with an ostomy include beet greens, parsley, buttermilk, cranberry juice, and yogurt. Eggs, broccoli, and cucumbers are gas-forming foods.

Which complication would the nurse suspect in the client who returns to the unit after an abdominal hysterectomy with an indwelling urine catheter present and sanguineous urine in the collection bag? 1 An incisional nick in the bladder 2 A urinary infection from the catheter 3 Disseminated intravascular coagulopathy 4 Uterine relaxation with increased bleeding

a. During abdominal hysterectomy the urinary bladder may be nicked accidentally. The client is not likely to have an infection with bleeding so soon after surgery. Bleeding would be present from other sites such as the incision, as well as the urine bag. The uterus is removed with a hysterectomy, therefore there is no uterine bleeding.

A nurse is caring for a client with diarrhea. For which acid-base disorder does the nurse assess the client? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

a. Intestinal secretions are high in bicarbonate because of the effects of pancreatic secretions. In conditions such as diarrhea, these fluids may be lost from the body before they can be reabsorbed. The decreased bicarbonate level produces the actual base deficit of metabolic acidosis.

The nurse is preparing a plan of care for a child with sickle cell crisis who will be admitted to the nursing unit. The nurse should include which interventions as a priority in the plan of care with the child? a. Initiate an IV line for fluids b. Consult with psychiatric department regarding genetic counseling c. Call blood bank, request preparation of a unit of packed RBC d. Call respiratory to prepare for intubation and mechanical ventilation

a. The priorities in management of sickle cell crisis are hydration therapy and pain relief. To achieve this, the child is given IV fluids to promote hydration and reverse the agglutination of sickled cells in small blood vessels. Opioid analgesics may be given to relieve the pain that accompanies the crisis. Genetic counseling is recommended but not during the acute phase of illness. Red blood cell transfusion may be done in selected circumstances such as aplastic crisis or when the episode is refractive to other therapy. Oxygen would be administered according to individual need, but the client would not require intubation and mechanical ventilation.

A nurse reviewing a client's laboratory results sees a magnesium level of 1.0 mg/dL (0.41 mmol/L). Which clinical manifestation would the nurse expect to note in this client in light of this laboratory finding? a. Bradycardia b. Hypotension c. Chvostek sign d. Diminished deep tendon reflexes

c. The normal serum magnesium level ranges from 1.6 to 2.6 mg/dL. A magnesium level of 1.0 mg/dL (0.41 mmol/L) indicates hypomagnesemia. Clinical manifestations of hypomagnesemia include tachycardia, shallow respirations, hypertension, anorexia, nausea, abdominal distention, irritability and confusion, hyperreflexia, the Trousseau and Chvostek sign, tremors, and seizures. ECG findings include tall T waves and depressed ST segments. Bradycardia, hypotension, and diminished deep tendon reflexes are manifestations associated with hypermagnesemia.

The nurse is developing a plan of care for a client who will receive a continuous IV infusion of 5% dextrose at a rate of 100 mL/hr. How frequently should the nurse plan to change the bag of IV fluids? a. Weekly b. Every 24 hours c. Every 48 hours d. Every 72 horus

B. As a means of helping prevent complications associated with IV therapy, the bag of fluids should be changed every 24 hours.

A medical-surgical nurse completes the admission assessment on a client diagnosed with a urinary tract infection. The client's admitting weight is 165 lb (74.8 kg). The vital signs are: temperature 96°F (35.6°C), pulse 110 beats per minute, respirations 20 per minute, and blood pressure 88/56 mm Hg. The client received 3 L of normal saline in the emergency department. The total urine output for the past 2 hours was 20 mL via a urinary drainage system. Which intervention would the nurse recommend to the primary health care provider? 1 Transfer the client to a critical care unit. 2 Discontinue the urinary catheter immediately. 3 Administer another 1 L bolus of sodium chloride. 4 Begin a dopamine hydrochloride drip for renal perfusion.

1. The client has a known infection, is exhibiting signs of sepsis, and is unresponsive to fluid therapy as evidenced by the low blood pressure. The client is showing signs of renal failure. The client is manifesting probable signs of septic shock requiring a higher level of care. This question requires the medical/surgical nurse to synthesize the client's manifestations and make an evaluation of the need for more invasive care than is available on the admitting unit. Giving another fluid is plausible, but this client weighs 75 kg, requiring a maximum of 3 L of fluid to be given before a diagnosis of severe sepsis. The client requires more invasive monitoring than can be done on a medical/surgical unit to determine if more fluid or vasopressors are required. The urinary catheter is necessary to continue monitoring the urine output in this acute client.

The home health nurse develops a plan of care for the client. Which actions should the nurse include in the plan as a case manager of the client's care? a. Organize, manage, and balance health care services needed to the client b. Report daily to all members of the health care team to advise them of the plans c. Plan weekly meetings with all persons involved in the care of the client to assess status d. Conduct daily teaching sessions for the client and s/o about the case management process

1. The role of case manager is to organize, manage, and balance health care services needed for the client.

A child has partial-thickness burns of the face and upper chest. Which is the priority nursing assessment for the first 24 hours? 1 Wound sepsis 2 Pulmonary distress 3 Fear and separation anxiety 4 Fluid and electrolyte imbalance

2. Inhalation burns are usually present with facial burns, regardless of depth; the immediate threat is asphyxia from irritation and edema of the respiratory passages. Wound sepsis will not be evident until the 3-5 day. This child is too old for separation anxiety. Fluid losses reach their maximum about the 4th day.

Which finding would the nurse observe in a client with conversion disorder who is unable to move the right arm? 1 Feeling depressed 2 Appearing composed 3 Demonstrating free-floating anxiety 4 Exhibiting tension when discussing symptoms

2. The client would appear composed. The client with a conversion disorder literally converts the anxiety to the symptom. Once the symptom develops, it serves as a defense against the anxiety and the client is diagnostically almost anxiety free. In a conversion disorder, the reactions the nurse would expect to encounter are not in proportion to the disability; therefore, the affected client os not usually depressed. The conflict is resolved by the paralysis of the arm; therefore, the anxiety is under control and the client would not demonstrate free-floating anxiety.

In providing effective nursing care to clients from different cultural backgrounds, which strategy would the nurse follow? 1 Advise clients that some cultural practices may be harmful to health. 2 Provide care that fits the clients' cultural beliefs. 3 Strictly adhere to organization policies regarding nursing care. 4 Ignore the cultural aspect and focus on the medical aspect of care.

2. When providing care to clients from different cultural backgrounds, nurses would be careful to provide care that fits the client's cultural beliefs. It helps provide effective nursing care to the satisfaction of the client. Advising clients against their cultural practices may offend them and should be avoided. Organization policies should be made flexible to incorporate cultural aspects of care. Ignoring the cultural aspect of client care may result in ineffective nursing care.

Which organization provides scope and practice guidelines on the roles and responsibilities for nursing and nursing specialties? Select all that apply. One, some, or all responses may be correct. 1 State Nursing Association 2 National League of Nursing 3 American Nurses Association 4 Academy of Medical Surgical Nurses 5 Quality and Safety Education for Nurses

3. The American Nurses Association develops and publishes scope and standards of practice guidelines for nursing and nursing specialties. Many professional organizations have state-level nursing associations, but they do not publish standards and scope of practice. The National League of Nursing is a professional organization related to the education of nurses. The Academy of Medical Surgical Nurses publishes scope and standards of practice for general medical surgical nursing, but not nursing and nursing specialties. Quality and Safety Education for Nurses supports development of the knowledge, skills, and attitudes needed to improve the quality and safety of the health care system.

During an infant's routine visit to the pediatric clinic, the nurse identifies white patches adhering to the mucosa of the infant's mouth. Which would be the initial action by the nurse? 1 Swab a patch to obtain a specimen for a culture. 2 Scrape off the patches with a tongue blade or cotton swab. 3 Report abnormal findings to health care provider after completing physical examination. 4 Tell the mother to cleanse the mouth thoroughly after each feeding.

3. The nurse needs to report the abnormal assessment finding to the health care provider so further testing can be prescribed. Documentation and reporting of nursing findings during assessment is a nursing function; this facilitates early treatment. Scraping an area of one of the lesions and sending the specimen for a biopsy is beyond the scope of nursing practice. The microorganism causing the patches should be determined; they are often caused by candidiasis (thrush), a fungal infection. The patches should not be removed forcibly because this may further injure the delicate oral mucosa. A further assessment of the oral cavity should be conducted immediately. Although teaching the mother to rinse the mouth after a feeding is advisable, the microorganism causing the problem should be identified first.

The nurse is giving a bed bath to an assigned client when an assistive personnel (AP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action? 1.Finish the bed bath and then administer the pain medication to the other client. 2.Ask the AP to find out when the last pain medication was given to the client. 3.Ask the AP to tell the client in pain that medication will be administered as soon as the bed bath is complete. 4.Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

4. The nurse is responsible for the care provided to assigned clients. The appropriate action in this situation is to provide safety to the client who is receiving the bed bath and prepare to administer the pain medication. Options 1 and 3 delay the administration of medication to the client in pain. Option 2 is not a responsibility of the AP.

Which action would the nurse implement when providing care for a client with malaria? 1 Institute seizure precautions. 2 Prepare for blood transfusions. 3 Maintain isolation precautions. 4 Provide nutrition between paroxysms.

4. There are three paroxysms with malaria (cold, hot, and sweat stages cycling every 36-72 hours). Maintaining adequate nutritional and fluid balance is essential to life and must be accomplished during periods when intestinal motility is not excessive so gastrointestinal absorption can occur. Although shaking chills may occur, seizures generally do not occur. Blood transfusions are not used in the treatment of malaria. Maintaining isolation precautions is unnecessary; infection can occur only through direct serum contact or a bite from an infected Anopheles mosquito.

Which action by the nurse leader is indicative of transactional leadership? 1 Accounting for the needs and abilities of individual employees 2 Encouraging the novel and innovative thinking of the employees 3 Motivating the employees by articulation of an inspirational vision 4 Inspiring the self-interest of the employees by offering external rewards

4. Transactional leadership relies on the power of organizational position and formal authority to reward or punish performance. Offering external rewards to motivate the self-interest of employees is a type of transactional leadership. The transformational leader can motivate employees by accounting for their needs and abilities individually. Encouraging the novel and innovative thinking of employees is a characteristic of transformational leadership. The transformational leader helps motivate employees by articulation of an inspirational vision.

The nurse understand that which vaccine may cause intussusception in children? a. Rotavirus b. Hepatitis c. MMR d. Diphtheria, tetanus, pertussis

A. Rotavirus vaccines very rarely cause intussusception, a form of bowel obstruction in which the bowel telescopes in on itself. Hepatitis vaccines can cause anaphylactic reactions. The MMR vaccines carries a small risk of causing acute encephalopathy, convulsions, and a shock-like state.

Which intervention would be classified as an independent nursing care function? Select all that apply. One, some, or all responses may be correct. 1 Inserting a Foley catheter 2 Administering a medication 3 Starting an intravenous infusion 4 Preparing a client for diagnostic tests 5 Positioning a client to prevent pressure ulcer formation

5. Independent functions are those that the nurse initiates without supervision or direction from others. An example would be positioning a client to prevent ulcer formation. Health care provider-initiated interventions include those performed according to prescriptions received, such as inserting a Foley catheter, administering medications, starting an intravenous infusion, and preparing clients for diagnostic testing.

The nurse is preparing to perform an assessment on a child being admitted to the hospital with a diagnosis of sickle cell crisis, vaso-occlusive crisis. Which findings should the nurse expect to note? SATA a. Pallor b. Fever c. Joint swelling d. Blurred vision e. Abdominal pain

A, B, C, E Sickle cell crises are acute exacerbations of the disease. Vaso-occlusive crisis is caused by the stasis of blood with clumping of cells in the microcirculation, ischemia, and infarction. Manifestations include pallor; fever; painful swelling of hands, feet, and joints; and abdominal pain.

Which situation requires the most immediate intervention by a nurse manager? a. A UAP is demonstrating verbally abusive behaviors toward a resident with dementia who is confused and disoriented b. A newly hired UAP asks for assistance to correctly measure and document the fluid intake of a resident with dysphagia c. A resident with Parkinson's disease is drooling excessively and refuses to allow the staff to feed him d. A resident with Alzheimer's disease is agitated and demands to be released from his geriatric chair

A; abusive behavior toward any resident places the resident at risk for further abuse that could potentially escalate to assault. The nurse manager has an ethical responsibility to advocate for those residents unable to defend themselves. Drooling is common in Parkinson's disease and is not a risk to the resident; since the client in option D is secured in the chair, this does not pose an immediate risk.

A nurse reviews a client's urinalysis. Which findings does the nurse recognize as abnormal? SATA a. pH of 6 b. Glucose noted c. Casts noted d. An absence of protein e. The presence of ketones f. Specific gravity of 1.018

B, C, E The normal pH range of urine is 4.5 to 7.8, and normal specific gravity ranges from 1.016 to 1.022. The urine is typically screened for protein, glucose, ketones, bilirubin, casts, crystals, red blood cells, and white blood cells, none of which should be present.

A client with liver cancer who is undergoing chemotherapy tells the nurse that some foods on the tray taste bitter. Which food does the nurse suggest that the client eliminate? a. Beef b. Custard c. Potatoes d. Cantaloupe

Beef Chemotherapy may distort how certain foods taste to the client. Beef and pork are often reported by people undergoing chemotherapy to taste bitter or metallic.

A nurse is teaching a client with an ileostomy about foods that could result in the production of liquid stools. Which food selected to eat indicates need for further instruction? a. Bran b. Pasta c. Boiled rice d. Low-fat cheese

Bran Ileostomy output is liquid. The addition or elimination of various foods can help thicken this liquid drainage. Bran is high in fiber and will increase output of liquid stool. Foods that help thicken the stool of a client with an ileostomy include pasta, boiled rice, and low-fat cheese.

Calcitriol is prescribed for a client with hypocalcemia. The nurse has instructed the client in foods that may interfere with calcium absorption. The nurse realizes the teaching is effective if the client verbalizes the importance of limiting which items? SATA a. Bran b. Milk c. Clams d. Spinach e. Orange juice

Bran, Spinach The client taking a medication to treat hypocalcemia should be instructed to avoid excessive consumption of spinach, rhubarb, bran, and whole-grain cereals, which all may limit calcium absorption. Good dietary sources of calcium include milk, dark-green leafy veggies, clams, oysters, sardines, and orange juice.

A nurse is reviewing the laboratory results of a client with Addison's disease. Which finding is most closely correlated with this disorder? a. Calcium level of 8.6 mg/dL (2.15 mmol/L) b. Sodium level of 145 mEq/L (145 mmol/L) c. Potassium level of 5.5 mEq/L (5.5 mmol/L) d. Blood glucose level of 110 mg/dL (6.1 mmol/L)

C. Laboratory testing in Addison's disease reveals hypoglycemia, hyperkalemia, hyponatremia, and hypercalcemia. The normal blood glucose level ranges from 70 to 110 mg/dL. The normal potassium level ranges from 3.5 to 5.0 mEq/L. The normal sodium level ranges from 135 to 145 mEq/L. The normal calcium level ranges from 8.6 to 10 mg/dL.

1. The patient has a vacuum-assisted drain next to the surgical suture line. How does the wound drain promote wound healing? A. It increases pressure in the wound bed and compromises tissue perfusion. B. It decreases pressure in the wound bed and compromises tissue perfusion. C. It decreases pressure in the wound bed and promotes tissue perfusion. D. It increases pressure in the wound bed and promotes tissue perfusion.

C. Draining excess fluid from the surgical site decreases pressure and promotes tissue perfusion to support healing. Drains decrease, not increase, the pressure.

Levodopa is prescribed for a client with Parkinson disease. What vitamin needs to be avoided while taking this? a. Thiamine b. Riboflavin c. Pyridoxine d. Ascorbic acid

C. Pyridoxine can decrease the amount of levodopa that reaches the CNS. As a result, the therapeutic effect is reduced.

Which objective assessment is consistent with a diagnosis of scoliosis? a. Concave angulation of the lumbar spine b. Convex angulation of the thoracic spine c. Rib hump when bending over d. Increased hair distribution at the site of curvature

C; In scoliosis, a hump in the area of the scapula is apparent on one side when the child is bending forward. Option a is a sign of lumbar lordosis; option b is a sign of kyphosis

Which of the following IV solutions is considered hypertonic? a. 0.9% NS b. 5% dextrose in water c. 0.45% NS d. 5% dextrose in 0.45% NS

D. A hypertonic solution is more concentrated than body fluids. These include 5% dextrose in 0.45% NS, 5% dextrose in 0.9% NS, 3% saline solution, 5% saline solution, 10% dextrose in water, and 5% dextrose in LR.

The nurse is caring for a client with a chest tube drainage system. When the client is being turned on his/her side, the tube is dislodged from his/her chest. Which immediate action should the nurse take? a. Call a code b. Take the client's vital signs c. Ask the client to hold his/her breath d. Apply pressure over the chest tube insertion site

D. If a chest tube is dislodged, the nurse's immediate action is to pinch the skin opening shut and apply pressure over the chest tube insertion site. A gauze dressing is applied, and three sides of the dressing are taped. The nurse also notifies the primary health care provider. There is no reason to call a code. The nurse may take the client's vital signs, but this is not the immediately necessary action. Having the client hold his breath serves no useful purpose.

To ensure proper distribution of ear medication after instillation, what will the nurse instruct an adult patient to do? A. Have a family member instill the medication. B. Avoid contaminating the medication's applicator tip. C. Instill the medication at the time ordered by the provider. D. Instill the medication after gently pulling the ear up and back.

D. Pulling the pinna up and back straightens the ear canal in the adult patient.

A client recovering from acute kidney injury is being discharged. The nurse determine that the client understands the diet regimen when the client states that he will plan a diet low in which substance? a. Fats b. Vitamins c. Potassium d. Carbs

Potassium Most excretion of potassium and control of potassium balance is carried out by the kidneys. In a client with AKI, potassium intake is limited. The primary mechanism of potassium removal during AKI is dialysis.

A client with HF and HTN who has been admitted to the hospital is unable to make own selections from the menu. What meal does the nurse select for the client's supper? a. Smoked ham, fresh carrots, boiled potato b. Hot dog in a bun, sauerkraut, baked beans c. Turkey, baked potato, salad with oil and vinegar d. Shrimp, baked potato, salad with blue cheese dressing

Turkey, baked potato, salad with oil and vinegar Foods that are high in sodium should be limited in the diet of this client. Foods in the meat group that are higher in sodium include bacon, lunch meat, chipped or corned beef, ham, hot dogs, kosher meat, smoked or salted meat or fish, and a variety of shellfish. These foods should be avoided or strictly limited for clients with HTN.

A nurse monitoring the 24-hour fluid balance of a client with diarrhea calculates the client's intake as 2500 mL and notes that urine output is 1500 mL and fecal output 150 mL. What is the additional expected maximal amount of insensible fluid loss the nurse should include in the calculation? a. Skin, 800 mL; lungs, 600 mL b. Skin, 400 mL; lungs, 500 mL c. Skin, 200 mL; lungs, 300 mL d. Skin, 100 mL; lungs, 100 mL

a. Water enters the body by way of three sources: oral liquids, water in foods, and water formed by the oxidation of foods. The average total amount of water taken into the body by all three sources is 2300 to 2900 mL/day. Normal body fluid excretion includes that through the skin (600 to 800 mL), lungs (400 to 600 mL), gastrointestinal tract (100 mL), and kidneys (1500 mL). Water lost through the skin and lungs is known as insensible loss because the individual is unaware that the water is being lost.

A nurse provides instructions to a client with type 1 diabetes mellitus about home care measures to treat hypoglycemia. The nurse determines that the client understands the instructions if which statement is made? a. I will eat six saltine crackers b. I will call the health care provider c. I will report to the emergency department d. I will take an additional dose of regular insulin

a.Hypoglycemia is the term used to describe a blood glucose level below 70 mg/dL. If hypoglycemia is suspected, the client should obtain a glucose reading immediately. The client must consume a substance that contains 10 to 15 g of carbohydrates — for instance, commercially prepared glucose tablets, six to 10 Life Savers or other hard candies, 4 teaspoons of sugar, four sugar cubes, 1 tablespoon of honey or syrup, a half-cup of fruit juice or regular (nondiet) soft drink, 8 oz of low-fat milk, six saltines, or three graham crackers. Administering regular insulin will lower the blood glucose. It is not necessary to notify the health care provider or to report to the emergency department for a single episode of hypoglycemia. The client should, however, contact the health care provider if hypoglycemia were to persist or hypoglycemic episodes were frequent.

6. The nurse is teaching a patient how to change their drainage bag. Which response demonstrates that the patient understands removal of the old pouch? A. "I should use a moist cloth to remove the old pouch and then dispose of it." B. "I should use a moist cloth to move the old pouch and wash it out and replace it." C. "I should use alcohol to remove the old pouch and then throw it out in the trash." D. "I should never use anything to remove the old pouch because it will increase the chance of infection."

A. The patient should be taught to use a moist cloth or adhesive remover to facilitate removal of the old pouch as this limits potential damage to the skin. Verbalization of this statement indicates the patient understood the information provided. Pouches should be discarded after use, not rinsed and reused.

The nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the client's record to correct the error. The nurse should take which action to correct the error? SATA 1. Documenting a late entry into the client's record 2. Draw 1 line through the error, initialing it and dating it 3. Trying to erase the error for space to write in the correct data 4. Using whiteout to delete the error to write in the correct data 5. Write a concise statement to explain why the correction was needed 6. Document the correct info and end with the nurse's signature and title

2, 6 If the nurse makes an error in narrative documentation, the nurse should follow agency policy. This includes drawing 1 line through the error, initialing and dating the line, and then documenting the correct information. A late entry is used to document additional information not remembered at the initial time of documentation, not to make a correction of an error. Documenting the correct information with the nurse's signature and title is correct. Erasing data from the client's record and the use of whiteout are prohibited. There is no need to write a statement to explain why the correction was necessary.

A nurse and an assistive personnel (AP) found an adult client on the bathroom floor who has a pulse but is unresponsive and not breathing. The nurse determines the AP is delivering an adequate number of rescue breaths if the AP delivers how many breaths per minute? 6 10 16 20

B. During cardiopulmonary resuscitation (CPR), the rescuer delivers 8 to 10 breaths per minute to the adult victim. Each rescue breath is delivered over 1 second at a rate of 1 breath every 6 to 8 seconds. Six, 16, and 20 breaths per minute are incorrect.

The nurse is caring for a client who has had acute pancreatitis. Which change best indicates the client is recovering from pancreatitis? a. An increased amylase level b. A decrease in the lipase level c. Active bowel sounds in all four quadrants d. Abdominal pain that is relieved by lying down

B. Pancreatitis is characterized by an increased amylase and lipase level, abdominal pain, even in the recumbent position. The bowel sounds can remain active. A decreased lipase level indicates the client is recovering.

Which are common components of an advance directive for healthcare? SATA a. Appointment of another person to make healthcare decisions if the client is unable b. Specific or general instructions about physical healthcare treatment c. The naming of individuals to whom personal possessions will be given in the event of death d. Specific or general instructions about mental or psychological healthcare treatment e. A section explaining the document is legal and cannot be changed once the client has signed it.

A, B, D Also known as a durable power of attorney, option A can be part of an advance directive. It names another person to make healthcare decisions if the individual is mentally or physically unable to do so. Decisions or preferences about physical healthcare treatment and the use or nonuse of a ventilator can be outlined in the advanced directive. Decisions or preferences about mental or psychological healthcare treatment such as the use or nonuse of electrical shock treatment can be outline in an advanced directive. An individual can change their advance directive if the individual has the mental capacity to do so and is acting freely without pressure from another person or agency.

The nurse is teaching a client about the late signs of testicular cancer. The nurse recognizes the client understands the teaching if the client selects which signs of late testicular cancer? Select all that apply. a. Bone pain b. Fluid in the scrotum c. Painless testicular swelling d. Presence of abdominal masses e. Dragging sensation in the scrotum

A, B, D Testicular cancer arises from germinal epithelium from the sperm-producing germ cells or from nongerminal epithelium from other structures in the testicles. It may metastasize to the lung, liver, bone, and the adrenal glands. Early detection is made through routine testicular self-examination. The client may experience painless testicular swelling or a dragging sensation in the scrotum as early signs. Late signs, indicating metastasis, include testicular pain, back or bone pain, fluid in the scrotum, and respiratory symptoms; palpable lymphadenopathy, abdominal masses, and gynecomastia may also denote metastasis.

Which behavior(s) are commonly associated with caregiver role strain? SATA a. Reports of physical symptoms such as frequent headaches b. Feels a sadness that will not go away c. Allows other family members to provide care one day per week d. frequently forgets to change care recipient's soiled linens e. Withdraws from family and friends

A, B, D, E Caregivers who are experiencing stress often withdraw from family, friends, and social activities. Abuse or neglect is sometimes associated with increased caregiver stress. Mental health issues, including depression, are prevalent among caregivers of clients with chronic illnesses. Reports of frequent physical symptoms are a sign of role strain as well. Allowing other family members to provide care is therapeutic to caregiving and does not indicate increased stress.

The nurse is reviewing the prescriptions for a client admitted with a diagnosis of idiopathic autoimmune hemolytic anemia. The nurse prepares the client for treatment of this disorder, understanding that which mat be recommended? SATA a. Tranfusions b. Splenectomy c. Radiation therapy d. Corticosteroid medication e. Immunosuppressive agents

A, B, D, E Idiopathic autoimmune hemolytic anemia is a decrease in the number of RBC due to increased destruction by the body's immune system. It is an acquired disease that occurs when antibodies form against a person's own RBC. In the idiopathic form, the cause is unknown. It is treated with corticosteroids. Other treatments may include transfusion, splenectomy, and occasionally, immunosuppressive medications.

Which clinical manifestations of hypokalemia will the nurse expect to note while assessing a client? Select all that apply. a. Weak peripheral pulses b. Orthostatic hypotension c. Decreased urine output d. An absence of deep tendon reflexes e. Decreased bowel sounds and constipation

A, B, D, E The clinical manifestations of hypokalemia include weak and irregular pulse, as well as orthostatic hypotension. The client also experiences deep tendon hyporeflexia, muscle weakness, leg cramps, and paresthesias. Bowel sounds are hypoactive, and the client may experience nausea, vomiting or constipation. Hypokalemia inhibits the ability of the kidneys to concentrate urine, leading to increased urine output.

The nurse is caring for a client with acute coronary syndrome. Which manifestations would lead the nurse to suspect that cardiogenic shock is developing? Select all that apply. a. BP of 88/60 mm Hg b. Pulmonary congestion c. Flushed, diaphoretic skin d. Heart rate of 58 beats/min e. Respiratory rate of 18 beats/min f. Urine output of 90 mL in the past 4 hours

A, B, F The manifestations of cardiogenic shock include tachycardia, tachypnea, a BP lower than 90 mm Hg systolic, pulmonary congestion, and urine output of less than 30 mL/hr. Additional manifestations include cool and clammy skin, poor peripheral pulses, tachypnea, disorientation, restlessness, and confusion, and chest discomfort.

Which tasks should be assigned to an LPN, rather than a UAP? SATA a. Check residual on a tube feeding for a child with a PEG tube b. Transport an infant with rotavirus to the treatment room for IV insertion c. Perform a straight catheterization for urine specimen collection d. Take the tympanic temperature of an infant e. Distribute a snack to a child with diabetes

A, C The UAP is not usually trained to perform an invasive procedure such as checking residual or sterile procedures such as catheterization. The UAP can safely be assigned to transport clients, take vital signs, and can distribute snacks BUT the UAP should not be assigned of selecting the snack.

Health care disparities are differences in patient access to or availability of appropriate health care services. Which factors could contribute to a patient experiencing health care disparity? a. Living in a rural area b. Obtaining a high school education c. Being underinsured d. Speaking a different language than most health care professionals e. Earning a middle-class income

A, C, D Many factors affect patient access to quality health care services, including geographic location, cultural variables, and resources. For example, living in a rural area far from quality health care facilities, being uninsured or underinsured, or experiencing a language barrier when seeking health care can all contribute to health care disparity.

The nurse is assessing a dark-skinned client for signs of anemia. The nurse should focus on assessment of which structures? SATA a. Lips b. Tongue c. Earlobes d. Conjunctiva e. Mucous membranes

A, D, E Changes in skin color can be difficult to assess in the dark client. Color changes are most easily seen in areas of the body where pigmentation is not influenced by exposure to sunlight. The nurse should assess the lips, conjunctiva, and oral mucous membranes for signs of anemia.

Critical Care Access Hospitals are specially designated Health Care Organizations that must meet which of the following criteria? a. Maintain an annual average patient length of stay of no more than 96 acute inpatient hours b. Have no more than 50 inpatient beds c. Employ at least 20 physicians, nurses, UAPs, and other health care professionals d. Be located in a rural area at least 35 miles away from any other hospital e. Offer 24-hour, 7 day a week emergency care

A, D, E Critical Care Access Hospitals are specially designated Health Care Organizations that must meet the following criteria: Be located in a rural area at least 35 miles away from any hospital, have no more than 25 inpatient beds, maintain an annual average patient length of stay of no more than 96 acute inpatient hours, and offer 24/7 emergency care.

Which of the following are risk factors for Alzheimer's disease? SATA a. advancing age b. increased serum calcium c. use of aluminum products d. father and uncle with alzheimers e. previous head trauma

A, D, E The risk for developing Alzheimers disease increases as age advances. A family history is a known risk factor, as well as a history of repeated head trauma.

A client fell while attempting to transfer to the bedside commode without calling for assistance. In responding to the situation, which tasks can be delegated to the UAP? SATA a. Place covers around the resident for warmth if needed b. Ask the resident to describe what happened c. Contact a family member to report the fall d. Observe for any injury to the head or neck e. Obtain non-skid socks from the supply room and apply them to the client

A, E After completing initial assessment, the nurse can assign the UAP to perform comfort measures. Non-skid socks may prevent a future fall and this task can be delegated by the RN. The UAP cannot communicate with the family about injury or assess the client for injury.

A nurse is reviewing the medical records of the clients hospitalized on the medical-surgical unit. Which of the clients would the nurse identify as being at risk for respiratory alkalosis? Select all that apply. a. A client with a fever b. A client with bronchitis c. A client with postoperative atelectasis d A client with chronic obstructive pulmonary disease (COPD) e. A client who is anxious and worried about pending biopsy results

A, E Respiratory alkalosis is caused by conditions that result in overstimulation of respiratory status. These conditions include those that involve increased metabolism (e.g., fever, hyperventilation, hypoxia, hysteria, overventilation by mechanical ventilators, pain). Any condition that causes obstruction of the airway or depresses respiratory status (bronchitis, atelectasis, COPD) can cause respiratory acidosis.

Which tasks can be delegated to a UAP? SATA a. Enter obtained vital signs in the medical record b. Ask the client to describe his pain and discomfort c. Collect the client's psychosocial history d. Identify potential nursing diagnoses for the plan of care e. Place a bedside commode in the room

A, E. The UAP can bring durable medical equipment into a room and can take vitals.

A nurse provides home care instructions to a client who has been hospitalized for acute diverticular disease. Which instruction is a priority for the nurse to give the client to prevent the occurrence of an acute episode? a. Avoid lifting, straining, or coughing. b. Restrict fluid intake to 1000 mL daily. c. Avoid foods that contain whole grains. d. Restrict consumption of fruits and vegetables.

A. Acute diverticular disease is managed by means of the prevention of constipation through the use of a high-fiber diet containing fruits, vegetables, and whole grains. The client is instructed to increase fluid intake to 2500 to 3000 mL daily unless this is contraindicated. The client should also consume a small amount of bran daily, as prescribed, to increase stool mass and softness. The client should refrain from lifting, straining, coughing, or bending as a means of avoiding increased intraabdominal pressure.

The nurse should evaluate that defibrillation of a client was most successful if which observation was made? a. Arousable, sinus rhythm, BP 116/72 b. Nonarousable, sinus rhythm, BP 88/60 c. Arousable, marked bradycardia, BP 86/54 d. Nonarousable, supraventricular tachycardia, BP 122/60

A. After defibrillation, the client requires continuous monitoring of electrocardiographic rhythm, hemodynamic status, and neurological status. Respiratory and metabolic acidosis develop during ventricular fibrillation because of lack of respiration and cardiac output. These can cause cerebral and cardiopulmonary complications. Arousable status, adequate BP, and a sinus rhythm indicate successful response to defibrillation.

A client who has undergone vascular surgery of the legs suddenly complains of dyspnea and sharp chest pain. The nurse quickly checks the client and notes the presence of tachycardia on the cardiac monitor. Which action should the nurse take immediately? a. Contact the surgeon b. Contact the respiratory therapist c. Check the client's apical heart rate d. Check the client's peripheral pulses

A. Any complaint of sudden sharp chest or upper abdominal pain must be reported immediately to the surgeon. Pulmonary embolism is a serious postoperative complication that can cause sudden death. A clot or part of a clot breaks away from a vessel and travels through the heart and into the pulmonary circulation and may occlude a pulmonary vessel, resulting in a pulmonary embolism. Common signs/symptoms include dyspnea, sudden sharp chest or upper abdominal pain, tachypnea and tachycardia, anxiety, and cyanosis. A respiratory therapist may be needed during treatment, but contacting the therapist would not be the immediate action. There is no useful reason for checking the client's apical heart rate, because the client is attached to a cardiac monitor, which displays the heart rate. Likewise, there is no useful reason for checking the peripheral pulses.

Which action by the client indicates the need for further instruction on insulin administration? SATA a. Aspirating before administering the dose b. Using a 27-gauge needle to administer the insulin c. Administering rapid-acting insulin in the abdomen d. Holding the needle in place for several seconds after administering the insulin e. Identifying areas where 1 inch of subcutaneous fat can be pinched for insulin administration

A. Aspiration is not performed for insulin administration. The client would use a 27-gauge needle, and the abdomen is an appropriate location for administering rapid-acting insulins. The client would hold the needle in place for several seconds after administering the insulin. Appropriate locations to administer insulin are those where 1 inch of subcutaneous fat can be pinched.

A client arrives at the emergency department (ED) complaining of chest pain, and an MI is suspected. Laboratory studies indicate that the troponin T level is 0.4 ng/dL (0.4 mcg/L) and the troponin I is 2.0 ng/mL (2.0 mcg/L). On the basis of these findings, which action by the nurse is appropriate? a. Preparing to transfer the client to the coronary care unit b. Informing the client that he has sustained a massive heart attack c. Telling the client that there was no heart attack but simply angina d. Informing the client that the laboratory results are within their normal ranges

A. Because the troponin levels identified in the question are higher than normal, it is likely that the client has sustained an MI. The appropriate action in this situation is preparing the client for transfer to the coronary care unit. Increased amounts of troponins are released into the bloodstream when an infarction causes damage to the myocardium. The troponin T is usually less than 0.1 ng/dL, and a higher value is consistent with MI. The troponin I is usually lower than 0.6 ng/mL, and a value higher than 1.5 ng/mL is consistent with MI. Troponin levels increase as soon as 3 hours after myocardial injury; troponin I levels may remain increased for 7 to 10 days and troponin T levels for as long as 10 to 14 days. Telling the client that there was no heart attack, just angina, and letting the client know that the laboratory results are within their normal ranges are therefore both incorrect. It is inappropriate to tell a client that a "massive heart attack occurred".

The mother of a child with leukemia who has not had varicella (chickenpox) receives a telephone call from the school nurse, who tells her that one of her child's classmates has contracted chickenpox. Which instruction to the mother by the nurse is most appropriate? a. Contacting the child's pediatrician b. Monitoring her child closely for signs of infection c. Encouraging her child to wear a mask while in school d. Keeping her child out of school until the child with varicella recovers

A. Chickenpox can be deadly to the immunocompromised child, whose body may not be able to fight varicella adequately. If a child who has not had chickenpox is exposed to someone with varicella, the child should receive varicella zoster immune globulin within 96 hours of exposure. Therefore, the mother is advised to contact the child's pediatrician. It is unnecessary to keep the child out of school or to have the child wear a mask while in school. Although the mother should monitor her child for signs of infection, this is not the most appropriate instruction of those provided in the options.

3. The nurse arranges a nutrition consultation for an obese patient with a heavily exudative wound. The nurse should anticipate which recommendation? A. A nutritional supplement drink high in calories and protein B. A nutritional supplement drink low in calories and full of electrolytes C. A nutritional supplement drink high in calories, vitamins, and minerals D. A nutritional supplement drink low in calories and protein

A. Energy, in the form of calories and protein are needed to help with wound healing. Excess wound drainage contributes to protein depletion, which may compromise wound healing. Electrolytes may also be depleted by wound drainage and may need to be replaced, but a low-calorie diet and weight loss are not recommended during wound healing. A high-calorie supplement with vitamins and minerals may help would healing, but the patient still requires protein supplementation.

A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is restless and the pulse rate is increased. As the nurse continues the assessment, the client begins to vomit a copious amount of bright-red blood. The nurse should take which immediate action? a. Notify the surgeon b. Continue the assessment c. Check the client's blood pressure d. Obtain a flashlight, gauze, and a curved hemostat

A. Hemorrhage is a potential complication after tonsillectomy and adenoidectomy. If the client vomits a large amount of bright-red blood or the pulse rate increases and the patient is restless, the nurse must notify the surgeon immediately. The nurse should obtain a light, mirror, gauze, curved hemostat, and waste basin to facilitate examination of the surgical site. The nurse should also gather additional assessment data, but the surgeon must be contacted immediately.

Which response indicates improper follow-through on the part of a delegatee? a. Failure to report results and findings .b Failure to understand skills and abilities c. Failure to provide clear and concise directions d. Failure to cooperate with other team members

A. Improper follow-through on the part of a delegatee is a failure to report results and findings. Improper follow-through occurs the delegator does not understand the skills and abilities of the delegatee and does not provide clear and concise instructions. The lack of cooperation with team members may be improved by educating, guiding, and monitoring the delegatee.

The nurse has provided medication instructions to a client with an iron deficiency anemia who will be taking iron supplements. Which statement made by the client indicates an understanding of this medication? a. I need to increase my fluids b. I should eliminate fiber from my diet c. I need to take the medication with water before a meal d. I should be sure to chew the tablet thoroughly before swallowing it

A. Iron preparations can be very irritating to the stomach and are best taken between meals. Because iron supplements may be associated with constipation, the client should increase fluids and fiber in the diet to counteract this side effect of therapy. Iron preparations should be taken with a substance that is high in vitamin C to increase its absorption. The tablet is swallowed whole and not chewed.

A client has been given a diagnosis of multiple myeloma. Which result does the nurse reviewing the client's laboratory findings recognize as being specifically related to this diagnosis? a. Increased calcium level b. Decreased blood urea nitrogen (BUN) c. Increased white blood cell (WBC) count d. Decreased number of plasma cells in the bone marrow

A. Multiple myeloma is characterized by hypercalcemia, anemia, increased BUN, and an increased number of plasma cells in the bone marrow. Hypercalcemia is a result of the release of calcium from deteriorating bone tissue. An increased WBC count may or may not be present and is not specifically related to this disease.

5. Skin barriers come in multiple forms and may be used individually or in combination with one another. What is the primary purpose of a skin barrier? A. Prevent moisture-associated dermatitis B. Prevent frequent dressing changes C. Prevent moisture-associated infections D. Prevent frequent protein depletion

A. Skin barriers serve primarily to provide a layer of protection to the intact periwound and surrounding skin of the wound, thus avoiding moisture-associated dermatitis or denudation. They can also help absorptive dressings or pouches remain in place longer, thereby decreasing dressing change frequently. Excess moisture in a wound that is not effectively wicked away may increase risk of infection, but the use of skin barriers does not directly affect this process. Heavy wound exudate contributes to protein loss, but the use of skin barriers does not directly affect this process.

Which action by the nurse will best facilitate adherence to the treatment regimen for a client with a chronic illness? a. Arranging for home health care b. Focusing on managing a single illness at a time c. Communicating with one provider only to avoid confusion of the client d. Allowing the client to teach a support person about their treatment regimen

A. Nursing follow-up visits are important in promoting health for individuals with chronic illness; therefore, arranging for home health care is an important strategy. Focusing on a single illness does not effectively manage an individual with multiple chronic diseases—rather, the "big picture" needs to be understood in managing these clients. Interprofessional collaboration is important in safely managing individuals with chronic diseases, and often involves consulting with specialist providers. Nurses play a key role in facilitating communication between providers and specialists. Inclusion of the client and support person(s) in health care decisions helps increase adherence to a complex health care regimen, and the nurse should be the facilitator of this communication

A nurse is having dinner with a friend at a restaurant when a woman at a nearby table suddenly clutches her neck with both hands. Suspecting that the woman is choking, the nurse quickly approaches her. What action should the nurse take first? a. Asking the woman whether she can speak b. Helping the woman into a supine position c. Striking the woman's back forcefully with a fist d. Opening the woman's airway and attempting to perform ventilation

A. One sign of airway obstruction is the universal signal for choking (the victim clutches the neck with one or both hands). When someone appears to be choking, the first action is to ask the victim, "Are you choking?" or "Can you speak?" If the victim can cough forcefully or speak, the rescuer need not intervene and should monitor the victim. The victim will not be able to speak or cough if he or she is choking. If an obstruction is present, the rescuer administers the abdominal thrust maneuver and notifies the emergency response system. Opening the woman's airway and attempting to perform ventilation and placing the woman in a supine position are both steps of the abdominal thrust maneuver for an unconscious victim. Striking the woman on the back forcefully with a fist is an incorrect action, can be harmful, and is not a component of the abdominal thrust maneuver.

The nurse provides safety instructions to a client who will be using oxygen at home. Which statement by the client indicates a need for further teaching? a. "I can turn my oxygen up higher if I have trouble breathing." b. "I'll hang an 'Oxygen in Use' sign in the window near my front door." c. "I'll make sure that the oxygen cylinder is secured so that it won't fall over." d. "I need to stay at least 10 feet away from any open flame, like a burning candle, when I'm using my oxygen."

A. Oxygen is a medication and should not be adjusted without a primary health care provider's prescription. If the client experiences trouble breathing, the primary health care provider should be contacted. The client should place an "Oxygen in Use" sign in the window of the home, should ensure that the oxygen cylinder is secure, and needs to stay at least 10 feet away from any open flame.

The patient asks why a Penrose drain is in place. Which response by the nurse provides the best explanation? A. "The drain prevents the accumulation of excessive fluid that can lead to complications such an infection. B. "The drain is in place so that we can monitor the color of the drainage in case you develop an infection." C. "Unfortunately you had complications from your surgery and we need to drain the excess fluid." D. "Your surgeon prefers to leave Penrose drains in after this type of procedure."

A. Penrose drains are left in place to prevent the accumulation of excessive amounts of fluid that can lead to complications such as infection, decreased tissue perfusion, and impaired healing. Wound exudate is a normal by-product of the healing process. The presence of a drain does not necessarily indicate any kind of complication.

The patient has a Penrose drain in a surgical wound. The nurse knows that this drain is promoting healing by which action? A. Using passive drainage to prevent an accumulation of excess fluid B. Using suction drainage to remove excess fluid C. Using active drainage to prevent an accumulation of excess fluid D. Using vacuum drainage to remove excess fluid

A. Penrose drains work passively, relying on a pressure gradient, capillary action, and gravity to drain excess fluid from a wound. Active drains sue suction or vacuum negative pressure to remove fluid from a wound.

A client reports for a scheduled EEG. Which statement by the client indicates a need for additional preparation? a. I didn't shampoo my hair b. I ate breakfast this morning c. I did not take my anticonvulsant today d. It was hard not to drink coffee this morning, but I knew that I couldnt so i didnt.

A. Pre-procedure care for EEG involves client teaching about the procedure, ensuring that the client's hair has been freshly shampooed, and providing a light meal and fluids to prevent hypoglycemia, which could alter brain waves. Medications such as antidepressants, tranquilizers, and anticonvulsants are withheld for 24 to 48 hours before the procedure as prescribed. Stimulants such as coffee, tea, cola, alcohol, and cigarettes are also withheld.

Which instruction would help ensure the maximum therapeutic response when a patient self-administers ear medication? A. Remain in the lateral position (unaffected side) for a few minutes after instillation. B. Bring refrigerated ear medication to room temperature before instillation. C. Place a cotton ball firmly into the ear canal for 30 minutes after instillation. D. Apply a warm, damp washcloth to the external ear to remove any crusted discharge.

A. Remaining in the lateral position for a few minutes after instillation allows the medication to remain in contact with the tissues of the ear canal. Although it is appropriate to bring refrigerated ear medication to room temperature, doing so has no effect on therapeutic response. A cotton ball is gently inserted into the ear canal for 15 minutes, and ONLY when ordered.

A client hospitalized with prostate cancer is undergoing chemotherapy. While the nurse is helping the client with hygiene care, the client suddenly complains of severe back pain and numbness of the lower extremities. The nurse should take which immediate action? a. Contact the health care provider b. Administer pain medication c. Take the client's blood pressure d. Allow the client to rest and complete the bath later

A. Spinal cord compression and damage occur when a tumor enters the spinal cord or when the vertebral column collapses as a result of tumor entry. A tumor may begin in the spinal cord or spread from another area of the body, such as the prostate gland, lung, breast, or colon. Spinal cord compression causes back pain, usually before neurological deficits occur. Such deficits include tingling; numbness; loss of urethral, vaginal, and rectal sensation; and muscle weakness. If paralysis occurs, it is usually permanent. The nurse would contact the health care provider to report the occurrence. Although pain medication may be needed, it is most appropriate to contact the health care provider so that a thorough evaluation of the client's pain may be conducted. Allowing the client to rest and completing the bath at a later time may be necessary, but this action delays necessary intervention. The nurse would expect the client's blood pressure to be increased if the client is in pain, and although the blood pressure would be measured, the most appropriate action is to contact the health care provider about the sudden occurrence of severe pain.

A client is undergoing high-dose warfarin sodium therapy. The nurse checks the client's laboratory results and sees that the INR is 3.5. Which determination should the nurse make on the basis of this result? a. This value is expected. b. The dose of warfarin sodium needs to be adjusted. c. The primary health care provider should be notified, because the INR is too low. d. The primary health care provider should be notified, because the INR is too high.

A. The INR should be maintained at 2.0 to 3.0 in a client undergoing standard warfarin sodium therapy and 3.0 to 4.5 in a client undergoing high-dose therapy. A value of 3.5 is therefore expected.

A nurse checks the laboratory test results of a client who is undergoing chemotherapy and notes that the client's platelet count is 90,000 cells/mm. In light of this result, which action by the nurse is appropriate? a. Instituting bleeding precautions b. Instituting neutropenic precautions c. Informing the client that the test result is normal d. Educating the client about the importance of increasing iron in the diet

A. The appropriate action by the nurse would be to institute bleeding precautions for the client. Platelets are produced by the bone marrow to function in hemostasis. The normal platelet count ranges from 150,000 to 400,000 cells/mm. A decrease in the number of platelets puts the client at risk for bleeding. Neutropenic precautions are instituted when the WBC count is low because the client is at risk for infection. Increasing dietary iron would not help increase platelet formation.

A nurse is reviewing laboratory results for a newly admitted client. Which serum lab result does the nurse document as abnormal? a. Serum creatinine 0.2 mg/dL (17.6 μmol/L) b. Prothrombin time 11.0 to 12.5 seconds; 85% to 100% c. Sodium cholesterol d. Serum sodium (NA) 136 to 145 mEq/L or 136/145 mmol/L (SI units)

A. The normal serum creatinine level ranges from 0.6 to 1.3 mg/dL (53-115 μmol/L). A result of 0.2 mg/dL (17.6 μmol/L) represents a low value; the other incorrect options are normal values.

7. The nurse is changing a drainage bag on a patient. Upon inspection of the wound edges, the nurse observes that the skin is dark and flaking. Which intervention is the best next step? A. Notify the practitioner about the change in the patient's skin. B. Apply a barrier cream to the dark skin to keep it clean. C. Continue the change as before, documenting the skin condition in the record. D. Cover the edges in dry dressing and allow the wound edges to dry.

A. The nurse should notify the practitioner about the change in the patient's skin. Dark, flaking skin could be a sign that the tissue may be necrotic and may need debridement by the practitioner. The other options do not address the potential complication.

A nurse checking the laboratory results of a client with renal calculi notes that the creatinine level is 4.5 mg/dL (398 mcmol/L) and the BUN is 45 mg/dL (16.1 mmol/L). In light of these results, which action should the nurse take first? a. Contacting the primary health care provider to report the results b. Placing the results in the client's medical record c. Instructing the client to decrease dietary intake of protein d. Letting the client know that the results are normal, indicating that there is no kidney damage

A. The nurse would place the results in the client's medical record but would contact the primary health care provider first. The normal creatinine level ranges from 0.6 to 1.3 mg/dL, and the normal BUN reading ranges from 8 to 25 mg/dL. Because the client's laboratory values are higher than normal, the nurse should contact the primary health care provider and report the results. Decreasing the client's intake of protein is not an appropriate action unless this type of diet is prescribed.

A client presents to the emergency department with upper GI bleeding and is in moderate distress. In planning care, what is the priority nursing action for this client? a. Assessment of vital signs b. Completion of abdominal exam c. Insertion of the prescribed NG tube d. Thorough investigation of precipitating events

A. The priority nursing action is to assess the vital signs. This would provide information about the amount of blood loss that has occurred and provide a baseline by which to monitor the progress of treatment. The client may be unable to provide subjective data until the immediate physical needs are met. Although an abdominal examination and an assessment of the precipitating events may be necessary, these actions are not the priority. Insertion of a nasogastric tube is not the priority and will require a primary health care provider's prescription; in addition, the vital signs should be checked before performing this procedure.

Which client should be assigned to a staff RN, rather than a staff LPN? a. A 2-year-old with diabetes who has been vomiting all night b. A 4-year-old with a rash creating a slapped appearance on the face c. An infant boy with a fever of 101 who has been pulling on his ear d. A 2-month-old with a pulse of 140 who needs routine immunizations

A. This child, who may be hyperglycemia and dehydrated, requires the highest of nursing expertise for assessment and care. Option B is probably fifth disease, and does not require RN expertise as much as option A. Option C is most likely an ear infection, and is not as immediate as another option. Option D shows a normal pulse rate and does not require expertise of the RN.

A nurse manager in a pediatric facility is approached by a staff RN regarding several telephone messages from clients. Which situation requires the most immediate follow-up by the nurse? a. A mother expressing concern that her baby refuses to take formula, stating the infant's "soft spot" seems more sunken b. A grandmother asking for immunization information, stating her 5-year-old grandchild has never been immunized. c. A parent calling to ask if it is necessary to keep her child with a sore throat home from school d. A mother stating that she sent her child to school but is concerned about his eye, which is pink and painful

A. This situation indicates the infant is probably dehydrated, and dehydration can lead to a rapid loss of physiologic integrity in an infant. The nurse needs to respond to this first.

What is the best way to minimize discomfort caused by the instillation of ear medication? A. Warm the eardrops to room temperature before instillation. B. Wear treatment gloves during the application process. C. Ask the patient to sit while introducing the medication. D. Use a cotton-tipped applicator to remove any visible cerumen.

A. Warming the medication to room temperature minimizes the risk if vertigo and/or nausea from instillation of the eardrops. Although it is appropriate to wear gloves if the patient has ear drainage, doing so does not minimize the patient's discomfort. Instilling the medication with the patient in a sitting position will have little or no effect on the post-discomfort.

A nurse arrives at the home of a neighbor, who called for help when her husband fell off a ladder during a seizure. The neighbor tells the nurse that she called 911 and that an ambulance is on the way. The nurse assesses the man and determines that he is unconscious without a pulse. After performing 30 chest compressions, the nurse prepares to deliver rescue breaths and uses which method to open the man's airway? The jaw-thrust maneuver The head tilt-chin left method Lifting the chin and using the fingers to open the mouth Placing the fingers in the victim's mouth, using a hooking action

A. When injury to the head, neck, or spinal cord is suspected, the jaw-thrust maneuver is used to open the airway. This maneuver maintains proper head and neck alignment, thereby reducing the risk of further damage. The head tilt-chin lift method is the preferred method of opening the victim's airway and is used if no head, neck, or spinal cord injury is suspected. Lifting the chin and using the fingers to open the mouth and placing the fingers in the victim's mouth with the use of a hooking action are incorrect methods that would not effectively open the airway. Additionally, the nurse would not place fingers in the mouth of a client who has had a seizure.

Which intervention would the nurse include in the plan of care for a client being treated with lithium for bipolar disorder? Select all that apply. One, some, or all responses may be correct. 1 Monitoring blood levels 2 Assessing for slurred speech 3 Evaluating intake and output 4 Instructing the client to limit caffeine intake 5 Advising the client to use reliable birth control

ALL. Lithium has a narrow therapeutic range, and the nurse would regularly monitor the client's lithium levels. Slurred speech can be a sign of toxicity in clients taking lithium. Clients taking lithium long term often have polyuria (50% to 70%), which the nurse can monitor for by assessing intake and output. Caffeine can alter the medication's effectiveness. Clients do not need to completely eliminate caffeine, but they would be instructed to limit their intake. Lithium is a category D pregnancy risk medication; it may cause fetal harm during the first trimester of pregnancy. Clients who could become pregnant should be informed of the risks and advised to use reliable birth control to prevent pregnancy.

Which instructions should the nurse include in the discharge teaching plan of a male client who has had an MI and has a new prescription for nitroglycerin? SATA a. Keep the medication in your pocket so that it can be accessed quickly b. Call 911 if chest pain is not relieved after one nitroglycerin c. Store the medication in its original container and protect it from light d. Activate the emergency medical system after 3 doses of medication e. Do not use within 1 hour of taking sildenafil (Viagra)

B, C Emergency action should be taken if chest pain is not relieved after one nitroglycerin tablet. The medication should be kept in the original container to protect from light. Keeping the medicine in the shirt pocket provides an environment that is too warm. The newest guidelines recommend calling 911 after one nitroglycerin if chest pain is not relieved. Nitro and other nitrates should NEVER be taken with sildenafil.

Which of the following prescriptions would the nurse question for a client experiencing an acute hypertensive crisis? Select all that apply. a. Administering 40 mg furesomide IV b. Checking the BP and heart rate every 4 hour c. Keeping the client in a supine position at all times d. Administering oxygen e. Administering IV antihypertensives to maintain a diastolic blood pressure under 90 mm Hg

B, C Hypertensive crisis is an acute and life-threatening condition requiring immediate reduction in the blood pressure. Target organ damage (i.e., brain, heart, kidneys, retinas) may occur quickly, with death occurring as a result of stroke, renal failure, or cardiac disease. Oxygen is administered as prescribed. The head of the bed should be elevated. Diuretics and antihypertensives are administered to rapidly lower the BP to a non-life-threatening level. The BP should be checked every 5 to 15 minutes until it is within parameters, then no less frequently than every 30 minutes.

The patient's postoperative wound drain was removed yesterday. Today, the nurse notices increased drainage on the dressing, pain at the wound site, and a low-grade fever. What should the nurse conclude from these findings? A. These changes in wound drainage require replacement of the wound drain. B. These signs and symptoms suggest an infection at the wound site. C. These changes indicate a normal postoperative wound healing process. D. These signs and symptoms suggest that treatment will require antibiotics to support wound healing.

B. Signs if wound infection should be monitored after a wound drain is removed. Fever, elevated WBC count, pain; increased tenderness, and a change in the amount, color, or odor of the wound drainage suggest an infection.

A nurse provides information to a client who has undergone a Billroth II procedure about dietary measures to prevent dumping syndrome. Which menu choices by the client indicates an understanding of the teaching? Select all that apply. a. Milk b. Rice c. Eggs d. Beef

B, C, D Dumping syndrome, a complication of gastric resection, is the rapid emptying of gastric contents into the small intestine. To prevent or minimize dumping syndrome, the client is instructed to eat a high-protein, high-fat, low-carbohydrate diet; to eat small, frequent meals; to avoid drinking fluids with meals; avoid milk, sweets, and other foods containing sugars; and to lie down after meals. Rice, eggs, and beef are all acceptable foods.

After receiving report from the night shift charge nurse, which activities should Alex, the day shift charge nurse anticipate completing during the first hour? a. Distribute breakfast trays as they arrive on the unit b. Assign clients to staff nurses according to acuity c. Identify tasks needed for assignment and delegation d. Reconcile a client's medication prescriptions e. Inspect the code cart equipment and supplies f. Delegate tasks to UAP

B, C, E, F Delegating tasks to UAPs for the day is a charge nurse action that should be performed during the first hour of the shift to make good use of unit personnel resources. Inspecting the code cart is a charge nurse action that must be performed during the first hour to ensure that emergency equipment is available and functional. The charge nurse should first identify the tasks needed for assignment and delegation during the first hours of the shift. Making client assignments is a charge nurse action needed within the first hour. Distributing breakfast trays should be delegated to UAPs. Medication reconciliation is not required during the first hour of a shift, but should be performed after client admission to the hospital ASAP.

The nurse is reviewing the manual of disaster preparedness and response for the annual hospital disaster drill. The nurse reads that which are functions of the American Red Cross as opposed to FEMA in the US? SATA a. Provide monetary relief b. Provide crisis counseling c. Identify and train personnel d. Issue presidential declarations e. Deploy National Guard troops f. Handle inquiries from families

B, C, F In general, the ARC provides support to individuals in a disaster, whereas FEMA deals with regional responses to disasters, such as issuing presidential declarations, providing monetary relief, and deploying national guard. The ARC has been given authority by the government to identify and train personnel for a disaster and provide disaster relief, including crisis counseling, operating shelters, and handling family inquiries.

A community health nurse is preparing a poster for an educational session for a group of women with whom she will be discussing the risk factors for breast cancer. Which factors increase the risk for breast cancer and should be listed on the poster? Select all that apply. a. Multiparity b. Early menarche c. Early menopause d. Family history of breast cancer e. Exposure of the chest to high-dose radiation f. Previous cancer of the breast, uterus, or ovaries

B, D, E, F Risk factors for breast cancer include family history; age; early or late menarche; late menopause; previous cancer of the breast, uterus, or ovaries; nulliparity or late first birth; exposure of the chest to high-dose radiation.

The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which instruction to the mother? a. Feed the newborn less frequently b. Continue to breast-feed every 2-4 hours c. Switch to bottle-feeding the infant for 2 weeks d. Stop breast-feeding and switch to bottle-feeding permanently

B. Hyperbilirubinemia is an elevated serum bilirubin level. At any serum bilirubin level, the appearance of jaundice during the first day of life indicates a pathological process. Early and frequent feeding hastens the excretion of bilirubin. Breast-feeding should be initiated within 2 hours after birth and every 2 to 4 hours thereafter. The infant should not be fed less frequently. Switching to bottle-feeding for 2 weeks or stopping breast-feeding permanently is unnecessary.

A nurse provides self-care instructions to a client who has had a permanent pacemaker inserted. Which statements by the client indicate a need for further instruction? Select all that apply. a. "I'll start keeping a pacemaker identification card in my wallet." b. "I can expect some swelling and drainage from the pacemaker insertion site." c. "I need to call the doctor if I have any weakness, dizziness, or shortness of breath." d. "I need to let all my health care providers know that I've had this pacemaker inserted." e. "I don't need to worry about airport security scanners, because the pacemaker won't be affected by them at all."

B, E If the client notes any fever or redness, swelling, or drainage from the insertion site, the health care provider should be notified; these signs could indicate the presence of infection. The client is also instructed to inform airport security of the pacemaker, because it may set off security devices. Notifying all health care providers of the insertion of the pacemaker, carrying an identification card, and notifying the health care provider of weakness, dizziness, or shortness of breath are all correct actions.

A nurse is reviewing the medical records of the assigned clients. Which of them are at risk of metabolic alkalosis? Select all that apply. a. A client with COPD b. A client with heart failure who is receiving large doses of a diuretic c. A client with malnutrition who will be started on parenteral nutrition d. A client with rheumatoid arthritis who is receiving high doses of acetylsalicylic acid (aspirin) e. A client who has just undergone surgery and has a nasogastric tube that is attached to intermittent suction

B, E Metabolic alkalosis may occur when excessive amounts of acid substance and hydrogen ions are lost from the body (e.g., through gastric suctioning or the use of diuretics). The client with COPD is at risk for respiratory acidosis. The client with malnutrition and the client taking high doses of acetylsalicylic acid (aspirin) are at risk for metabolic acidosis.

A nurse is preparing a list of instructions regarding stoma and laryngectomy care to a client who has undergone laryngectomy. Which instructions should be included in the list? Select all that apply. a. Restrict fluid intake. b. Obtain a medical alert bracelet. c. Keep humidity in the home low. d. Avoid wearing high-collared clothing. e. Prevent debris from entering the stoma. f. Avoid swimming and use care when showering.

B, E, F The nurse should teach the client how to care for the stoma, tailoring the instructions to the type of laryngectomy that has been performed. Most interventions focus on protection of the stoma and the prevention of infection. The client is instructed to avoid swimming and to use care when showering, to avoid exposure to people with infections, to prevent debris from entering the stoma, and to obtain a medical alert bracelet. Additional interventions include wearing a stoma guard or high-collared clothing to cover the stoma, increasing humidity in the home, and increasing fluid intake to 3000 mL/day to keep secretions thin. TEST-TAKING ST

The nurse is explaining the different types of drains to a nursing student. Which statement by the nursing student demonstrates understanding of the different types of drains? A. "A Penrose drain is a type of active drain." B. "Active drains use suction to removed fluid from a wound." C. "Active drains are dependent on a pressure gradient or gravity to draw fluid out of the wound." D. "Passive drains require a pressure gradient, with the pressure inside the wound to be lower than the pressure outside the wound."

B. Active drains use suction or vacuum to remove fluid from a wound. This may be in the form of vacuum suction, or through the use of suction within the drain itself, as in a Jackson-Pratt. A Penrose drain is a passive type, requiring a pressure gradient, gravity, or capillary action. For a passive drain to work, the pressure inside the wound must be higher than the pressure outside.

A client who was exposed to cold for a prolonged period is brought to the emergency department. The nurse, conducting an assessment of the client, notes acute frostbite of the fingers of the left hand. Which action should the nurse take immediately? a. Placing the client's fingers in cold water for 15 to 20 minutes b. Placing the client's fingers in warm water for 15 to 20 minutes c. Placing the client's fingers in warm water for 5 minutes, then debriding any obvious blisters d. Placing the client's fingers in cold water for 10 minutes and then warm water for 10 minutes and continuing this pattern for 1 hour

B. Acute frostbite is treated with rewarming the affected tissue in a water bath (98.6° to 104° F) for 15 to 20 minutes. Slow thawing or interrupted periods of warmth are avoided because they may contribute to cell damage. After thawing, the extremity is left exposed to permit monitoring of local tissue changes. Blisters are left intact.

After instructing a patient in the self-administration of antibiotic eardrops, what must come first in the nurse's assessment? A. The patient's understanding of the medication's purpose B. The patient's hand grasp, strength, coordination, and ability to manipulate the applicator C. The patient's comprehension of the dosage instructions provided with the medication D. The patient's ability to recognize the signs of an allergic reaction to the medication

B. After demonstrating the technique for instilling the ear medication, the nurse must ensure that the patient is physically capable of safely self-administering the medication. This takes priority.

A nurse is conducting an assessment of a client who underwent partial gastrectomy 12 hours ago. On auscultating the abdomen, the nurse does not hear bowel sounds. What is the most appropriate action for the nurse to take? a. Contact the surgeon b. Document the findings c. Encourage the client to increase oral fluid intake d. Help the client walk and then check again for bowel sounds

B. An absence of bowel sounds 12 hours after surgery is an expected finding; the nurse would document the finding and continue assessing the client. After abdominal surgery, motility of the gastrointestinal tract is diminished and normal bowel tone and peristalsis may be faint or absent in all four abdominal quadrants. Motility normally resumes within 24 hours of surgery in the small intestine and within 3 to 5 days in the large intestine. It would not be necessary to contact the surgeon at this time. After partial gastrectomy, the client would be prohibited from eating or drinking and would have a nasogastric tube attached to suction. Encouraging the client to increase oral fluid intake is therefore incorrect. Ambulation will aid the restoration of normal gastrointestinal function but will not restore it immediately.

Which instruction should be given to a patient to ensure safety when self-applying an antibiotic ointment? A. It is not necessary to allow refrigerated eye medication to warm to room temperature before administration. B. Do not apply pressure directly to the eyeball when removing excess medication. C. When cleaning the eye before administration, gently wash from the outer to the inner canthus. D. Apply a warm, damp washcloth to the eye for several minutes to remove any crusted discharge.

B. Applying pressure to the eyeball may injure the eye. Eye medication should be at room temperature before administration. Washing from the outer to inner canthus could lead to infection. Applying a warm, damp washcloth to the eye to remove crusted discharge is appropriate but does not pertain to safety.

A nurse preparing to administer a tube feeding checks the nasogastric tube for placement and residual volume. The nurse determines that the tube is correctly placed but aspirates 275 mL of contents from the client's stomach. Which action by the nurse is appropriate? a. Administering half of the prescribed feeding b. Hold the feeding and notifying the primary health care provider of the volume of aspirate c. Maintaining the client in a high Fowler position while administering the feeding d. Removing the 275 mL of aspirate from the client's stomach and discarding it, then administering the current feeding

B. If a large volume of aspirate (250 mL or more) is obtained, the aspirate is returned to the client's stomach (unless it is abnormal), the feeding is withheld, and the primary health care provider is notified. A large volume of aspirate indicates delayed gastric emptying, which may contribute to gastric distension, esophageal reflux, and vomiting, all of which place the client at risk for aspiration. Returning aspirate to the client prevents excessive loss of electrolytes.

During drain removal, the nurse meets resistance. What should the nurse do? A. Continue with the procedure, tugging firmly on the drain to loosen it B. Stop the procedure and inform the practitioner C. Instruct the patient to take a deep breath and continue pulling gently D. Stop and ask a colleague to assist with the procedure

B. If resistance is felt during drain removal, the nurse should stop the procedure and inform the practitioner. Resistance suggests a complication, such as tissue adhering to the drain. The nurse should not attempt to remove a drain with firm pressure. Asking the patient to breathe deeply may decrease discomfort, however, the nurse should not forcefully remove it.

The nurse provides instructions to a client with type 1 diabetes mellitus with regard to foot care. The nurse determines there is a need for further teaching if the client makes which statement? a. I will inspect my feet daily. b. I will walk barefoot only at home. c. I will wash my feet with warm water and a mild soap. d. I will check my shoes for foreign objects before putting them on.

B. In clients with diabetes mellitus, minor foot problems may progress to major problems, in some cases severe enough to necessitate amputation. Many foot problems can be prevented with proper foot care. The client is instructed not to walk barefoot, even at home. Inspecting the feet daily, using warm water and a mild soap to wash the feet, and checking shoes for foreign objects before putting them on are all appropriate foot care measures for the diabetic client. The client should also avoid thermal injuries from hot water, heating pads, and baths; prevent moisture from accumulating between the toes; wear socks to keep the feet warm and change them daily; and trim toenails straight across and smooth nails with an emery board.

When administering an intradermal injection, which outcome would require the nurse to withdraw the needle and begin again? A. Aspiration of blood prior to injecting the medication B. Inability to feel resistance when injecting the medication C. Formation of a 6-mm bleb at the injection site D. Appearance of a lesion resembling a mosquito bite at the injection site

B. Lack of resistance as the intradermal medication is injected indicates that the needle is not in the dermal layer and must be repeated.

When obtaining assessment data from a client with a microcytic normochromic anemia, which should the nurse question the client about? a. Folic acid intake b. Dietary intake of iron c. A history of gastric surgery d. A history of sickle cell anemia

B. Microcytic normochromic anemia involves presence of small, pale-colored red blood cells. Causes are iron deficiency anemia, thalassemia, and lead poisoning. Folic acid deficiency is caused by macrocytic normochromic cells; these are large RBC. Gastric surgery can result in vitamin B12 deficiency. Sickle cell anemia results in sickled cells and erythrocyte destruction.

The nurse is monitoring a client with renal failure who is at risk for fluid volume excess. Which assessment finding is indicative of this fluid imbalance? a. Flat neck veins b. Increased blood pressure c. Poor skin turgor with tenting d. Diminished peripheral pulses

B. Signs of fluid volume excess include a bounding, rapid pulse; increased blood pressure and respiratory rate; dyspnea; crackles on auscultation of the lungs; pitting edema; distended neck and hand veins; and altered level of consciousness. Flat neck veins, poor skin turgor with tenting, and diminished peripheral pulses are signs of a fluid-volume deficit.

The nurse is preparing to administer 1 mg of hydromorphone, a schedule II opioid. The medication is available in a premeasured syringe of 2 mg/mL. Which action is correct? a. Return the unused portion of the medication to the pharmacy b. Ask a second nurse to witness disposal of the unused portion c. Administer the 1 mg dose and save the remainder for the next dose d. Administer the 1 mg dose and discard the unused portion.

B. The Controlled Substances Act requires the nurse to have a second nurse witness disposal of unused scheduled medications. Both nurses will document on the required form. Unused portions are not saved or reused.

The nurse is reviewing the diagnostic tests performed in an adult with a connective tissue disorder. The erythrocyte sedimentation rate (ESR) is reported as 35 mm/hr (35 mm/hr). How should the nurse interpret this finding? a. Normal b. Indicating mild inflammation c. Indicating severe inflammation d. Indicating moderate inflammation

B. The ESR blood test confirms the presence of inflammation or infection in the body. The normal ESR range is less than or equal to 15 in a male and less than or equal to 20 in a female. Generally, an ESR value of 30-40 indicates mild inflammation, 40-70 indicates moderate inflammation, and 70-150 indicates severe inflammation.

A primary health care provider prescribes that the ammonia level be tested in a client with hepatic cirrhosis. The nurse transcribes the prescription and schedules the test for the next morning. Which appropriate action should the nurse take in preparation for the test? a. Requesting a liquid breakfast for the client on the morning of the test b. Imposing NPO status for the client starting 10 hours before the test c. Asking the dietary department to send an early breakfast to the client on the morning of the test d. Instructing the client to eat a high-fat snack at bedtime on the evening before the test and again on the morning of the test

B. The client must fast for 8 to 10 hours, except for water, and refrain from smoking for 8 to 10 hours before the test, because smoking increases the ammonia level. Ammonia, a byproduct of protein catabolism, is created mainly by bacteria acting on proteins present in the gut. Ammonia is metabolized by the liver and excreted by the kidneys as urea. An increased level resulting from hepatic dysfunction may lead to encephalopathy. In the incorrect options, the client is being allowed to consume fluids other than water and to eat.

The nurse provides information to the client about measures to treat gastroesophageal reflux disease (GERD). Which statement by the client indicates the need for further teaching? a. "I should stop drinking caffeinated coffee." b. "I should lie down for at least an hour after I eat." c. "I should prop up the head of my bed." d. "I shouldn't eat or drink anything for 2 hours before bedtime."

B. The client with GERD should avoid foods and positioning that decrease lower esophageal sphincter pressure or cause esophageal irritation. The client should consume a low-fat, high-fiber diet in small, frequent meals; minimize the amount of liquids drunk at mealtimes; and avoid reclining for 1 hour after eating; The client should also avoid caffeine, tobacco, and carbonated beverages; avoid eating and drinking 2 hours before bedtime; avoid wearing tight clothes; and elevate the head of the bed on 6- to 8-inch blocks.

A nurse is monitoring a client with emphysema in whom respiratory acidosis has developed. Which clinical manifestation of this acid-base imbalance would the nurse expect to note? a. pH of 7.50 b. Potassium level of 5.5 mEq/L (5.5 mmol/L) c. Complaints of paresthesias by the client d. Decreased rate and depth of respirations

B. The normal potassium level is 3.5 to 5.1 mEq/L. In respiratory acidosis, potassium moves out of the cells, producing hyperkalemia. The normal pH is 7.35 to 7.45. In acidosis, the pH decreases and respiratory rate and depth increases. Paresthesias (numbness and tingling of the fingers and toes) occur in alkalotic disorders.

A nurse reviews a client's laboratory results and notes that the client's potassium level is 3.1 mEq/L (mmol/L). In light of this finding, which action by the nurse is most appropriate? a. Filing the report in the client's medical record b. Notifying the client's primary health care provider of the potassium level c. Asking the laboratory to repeat the test and verifying the potassium level d. Asking the dietary department to restrict potassium-containing foods and fluids in the client's meals

B. The normal potassium level ranges from 3.5 to 5.1 mEq/L. A potassium level of 3.1 mEq/L is low and the most appropriate action would be to report it to the primary health care provider. Although the report would be filed in the client's record, the nurse must also notify the primary health care provider. There is no reason to ask the laboratory to repeat the test to verify the result, although the test might be repeated after treatment for the low level. The client is given a diet containing potassium-rich foods if the potassium level is low.

A nurse is providing self-care instructions to a client whose serum phosphorus level is 2.3 mg/dL (0.74 mmol/L). The nurse realizes these were effective if the client mentions beginning which activity? a. Eat foods high in calcium. b. Eat foods high in phosphorus, such as dairy products, nuts, and legumes. c. Take phosphate-binding medications daily with meals or immediately after meals. d. Read the labels on over-the-counter medications and avoid phosphate-containing medications such as laxatives and enemas.

B. The normal serum phosphorus level ranges from 2.7 to 4.5 mg/dL. A serum phosphorus level of 2.3 mg/dL (0.74 mmol/L) indicates hypophosphatemia. Therefore the nurse would teach the client self-care measures to increase the phosphorus level. The nurse would instruct the client to eat foods that are high in phosphorus. Avoiding medications that contain phosphate, taking phosphate-binding medications, and eating foods high in calcium are measures for the client who has hyperphosphatemia.

The nurse aide is bathing a patient with a drainage bag in place and observes that the skin around the bag is red and warm to the touch. What action should the nurse take next? A. Contact the practitioner because these may be signs of excess drainage of exudate. B. Contact the practitioner because these may be signs associated with infection. C. Document the patient's skin condition in the patient's record and continue to monitor. D. Change the pouch because these are signs that the bag is too full.

B. The nurse should contact the practitioner because these are signs associated with infection. Other signs of infection include edema, induration, increased tenderness or pain, elevated WBC count, changes in the amount, color, or odor of wound drainage, and periwound skin breakdown. These are not signs of excess drainage or the pouch is too full. While the nurse should document the patient's skin condition in the patient record and continue to monitor the patient's skin, he or she should notify the practitioner first.

4. The nurse has completed discharge education for a patient with a wound. The nurse recognizes that further teaching is needed when the patient makes which statement? A. "The red and bloody drainage should decrease over the next few days." B. "If I notice any thick, yellow drainage, I just need to take a shower." C. "The lighter, thin, yellow-colored drainage I see indicates normal wound healing." D. "If my pain gets worse or there is more drainage, I will call my doctor."

B. Thick, yellow drainage is usually purulent, which may indicate a wound infection and should be reported before the patient does anything. Red or bloody exudate is not uncommon and normally decreases as wound healing continues. Light, thin, yellow, or serous exudate is a normal function of wound healing. Pain normally improves, and drainage decreases over time.

Which client should be assigned to an LVN rather than an RN? a. A client with Addison's disease who is experiencing tremors and diaphoresis b. An afebrile client who is 2 days postoperative with an abdominal incision and a Jackson-Pratt drain c. A client who is scheduled to be discharged after receiving instruction about colostomy care d. A client with diabetes who reports pain 2 days after an above-the-knee amputation

B. This afebrile client requires routine postoperative care which can be completed by the PN.

On an oncology unit, many of the clients have problems related to pain. Which client experiencing pain management problem is the most appropriate to assign to a PN? a. Switching from IV to oral opioid analgesics in preparation for discharge b. Complaining of constipation after using analgesics for one week c. Refusing pain medication after surgery due to a fear of drug addiction d. Exhibiting a Cheyne-Stokes respiratory pattern following a dose of morphine

B. This client is stable and does not require reteaching or support from the RN. The needs of this client can be managed by the PN. The client in option A needs assessment and client teaching provided by an RN to ensure adequate pain management prior to discharge. Option C client also needs teaching from an RN. Option D, this client is physiologically unstable and requires assessment by the RN.

Which client should be assigned to an RN rather than a PN? a. Inability to perform his own colostomy care due to weakness b. Unwilling to observe his new ileostomy stoma and pouch c. Undergoing a 24 hour calorie count after losing weight d. Preparing for transfer to a skilled care unit for wound management

B. This client requires emotional support, assessment, and teaching best provided by an RN. The option A client is stable and has no specific needs that require RN expertise, and the same goes for option C and D.

When placing an intraocular disk, the nurse recognizes that it is in the correct position by assessing what? A. Visibility of the disk over the cornea B. Lack of visibility of the disk as it is placed under the lower eyelid C. Lack of visibility as it is placed under the upper eyelid D. Visibility of a small portion of the disk extending slightly above the lower eyelid

B. When placed correctly against the sclera under the lower eyelid, the intraocular disk should nor be visible. It is not placed on the cornea or under the upper eyelid. The nurse should NOT be able to see even a small portion of it.

The nurse is assigned to care for a client who has a Salem Sump tube inserted into the stomach and will be attached to low continuous suction. Which actions should the nurse plan to take? Select all that apply. a. Irrigating the air vent (pigtail) lumen every 4 hours b. Clamping the air vent lumen to prevent drainage from the lumen c. Positioning the client with the head of the bed elevated 30 degrees d. Positioning the air vent lumen so that it is higher than the client's stomach e. Instilling 30 mL of air into the air vent and irrigating the main lumen with normal saline solution if leakage occurs through the air vent

C, D, E The Salem Sump tube has two lumens, one for removal of gastric contents and one to provide an air vent. A blue "pigtail" is the air vent that connects with the second lumen. The head of the bed is elevated 30 degrees unless otherwise prescribed. When the sump tube's main lumen is connected to suction, the air vent permits free, continuous drainage of secretions. The air vent should never be clamped off, connected to suction, or used for irrigation, and it should be kept higher than the client's stomach to prevent drainage. If leakage occurs through the air vent, 30 mL of air is instilled into the vent and the main lumen is irrigated with normal saline solution.

A nurse is watching as an AP measures the BP of a hypertensive client. Which actions on the part of the AP would interfere with accurate measurement and prompt the nurse to intervene? SATA a. Measuring the BP after the client has sat quietly for 5 minutes b. Having the client sit with the arm bared and supported at heart level c. Using a cuff with a rubber bladder that encircles at least 60% of the limb d. Measuring the BP after the client reports having just drank a cup of coffee e. Allowing the client to talk as the BP is being measured

C, D, E The client should not smoke tobacco or drink a caffeinated beverage for at least 30 minutes before having the BP measured. The bladder of the cuff should encircle at least 80% of the limb being measured. The client should be seated with the arm bared, positioned with support and at heart level. The client should sit with the legs on the floor, feet uncrossed, and not speak during the recording. The client should rest quietly for 5 minutes before the reading is taken.

Which interventions should the nurse include in the plan of care for a client with hypothyroidism? Select all that apply. a. Providing a cool environment for the client b. Instructing the client to consume a high-fat diet c. Instructing the client about thyroid-replacement therapy d. Encouraging the client to consume fluids and high-fiber foods e. Instructing the client to contact the health care provider if chest pain occurs f. Informing the client that radioactive iodine preparations may be prescribed to treat the disorder

C, D, E The signs/symptoms of hypothyroidism are the result of decreased metabolism caused by low levels of thyroid hormones. Interventions are aimed at replacing the hormones and addressing the signs and symptoms of decreased metabolism. The nurse encourages the client to consume a balanced diet that is low in fat for weight reduction and high in fluids and high-fiber foods to help prevent constipation. The client is often intolerant of cold and requires a warm environment. The client should be instructed to notify the health care provider if chest pain occurs, because this could be an indication of overreplacement of thyroid hormone. Radioactive iodine preparations may be used to destroy thyroid cells in the treatment of hyperthyroidism.

Flail chest is diagnosed in a client who sustained injury in a high-speed motor vehicle crash. Which findings should the nurse expect to note during assessment of the client? Select all that apply. a. Bradycardia b. Hypertension c. Severe chest pain d. Diminished breath sounds e. Puffing out of the loose chest area during expiration f. An inward movement of the loose chest area during inspiration

C, D, E, F Flail chest occurs as a result of blunt chest trauma associated with accidents. The loose segment of the chest wall opposes the expansion and contraction of the rest of the chest wall. The client experiences paradoxical respiration (inward movement of the loosened segment of thorax during inspiration, with outward movement during expiration), severe chest pain, and diminished breath sounds. Dyspnea, tachycardia, hypotension, and cyanosis may occur as well.

The nurse working in a community outreach program for foster children plans care knowing that which health conditions are common in this population? SATA a. Asthma b. Claustrophobia c. Sleep problems d. Bipolar disorder e. Aggressive behavior f. ADHD

C, D, E, F Foster children are at risk for a variety of health conditions later in life, including ADHD, aggressive behavior, anxiety disorder, bipolar disorder, depression, mood disorder, PTSD, reactive detachment disorder, sleep problems, prenatal drug or alcohol exposure, and personality disorder. Claustrophobia and asthma are NOT specifically related to foster children.

The nurse should include which information in the preoperative plan of care for a client with appendicitis? Select all that apply. a. Administer a Fleet enema b. Allow sips of clear fluids only c. Apply an ice bag to the abdomen d. Administer 15 mL milk of magnesia orally e. Insert an intravenous (IV) line and infuse IV fluids as prescribed

C, E A concern for a client with appendicitis is rupture and resultant peritonitis. Surgery, generally performed laparoscopically, is performed as soon as the diagnosis is made. To ensure that the stomach is empty in the event that surgery is needed, the client is kept on NPO status. Antibiotics and fluid resuscitation are administered before surgery. Laxatives and enemas are especially dangerous because the resulting increased peristalsis may cause perforation of the appendix. An ice bag may be applied to the right lower quadrant to decrease inflammation; head could cause the appendix to rupture.

A nurse is reviewing the medical records of the clients for whom she will be caring. Which of these clients does the nurse identify as being at risk for a fluid-volume deficit? Select all that apply. a. A client with congestive heart failure b. A client with syndrome of inappropriate antidiuretic hormone c. A client with a nasogastric tube attached to suction d. A client undergoing long-term corticosteroid therapy e. A client with a fever who is experiencing severe diaphoresis

C, E Clients at risk for fluid-volume deficit include those with inadequate intake of fluids, those taking diuretics, and those with any condition that increases fluid loss (e.g., hemorrhage, excessive perspiration, vomiting, diarrhea, gastrointestinal suction or drainage, third-space fluid shifts, ketoacidosis, diabetes insipidus). The client with congestive heart failure, the client with syndrome of inappropriate antidiuretic hormone, and the client undergoing long-term corticosteroid therapy are all at risk for fluid-volume excess.

Several residents are needing assistance to get to the dining room. Which residents need the assistance of an LPN rather than a UAP? SATA a. A legally blind, elderly man with a shuffling gait, who uses the hallway railings to assist in ambulation b. An elderly woman, 4 weeks post-hip surgery, who ambulates with a walker but becomes easily fatigued c. A client with type I diabetes who reports feeling sweaty and tired d. An elderly man with diabetes, 2 days after a toe amputation, who requests help transferring to a wheelchair e. An elderly woman who has experienced pneumonia and DVT and who has been on bed rest for 2 weeks

C, E Option C shows signs of a hypoglycemic reaction which may require emergency intervention by the LPN. The client in option E is at high risk for orthostatic hypotension and syncope as a result of prolonged bed rest and should be assisted by an LPN rather than a UAP. A UAP can assist residents with a fall risk who have no additional problems requiring a higher degree of expertise.

A nurse is reviewing the medical records of the assigned clients. Which client is at the greatest risk for hypercalcemia? a. A client with Crohn disease b. A client with lactose intolerance c. A client with severe dehydration d. A client who has undergone thyroidectomy

C. Causes of hypercalcemia include excessive oral intake of calcium or vitamin D, renal failure, the use of thiazide diuretics, hyperparathyroidism, hyperthyroidism, the use of medications such as glucocorticoids or lithium carbonate, dehydration, adrenal insufficiency, and immobility. Hypothyroidism, malabsorption syndromes such as Crohn disease, and lactose intolerance are causes of hypocalcemia.

A nurse provides home care instructions to a client with acute hepatitis. Which statement by the client indicates a need for further teaching? a. "I need to eat frequent small meals." b. "I need to eat foods high in carbohydrates and low in fat." c. "I need to maintain my normal physical activity and daily routine." d. "I need to avoid close physical contact with other people until my test results are negative."

C. A client with hepatitis needs considerable rest during the acute phase of illness to promote healing of the liver. The permissible level of physical activity is based on the client's degree of fatigue and the severity of disease. Rest periods should be arranged throughout the day. The client should eat small frequent meals that are high in carbohydrate and low in fat. Close personal contact (e.g., kissing, sexual activity) should be discouraged until testing for hepatitis B surface antigen (HBsAg) returns a negative result.

A nurse is monitoring the intake and output of a client with a Foley catheter who returned from surgery at 1 p.m. On the client's return, the nurse empties 100 mL of urine from the catheter drainage bag. At 4 p.m., the nurse checks the client's urine output and notes that the bag contains 40 mL. What is the most appropriate action for the nurse to take? a. Continue to monitor the client's urine output. b. Increase the rate of administration of IV fluids. c. Notify the surgeon of the decreased urine output. d. Document the urine output on the fluid balance form.

C. Although the nurse would document the urine output, the most appropriate action would be to contact the surgeon. Urine output is closely monitored after surgery until normal urinary tract function has been reestablished. A urine output of at least 30 mL/hr is required to maintain adequate kidney function. Because the client has produced only 40 mL of urine in 3 hours, the surgeon should be notified. Continuing to monitor the client's urine output would delay necessary interventions. The nurse would not increase the rate of administration of IV fluids without a specific prescription to do so.

An RN and a PN from the float pool are sent to work on an Oncology unit. The RN works in Day surgery and PACU, and has her ACLS certification. Which client care assignment makes use of this RN's expertise? a. Administer a client's scheduled chemotherapy treatment b. Insert a client's PICC line c. Monitor a client with thrombocytopenia who is receiving platelets d. Provide discharge teaching for a client scheduled for radiation therapy

C. An RN working in a surgical setting is likely to have expertise in the administration of blood products and the care of clients at risk for bleeding. She also probably has experience with administration of IV fluids and medications, but the administration of IV chemotherapy requires specialized training. She also could insert peripheral IVs, but the insertion of a PICC requires specialized training as well. She is likely to have expertise in teaching postoperative care but not the information needed to prepare a client for radiation therapy.

2. Several days after surgery, a patient's abdominal wound produces copious serosanguineous exudate. The surgical team has asked that the exudate be controlled with absorptive dressing changes as needed. The patient expresses frustration at having to change gowns every few hours. After contacting the wound care nurse, the nurse should anticipate which recommendation? A. Applying more layers of gauze with each dressing change B. Informing the patient to limit activity to decrease wound output C. Applying a wound management system or ostomy pouch D. Informing the practitioner that a wound drain is indicated

C. Applying a wound management system or ostomy pouch is an effective way to contain excessive exudate and improve the client's comfort by reducing leakage and frequent dressing changes. Layering additional gauze is not an effective means of removing excess would fluid and would not eliminate dressing saturation and leakage, which are disturbing the patient. Asking the patient to limit activity would not change the amount of exudate and could contribute to other postoperative complications. Wound drains require surgical insertion; other options should be explored before a drain is placed.

The nurse asks the student nurse, "What does it means when an antibiotic is classified as a bactericidal agent?" The nurse determines a correct understanding with which statement? a. It has low efficacy b. It has a very low potency c. It kills the infectious agent d. It slows the growth of the infectious agent

C. Bactericidal agents cause bacterial cell death and lysis and thus kill the infectious agent. Potency refers to the strength of an antibiotic, and efficacy is related to antibiotic effectiveness. An antibiotic is classified as bacteriostatic if the agent slows bacterial growth, allowing the body to complete the cycle of destruction.

Blood is drawn from a client with suspected hyperparathyroidism for a calcium assay, and a calcium level of 18 mg/dL (4.5 mmol/L) is detected. How should the nurse interpret this result? a. The calcium level is normal. b. The calcium level is low, indicating hyperparathyroidism. c. The calcium level is higher than normal, indicating hyperparathyroidism. d. The calcium level is on the low end of the normal range, indicating the need to increase dietary calcium.

C. Calcium functions in bone formation, nerve impulse transmission, and contraction of myocardial and skeletal muscles. It also aids in blood clotting by converting prothrombin to thrombin. The calcium concentration normally ranges from 8.6 to 10.0 mg/dL. Therefore, a calcium level of 18 mg/dL (4.5 mmol/L) is high, and the other options are incorrect.

The school nurse receives a telephone call from a physical education teacher, who says that a student with diabetes mellitus is feeling shaky and weak. Which action should the nurse tell the teacher to take immediately? a. Laying the student on the floor b. Staying with the student until the nurse arrives c. Giving the student a glass of orange juice or non-diet soda d. Calling for an ambulance to bring the student to the emergency department

C. Exercise can cause the blood glucose level to drop. Shakiness and weakness are signs of a hypoglycemic reaction in a diabetic client. A hypoglycemic reaction is treated promptly with a substance that contains 10 to 15 g of carbohydrates — for instance, commercially prepared glucose tablets, six to 10 Life Savers or other hard candies, 4 teaspoons of sugar, four sugar cubes, 1 tablespoon of honey or syrup, a half-cup of fruit juice or regular (non-diet) soft drink, 8 oz of low-fat milk, six saltines, or three graham crackers. If the symptoms are not relieved in 15 minutes, the treatment is repeated. Laying the student on the floor, staying with the student until the nurse arrives, and calling for an ambulance would each delay necessary interventions. There is no need to call an ambulance at this time.

The nurse provides home care instructions to a client who will be discharged from the ambulatory care unit after arthroscopy of the right knee. Which statement by the client indicates a need for further teaching? a. "I should elevate my right leg for the next 24 to 48 hours." b. "If I get a fever or my knee keeps swelling, I should call the primary health care provider." c. "I can put a heating pad on my right knee for the next 24 to 48 hours." d. "I may have some knee discomfort and can take the pain medication that the primary health care provider prescribed."

C. Ice, not heat, is often applied to the surgical site during the 24 to 48 hours after arthroscopy as a means of minimizing swelling. The client may experience some pain after the procedure, and the primary health care provider will prescribe pain medication. The client is instructed to elevate the extremity for 24 to 48 hours after the procedure. Walking without bearing weight on the affected leg is usually permitted once sensation returns (crutches may be needed), but the client is instructed to limit activity as prescribed after the procedure. The client is informed of any complications that may occur and is advised to notify the primary health care provider if he/she experiences fever or increased knee pain and swelling after the procedure.

Which monitored pattern of fetal heart rate alerts the nurse to seek immediate intervention by the health care provider? A. an increase from 142-140 to 160-168/min with fetal movement B. A decrease from the baseline of 138-148 to 128-132 beats/min that mirrors the contraction pattern C. A baseline FHR from 112-120 beats/min between contractions d. A baseline fetal heart rate from 168-170 beats/min with a decline in the heart rate after the onset of a contraction

C. Late decelerations indicate uteroplacental insufficiency and are indicative of complications. When occurring with absent variability and tachycardia, the situation is ominous. 130 beats/min is an expected HR. Options A and B are not AS critical.

A client asks the nurse why the HCP changed to a different antibiotic for treating streptococcal throat infection. The nurse should make which best response? a. Antibiotics all have the same method of action b. You probably misunderstood what the HCP said. c. Bacteria are capable of developing resistance to frequently used antibiotics d. Try this medication, and if youre not better in 5-7 days, come back to the office.

C. Many infections can have the same symptoms but are caused by different organisms or by organisms that have developed a resistance to a certain antibiotic and require a change to a different antibiotic. Antibiotics that are specific to the type of pathogen causing the infection are prescribed, and selection of the correct antibiotic is important. To say that the client misunderstood does not answer the client's question. The advice to try a medicine and wait 5 to 7 days does not give the client correct information, and the client might need to return sooner to the PHCP if symptoms are still evident.

A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets about to take which action? a. Preparing the client for a perfusion scan b. Attaching the client to a cardiac monitor c. Administering oxygen by way of nasal cannula d. Ensuring that the intravenous (IV) line is patent

C. Pulmonary embolism is a life-threatening emergency. Oxygen is immediately administered nasally to relieve hypoxemia, respiratory distress, and central cyanosis, and the primary health care provider is notified. IV infusion lines are needed to administer medications or fluids. A perfusion scan, among other tests, may be performed. The electrocardiogram is monitored for the presence of dysrhythmias. Additionally, a urinary catheter may be inserted and blood for arterial blood gas determinations drawn. The immediate priority, however, is the administration of oxygen.

The nurse administers regular insulin, 8 units subcutaneously, to a client at 8 AM, 30 minutes before breakfast. At which time is the client most at risk for a hypoglycemic reaction? a. 9:30 am b. 10:30 am c. 12:00 pm d. 3:00 pm

C. Regular insulin is short-acting and peaks between 2-3 hours after administration. The client is most at risk for a hypoglycemic reaction during the peak times.

A nurse is hiking in the woods with some friends when one of the friends sustains a snakebite on the ankle. What action should the nurse take first? a. Immobilizing the affected extremity b. Removing jewelry and constricting clothing c. Moving the victim to a safe area away from the snake d. Covering the victim with available items to keep him warm

C. Some snakes are venomous, and a bite may cause a systemic reaction in the victim. The priority is moving the victim to a safe area away from the snake and encouraging the victim to rest to slow venom circulation. Next, constricting clothing and jewelry are removed before swelling occurs. The extremity is immobilized and kept below the level of the heart. The victim is kept warm and is not allowed to consume alcoholic or caffeine-containing beverages, which may speed absorption of the venom. If the victim is not immediately transported to an emergency department, a constricting band may be applied proximal to the wound to slow the circulation of venom.

The client asks the nurse how long she will have to take tamoxifen for breast cancer treatment. Which response by the nurse is appropriate? A "You'll have to take it for the rest of your life." B "You'll need to take it for 10 days, like an antibiotic." C "You'll need to take it for 5 years, after which it will be discontinued." D "You'll need to take it for several months, until the bone pain subsides."

C. Tamoxifen is an estrogen antagonist antineoplastic medication that has been found to be effective in 50-60% of women with estrogen-receptor-positive cancer of the breast. After 5 years of administration there is an increased risk of complications, and the medication is discontinued. Tamoxifen usually is prescribed for 5 years after initiation of therapy, not for the rest of the client's life; this duration will not produce positive effects for the client. Tamoxifen may cause the adverse effect of bone pain, which indicates the medication's effectiveness. Medication is given to manage the pain and the tamoxifen is continued.

A nurse has a prescription to discontinue a client's nasogastric tube. The nurse auscultates the client's bowel sounds, positions the client properly, and flushes the tube with 15 mL of air to clear secretions. The nurse then instructs the client to take a deep breath followed by what client action? a. Exhale during tube removal b. Bear down during tube removal c. Hold the breath during tube removal d. Breathe normally during tube removal

C. The client is asked to take a deep breath because the airway will be temporarily obstructed during tube removal. The client is then asked to hold the breath while the tube is being withdrawn. Bearing down and exhaling could each interfere with tube removal by increasing intrathoracic pressure. Normal breathing could result in aspiration of gastric secretions during inhalation.

The nurse is providing pre-procedure instructions to a client who is scheduled for a endoscopic colonoscopy. Which teaching should be provided to the client? a. General anesthesia is required for the test to be performed. b. Hospitalization is required for 24 hours after the procedure. c. Complete bowel preparation is necessary before the procedure. d. Liquids and soft foods only are allowed on the morning before the test.

C. The client should consume a liquid diet for at least 24 hours before a colonoscopy and is usually on NPO status after midnight on the night before the procedure. Complete bowel preparation is necessary to enable the primary health care provider to visualize the entire colon. The primary health care provider prescribes medication that will help relax the client; general anesthesia is not necessary. The procedure is usually performed in an ambulatory care setting, and the client is discharged home after the procedure once his or her condition is stable.

In which site would it be inappropriate to administer an intradermal injection? A. Lower abdomen of an obese patient B. Upper back of a patient who is on bed rest C. Right deltoid of a high school softball pitcher D. Left forearm of a patient with right-sided weakness

C. The deltoid area is not an acceptable injection site for any patient receiving an intradermal injection. If the forearm and back cannot be used, it is acceptable to use sites routinely used for subcutaneous injections.

A client with histoplasmosis has the following arterial blood gas (ABG) results: pH 7.30, PaCO2 58 mm Hg (7.72 kPa), PaO2 75 mm Hg (9.93 kPa), HCO3 26 mEq/L (26 mmol/L). Which acid-base disturbance does the nurse recognize in these results? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

C. The normal pH is 7.35 to 7.45. The normal PaCO2 is 35-45 mm Hg (4.66-5.98 kPa). The normal HCO3 (bicarbonate) is 22-26 mEq/L (22-26 mmol/L). The normal PaO2 is 80-100 mm Hg (10.6-13.33 kPa). Acidosis is defined as a pH of less than 7.35; alkalosis is defined as a pH greater than 7.45. In a respiratory condition, an opposite effect is seen between the pH and the PCO2. In respiratory acidosis, the pH is decreased and the PCO2 is increased. Metabolic acidosis is present when the HCO3 is less than 22 mEq/L (22mmol/L); metabolic alkalosis is present when the HCO3 is greater than 26 mEq/L (26 mmol/L). This client's ABG values are consistent with respiratory acidosis.

A client with hyponatremia accompanied by a fluid-volume deficit is being treated with IV normal saline solution. Which serum sodium laboratory finding indicates to the nurse that the treatment has been effective? a. 120 mEq/L (120 mmol/L) b. 130 mEq/L (130 mmol/L) c. 140 mEq/L (140 mmol/L) d. 150 mEq/L (150 mmol/L)

C. The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A reading of 120 or 130 mEqL (120 or 130 mmol/L) indicates hyponatremia. A finding of 150 mEq/L (150 mmol/L) denotes hypernatremia.

The nurse manager is reviewing documentation describing a client's progress in terms of a critical path (Care Map) for postoperative colon resection recovery. The nurse manager notes that, although the documentation is complete, the client has made minimal progress in the areas of mobility and pain control during the prior 48 hours. Who should the nurse manager contact next? a. Assigned nurse, to increase client care interventions b. Family, to determine what is wrong and provide suggestions c. Case manager, to determine whether the predicted variance has been negotiated with health insurer d. PHCP and assigned nurse, to determine measures to DC the client

C. The nurse manager of the unit is accountable for cost recovery. In this situation, documentation is complete; however, each client's progress along the critical path can vary. Option 1 is incorrect because there is no indication that the care is ineffective; the subject is cost recovery, so option C is correcy.

A nurse manager of a pediatric facility arrives to work with multiple phone messages. Which phone message requires the most immediate response by the nurse? a. A physician who needs information about a suspected child abuse victim who was admitted to the medical center the previous day b. The daycare center director who reports the onset of a large number of head lice among the preschool-aged children c. A school social worker who is reporting that a local teenager who often hands out around the clinic has made death threats and expressed thoughts of suicide d. A teenager who sounds distraught and requests information right away about STDs.

C. The nurse needs additional information as quickly as possible in order to attempt to deter possible harm to the teenager and others. This situation has highest priority since the teenager has threatened harm to himself and others. The situation in option B needs intervention, but is of less immediacy than option C. Option A is a concern for child safety, but this child has already been admitted to the medical center and is not top priority. Option D needs prompt attention but is of less concern than option C.

A client who has just undergone bowel resection calls the nurse and reports feeling a "popping sensation" while performing coughing and deep-breathing exercises. The nurse removes the client's abdominal dressing and notes that a loop of bowel is protruding through the abdominal incision. The nurse immediately places the client in a low Fowler's position with knees bent and contacts the surgeon. Which action should the nurse take next? a. Administer pain medication b. Check the client's temperature c. Apply a sterile normal saline dressing to the incision d. Ask a nursing assistant to stay with the client until the surgeon arrives

C. The nurse should next apply a non-adherent sterile dressing (e.g., a normal saline dressing) to the incision. Wound evisceration is the protrusion of an internal organ through an abdominal incision. It is a surgical emergency, and the surgeon must be notified. The client is placed in a low Fowler's position. Although wound infection is a concern, checking the client's temperature is not the priority. Although the client may experience pain with an evisceration, administering pain medication is not the next action. Additionally, the client will need to undergo surgical repair, and the surgeon may prescribe specific medications before the procedure. It is inappropriate to ask a nursing assistant to stay with the client. The client must be monitored closely for signs/symptoms of shock.

A client who has undergone a renal biopsy calls the nurse in the primary health care provider's office and tells her/him that he/she has a minor headache and would like to know what he/she can take to relieve it. After checking with the primary health care provider, which medication does the nurse inform the client that it is acceptable to take? a. Ibuprofen b. Naproxen c. Acetaminophen d. Acetylsalicylic acid

C. The nurse tells the client that it is acceptable to take acetaminophen. Bleeding is a complication of renal biopsy. To prevent bleeding, the client is instructed to avoid lifting heavy objects and engaging in strenuous activity for 2 weeks after biopsy. The client is also instructed not to take any anticoagulant or antiplatelet medications until permission is given by the primary health care provider. Nonsteroidal anti-inflammatory drugs (NSAIDs; e.g., ibuprofen, naproxen) can cause nephrotoxicity. Acetylsalicylic acid inhibits platelet aggregation and has an anticoagulant effect. Acetaminophen is hepatotoxic but not nephrotoxic.

Blood tests are performed on a female client who has been complaining of weakness and fatigue. The results indicate a hemoglobin level of 11 g/dL (110 mmol/L) and a hematocrit of 32%. Which action should the nurse take on the basis of these results? a. Telling the client that the results are normal b. Telling the client she will need a blood transfusion c. Providing instruction regarding foods that contain iron d. Telling the client that the result is critically low and preparing to administer IV iron

C. The nurse would provide instruction to the client regarding foods that contain iron. In a female client, the normal hemoglobin level is 12 to 15 g/dL and the normal hematocrit is 35% to 47%. A hemoglobin level of 11 g/dL (110 mmol/L) and a hematocrit of 32% are lower than normal but not critically low. The client would not require a blood transfusion or IV iron. Recall the normal levels of hemoglobin and hematocrit. Knowing that the levels identified in the question are not normal will assist you in eliminating the option in which the nurse tells the client that results are normal. Next eliminate options that are comparable or alike in that they indicate that the client's levels are low and require aggressive intervention.

The nurse has received an order to shorten the patient's Penrose drain. Which statement regarding placement of the safety pin is accurate? A. Move the existing safety pin down from the old location to a new location closer to the skin. B. Place a new safety pin through the drain, taking care to gently pierce the skin to secure the drain. C. Place a new, clean safety pin through the drain close to where the drain exits the wound. D. Leave the safety pin in place so that it is apparent that the drain has been pulled out the appropriate length.

C. The safety pin should be placed close to the wound so that the drain will not slip back in. By leaving the pin in the same place, the drain may accidentally slip back into where it was before it was shortened. A new, clean pin should always be used. The pin is not used to secure the drain to the skin, and the nurse should exercise caution to prevent the pin from piercing the skin and causing further injury.

A client returns from the PACU after abdominal surgery. Which position in the bed does the nurse initially select for the client after helping move the client from the stretcher to the bed? a. Prone b. Supine c. Low Fowler's d. High Fowler's

C. Unless contraindicated, the client is placed in the low Fowler's position after surgery to maximize thorax size for lung expansion. The high Fowler's position would restrict thorax size. Occasionally the primary health care provider prescribes the side-lying position; however, this position is not presented as one of the options. Because of the risk of aspiration, the nurse should avoid using the supine position until pharyngeal reflexes have returned. In the prone position, the client lies on the stomach; this is not safe or comfortable for the client who has undergone abdominal surgery.

The practitioner orders a patient's wound drain to be removed. The nurse observes that the amount of wound drainage has not decreased recently, and the color remains sanguineous. What should the nurse do? A. Proceed with the order as directed and remove the drain B. Monitor the amount and type of drainage for 12 hours and then clarify the order C. Inform the practitioner of the amount and type of drainage and clarify the order D. Proceed with the order but apply highly absorbent dressings after drain removal

C. Wound drainage should decrease, and the color should change from sanguineous to serosanguineous before drain removal. The nurse should express concern regarding the amount and color of the wound drainage and clarify the order. Waiting 12 hours to clarify the order may result in further complications. A highly absorbent dressing may be indicated to manage the level of exudate, but it does not address the concerns regarding the amount and color.

What is the primary action of magnesium sulfate when given in preeclampsia? a. An antihypertensive b. A diuretic c. A CNS depressant d. A calcium channel blocker

C; magnesium sulfate depresses the CNS by interfering with the neuromuscular junction. It is given to prevent or control eclamptic seizures. While there is some relaxation of blood vessel walls resulting in a slight decrease in the BP, magnesium sulfate is not an antihypertensive. If a pregnant client needs an antihypertensive, the drugs of choice are hydralazine or labetalol.

The nurse has provided education for a client at risk for hypokalemia about foods that are high in potassium. The nurse determines teaching is effective if the client states she will increase her intake of which of the following? Select all that apply. a. Egg b. Cocoa c. Cheese d. Spinach e. Tomatoes f. Strawberries

D, E, F Most foods contain some potassium. Food containing significant amounts of potassium include vegetables, especially dark-green leafy ones; dried fruits; oranges and orange juice; bananas; whole grains; beef, legumes; strawberries; tomatoes; potatoes; and milk. Eggs are high in iron. Cocoa is high in manganese. Cheese is high in calcium.

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included? SATA a. Avoid stimulation b. Decrease fluid intake c. Expose all of the newborn's skin d. Monitor skin temperature closely e. Reposition the baby every 2 hours f. Cover the newborn's eyes with eye patches

D, E, F Phototherapy is the use of intense fluorescent light to reduce serum bilirubin levels in the newborn. Adverse effects from treatment, such as eye damage, dehydration, or sensory deprivation can occur. Interventions include exposing as much of the skin as possible but the genital area. The newborn's eyes are also covered, ensuring that the eyelids are closed when shields or patches are applied. They are removed at least once per shift to inspect the eyes for infection, irritation, and to allow eye contact. The nurse measures the lamp energy output to ensure efficacy of the treatment, monitors skin temperature, and increases fluids to compensate for water loss. The infant may have loose green stools and green-colored urine. The newborn's skin color is monitored with the light turned off every 4-8 hours and is monitored for bronze baby syndrome, a grayish brown discoloration. The newborn is repositioned every two hours, and stimulation is provided. After treatment, the newborn is monitored for signs of hyperbilirubinemia because rebound elevations can occur after therapy is discontinued.

The nurse is working with a new nurse employee, caring for a child who has had a craniotomy via supratentorial approach to remove a brain tumor in the right hemisphere. The nurse realizes the new employee understands positioning guidelines after surgery if the new employee states that the child should be positioned in which manner? a. Trendelenburg b. flat on the left side c. flat on the right side d. With the head elevated

D. A supratentorial tumor is located within the anterior two thirds of the brain, mainly in the cerebrum. In a supratentorial procedure, the head is usually elevated above the level of the heart to facilitate drainage of CSF and to decrease excessive blood flow to the brain to prevent hemorrhage. In an infratentorial procedure, the child is usually positioned flat and on one side or the other. The child is not placed in the Trendelenburg position, which increases ICP and therefore the risk of hemorrhage.

The nurse is providing home care information to a client who has undergone a skin biopsy. Which information should the nurse include in the instructions? a. Soak the site in warm water 3x a day b. Expect redness and drainage at the biopsy site c. Expect a significant amount of pain at the site d. Keep the dressing dry and in place for at least 8 hours

D. After a skin biopsy, the nurse instructs the client to keep the dressing dry and in place for at least 8 hours. After the dressing is removed, the site is cleansed daily with tap water or saline solution to remove dried blood or crusts. The primary health care provider may also prescribe a topical antibiotic ointment to minimize local bacterial colonization. The nurse instructs the client to report the presence of redness or excessive drainage at the biopsy site. Pain should be minimal after a skin biopsy.

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? a. A postoperative client preparing for discharge with a new medication b. A client requiring daily dressing changes of a recent surgical incision c. A client scheduled for a chest x-ray after insertion of a NG tube d. A client with asthma who requested a breathing treatment during the previous shift

D. Airway is always the highest priority, and the nurse would attend to the client with asthma who requested a breathing treatment during the previous shift. This could indicate that the client was experiencing difficulty breathing. The clients described in options 1, 2, and 3 have needs that would be identified as intermediate priorities.

The nurse is preparing to care for a client with chronic kidney disease and anemia. Which describes the relationship between chronic kidney disease and anemia? a. Lack of angiotensin I may cause anemia b. Increased production of aldosterone leads to anemia c. Anemia is caused by insufficient production of renin d. Decreased production of erythropoietin is causing anemia

D. Clients with CKD do not manufacture adequate amounts of erythropoietin, which is a glycoprotein needed to synthesize RBC. Renin, aldosterone, and angiotensin assist in maintaining BP.

Escharotomy is performed on the legs of a client who has sustained circumferential burns. Which parameter does the nurse use to evaluate the effectiveness of the procedure? a. Blood pressure b. Apical pulse rate c. Body temperature d. Dorsalis pedis pulses

D. Escharotomy is the primary surgical procedure for the treatment of inadequate tissue perfusion in the presence of a burn injury. In this procedure, an incision is made through the burn eschar to relieve pressure caused by the restricting force of the circumferential burns on the extremity and to improve circulation. To evaluate the effectiveness of the procedure, the nurse checks the pedal pulses. Although the nurse would check the client's apical pulse rate and blood pressure to determine circulatory status and the client's temperature as an indicator of possible infection, these measurements would not reveal the effectiveness of the escharotomy.

A nurse is reading the results of a biopsy of cervical lymph nodes from a client with suspected Hodgkin's lymphoma. Which finding should the nurse expect to see documented in the results if Hodgkin's lymphoma is confirmed? a. Blast cells in the blood b. Increased platelet count c. Bence-Jones protein in the urine d. Reed-Sternberg cells in the lymph nodes

D. Hodgkin's lymphoma is a cancer that usually originates in a single lymph node or a single chain of nodes. The lymphoid tissues within the node undergo malignant transformation, usually initiating some inflammatory processes. These nodes contain a specific transformed cell, known as the Reed-Sternberg cell, which is a marker for Hodgkin's lymphoma. Blast cells, cells in an immature phase, may be seen in leukemia. The platelet count usually decreases when treatment (i.e., radiation or chemotherapy) is started. In multiple myeloma, the abnormal plasma cells produce an abnormal antibody (myeloma protein, a.k.a. Bence-Jones protein), which is found in the blood and urine.

The nurse is performing an assessment on a client with a diagnosis of anemia that developed as a result of blood loss after a traumatic injury. The nurse should expect to find which sign as a result of anemia? a. Bradycardia b. Muscle cramps c. Increased RR d. SOB with activity

D. HomeHelpCalculator Study Mode Question 6 of 14 ID: 1490 | Adult Health_Hematological Questions_final.htm #1710 PreviousGoNext StopBookmark Rationale Strategy Reference Labs Submit The nurse is performing an assessment on a client with a diagnosis of anemia that developed as a result of blood loss after a traumatic injury. The nurse should expect to find which sign or symptom in the client as a result of the anemia? Rationale:The client with anemia is likely to experience shortness of breath and complain of fatigue because of the decreased ability of the blood to carry oxygen to the tissues to meet metabolic demands. The client is likely to have tachycardia, not bradycardia, as a result of efforts by the body to compensate for the effects of anemia. Muscle cramps are an unrelated finding. Increased respiratory rate is not an associated finding.

The nurse is changing the ties on a client's tracheostomy. During the procedure, the client coughs and the tracheostomy tube is dislodged. Which immediate action should the nurse take? a. Calling respiratory therapy to replace the tube b. Covering the stoma with a sterile dressing and ventilating the client manually with a resuscitation bag c. Placing the client in the high Fowler position and encouraging the client to breathe deeply through the stoma until help arrives d. Inserting the obturator into the replacement tracheostomy tube, lubricating the tip with saline solution, and inserting the tube into the stoma

D. If a tracheostomy tube is accidentally dislodged, the nurse's immediate action is to try to replace it. If retention sutures are present, they are grasped and the opening spread. A hemostat can also be used to spread the opening to facilitate replacement of the tube. The obturator is inserted in the replacement tube and lubricated with saline solution poured over the tip, after which the tube is inserted in the stoma at a 45-degree angle to the neck. If the nurse is unsuccessful in replacing the tube, the client is ventilated with a resuscitation bag until help arrives. Minor dyspnea may be relieved with the use of the semi-Fowler position until help arrives. The nurse may need to call respiratory therapy for assistance, but the immediate action is replacement of the tube.

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? a. Pt complaining of muscle aches, a headache, and history of seizures b. A client who twisted her ankle when rollerblading and is requesting pain medication c. A client with a minor laceration on the index finger sustained while cutting veggies d. A client with chest pain who states that he just ate pizza with a very spicy sauce

D. In an emergency department, triage involves brief client assessment to classify clients according to their need for care and includes establishing priorities of care. The type of illness or injury, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, and acute neurological deficits and those who have sustained chemical splashes to the eyes are classified as emergent and are the highest priority. Clients with conditions such as a simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as a second priority. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as nonurgent and are a third priority.

The nurse is planning care for a client who has had a cholecystectomy with T-tube placement. Which nursing intervention should be emphasized as the priority in the plan of care? a. Provide a full liquid diet once clear liquids are tolerated. b. Help position the client into the semi-Fowler position. c. Administer pain and antiemetics as promptly as possible. d. Have the client turn, cough, and deep breathe every 2 hours.

D. It is most critical to prevent atelectasis following abdominal surgery, as the client may hypoventilate, due to the location of the incision. Providing full liquids is not as high a priority as preventing atelectasis. Positioning the client into the semi-Fowler position allows bile to drain into the bile bag, but preventing atelectasis is a higher priority. It is crucial to administer pain and antiemetics promptly, but preventing atelectasis is a higher priority.

An emergency department nurse is caring for a client with diabetic ketoacidosis who is being treated with a continuous IV infusion of regular insulin and IV fluids. For which expected outcome of treatment for the disorder should the nurse monitor the client? a. Fruity-smelling breath b. Deep, rapid respirations c. Arterial blood pH of 7.30 d. Potassium level of 3.5 mEq/L (3.5 mmol/L)

D. Metabolic acidosis occurs when excessive amounts of acids are added to the body's fluids or when bicarbonate is lost. In diabetic ketoacidosis, glucose either cannot be used or is unavailable for oxidation. The body compensates for this unavailability by using body fat for energy, producing abnormal amounts of ketone bodies in the process. Fruity-smelling breath develops as a result of improper fat metabolism. The rate and depth of respirations increase in proportion to the increase in hydrogen ion (H+) concentration; respirations are rapid and deep and not under voluntary control (Kussmaul respirations). In acidotic conditions, the pH decreases and potassium moves out of the cell to make room for H+, and therefore the serum potassium level increases. Once treatment has been initiated and the acidosis corrected, the potassium level begins to decrease, after which the client must be monitored carefully, because hypokalemia may develop.

A nurse is gathering subjective data from a client with suspected bladder cancer. Which early manifestation of bladder cancer the nurse would expect the client to report? a. Flank pain b. Groin discomfort c. Lower back pain d. Painless hematuria

D. Painless hematuria is the first sign of a bladder tumor in most clients. It may be gross or microscopic and is usually intermittent. Dysuria and urinary frequency or urgency are the usual symptoms when infection or obstruction is present. Flank pain indicates renal involvement. Lower back pain and groin discomfort may occur later in the course of the disease.

The patient has a Penrose drain and asks the nurse when it will be removed. Which statement from the nurse is the best response? A. "Your surgeon will decide when to remove the drain." B. "The drain is usually removed on postoperative day 3." C. "The drain will be removed when the color of the drainage turns from red to yellow." D. "Usually the drain is removed when there is a minimal amount of drainage."

D. Penrose drains are usually removed when the amount of drainage is minimal. Although the decision to remove the drain is up to the HCP, that response does not sufficiently answer the question. It is the amount of drainage that determines appropriateness for removal, not the amount of time the drain has been in or the color of the drainage.

The nurse planning care for a military veteran should prioritize nursing interventions targeted at managing which condition, if present, that commonly occurs in this population? a. HTN b. Hyperlipidemia c. Substance abuse disorder d. PTSD

D. Post-traumatic stress disorder (PTSD) is extremely common in this population. Identifying and treating mental health disorders assists in mitigating suicide risk. Treatment of comorbid conditions such as PTSD may also help address any substance use disorder. Use of screening tools in identifying substance use disorder is helpful. Treatment of PTSD includes exposure therapy, psychotherapy, and family/group therapy. Hypertension and hyperlipidemia are important but not the priority; the risk of suicide and other safety concerns associated with PTSD are the priority for this population.

A nurse is grocery shopping when a woman screams, "Help me! He's choking on a piece of candy!" On rushing to the scene, the nurse sees that the woman's 4-year-old son is having respiratory difficulty and hears high-pitched inspiratory noises from the child. Which action should the nurse immediately take? a. Calling 911 on a cell phone b. Laying the child on the floor c. Placing the child across her lap and delivering five back blows d. Standing behind the child and administering abdominal thrusts

D. The abdominal thrust maneuver is recommended for use in adults and children 1 year of age and older. If the victim is coughing but the cough is ineffective or if the victim exhibits respiratory difficulty accompanied by a high-pitched noise while inhaling, help is needed. The nurse must immediately stand behind the child and administer abdominal thrusts. Although the emergency response system should be activated, this is not the nurse's immediate action. The nurse must stay with the child and administer care and ask the child's mother to call 911. Back blows and chest thrusts are administered to an infant who is choking. An unconscious child would be placed in a supine position.

The nurse has provided instructions to the mother of a child with sickle cell disease regarding measures that will prevent a sickle cell crisis. Which client statement indicates understanding? a. My child needs to avoid any exercise b. My child needs to avoid increasing any fluid intake c. My child needs to avoid going outside in warm weather d. My child needs to avoid situations that may lead to infection

D. The child should avoid infections, which can increase metabolic demands and cause dehydration, precipitating a sickle cell crisis. Fluids are important to prevent dehydration, which could lead to sickle cell crisis. Warm weather and mild exercise do not need to be avoided, but measures need to be taken to avoid dehydration during these conditions.

The nurse is preparing to help a primary health care provider perform a lumbar puncture. Which position should the nurse assist the client to assume? a. Lithotomy, with the knees drawn up to the abdomen b. Prone, with the legs flexed and the head hyperextended c. Lying on the left side with the legs straight and the head flexed to the chest d. Lateral recumbent, with the knees drawn up to the abdomen and the head flexed to the chest

D. The client is placed in the lateral recumbent position, with the back as near the edge of the bed as possible. A lumbar puncture is a means of obtaining CSF for analysis. A spinal needle is inserted through the L3-L4 interspace and into the lumbar subarachnoid space to obtain the CSF, measure CSF fluid or pressure, or instill air, dye, or medications. The nurse helps the client draw the knees to the abdomen and flex the head to the chest. This position helps separate the vertebrae so that the needle can be inserted more easily. None of the other positions provides easy access to the L3-L4 interspace.

A client being discharged home after renal transplantation has a risk for infection related to immunosuppressive medication therapy. The nurse determines that the client needs further teaching on measures to prevent and control infection if the client states that it is necessary to take which action? a. Take oral temperature daily b. Use good hand washing technique c. Take all scheduled medications exactly as prescribed d. Monitor urine character and output at least 1 day each week

D. The client receiving immunosuppressive medication therapy must learn and use infection control methods for use at home. The client self-monitors urine output and its characteristics on a daily basis. The client must learn proper hand-washing technique and should take the temperature daily to detect early infection. This is especially important because the client also takes corticosteroids, which mask signs and symptoms of infection. All medications should be taken exactly as prescribed.

A client in V-fib is about to be defibrillated. To convert this rhythm effectively, the monophasic defibrillator should be set at which energy level (in joules) for the first delivery? a. 50 J b. 120 J c. 200 J d. 360 J

D. The energy level used for all defibrillation attempts with a monophasic defibrillator is 360 joules.

A primary health care provider asks the nurse to DC tube feeding in a client who has a terminal condition. The HCP tells the nurse that the request was made by the client's spouse and children. What should the nurse check for FIRST before carrying out the prescription? a. Court approval to DC the treatment b. Approval by the institutional ethics committee c. A written prescription by the HCP to remove the tube d. Authorization by the family to DC the treatment

D. The family or legal guardian can make treatment decisions for the client who is unable to do so. Once the decision is made, the HCP writes the prescription. Generally, the family makes decisions in collaboration with the HCP and other health care workers. Therefore, the remaining options are not correct. Court approval may be needed if a conflict arises or if there is no legal guardian.

A client enters the hospital emergency department with a nosebleed. On assessment, the client tells the nurse that the nosebleed just suddenly began. The nurse notes no obvious facial injury. What is the initial nursing action? a. Insert nasal packing b. Prepare a nasal balloon for insertion c. Place the client in semi-fowlers, and apply ice pack to the nose d. Sit the client down, ask the client to lean forward slightly, and apply pressure to the nose for 5-10 minutes.

D. The initial nursing action for a client with a nosebleed is to sit the client down, ask the client to lean forward slightly, and apply pressure to the nose for 5-10 minutes. Inserting nasal packing or preparing a nasal balloon are not initial interventions. These are used when conservative measures fail. Placing the client in a semi-fowlers would promote swallowing blood, which adds risk of vomiting and resultant aspiration.

A nurse reviewing the results of an arterial blood gas determination notes a pH of 7.50, PCO2 of 30 mm Hg, and bicarbonate (HCO3-) of 20 mEq/L (20 mmol/L). The nurse determines that the client is exhibiting: a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

D. The normal pH is 7.35 to 7.45. The normal partial pressure of carbon dioxide (PCO2) is 35 to 45 mm Hg and the normal bicarbonate (HCO3-) level is 22 to 27 mEq/L. In acidosis the pH is down, and in alkalosis the pH is up. Therefore this client is experiencing alkalosis. In a respiratory imbalance, the response of the pH and PCO2 will be in opposition. Because the pH is increased and the PCO2 is low, this client is experiencing respiratory alkalosis. In a metabolic imbalance, the responses of the pH and HCO3- will correspond.

A nurse in the cardiac telemetry unit is reviewing a client's laboratory results and notes that the potassium level is 5.8 mEq/L (5.8 mmol/L). In light of this laboratory value, which finding would the nurse expect to note while looking at the client's cardiac monitor? a. Inverted T waves b. Prominent U wave c. ST-segment depression d. Widened QRS complexes

D. The normal range of potassium is 3.5 to 5.1 mEq/L (3.50 to 5.10 mmol/L). Therefore this client is experiencing hyperkalemia. ECG findings noted in hyperkalemia include tall, peaked T waves; widened QRS complexes; prolonged PR intervals; and flat P waves. Inverted T waves, prominent U wave, and ST-segment depression are found in hypokalemia.

A client who has been complaining of frequent heart palpitations is fitted with a 24-hour Holter monitoring device. Which instructions about the 24-hour Holter monitor should the nurse provide to the client? a. Taking a shower is acceptable but tub bathing is not. b. The device must be removed when the client is using a microwave oven. c. It is important to stay on bed rest as much as possible while the device is in place. d. It is important to document the time and description of any palpitations or other unusual feelings.

D. The nurse should tell the client to document the time and description of any palpitations or other unusual feelings. Holter monitoring is a noninvasive test in which the client wears a monitor that records the heart rhythm for 24 to 48 hours. It identifies dysrhythmias if they occur and aids evaluation of the effectiveness of antidysrhythmics or pacemaker therapy. The client is instructed to resume normal daily activities and to maintain a diary documenting activities and any signs/symptoms that may develop. The client should not take a bath or a shower while the monitoring device is in place. The device is not affected by the use of microwave oven, and the client should not remove the device.

The nurse is changing a drainage pouch and notices leaking exudate on the patient's gown and sheet. Which is the best action for the nurse to take? A. Contact the practitioner to let him or her know that there is excess drainage. B. Attach the drainage bag to low wall suction to drain away the excess exudate. C. Pack sterile gauze inside the drainage pouch to absorb the excess exudate. D. Use barrier cream and ensure that there are no wrinkles in the new pouch barrier.

D. The nurse should use a barrier cream and ensure that there are no wrinkles in the pouch barrier to ensure a good seal. Exudate leakage generally occurs with a poor seal of the drainage pouch. There is no evidence presented that the amount exudate is excessive. If the leak persists and the amount of exudate is determined to be excessive, the nurse should contact the HCP and anticipate an order to attach a larger drainage bag or to attach the bag to low wall suction. The nurse should not apply low wall suction without an order; sterile gauze should not be placed inside the pouch.

The low-pressure alarm sounds on a client's ventilator. The nurse immediately assesses the client and tries to determine the cause of the alarm but is unable to do so. Which immediate action should the nurse take? a. Calling a code b. Calling the anesthesiologist c. Stat-paging respiratory therapy d. Ventilating the client manually, using a resuscitation bag

D. The nurse's immediate action is to ventilate the client manually with a resuscitation bag. Mechanical ventilators have alarm systems that warn the nurse of a problem with either the client or the ventilator. Alarm systems must be activated and functional at all times. The nurse must recognize an emergency and intervene promptly so complications are prevented. If the cause of an alarm cannot be determined, the nurse immediately ventilates the client manually with a resuscitation bag until the problem is corrected. There is no information in the question indicating the need to call a code. An anesthesiologist would be needed if an endotracheal tube needed to be inserted. The nurse may need to contact a respiratory therapist, but the immediate action is to provide oxygen to the client.

A client who has a pulmonary artery wedge pressure (PAWP) reading of 18 mm Hg would most likely be experiencing which condition? a. Dehydration b. Hypovolemia c. Afterload reduction d. Left ventricular failure

D. The pulmonary artery wedge pressure (PAWP), which is also known as pulmonary artery occlusive pressure (PAOP), normally ranges between 6 and 12 mm Hg. Elevations in PAWP may indicate left ventricular failure, hypervolemia, mitral regurgitation, or intracardiac shunt, whereas decreases may indicate hypovolemia or afterload reduction.

The outpatient clinic nurse is reviewing phone messages from last night. Which client should the nurse call back first? A.An 18-year-old woman who had a positive pregnancy test and wants advice on how to tell her parents B.A woman with type 1 diabetes who has just discovered she is pregnant and is worried about her fingerstick glucose C.A women at 24 weeks of gestation crying about painful genital lesions on the vulva and urinary frequency D.A women at 30 weeks of gestation who has been diagnosed with mild preeclampsia and is unable to relieve her heartburn

D. The woman with epigastric pain should be called first. One of the cardinal signs of eclampsia, a life-threatening complication of pregnancy, is epigastric pain. Options A, B, and C are less serious and should be called after option D.

The nurse is preparing to help a primary health care provider perform a left-side thoracentesis. Into which position should the nurse place the client for this procedure? a. Prone b. Left Sims c. Supine on the left side d. Upright, at the side of the bed

D. Thoracentesis is the insertion of a needle through the chest wall into the pleural space to obtain specimens for diagnostic evaluation, to remove pleural fluid, or to instill medication into the pleural space. The client is positioned sitting upright, with the elbows on an over bed table and the feet supported. If the client cannot sit up, he or she lies in bed on the unaffected side with the head of the bed elevated 45 degrees. Positioning the client prone, in the left Sims position, or supine on the left side would be incorrect.

While making rounds a client asks the nurse, "What's wrong with that lady in the room next to me? She cries out all night long, I hope she is okay." What is the nurse's best response? a. Shes okay; she just gets confused at night b. I'm not allowed to say anything to you about her c. She has Alzheimer's disease and gets very upset because she is not home. d. I'm sure it's upsetting to hear her cry, but I am not able to discuss details about other clients.

D. To keep client information confidential, the nurse should not discuss any aspects of a client's care with other clients or with staff who are not involved in the client's care. Simply saying "I'm not allowed" is correct but abrupt. The correct answer acknowledges the client's concern yet preserves the other client's privacy. Relaying any information about the other client would be a violation of that client's privacy and would not be in compliance with the Health Insurance Portability and Accountability Act.

4. While preparing supplies on a sterile field, a gauze pad falls off the sterile field. What should the nurse do? A. Nothing B. Create a new sterile field C. Use sterile forceps to move the gauze pad toward the center of the sterile field D. Dispose of the gauze before continuing the procedure

A. The gauze fell outside of the sterile field, and the field has not been contaminated. The nurse can leave the gauze where it is and discard it with the other used supplies at the conclusion of the procedure. Creating a new sterile field is not needed. Using forceps to move the gauze pad back onto the sterile field would contaminate the field. Disposing of the gauze would cause the nurse to break sterile field.

The nurse obtains a bag of parenteral nutrition solution from the nursing unit refrigerator. On inspecting the solution, the nurse notes that it is cloudy. Which action should be taken? a. Return it to the pharmacy b. Shake the solution vigorously to disperse cloudiness c. Assume that the lipids has been added to the solution d. Allow the solution to warm to room temperature and recheck

A. The nurse must check the solution before administration. If contamination is suspected, the only safe option is to return it to the pharmacy.

A nurse reviewing lab results sees that the serum phenytoin level of a client who is taking oral phenytoin, 300 mg/day, is 22 mcg/ml. What action should be taken first? a. Call the HCP b. Administer the next dose c. Place the lab result in the client's record d. Inform the client that the result is WNL

A. The therapeutic range of phenytoin is 10-20.

The nurse has confirmed placement of a central venous catheter and is preparing to administer a PN solution. Which actions should be taken? SATA a. Obtaining an electronic infusion device b. Checking the PN solution for clarity and color c. Hanging the PN solution as soon as it is removed from refrigerator d. Checking components of the PN solution against HCP prescription e. Using IV tubing that will allow concurrent administration of prescribed medications, albumin, and blood products

A, B, D To prevent fluid overload, PN is always administered with the use of an electronic infusion device. The PN solution is checked for clarity and color to ensure that the solution is not contaminated. The nurse always checks the components of the HCP prescription to ensure that the client is receiving the prescribed nutrition. PN solution contains a high amount of glucose, making it an excellent medium for bacteria growth. Therefore PN that is not being used is refrigerated. It should be removed 30 minutes-1 hour before use to allow the temperature of the solution to warm to room temperature. Medications, albumin, and blood are NOT administered through the PN line because of the possibility of incompatibilities.

In caring for a severely malnourished patient receiving PN via a central venous access catheter, which actions should be done by the nurse to prevent or identify potential complications? SATA a. Weighing patient daily b. Monitoring the daily liver function tests c. Monitoring the daily electrolyte labs d. Monitoring the daily serum albumin, prealbumin, and transferrin levels e. Assessing her blood sugar every 6 hours for 48 hours, then daily

A, C, E The nurse should weigh the client daily to monitor for weight gain. Electrolyte disturbances and hyperglycemia can occur if a patient is severely malnourished and started on PN. Many infections occur with central lines and the risk for infection increases with the high levels of glucose that are present in the PN solution. Additionally, the central line dressing should be changed every 5-7 days or if moist. The liver function tests and albumin/transferrin levels will not change rapidly and are checked weekly.

Which interventions are appropriate for use by the nurse administering an IM injection to an infant? SATA a. Inject into the vastus lateralis muscle b. Use the ventrogluteal muscle for injection c. Use a 1.5 inch 20-gauge needle and a 3 mL syringe d. Ask someone else to hold the infant while you give the injection e. Use a .5 inch 25-gauge needle to administer the medication

A, D, E The only muscle large enough for IM injections in the infant is the vastus lateralis. The nurse should ask someone else to hold the infant to help prevent damage resulting from movement during the injection. Another nurse or parent may help hold the child. The needle should be .5 inches long, 25 gauge, because of the infant's small muscle mass. The ventrogluteal muscle is used in children older than 18 months and in adults.

The nurse is preparing to administer lipids IV which has been sent up from the pharmacy in a glass bottle. Which items should the nurse obtain to help administer this solution? SATA a. Alcohol swab b. Thermometer c. 0.22 filter d. Vented IV tubing e. Bottle of lipids f. BP cuff and stethoscope

A, D, E When administering lipids, the nurse will need the lipid solution, vented IV tubing, and an alcohol swab. Vented IV tubing is used because the lipid solution is supplied in a glass container for administration. The alcohol swab is needed to clean the IV port on the primary IV tubing at the site of insertion of the lipid tubing. An IV filter is not used to administer a lipid emulsion only solution because particles in the solution are too large to pass through the filter. If the fat emulsion is to be added to the PN solution, then a filter gauge of 1.2 or later is needed. A thermometer and BP cuff are not needed to start the solution.

The RN is a case manager for the ER. A client is brought to the ER by emergency personnel after sustaining a gunshot wound to the abdomen. The client, bleeding profusely, requires an immediate blood transfusion of whole blood, but his blood type is unknown. The case manager determines appropriate action was taken if which type of blood was requested from the blood bank? a. O- b. O+ c. AB+ d. AB-

A. Whole blood is used in the event of major blood loss. Typing and crossmatching are normally performed to check for the presence of the Rh factor, and to ensure compatibility with the donor's blood. In an emergency however, the client may be transfused with O- blood, the "universal" donor.

The nurse is participating in a care conference. The HCP tells the resident that the client needs an IV infusion of an isotonic solution. Which solution should the nurse expect? a. 0.9% NS b. 0.45% NS c. 10% dextrose in water d. 5% dextrose in 0.9% normal saline

A. An isotonic solution increases the volume of extracellular fluid volume. One example is 0.9% NS. A hypotonic solution is a solution that is more dilute and has a lower osmolality than body fluids, such as 0.45% NS. A hypertonic solution is more concentrated or has a higher osmolality than body fluids such as 10% dextrose in water, or 5% dextrose in 0.9% NS.

The nurse has obtained a unit of packed RBC from the blood bank for administration to a client. While preparing to administer the transfusion, the nurse is called to attend to an emergency involving another client. Before leaving to go to the other client, what should the nurse ask another staff member to do? a. Return the blood to the blood bank b. Place the blood in the nursing unit's refrigerator c. Attach the blood to the client's IV line because the client's identity and the information on the unit of blood has already been matched d. Bring the unit of blood to the client's bedside and explain to the client that the blood will be infused once the emergency has been taken care of

A. Blood bank safety protocol dictates that refrigerated blood components not be returned to inventory if they have been warmed to more than 50 degrees. Therefore the maximal amount of time for which a unit of blood can be out of storage is 30 minutes. Thus, the nurse would not leave the unit of blood at the bedside or attach it to the IV line. Blood is not placed in the nursing unit refrigerator, because its temperature may not be adequate for blood storage. The appropriate nursing action is to have the unit of blood returned to the blood bank.

Cyclosporine is prescribed for a client who has undergone a kidney transplant. Which should the nurse plan to monitor most closely? a. Temperature b. Platelet count c. Apical heart rate d. Peripheral pulses

A. Cyclosporine is an immunosuppressant used to prevent organ rejection. The most common adverse effects are nephrotoxicity, infection, HTN, tremor, and hirsutism. Of these, nephrotoxicity and infection are the most important. Therefore the client's temperature should be monitored closely.

2. The nurse is preparing to administer an enema. How can the nurse best facilitate insertion of the rectal tube? A. Lubricate the first 6.5 to 7.5 cm (2.5 to 3 inches) of the tip of the tube. B. Place the patient in a side-lying position with the right knee flexed. C. Flush the tube with the solution. D. Hold the tube in the rectum until all of the fluid has been instilled.

A. Lubricating the first 6.5 to 7.5 cm facilitates insertion of the rectal tube. Placing the patient in a side-lying position with the right knee flexed aids in retention of the solution. It does not facilitate insertion of the rectal tube. Flushing the tubing with solution will not facilitate insertion of the rectal tube. Holding the tube in the rectum until all of the fluid has been instilled helps minimize the possibility of expelling the rectal tube. It does not, however, facilitate insertion of the tube.

A client with TB has been taking isoniazid, and now the HCP has added rifampin to the regimen. The client calls the nurse and reports that her urine has been red-orange since she started taking the rifampin. Which response is correct? a. This is an expected side effect of rifampin. b. Bring a urine specimen to the HCP office for analysis. c. The change in urine color is a result of the medication combination d. Increase your fluid intake. The medication may be causing hemorrhagic cystitis.

A. Rifampin is an antitubercular medication that is used in conjunction with at least one other antitubercular medication for the treatment of TB. An expected side effect is a red-orange or red-brown discoloration of the urine, feces, saliva, skin, sweat, sputum, or tears. Because this side effect is expected, it is not necessary to have the client bring a specimen to the HCP office.

2. A patient requires all of the following interventions. Which one would the nurse perform last? A. Change the dressing on the patient's newly established suprapubic catheter. B. Administer the patient's prescribed medication. C. Offer the patient a bedpan. D. Position the patient for maximum comfort and ease of breathing.

A. Since this is a sterile procedure, the nurse will address the patient's oxygen requirements and his/her comfort and elimination needs prior to completing the procedure. The nurse will also complete priority tasks such as medication administration before establishing a sterile field.

The first step of a health history interview is: a. The establishment of trust b. Asking the client about their chief complaint c. Actively engaging family members d. Explaining the patient's bill of rights

A. The first step of a health history interview is to establish trust. The health history is typically the first contact with the client and, in order to establish a therapeutic nurse-client relationship, the establishment of trust is essential. The Patient's Bill of Rights should be explained upon admission, however, this is not part of a health history. At times it is appropriate to involve family, however, this cannot be effectively done until trust is established. The chief complaint is part of the history but trust is the first step.

Timolol maleate eyedrops have been prescribed to reduce IOP in a client with open-angle glaucoma. When teaching the client about the medication, the nurse ensures that the client knows how to perform which procedure? a. Check his pulse b. Measure his weight c. Take his temperature d. Measure his intake and output

A. Timolol maleate is a beta-adrenergic-blocking medication that reduces IOP by diminishing the production of aqueous humor. Beta-blockers can be absorbed in amount sufficient to cause systemic effects. Blockage of cardiac beta-1 receptors can produce bradycardia and atrioventricular heart block. Therefore the client should be taught how to take the pulse.

A topical glucocorticoid preparation has been prescribed for a client in whom local dermatitis has developed as a result of an insect bite. What should the nurse include when teaching the client about the medication? a. Rub the cream gently into the skin b. Cover the site with plastic wrap after applying the cream c. Apply an occlusive dressing over the site after applying the cream d. Apply the cream in a thick layer over the site of the bite and on 2 inches of surrounding skin

A. Topical glucocorticoids can be absorbed into the systemic circulation. Therefore they should be applied in a thin layer and gently rubbed into the skin. The client is told not to use occlusive dressings unless instructed by the HCP.

The nurse provides medication instructions to a client. Which statements by the client indicate the need for follow-up and additional teaching? SATA a. I need to check my pulse before taking my heart medicaiton b. I need to stop taking the medication if I have any side effects c. I can take herbal medications if i want, because they come from plants d. I should wear a medic-alert bracelet for as long as Im taking this blood thinner e. I need to take this antibiotic until all of it is gone, even if I am feeling better

B, C One component of medication instructions is teaching the client how to take his temperature, pulse, and BP. The client is also taught to never adjust a dose or abruptly stop taking the medication. If side effects occur, the client should contact the HCP. OTC medication, including herbal preparations, must be avoided unless specifically approved by the HCP, because they may interact with prescribed medications. Clients taking medications such as anticoagulants, oral hypoglycemics or insulin, certain cardiac medications, corticosteroids and glucocorticoids, animyasthenics, anticonvulsants, and MAOIs need to wear a medic-alert bracelet. Medication compliance is important, and finishing an antibiotic must be stressed to the client.

A nurse is preparing to administer digoxin, 0.125 orally, to a client with HF. Which findings indicate the need to withhold the medication and contact the HCP? SATA a. The client complains of being hungry b. The client complains of double vision c. The client's digoxin level is 1.8 d. The client's potassium level is 3 e. The client's apical heart rate is 62

B, D The therapeutic level ranges from 0.5-2.0. Signs of toxicity include anorexia or nausea and vomiting; visual disturbances: diplopia, blurred vision, yellow-green halos; bradycardia; and photophobia. The HCP is alerted if signs of toxicity are noted. An increased risk of toxicity exists if the client has hypokalemia.

A nurse is observing a new nurse who is preparing to administer 1 inch of topical nitroglycerin ointment to a client with angina pectoris. Which actions indicate the new nurse needs further education? SATA a. Wearing gloves b. Applying the ointment to skin with hair c. Removing previously applied ointment d. Rubbing the ointment into the skin e. Measuring out the correct amount of ointment on the paper applicator f. Taping the paper applicator in place once the ointment has been applied

B, D To promote medication absorption as intended, the nurse would avoid rubbing the ointment into the skin or applying the ointment to hairy areas. The nurse always wears gloves when applying topical medications; in this case, gloves are especially important because the nurse could be subject to the effects of the medication if it were to come into contact with the nurse's skin. Before applying nitroglycerin ointment, the nurse would remove the previously applied ointment and cleanse the skin. The correct amount of medication is measured out on the appropriate paper applicator, after which the applicator is taped in place on the client's body.

The nurse determines which clients are candidates for parenteral nutrition? SATA a. A client with pneumonia b. A client with a severe burn injury c. A client with CHF d. A client scheduled for a cholecystectomy e. A client with DM who has an ulcer on the right ankle f. A client undergoing chemotherapy who is experiencing severe vomiting and diarrhea

B, F PN is indicated when the GI tract is severely dysfunctional or nonfunctional; when the client has undergone multiple GI surgeries or has sustained GI trauma; in clients experiencing severe intolerance of enteral feedings or intestinal obstruction; and in clients with other conditions in which the bowel needs rest. Conditions include AIDS, cancer, malnutrition, burns, chronic vomiting and diarrhea, diverticulitis, inflammatory bowel disease, pancreatitis, severe anorexia nervosa, and hypermetabolic states such as sepsis.

5. Which action would minimize the risk of infection when placing prepackaged supplies on an established sterile field? A. Wear clean treatment gloves. B. Collect supplies with sterile gloves to avoid contamination. C. Do not allow the wrapper to touch the sterile field. D. Place the supplies on the 1-inch perimeter of the sterile field.

C. Allowing contact of the prepackaged wrapper with the sterile field would result in contamination. Wearing gloves is not needed when adding prepackaged supplies to an established sterile field, or when collecting supplies. Supplies should be well within the 1-inch border of the sterile field.

A client who is receiving a continuous IV infusion through a peripheral site suddenly complains of pain along the vein at the location of the catheter. The nurse quickly assesses the client and notes a weak, rapid pulse; cyanosis of the nail beds; and a decrease in BP. Suspecting catheter embolism, the nurse removes the IV catheter and sees the tip is broken off. What immediate action should the nurse take? a. Start an IV line at a different site b. Apply a tourniquet high on the limb of the IV site c. Call the OR to alert the staff that the client will need surgery d. Call the radiograph department to request an x-ray of the client's arm and shoulder

B. A catheter embolism occurs when the tip of the catheter breaks off and floats freely in a vessel. This can lead to an embolus. The signs of catheter embolism include pain along the vein; diminished BP; weak rapid pulse; cyanosis of nail beds; and loss of consciousness. The nurse would carefully remove the catheter, inspect it, and place a tourniquet high on the limb if the catheter tip has broken off. The HCP is then notified. The client is prepared for an x-ray and for surgery to remove catheter fragments if prescribed.

An IV catheter was inserted into a client 1 hour ago. Assessing the IV site, the nurse notes the presence of bruising. The nurse also finds that the area is swollen and the patient complains of pain at the site. Which action by the nurse is most appropriate? a. Notifying the HCP b. Removing the IV catheter and applying pressure to the site c. Elevating the extremity and rechecking the site in 1 hour for a decrease in the swelling d. Telling the client that the bruising is normal and occurred as a result of the insertion.

B. A hematoma is a collection of blood in the tissue that occurs after an unsuccessful venipuncture or after a venipuncture is discontinued. It is characterized by swelling, discoloration, and bruising at the site. The client may also complain of pain at the site. If a hematoma develops, the nurse removes the IV catheter, elevates the extremity, and applies pressure. This occurrence is not normal, but it is not needed to notify the HCP unless policy indicates to do so.

A central venous catheter is inserted for the administration of PN. Which action should the nurse take to confirm placement of the catheter? a. Auscultates lungs b. Checks result of post-insertion chest x-ray with HCP c. Checks insertion site for signs of infiltration while the PN solution is being infused d. Attaches a syringe to the access catheter and pulls back on the plunger, looking for backflow of blood

B. After the HCP inserts the central venous access catheter but before the catheter is used for infusions, the placement is checked by x-ray exam.

Which action would the nurse take to ensure the safety of an older adult patient who has received an enema? A. Assess for the presence of external hemorrhoids. B. Provide assistance to the bathroom for expulsion of fluid and stool. C. Document the patient's physical response to the enema. D. Instruct the patient to attempt to retain the fluid for 2 to 5 minutes.

B. Assisting an older adult to the bathroom helps ensure the patient's safety because it may prevent a fall. While a patient with hemorrhoids may require special care during insertion of the tip of the rectal tube, this intervention pertains to the patient's comfort, not to his or her safety. Documenting the patient's physical response to the enema is appropriate, but this action pertains to recording and reporting, not safety. Instructing the patient to attempt to retain the fluid for 2 to 5 minutes may help make the enema more effective, but will not make it safer.

The nurse is caring for a client who has undergone surgery. The client is anxious and complains of incision pain. The nurse conducts a pain assessment, checks the client's vital signs, and notes that the client's blood pressure and pulse rate have increased. On the basis of these findings, which action by the nurse is most appropriate? a. Contacting the primary health care provider b. Preparing to administer pain medication c. Checking for signs/symptoms of postoperative hemorrhage d. Consulting with the primary health care provider about administering an antianxiety medication

B. Because increases in pulse and blood pressure are expected in a client who is anxious and in pain, most appropriate action by the nurse would be to prepare and administer pain medication. Anxiety, fear, pain, and emotional stress all result in sympathetic stimulation, which increases the heart rate, cardiac output, and peripheral vascular resistance. Sympathetic stimulation also increases the blood pressure. There is no reason to contact the primary health care provider at this time. Hemorrhage would result in a decrease in blood pressure. Although a prescription for an antianxiety medication may be an option, it is not the most appropriate action to take on the basis of the information in the question.

Oral prednisone, 10 mg/day has been prescribed for a hospitalized client with a history of type 1 DM for the treatment of acute exacerbation of asthma. The nurse should monitor the client closely for what? a. Signs of hypoglycemia b. Signs of hyperglycemia c. The need to decrease the prescribed daily insulin dose d. The need to change the prescribed daily insulin to an oral hypoglycemic

B. Because of their effect on glucose production and utilization, glucocorticoids can increase glucose level, causing hyperglycemia and glycosuria. Clients with DM may need to increase the dosage of insulin or oral hypoglycemic medications during treatment with a glucocorticoid.

The nurse is preparing to monitor a client's oxygen saturation with the use of pulse oximetry. The nurse reads the client's health care record and notes a history of peripheral vascular disease. In light of this information, which part of the body should the nurse select for attachment of the sensor probe? a. Toe b. Ear c. Sole d. Finger

B. If the client has a history of peripheral vascular disease, the sensor probe should be attached to the ear or the bridge of the nose. The site chosen for placement of the sensor probe used to monitor oxygen saturation must have adequate local circulation and must be free of moisture. The sensor requires a pulsating vascular bed to identify hemoglobin molecules that absorb the light emitted by the probe. Alterations in circulation and moisture impede the ability of the sensor to detect oxygen saturation.

A pregnant client is receiving an IV infusion of oxytocin. Monitoring the client closely, the nurse suddenly notes the presence of uterine hypertonicity. Which action is taken immediately? a. Document the finding b. Turn the client on her side c. Stop the infusion d. increase the rate of the nonadditive solution

C. Oxytocin is an oxytocic agent used to induce labor. If uterine hypertonicity or a nonreassuring FHR occurs, the nurse must intervene to reduce uterine activity and increase fetal oxygenation. The nurse would immediately stop the infusion, increase the rate of the nonadditive solution, place the client in a side-lying position, and administer oxygen by face mask at 8-10L/min. The nurse would then notify the HCP, continue to monitor the client, and document the occurrence and findings.

The nurse asks a colleague to assist in counting a client's pulse to determine whether the client with a dysrhythmia has a pulse deficit. The nurse's colleague counts the client's apical heart rate while the nurse counts the client's radial rate. The nurse's colleague reports an apical heart rate of 90 beats/min, and the nurse obtains a radial rate of 76 beats/min. Which nursing action is most appropriate? a. Reassessing the client for a pulse deficit in 15 minutes b. Documenting that the client has a pulse deficit of 14 beats c. Asking another colleague to count the apical rate to verify the findings d. Asking the client to ambulate and then reassess the apical and radial rate

B. In the two-examiner technique for detecting a pulse deficit, the nurse and a colleague count the radial and apical pulses simultaneously and then compare the rates. The difference between the apical and radial pulse rates is the pulse deficit. If the client has an apical heart rate of 90 beats/min and a radial rate of 76 beats/min, the pulse deficit is 14 beats. The nurse would document this finding. The nurse would also report the finding to the primary health care provider. Although the nurse would continue to check for a pulse deficit, it would not be necessary to do so in 15 minutes. Asking a second colleague to count the apical rate to verify the findings raises doubt about the first colleague's ability to assess the apical heart rate. There is no useful reason for reassessing the pulse rates after asking the client to ambulate.

A client with terminal cancer is receiving morphine sulfate by continuous IV infusion. The nurse checks the clients VS and notes a pulse of 68, a BP of 100/58, and a RR of 10. Which action should be taken? a. Decrease rate of infusion b. Contact HCP c. Ask client to rate pain level d. Continue to monitor client VS

B. Respiratory depression is the most serious adverse effect of morphine. If the respiratory rate is slower than 12, or if bradycardia develops, the nurse would withhold the medication and notify the HCP.

The nurse is delegating to nursing assistive personnel (NAP) the administration of an enema for an older adult patient who is recovering from a stroke. The enema order reads, "Enemas until clear." Which statement made by NAP requires the nurse to follow-up? A. "I'll need help to turn her onto her side." B. "It may take three or four enemas to achieve a clear return." C. "I'll test the water temperature on the inside of my own wrist." D. "The enema will wear her out, so I'll wait until after she ambulates."

B. Stating it may take three or four enemas to achieve a clear return requires follow-up, since administering more than three enemas can cause fluid and electrolyte imbalance, especially in an older adult patient. The health care provider should be notified if the bowel has not been evacuated after three enemas. This requires no follow-up, since more than one person may be required to turn a patient onto her side. Testing the water temperature on the wrist is appropriate, so this statement requires no follow-up. Stating that the enema will wear her out reflects appropriate concern for the patient and requires no follow-up.

The nurse is working with a new nurse employee who is hanging a unit of packed RBCs. The nurse realizes the new nurse has taken correct action if the nurse takes which step once the nurse has hung the blood and adjusted the flow rate> a. Taking client VS b. Staying with the client and monitoring him closely for 15 minutes c. Asking the client whether he has ever had a reaction to a transfusion d. Placing the call bell next to the client and instructing him to call if he experiences anything unusual

B. The first 10-15 minutes of any transfusion is the most critical period. If a major ABO incompatibility exists or a severe allergic reaction such as anaphylaxis is going to occur, it is usually evident within the first 50 mL of the transfusion. Therefore the transfusion should be started at a slow rate and the client monitored closely for the first 15 minutes. If no reaction is noted during the first 15 minutes, the infusion can be increased to the prescribed rate. The client is asked about previous reactions before the blood is infused. VS are taken before the transfusion, after the first 15 minutes, and every hour until 1 hour has passed since the transfusion was completed.

3. Which direction to nursing assistive personnel (NAP) would help to maintain a sterile field while conducting a sterile procedure? A. "Please see to it that nothing contaminates this sterile field while I get some additional supplies." B. "I'd like you to make sure that the patient doesn't reach toward the sterile field while I'm changing the dressing." C. "Hand me the item closest to the edge of the sterile field." D. "Place a sterile drape over these supplies for a moment while I answer my other patient's call light."

B. The nurse may delegate to the AP the responsibility for monitoring the patient's behavior during a sterile procedure in order to minimize the risk that the patient's actions will contaminate the field. Responsibility for establishing or maintaining a sterile field cannot be delegated to an AP. The nurse cannot leave the sterile field once it is established. Handing an item to the nurse from the sterile field would contaminate it.

A nurse monitoring a client who is receiving IV theophylline checks the client's most recent blood level. The nurse documents that the level is therapeutic if which value is reported? a. 8 b. 14 c. 24 d. 32

B. The therapeutic theophylline level is 10-20.

Two RNs confirming blood product compatibility and verifying client identity for a client who is to receive a unit of packed RBCs are comparing the name and number of the clients ID band with the name and number on the unit of blood. The nurses note that the numbers are not identical. What should the nurses do? a. Hang the unit of blood b. Contact the blood bank c. Continue verifying client identity, then notify HCP d. Ask the unit secretary to prepare another ID band for the client that contains the number on the unit of blood

B. Two licensed nurses must check the HCP prescription, client identity, and ID band and number, verifying that the name and number are identical to those on the blood component tag. At the bed side, the client is asked to state name, which the nurse compares with the name on the client's ID band. The blood bag tag and label and the blood requisition form are assessed to ensure that ABO and Rh types are compatible, and the blood bag label is also checked to ensure that the correct components have been issued. If an inconsistency is found, the blood bank is notified immediately.

The nurse is monitoring a client receiving a blood transfusion. One hour after the transfusion is started, the client complains that her skin is extremely itchy. On assessment, the nurse notes a rash and suspects a transfusion reaction. Which action should the nurse take after immediately stopping the transfusion? a. Removing the IV catheter b. Contacting the HCP c. Completing a transfusion reaction report d. Rechecking the blood bag tags against the client's ID band

B. When a transfusion reaction occurs, the nurse first stops the blood transfusion, then maintains a patent IV line with NS solution and immediately notifies the HCP and blood bank. After taking these actions, the nurse would recheck the blood bag tags against the client's ID band, check client VS and urine output, treat symptoms in accordance with HCP prescriptions, send the blood bag and tubing to the blood bank, complete a transfusion reaction report and document the reaction in the client's record, and collect required blood and urine samples in accordance with agency protocol.

The nurse interprets a client's temperature reading, knowing that certain factors can affect body temperature. Which statements regarding body temperature are accurate? Select all that apply. a. Stress can cause a decrease in body temperature. b. Body temperature increases just before ovulation. c. Body temperature increases when the client has an infection. d. Body temperature is usually higher in the afternoon than in the morning. e. Body temperature may be lower than the true temperature if the temperature in the client's room is cool.

C, D, E Emotions (stress) increase hormone secretion, leading to increased heat production and a higher-than-normal temperature. Body temperature decreases slightly just before ovulation and usually increases by 1° F above normal during ovulation. Infective agents and the inflammatory response may cause an increase in temperature. Afternoon body temperature may be high normal as a result of the metabolic process, activity, and environmental temperature. Body temperature is lower in cold weather and higher in warm weather.

A nurse is instructing a client about the use of sulfisoxazole, which has been prescribed to treat the client's UTI. Which instructions should the nurse provide? SATA a. Expect itching to develop b. Limit fluid intake to prevent edema c. Apply sunscreen if exposure to sunlight is expected d. Use OTC corticosteroid cream for itchy rash e. Take the medication on an empty stomach with a full glass of water

C, E Sulfisoxazole is a sulfonamide. The appearance of a rash indicates hypersensitivity to the medication; the client is instructed to stop the medication and contact the HCP if itching or rash occurs. The client should not use OTC medications unless prescribed. The client is also instructed to take the medication on an empty stomach with a full glass of water; to avoid prolonged exposure to sunlight, wear protective clothing when in the sun, and apply a sunscreen to skin exposed to sunlight; and to consume 8-10 glasses of water each day to minimize risk of kidney damage.

Which action would the nurse take to reduce the risk of infection among patients and staff when administering an enema to an older adult patient with dementia? A. Lubricate the tip of the rectal tube. B. Pad the patient's bed thoroughly. C. Perform hand hygiene before donning gloves. D. Help the patient onto a bedpan to expel the enema fluid and stool.

C. Performing hand hygiene before donning gloves and after removing them is appropriate in order to reduce the risk of infection among patients and staff. While lubricating the tip of the rectal tube is appropriate, it pertains to instillation of the enema, not to reducing the risk of infection. Padding the patient's bed thoroughly is appropriate; it pertains to the patient's comfort, not to reducing the risk of infection. While helping the patient onto a bedpan is appropriate, it pertains to the procedure itself, not to reducing the risk of infection.

How does active listening result in better patient care? a. Active listening causes patients to be more compliant with their treatments. b. It demonstrates respect c. Health care professionals with good listening skills are able to uncover valuable information that can be used to provide better care d. Patients value providers who are good listeners.

C. Rationale: While active listening does demonstrate respect, and can foster a good provider-patient relationship, the benefit of active listening is in the valuable information that can be uncovered. Health care professionals with good listening skills are able to uncover valuable information that can be used to provide better care. While patients do value providers who are good listeners, the benefit of active listening is in the valuable information that can be uncovered.

Allopurinol has been prescribed to treat hyperuricemia in a client with gout, and the nurse provides instructions to the client. Which statement indicates the need for further teaching? a. I should take the medication with food b. I need to stop putting gravy on my food c. I need to limit my fluid intake while taking this d. I need to have my blood level of the medicine checked while taking it

C. Allopurinol, used to treat gout, reduces concentrations of uric acid in serum and urine. The client should increase fluid intake to at least 2000-3000 mL/day to prevent renal injury. The client should also avoid foods high in purines, such as gravy, wine, alcohol, organ meats, sardines, and salmon to help decrease levels of uric acid. The medication should be taken with meals or milk to minimize GI distress. The client should have periodic CBC, as well as determinations of serum and blood uric acid levels.

A client is being assessed for the presence of postural (orthostatic) hypotension. Which procedure should the nurse perform to assess the client for this condition? a. Taking the client's pulse while the client is standing, asking the client to lie down and retaking the pulse in 30 minutes, and finally, comparing the findings b. Taking the client's pulse while the client is lying down, asking the client to sit in a chair and retaking the pulse in 3 minutes, and, finally, comparing the findings c. Taking the client's blood pressure while the client is lying down, asking the client to sit in a chair and retaking the blood pressure in 1 to 3 minutes, asking the client to stand for 1 to 3 minutes and retaking the blood pressure a third time, and, finally comparing the findings d. Taking the client's blood pressure while the client is standing, asking the client to sit in a chair for 1 to 3 minutes and retaking the blood pressure, asking the client to lie down for 1 to 3 minutes and retaking the blood pressure a third time, and, finally, comparing the findings

C. Postural (orthostatic) hypotension is the presence of signs/symptoms of low blood pressure on rising to an upright position in a normotensive individual. The blood pressure is checked with the client supine, sitting, and standing. The readings are obtained 1 to 3 minutes after the client changes position. When documenting orthostatic blood pressure measurements, the nurse records the client's position in addition to the client's blood pressure.

A client receiving PN is exhibiting signs of an air embolism. Immediately after placing the client's head lower than the feet, how should the nurse next position the client? a. Prone b. On her back c. On the left side d. On the right side

C. The client should be placed in left side-lying position with the head lower than the feet if an air embolism is suspected. This position helps minimize the effect of the air travelling as a bolus to the lungs.

A nurse hangs a 500-mL bag of intravenous (IV) fluid for an assigned client. One hour later the client complains of chest tightness, is dyspneic and apprehensive, and has an irregular pulse. The IV bag has 100 mL remaining. Which action should the nurse take first? A. Remove the IV B. Sit the client up in bed C. Shut off the IV infusion D. Slow the rate of infusion

C. The client's symptoms are indicative of speed shock, which results from the rapid infusion of drugs or a bolus infusion. In this case, the nurse would note that 400 mL has infused over 60 minutes. The first action is to shut off the infusion; other actions may follow in rapid sequence: The nurse may elevate the HOB to aid in the client's breathing and then immediately notify the HCP.

The nurse suspects hyperglycemia in the client receiving PN if which signs are noted? SATA a. Seizures b. Sweating c. Diaphoresis d. Excessive thirst e. Increased urine output f. Kussmaul respirations

D, E, F The high concentration of glucose in PN puts the client at risk for hyperglycemia. Signs include excessive thirst, fatigue, restlessness, confusion, weakness, Kussmauls, diuresis, and in severe cases, coma. If a client presents with these symptoms, the blood glucose level is checked. Seizures, sweating, and diaphoresis are signs of hypoglycemia.

The nurse has delegated administration of a standard enema for a 72-year-old patient with constipation. Which statement made by nursing assistive personnel (NAP) requires the nurse to follow-up? A. "I'll warm up the solution before instilling it." B. "I'll place the patient in the left side-lying position with the right knee bent." C. "I'll put a waterproof pad under the patient before I start." D. "I'll instill the solution and then check in on my other patients until I get the call signal."

D. After instilling the solution, NAP should remain with the patient until he or she is ready to defecate, this statement requires follow-up. Warming the solution is appropriate. The patient is placed in a left side-lying position to allow the solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum. A waterproof pad may be placed under the patient if necessary.

The nurse is monitoring a client who is receiving IV fluids through a central line inserted into the subclavian. The client suddenly complains of chest pain and difficulty breathing. The nurse notes that the pulse rate has increased, the client is hypotensive, and that a loud churning sound is audible upon auscultation of the precordium. The nurse suspects air embolism. Which immediate action should the nurse take? a. Removing the IV catheter b. Calling the resuscitation team c. Elevating the head of the clients bed d. Placing the client in left lateral trendelenburg position

D. Air embolism occurs when air enters the central venous system during tubing changes, insertion, or breakage of the catheter. Signs include chest pain, tachycardia, hypotension, cyanosis, and a decreased LOC. A loud churning sound may be heard over the precordium, a result of air in the right ventricle. If this occurs, the nurse immediately clamps the catheter, places the client in left lateral trendelenburg position to trap the air in the right atrium, and notifies the HCP.

A client with breast cancer who has undergone a mastectomy will be receiving chemotherapy. The oncologist prescribes allopurinol, 100 mg daily to be started before the initiation of chemotherapy. The nurse should tell the client that the medication is used for what? a. To prevent nausea b. To prevent diarrhea c. To reduce postoperative incision pain d. To minimize an increase in the plasma uric acid level

D. Allopurinol is used to reduce the blood level of uric acid. The level of uric acid increases as a result of the breakdown of DNA that occurs after chemotherapy-induced cell death. As a means of minimizing any increase in the serum uric acid level, allopurinol should be administered before the start of chemotherapy.

A client with HF is being given furosemide and digoxin. The client calls the nurse and complains of anorexia and nausea. Which action should the nurse take first? a. Administer an antiemetic b. Administer the daily dose of digoxin c. DC the morning dose of furosemide d. Check result of lab testing for potassium on the sample drawn 3 hours ago

D. Anorexia and nausea are symptoms commonly associated with digoxin toxicity, which is compounded by hypokalemia. Early clinical manifestations of digoxin toxicity include anorexia, mild nausea, but these are frequently overlooked or not associated with the digoxin. Hallucinations and any change in pulse rhythm, color vision, or behavior should be reported. The nurse should first check the results of the potassium level, which will provide additional information when the nurse calls the HCP. The nurse should also check the digoxin reading if one is available.

A client is taking capreomycin sulfate as a component of pharmacological treatment for TB. The client calls the nurse and reports that he is experiencing ringing in the ears. How should the nurse respond? a. You should stop taking the medication immediately. b. Ringing in the ears is a harmless effect of this medication c. Ringing in the ears is an expected effect of the medication. d. You need to speak to the HCP about the problem.

D. Capreomycin is a second-line antiTB medication that is administered in conjunction with a first-line medication to treat TB. It can cause ototoxicity, resulting in hearing loss, tinnitus, and disturbance in balance. If these occur, the HCP must be notified. It is not an expected or harmless effect.

A pregnant client with preeclampsia is receiving an IV infusion of magnesium sulfate. Which medication, the antidote, does the nurse ensure is readily available? a. Vitamin K b. Acetylcysteine c. Protamine sulfate d. Calcium gluconate

D. Magnesium sulfate is a CNS depressant and anticonvulsant. It causes smooth muscle relaxation and is used to stop preterm labor, prevent preterm labor, and prevent/control seizures in preeclamptic and eclamptic clients. Calcium gluconate, which is an antidote to magnesium, should be placed in the room of the client receiving the magnesium. Acetylcysteine is the antidote to acetaminophen. Vitamin K is the antidote to warfarin. Protamine sulfate is the antidote to heparin.

A nurse provides medication instructions to a client with angina who will be taking nitroglycerin sublingually PRN for chest pain. Which statement indicates a need for further teaching? a. I should store the medication in a dark, tightly closed bottle b. I need to check the expiration date on the botle c. If I get a headache from the medication, I can take acetaminophen d. If the first tablet does not relieve by pain, I should put 2 tablets under my tongue 5 minutes after taking the first.

D. The nurse should instruct the client to take a sip of water before taking the medication, because mouth dryness may inhibit absorption. To terminate an acute anginal attack, sublingual nitroglycerin should be administered as soon as pain begins. Administration should not be delayed until pain has become severe. According to current guidelines for the non-hospitalized client, if pain is not relieved in 5 minutes after taking the first tablet, the client should call 911, since anginal pain that does not respond to nitroglycerin may indicate MI. While awaiting emergency care, the client can take 1 more tablet, and then a third 5 minutes later. The client should place the tablet under the tongue and allow it to fully dissolve. The nurse also instructs the client to store the medication in a dark, tightly closed bottle and to check expiration date, because expiration may occur within 6 months. The client can take tylenol for headache.

The nurse is caring for a client with breast cancer who has been undergoing chemotherapy. Blood tests indicate a low platelet count. A platelet transfusion is prescribed, and the nurse obtains the platelets from the blood bank. After carrying out the pretransfusion protocol, the nurse should administer the transfusion over what period of time? a. 2 hours b. 4 hours c. 6 hours d. 15-30 minutes

D. The volume of a unit of platelets may vary from 200 mL for single-donor platelets to 300 mL per unit for pooled platelets. Because the platelet is a fragile cell, platelet transfusions are administered rapidly once they have been brought to the client's room, usually over 15-30 minutes.

Tranylcypromine sulfate is prescribed for a client with depression and the nurse provides medication instructions to the client. Which statement by the client indicates need for further instruction? a. I should not eat bananas. b. I should get out of bed slowly in the morning. c. I need to carry a medic-alert card in my wallet. d. If i get a headache or any neck soreness, I can take some pain medication

D. Tranylcypromine sulfate, an MAOI, is used to treat depression. Certain pain medications, when combined with an MAOI, can cause a hypertensive crisis. The client is instructed to avoid consuming foods that contain tyramine such as bananas to help prevent hypertensive crisis. The client should also change position slowly to prevent orthostatic hypotension and is told that signs of hypertensive crisis such as neck soreness or stiffness must be reported immediately. The client is instructed to wear a medic-alert bracelet or carry a medic-alert card to alert others as needed that an MAOI is being taken.